Crazybasenji

They rode around the flight-line on blue bicycles wearing black caps with white letters that said “QC.” We called them “QC commandos” and other, less flattering names. The letters stood for Quality Control, and the guys that wore those caps were the bane of our existence. I was given to believe they would as soon write someone up as look at them. And by “write someone up” I mean write up an infraction of some regulation or other, which would go on our Air Force records. They were especially fond of infractions involving checklists.

We had checklists for just about everything, from launching the aircraft, through all the post- and pre-flight inspections, to refueling, installing the drag-chute, towing the jet to the wash rack or a hangar, etc, etc, etc. So, by association, checklists were seen as the bane of our existence. In reality, they weren’t that easy to use. They were all bundled together in a booklet about five or six inches wide by 11 or so long, and about six inches thick. The pages were in individual plastic sleeves to protect them from all the dirty, greasy crap they were likely to come into contact with through the course of a day on the flight-line. They were not light, compact, or “handy.” The print was necessarily small to get everything on those small pages, and the writing was typical of government technical manuals — over-done. My disdain for “checklists” was a learned behavior, even if somewhat justified at that point in my life.

Which is why I was curious about a book on checklists written by a surgeon. The Checklist Manifesto, by Atul Gawande goes on the list with the best books I’ve read this year. I think instinctively I knew that following a checklist for a lot of procedures was a better idea than just trying to wing it on memory alone, and this book bears that out. Gawande describes multiple instances where a written-out and checked-off set of steps for performing complex tasks made the difference between life and death. He doesn’t just stick to examples from his own medical specialty, either. His recounting of the “Miracle on the Hudson” was both an extraordinary story and a revealing view of why the pilot so consistently downplayed his “heroism.” After all, the pilot and the rest of the flight crew were only doing what was expected of them in the circumstances. They followed procedures that were written down and included in a checklist.

The book starts off with anecdotal stories of two surgeons swapping tales of hair-raising close calls in the operating room – about how a seemingly small item missed or a question not asked, a detail not known, nearly resulted in the death of a patient. That’s only the introduction. In the first chapter, Gawande recounts a story where everything went right, miraculously resulting in a drowning victim being restored to life. The two close calls occurred in large urban hospitals while the “miracle” took place in a rural hospital in a remote area high in the Austrian Alps. So what was the difference?

In researching the answer, Gawande discovered that the Alpine hospital emergency staff had devised a written protocol to follow whenever rescue crews notified the hospital that they were on their way with an accident or critical health victim. Knowing that lost time could mean lost lives, the hospital management handed the telephone-answering personnel and the rescue squads the power to coordinate what and who would be needed when the victim arrived. The EMTs would tell the hospital operator what kind of case they were bringing. The operator would then go through a list of specialists and other personnel to notify and tell them to stand ready. This was unprecedented. It put the power to orchestrate the first movement of the critical effort in the hands of those who normally were excluded from those types of decisions. And it worked.

As the second chapter opens, Gawande relates a story of a different kind of catastrophe. On October 30, 1935, Boeing was about to land a lucrative deal with the Army Air Corps to build the next generation long-range bomber for the U.S. Military. Although there was nominally a competition for the contract, Boeing was expected to be a shoe-in with its Model 299. The plane crashed almost immediately after take-off, killing the pilot and another crew member. The Air Corps chose the Douglas entry and declared the larger Boeing model “too much airplane” for one person to fly.

Although Boeing nearly went bankrupt over the event, a group of test pilots got together to solve the problem of “too much airplane.” What they came up with was a checklist for the pilot to use so he wouldn’t leave out any crucial steps in getting the craft airborne. The Boeing Model 299, renamed the B-17, went on to play a major role in the second world war.

According to Gawande, many industries are now “too much airplane for one person to fly.” Complexity has increased far beyond what even the most extensive training can prepare any one person to cope with on their own. Gawande uses a construction site for a high rise commercial building to show how the building industry has evolved from the “Master Builder” age, where one person was responsible for the design of a project and then personally oversaw the execution of all aspects of it, to a coordinated group effort requiring the expertise of many specialists. And he points to medicine as an example of a field still trying to make the “Master Builder” model work.

When a delegate from the World Health Organization (WHO) asked Gawande for his help in devising a way to make surgeries safer in developing nations, he at first didn’t see how it could be done. He had, by that time, seen that checklists could help reduce mistakes in some medical procedures, but considered surgery to have too many variables for a checklist to take into account. The checklist would be inconveniently long, or too vague, and would ultimately waste time. Still, he saw more instances where use of checklists in hospitals was lowering the incidence of surgical complications. Fewer complications saved lives, got patients home from the hospital sooner, and saved everyone money. Gawande decided to get his team together and try again to develop a workable checklist. The results of their efforts I’ll leave for you to discover. I’m sure you won’t be disappointed.