Lobbying for an operating room

BOOK EXTRACT

In Better: A Surgeon's Notes on Performance, doctor-writer Atul Gawande, a general surgeon in a Boston hospital, explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable. If you've ever had a frustrating hospital experience, this book provides a valuable firsthand view from the other side of a field where mistakes are both unavoidable and unthinkable.

Virginia Magboo was sixty-four years old, an English teacher, and she'd noticed a pebble-like lump in her breast. A needle biopsy revealed the diagnosis. The cancer was small "" three-quarters of an inch in diameter. She considered her options and decided on breast-conserving treatment "" I'd do a wide excision of the lump as well as what's called a sentinel lymph node biopsy to make sure the cancer hadn't spread to the lymph nodes. Radiation would follow.

The operation was not going to be difficult or especially hazardous, but the team had to be meticulous about every step. On the day of surgery, before bringing her to the operating room, the anaesthesiologist double-checked that it was safe to proceed. She reviewed Magboo's medical history and medications, looked at her labs in the computer and at her EKG. She made sure that the patient had not had anything to eat for six hours and had her open her mouth to note any loose teeth that could fall out or dentures that should be removed... Meanwhile, in the operating room, two nurses made sure the room had been thoroughly cleaned after the previous procedure and that we had all the equipment we needed. Everything was checked and cross-checked. Magboo and the team were ready.

By two o'clock I had finished with the procedures for my patients before her and I was ready too. Then I got a phone call.

Her case was being delayed, a woman from the OR control desk told me.

Why? I asked.

The recovery room was full. So three operating rooms were unable to bring their patients out, and all further procedures were halted until the recovery room opened up.

OK. No problem. This happens once in a while. We'll wait. By four o'clock, however, Magboo still had not been taken in. I called down to the OR desk to find out what was going on.

The recovery room had opened up, I was told, but Magboo was getting bumped for a patient with a ruptured aortic aneurysm coming down from the emergency room. The staff would work on getting us another OR.

I explained the situation to Magboo, lying on her stretcher in the pre-operative holding area, and apologised. Shouldn't be too much longer, I told her. She was philosophical. What will be will be, she said. She tried to sleep to make the time pass more quickly but kept waking up. Each time she awoke, nothing had changed.

At six o'clock I called again and spoke to the OR desk manager. They had a room for me, he said, but no nurses. After five o'clock, there are only enough nurses to cover seventeen of our forty-two operating rooms. And twenty-three cases were going at that moment "" he'd already made nurses in four rooms do mandatory overtime and could not make any more. There was no way to fit another patient in.

Well, when did he see Magboo going?

"She may not be going at all," he said. After seven, he pointed out, he'd have nurses for only nine rooms; after eleven, he could run at most five. And Magboo was not the only patient waiting. "She will likely have to be cancelled," he said. Cancel her? How could we cancel her?

I went down to the control desk in person. One surgeon was already there ahead of me lobbying the anaesthesiologist in charge. A second was yelling into the OR manager's ear on the phone. Each of us wanted an operating room and there would not be enough to go around. A patient had a lung cancer that needed to be removed. Another had a mass in his neck that needed to be biopsied. "My case is quick," one surgeon argued. "My patient cannot wait," said another. Operating rooms were offered for the next day and none of us wanted to take one. We each had other patients already scheduled who would themselves have to be cancelled to make room. And what was to keep this mess from happening all over again tomorrow, anyway?

I tried to make my case for Magboo. She had a breast cancer. It needed to be taken out. This had to happen sooner rather than later. The radioactive tracer, injected more than eight hours ago, was dissipating by the hour. Postponing her operation would mean she would have to undergo a second injection of a radioactive tracer "" a doubling of her radiation exposure "" just because an OR could not be found for her. That would be unconscionable, I said.

No one, however, would make any promises.