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Complications

Atul Gawande's Complications is a book that is set during Gawande's


residency. It deals with some of the ethical issues in the medical/surgical
practice. Each of these fourteen stories is true, and every new story makes you
realize in a different way the one main message Gawande set out to convey, the
one that ties all of the stories together: That doctors are only human.

Part One -- Fallibility


Fallibility includes titles "Education of a Knife", "The Computer and the
Hernia Factory", "When Doctors Make Mistakes", "Nine Thousand Surgeons",
and "When Good Doctors Go Bad." This part of the book deals with ethical
issues surrounding the education of doctors and the extent to which residents
should be allowed to perform surgery on people. It also acknowledges "the gap
between what we know and what we aim for."
"Education of a Knife" is about Gawande's initial failure at inserting central
lines into patients. As he tells patients that there are very few risks involved when
the procedure is in experienced hands, he feels conflicted for withholding from
the patient the fact that he does not have experienced hands, being only a
resident. He sees his mentor perform it many times, but has never gotten it right,
and he becomes more discouraged and frustrated and scared each time. A
woman had died of massive bleeding when a resident sliced through her vena
cava; a man had to have surgery because a resident lost control of the central
line being put in; a man had a heart attack when the wire caused ventricular
fibrillation. These were some of the disasters that occurred when residents tried
to put in central lines, and when Gawande is asking the patient's permission to
perform the procedure, he does not mention any of this. He wonders, to what
extent should residents be allowed to practice on people? He goes over in his
head the numerous surgical disasters that have taken place because a resident
did something wrong.
Does the need to educate surgeons warrant practicing on people during
residency, greatly increasing the risk of something going wrong? And, he writes,
should patients be given this choice? He recalls the time when his infant son had
to have heart surgery, and a resident approached him and asked if he could
assist. Gawande adamantly refused, wanting his child's life in the most
experienced and sure of hands. It is quite easy for people to say that patients
should let residents practice upon them, that these people need their education,
that there will always be a surgeon leading the operation. But, as Gawande
discovered, the decision is much more difficult when it is your own life, or that of
someone you love.
"When Good Doctors Go Bad" is the story of Hank Goodman (his name
has been altered for confidentiality), a man who started his career by being
brilliant in residency and coasting steadily to the top of his field. He was, for a
while, the most sought-after orthopedic surgeon around. And one of the things
that set him apart from other doctors was his compassion and dedication to his
practice. When a small boy needed his hip tapped late at night, Goodman rushed
in for him, even though he wasn't on call and he had no need to be there. He
went above and beyond, especially, he says, in residency. Goodman describes
the experience as "the four best years of my life". His unwillingness to turn
people down soon made him one of the busiest orthopedic surgeons in his state.
But somewhere along the way, he started to slip. He cut corners,
sometimes with dire consequences. His patients were hurt. Colleagues who once
looked to him for inspiration became horrified with the mistakes he was making,
and that he did not make efforts to right his wrongs. This was evident in cases
like Mrs. D's (patient's real name is confidential), a mother of two who came to
Goodman with fluid swelling in her knee. The week before, she'd had surgery to
remove similar fluid, but this time she said she was quite ill and that her knee
was unbearably painful. The flesh was red-hot, and there was discharge when he
inserted a needle into the joint. It was obvious that she was suffering from a
serious infection, but Goodman was busy and didn't bring her into the hospital, or
even refer her to someone else. He waved her away, calling her a whiner, and
within the week the infection had destroyed the cartilage in her knee, wrecking
the joint for good. With the cartilage gone, she had to have her knee fused,
making her unable to bend to pick up her child or run. Any doctor can make a
mistake like this when consumed with work and not fully paying attention, but
Goodman continued to make errors like this over and over again, refusing to
admit he was wrong when he inserted the wrong size screws into joints or put
pins into the hip of an eldery man whose X-rays showed that the problem was so
serious he needed an entire hip replacement. The thing that appalled his
colleagues was not the mistakes themselves, but that Goodman refused to admit
them or correct them.
Eventually, Goodman lost his license and took a much-needed break from
medicine. When asked what lead to the downfall of his career, he could only
shake his head and say, "I don't know what happened."

Part Two -- Mystery


Mystery includes titles "Full Moon Friday the Thirteenth", "The Pain
Perplex", "A Queasy Feeling", "Crimson Tide", and "The Man Who Couldn't Stop
Eating". These stories are about the unpredictable things in medicine that can't
be accounted for.
"The Pain Perplex" is about a man named Robert Scott Quinlan, who, after
fracturing his shoulder, developed severe pain spasms in his back. His CT scans,
X-rays, and other tests all came back clean, and no one could find any reason to
operate on his back. Gawande and the other doctors were skeptical, because his
entire workup was clean. Many chronic pain patients fake it for narcotic
prescriptions, and for many it is psychosomatic instead of merely physical. But
Quinlan was not on narcotics, claiming they didn't help, and his moods had been
the same as usual, with no added stress. The doctors had no idea what was
going on and couldn't think of a reason for him to be faking it. He wasn't
interested in drugs or trying to get a card for a handicap parking space because
he was lazy. But the disturbing thing about his case is that it is very typical.
Chronic patients are extremely common, and a dilemma doctors face is how to
know if they're faking it, and when to turn them away. Over time, Quinlan's back
pain worsened and he wanted an operation, but his tests showed no signs of a
ruptured or slipped disk, which is a common cause of chronic back pain in the
elderly and the most likely to be afflicting him, or any other problem. Studies point
to mundane things as a cause of chronic pain, "inorganic" factors such as
loneliness or job dissatisfaction. Quinlan's wife reported to the doctors that he
had been having mood swings and periods of depression, but no one was ever
sure if that was the cause or the result of his debilitating pain.

Part Three -- Uncertainty


Uncertainty includes titles "Final Cut", "The Dead Baby Mystery", "Whose
Body is it, Anyway?", and "The Case of the Red Leg". Part Three explores the
types of outside influences that can make or break the correctness of a medical
decision, and how they can complicate confirming or treating the diagnosis.
In "The Dead Baby Mystery", Marie Noe had lost all ten of her children as
infants. One was stillborn and one expired at the hospital shortly after birth, but
the other eight died at her home, where Noe said she found them all dead in their
cribs. Each year, thousands of infants die inexplicably in bed each year, a
circumstance dubbed Sudden Infant Death Syndrome, or SIDS. In 1998, when
Noe was seventy, new medical evidence was found that determined that she had
smothered her children with a pillow. Gawande writes that this puzzles him,
because the bodies of the infants were now just bone, making it seemingly
difficult to determine that the babies had been suffocated. So what was their
actual basis for charging Marie Noe with eight counts of first degree murder?
Under promise of anonymity, an official admitted that there was, in fact, no direct
evidence that proved Noe guilty of murder. She was charged under speculation.
A medical examiner working on the case said, "One SIDS death is a tragedy.
Two is a mystery. Three is murder." When it all comes down to it, sometimes
science isn't the deciding factor in decisions, but rather what people have to say.