PDF | Author-surgeon's book describes the limitations of surgery and Gawande's research interest is in improving surgical care in the US and. We note Gawande's observation that the exer- cise of autonomy means being able to relinquish it. 10 Par- ticipation in shared decision-making is defined as a. COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE. 53 Pages · · KB · Downloads ·English. by Gawande, Atul. Preview.
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Complications: A Surgeon's Notes on an Imperfect Science, by Atul Gawande. Picador, (Page references are to this paperback edition.) Pressed for time. 'Gawande is an accomplished author and doesn't shy away. from hot topics like Complications: A Surgeon's. Notes on an . Size Report. DOWNLOAD PDF. [PDF] Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande ePub^ Online^. 1. PDF Complications: A Surgeon's Notes.
If his fears are well grounded, he would need to do a biopsy and possibly an amputation. Can decisions like these best be made by algorithms free of the errors of human judgment? Or is there something to the idea that medical intuition offers insight into cases that defy all the usual expectations? Much is at stake here, starting of course with the lives and the well being of individual patients.
There are public policy implications as well, for both diagnosis and treatment. If insurance companies use algorithms and outcomes research and require physicians to adhere to their strict guidelines, what will be the result?
One possibility is that patients would no longer be victims of hidebound or arrogant physicians who would otherwise insist on doing things the way they have always done them.
A Surgeon's Notes on an Imperfect Science
But another possibility is that seasoned medical intuition is a crucial component of good medical decision-making which cannot be reduced to computer- programmable formulas. If so, public health would suffer from the loss of this imperfect yet precious all-too-human resource. Should medicine use its resources for this kind of problem? He writes like an anthropologist about the behavior of surgeons at a huge conference in Chicago. He notes that some of the glitz and carnival atmosphere mirror that of a Public Relations World Congress that 3 is taking place at the same time.
Once a year, however, there is a place full of people who do know. If these weekly meetings truly work as Gawande describes them, they suggest how institutions can operate to promote the virtues of humility, openness, and the best kind of ambition, the drive to improve. Judging by the character traits revealed in these essays, I cannot think of anyone who better embodies the intellectual and moral virtues of the medical profession than Atul Gawande.
A sea of fluid from the tumor occupied his right chest instead. Lee was living entirely off his left lung, and the tumor was pressing down on the airway to it, too.
The community hospital he was in did not have the resources to deal with this. So the doctors there sent him to us.
Complications: A Surgeon's Notes on an Imperfect Science
We had the specialists and high-tech equipment. But that didn't mean we were sure what to do.
By the time Lee arrived in our intensive care unit, his breathing was a buzzing, reedy stridor. You could hear it three beds away.
The scientific literature is unequivocal about this situation: it is deadly dangerous. Just laying him down could cause the tumor to cut off the remainder of his airway. Giving him sedatives or anesthesia could do the same. Surgery to remove the tumor is impossible. The question was how to download the child time to find out.
It wasn't clear he'd last the night. We had two nurses, an anesthesiologist, a pediatric surgery junior fellow, and three residents at the bedside, myself included; the senior pediatric surgeon was on his cell phone, driving in from home; an oncologist was on page. One nurse propped Lee up on pillows to make sure he was as upright as he could be.
The other put an oxygen mask on his face and hooked up monitors tracking his vital signs. The boy's eyes were wide and worried, and his breathing was about twice too fast.
His family was still far away, having to travel by ground. But he remained sweetly brave, as children do more often than you'd expect. My first instinct was that the anesthesiologist should put a stiff breathing tube into the boy's airway to fix it open before the tumor closed in. But the anesthesiologist thought this was nuts. She'd have to put the tube in without good sedation, with the kid sitting up, no less. And the tumor extended far along the airway.
She wasn't convinced she could reach a tube past it easily enough. The surgical fellow proposed another idea: if we put a catheter into the boy's right chest and drained off the fluid filling it, the tumor would tilt away from the left lung. On the phone, however, the senior surgeon was concerned that this could worsen matters.
Once you have unsettled a boulder, can you honestly say which way it will roll? No one was thinking of any better options, however. So ultimately he said to go ahead. I explained to Lee what we were going to do as simply as I could. I doubt he understood.
That may have been just as well. After we'd gathered all the supplies we needed, two of us held Lee tight, and another injected a local anesthetic between his ribs, then made a slit with a knife and pushed a foot-and-a-half-long rubber catheter in. Bloody fluid poured out of the tube by the quart, and for a moment I was afraid we'd done something terrible. But as it turned out, we'd done more good than we could have hoped for.
The tumor shifted rightward and somehow the airways to both lungs opened up. After watching him a few minutes, so did ours. Not until later did I wonder about our choice. It was little more than a guess about what to do a stab in the dark, almost literally. We had no backup plan should disaster have occurred.
Complications: A Surgeon's Notes on an Imperfect Science
And when I looked up reports of similar cases at the library afterward, I learned that other options did in fact exist. The safest thing, apparently, would have been to put him on a heart-lung bypass pump like the kind used during cardiac surgery, or at least to have one on standby. Talking with the others about it, though, I found that no one regretted a thing.
Lee survived. That was what mattered. And his chemotherapy was now under way. Testing of the fluid showed the tumor to be a lymphoma. The oncologist told me that this gave Lee a better than 70 percent chance of total cure.
These are the moments in which medicine actually happens. And it is in these moments that this book takes place the moments in which we can see and begin to think about the workings of things as they are.
We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists.
And this gap complicates everything we do. I am a surgical resident, very nearly at the end of my eight years of training in general surgery, and this book arises from the intensity of that experience. At other times I have been a laboratory scientist, a public health researcher, a student of philosophy and ethics, and a health policy adviser in government.
I am also a son of two doctors, a husband, and a parent. I have attempted to bring all of these perspectives to bear on what I have written here. But more than anything, this book comes from what I have encountered and witnessed in the day-to-day caring for people. You are an insider, seeing everything and a part of everything; yet at the same time you see it anew. In some way, it may be in the nature of surgery itself to want to come to grips with the uncertainties and dilemmas of practical medicine.
Surgery has become as high tech as medicine gets, but the best surgeons retain a deep recognition of the limitations of both science and human skill. Yet still they must act decisively. The book's title, Complications,,comes not just from the unex-pected turns that can result in medicine but also, and more fundamentally, from my concern with the larger uncertainties and dilemmas that underlie what we do.
This is the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I've joined the profession's ranks.Giving him sedatives or anesthesia could do the same. Gawande would, however, be happy to know that at least one study has shown that, contrary to common belief, there is no increase in deaths in early August, when newly qualified doctors become house officers.
As many of us have discovered in teaching bioethics, philosophical questions are conveyed most clearly and vividly through case studies. His family was still far away, having to travel by ground. Linda Kuglarz.
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