College level writing response(200-300 words)

College level writing response(200-300 words)

31915_ch00.i-v.qxd 2/1/08 3:06 PM Page i ‘A searing, deeply humane collection of essays about medical practice that has all the makings of a modern classic’ Sunday Times ‘Rich in fascinating detail … as engaging to the layman as to the practising or studying doctor’ Economist ‘Reading him is rewarding’ TLS ‘An introspective, enthusiastic, gifted and thoughtful storyteller … A brilliant diagnosis of medicine’s ills’ British Medical Journal ‘A fascinating study’ Irish Tatler ‘Gawande is an accomplished author and doesn’t shy away from hot topics like malpractice, while his writing is clear and refreshingly free from off-putting medical jargon.’ Sunday Tribune ‘Riveting’ Irish Examiner Atul Gawande is one of the world’s most distinguished doctors. A 2006 MacArthur Fellow, he is a general surgeon at the Brigham and Women’s Hospital in Boston, a staff writer for the New Yorker, an associate professor at Harvard Medical School and the bestselling author of Complications: A Surgeon’s Notes on an Imperfect Science, also published by Profile. He lives with his wife and children in Newton, Massachusetts. 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page ii a l s o b y At u l G awa n d e Complications: A Surgeon’s Notes on an Imperfect Science 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page iii Better 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page iv Better A S u r g e o n ’ s N ot e s o n Pe r f o r m a n c e 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page v Atul Gawande 31915_ch00.vi-xii.qxd 5/2/08 11:06 Page vi This paperback edition published in 2008 First published in Great Britain in 2007 by PROFILE BOOKS LTD 3A Exmouth House Pine Street London EC1R 0JH www.profilebooks.com First published in the United States of America in 2007 by Metropolitan Books Copyright © Atul Gawande, 2007, 2008 Several of these chapters have appeared, in different form, in the New Yorker and the New England Journal of Medicine 1 3 5 7 9 10 8 6 4 2 Designed by Meryl Sussman Lavavi Printed and bound in Great Britain by Bookmarque, Croydon, Surrey The moral right of the author has been asserted. All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of both the copyright owner and the publisher of this book. A CIP catalogue record for this book is available from the British Library. ISBN 978 1 86197 657 4 This book is printed on FSC certified paper Cert no. TT-COC-002227 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page vii For my parents and sister 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page viii 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page ix Contents Introduction 1 Part I Diligence 11 On Washing Hands The Mop-Up 29 Casualties of War Part II Doing Right Naked 73 What Doctors Owe Piecework 112 13 51 71 84 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page x The Doctors of the Death Chamber On Fighting 154 Part III Ingenuity 167 The Score 169 The Bell Curve 201 For Performance 231 Afterword: S uggestions for B ecoming a P ositive D eviant Notes on Sources Acknowledgments 259 271 249 130 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page xi Better 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page xii 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 1 Introduction S everal years ago, in my final year of medical school, I took care of a patient who has stuck in my mind. I was on an internal medicine rotation, my last rotation before graduating. The senior resident had assigned me primary responsibility for three or four patients. One was a wrinkled, seventy-something-year-old Portuguese woman who had been admitted because—I’ll use the technical term here—she didn’t feel too good. Her body ached. She had become tired all the time. She had a cough. She had no fever. Her pulse and blood pressure were fine. But some laboratory tests revealed her white blood cell count was abnormally high. A chest X-ray showed a possible pneumonia—maybe it was, maybe it wasn’t. So her

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internist admitted her to the hospital, and now she was 31915_ch01.001-275.qxd 2 2/1/08 3:06 PM Page 2 Better under my care. I took sputum and blood cultures and, following the internist’s instructions, started her on an antibiotic for this possible pneumonia. I went to see her twice each day for the next several days. I checked her vital signs, listened to her lungs, looked up her labs. Each day, she stayed more or less the same. She had a cough. She had no fever. She just didn’t feel good. We’d give her antibiotics and wait her out, I figured. She’d be fine. One morning on seven o’clock rounds, she complained of insomnia and having sweats overnight. We checked the vitals sheets. She still had no fever. Her blood pressure was normal. Her heart rate was running maybe slightly faster than before. But that was all. Keep a close eye on her, the senior resident told me. Of course, I said, though nothing we’d seen seemed remarkably different from previous mornings. I made a silent plan to see her at midday, around lunchtime. The senior resident, however, went back to check on her himself twice that morning. It is this little act that I have often thought about since. It was a small thing, a tiny act of conscientiousness. He had seen something about her that worried him. He had also taken the measure of me on morning rounds. And what he saw was a fourth-year student, with a residency spot already lined up in general surgery, on his last rotation of medical school. Did he trust me? No, he did not. So he checked on her himself. That was not a two-second matter, either. She was up on the fourteenth floor of the hospital. Our morning teaching conferences, the cafeteria, all the other places we had to be that day were on the bottom two floors. The elevators were notoriously slow. The senior resident was supposed to run one 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 3 Introduction 3 of those teaching conferences. He could have waited for a nurse to let him know if a problem arose, as most doctors would. He could have told a junior resident to see the patient. But he didn’t. He made himself go up. The first time he did, he found she had a fever of 102 degrees and needed the oxygen flow through her nasal prongs increased. The second time, he found her blood pressure had dropped and the nurses had switched her oxygen to a face mask, and he transferred her to the intensive care unit. By the time I had a clue about what was going on, he already had her under treatment—with new antibiotics, intravenous fluids, medications to support her blood pressure—for what was developing into septic shock from a resistant, fulminant pneumonia. Because he checked on her, she survived. Indeed, because he did, her course was beautiful. She never needed to be put on a ventilator. The fevers stopped in twenty-four hours. She got home in three days. What does it take to be good at something in which failure is so easy, so effortless? When I was a student and then a resident, my deepest concern was to become competent. But what that senior resident had displayed that day was more than competence—he grasped not just how a pneumonia generally evolves and is properly treated but also the particulars of how to catch and fight one in that specific patient, in that specific moment, with the specific resources and people he had at hand. People often look to great athletes for lessons about performance. And for a surgeon like me, athletes do indeed have 31915_ch01.001-275.qxd 4 2/1/08 3:06 PM Page 4 Better lessons to teach—about the value of perseverance, of hard work and practice, of precision. But success in medicine has dimensions that cannot be found on a playing field. For one, lives are on the line. Our decisions and omissions are therefore moral in nature. We also face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshaling hundreds of people—from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working—for the care of a single person. We are also expected to do our work humanely, with gentleness and concern. It’s not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling. Recently, I took care of a patient with breast cancer. Virginia Magboo was sixty-four years old, an English teacher, and she’d noticed a pebblelike 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 anesthesiologist double-checked that it was safe 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 5 Introduction 5 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 at least six hours and had her open her mouth to note any loose teeth that could fall out or dentures that should be removed. A nurse checked the patient’s name band to make sure we had the right person; verified her drug allergies with her, confirmed that the procedure listed on her consent form was the one she expected. The nurse also looked for contact lenses that shouldn’t be left in and for jewelry that could constrict a finger or snag on something. I made a mark with a felt-tip pen over the precise spot where Magboo felt the lump, so there would be no mistaking the correct location. Early in the morning before her surgery, she had also had a small amount of radioactive tracer injected near her breast lump, in preparation for the sentinel lymph node biopsy. I now used a handheld Geiger counter to locate where the tracer had flowed, and confirmed that the counts were strong enough to indicate which lymph node was the “hot” one that needed to be excised. 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. There is a sticker on the surgical instrument kit that turns brown if the kit has been heat-sterilized and they confirmed that the sticker had turned. A technician removed the electrocautery machine and replaced it with another one after a question was raised about how it was functioning. Everything was checked and cross-checked. Magboo and the team were ready. By two o’clock I had finished with the procedures for my 31915_ch01.001-275.qxd 6 2/1/08 3:06 PM Page 6 Better 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 preoperative holding area, and apologized. 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 available 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. 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 7 Introduction 7 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 canceled,” 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 anesthesiologist 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 patient 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 canceled 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. * * * 31915_ch01.001-275.qxd 8 2/1/08 3:06 PM Page 8 Better This is a book about performance in medicine. As a doctor, you go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with people. But it is not, you soon find out. In medicine, as in any profession, we must grapple with systems, resources, circumstances, people—and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve. How we have and how we do is my subject here. The sections of this book examine three core requirements for success in medicine—or in any endeavor that involves risk and responsibility. The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles. Diligence seems an easy and minor virtue. (You just pay attention, right?) But it is neither. Diligence is both central to performance and fiendishly hard, as I show through three stories: one about the effort to ensure doctors and nurses simply wash their hands; one about the care of the wounded soldiers in Iraq and Afghanistan; and one about the Herculean effort to eradicate polio from the globe. The second challenge is to do right. Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding. In this section I consider some of our most uncomfortable questions—such as how much doctors should be paid, and what we owe patients when we make mistakes. I tell the stories of four doctors and a nurse who have gone against medical ethics codes and participated in executions of 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 9 Introduction 9 prisoners. I puzzle over how we know when we should keep fighting for a sick patient and when we should stop. The third requirement for success is ingenuity—thinking anew. Ingenuity is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions. These are difficult traits to foster—but they are far from impossible ones. Here I tell the stories of people in everyday medicine who have, through ingenuity, transformed medical care—for example, the way babies are delivered and the way an incurable disease like cystic fibrosis is fought—and I examine how more of us can do the same. Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only humans ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one’s life is bound up in others’ and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question, then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well. Virginia Magboo lay waiting, anxious and hungry, in a windowless, silent, white-lit holding area for still two hours more. 31915_ch01.001-275.qxd 10 2/1/08 3:06 PM Page 10 Better The minutes ticked, ticked, ticked. At times, in medicine, you feel you are inside a colossal and impossibly complex machine whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to do better for people, might make a difference can seem hopelessly naïve. But it isn’t. Magboo asked me if there was any real prospect of her having her operation that night. The likelihood, I said, had become exceedingly small. But I couldn’t bring myself to send her home, and I asked her to hang on with me. Then, just before eight o’clock, I got a text message on my pager. “We can bring your patient back to room 29,” the display read. Two nurses, it turned out, had seen how backed up the ORs had gotten and, although they could easily have gone home, they volunteered to stay late. “I didn’t really have anything else going on anyway,” one demurred when I spoke to her. When you make an effort, you find sometimes you are not the only one willing to do so. Eleven minutes after I got the page, Magboo was on the operating table, a sedative going into her arm. Her skin was cleansed. Her body was draped. The breast cancer came out without difficulty. Her lymph nodes proved to be free of metastasis. And she was done. She woke up calmly as we put on the dressing. I saw her gazing upward at the operating light above her. “The light looks like seashells,” she said. 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 11 Part I Diligence 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 12 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 13 On Washing Hands O ne ordinary December day, I took a tour of my hospital with Deborah Yokoe, an infectious disease specialist, and Susan Marino, a microbiologist. They work in our hospital’s infection-control unit. Their full-time job, and that of three others in the unit, is to stop the spread of infection in the hospital. This is not flashy work, and they are not flashy people. Yokoe is forty-five years old, gentle voiced, and dimpled. She wears sneakers at work. Marino is in her fifties and reserved by nature. But they have coped with influenza epidemics, Legionnaires’ disease, fatal bacterial meningitis, and, just a few months before, a case that, according to the patient’s brain-biopsy results, might have been CreutzfeldJakob disease—a nightmare, not only because it is incurable 31915_ch01.001-275.qxd 14 2/1/08 3:06 PM Page 14 Better and fatal but also because the infectious agent that causes it, known as a prion, cannot be killed by usual heat-sterilization procedures. By the time the results came back, the neurosurgeon’s brain-biopsy instruments might have transferred the disease to other patients, but infection-control team members tracked the instruments down in time and had them chemically sterilized. Yokoe and Marino have seen measles, the plague, and rabbit fever (which is caused by a bacterium that is extraordinarily contagious in hospital laboratories and feared as a bioterrorist weapon). They once instigated a nationwide recall of frozen strawberries, having traced a hepatitis A outbreak to a batch served at an ice cream social. Recently at large in the hospital, they told me, have been a rotavirus, a Norwalk virus, several strains of Pseudomonas bacteria, a superresistant Klebsiella, and the ubiquitous scourges of modern hospitals— resistant Staphylococcus aureus and Enterococcus faecalis, which are a frequent cause of pneumonias, wound infections, and bloodstream infections. Each year, according to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection. The hardest part of the infection-control team’s job, Yokoe says, is not coping with the variety of contagions they encounter or the panic that sometimes occurs among patients and staff. Instead, their greatest difficulty is getting clinicians like me to do the one thing that consistently halts the spread of infections: wash our hands. There isn’t much they haven’t tried. Walking about the surgical floors where I admit my patients, Yokoe and Marino showed me the admonishing signs they have posted, the sinks 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 15 On Washing Hands 15 they have repositioned, the new ones they have installed. They have made some sinks automated. They have bought special five-thousand-dollar “precaution carts” that store everything for washing up, gloving, and gowning in one ergonomic, portable, and aesthetically pleasing package. They have given away free movie tickets to the hospital units with the best compliance. They have issued hygiene report cards. Yet still, we have not mended our ways. Our hospital’s statistics show what studies everywhere else have shown—that we doctors and nurses wash our hands one-third to one-half as often as we are supposed to. Having shaken hands with a sniffling patient, pulled a sticky dressing off someone’s wound, pressed a stethoscope against a sweating chest, most of us do little more than wipe our hands on our white coats and move on—to see the next patient, to scribble a note in the chart, to grab some lunch. This is, embarassingly, nothing new. In 1847, at the age of twenty-eight, the Viennese obstetrician Ignac Semmelweis famously deduced that, by not washing their hands consistently or well enough, doctors were themselves to blame for childbed fever. Childbed fever, also known as puerperal fever, was the leading cause of maternal death in childbirth in the era before antibiotics (and before the recognition that germs are the agents of infectious disease). It is a bacterial infection— most commonly caused by Streptococcus, the same bacteria that causes strep throat—that ascends through the vagina to the uterus after childbirth. Out of three thousand mothers who delivered babies at the hospital where Semmelweis worked, six hundred or more died of the disease each year—a horrifying 20 percent maternal death rate. Of mothers delivering at 31915_ch01.001-275.qxd 16 2/1/08 3:06 PM Page 16 Better home, only 1 percent died. Semmelweis concluded that doctors themselves were carrying the disease between patients, and he mandated that every doctor and nurse on his ward scrub with a nail brush and chlorine between patients. The puerperal death rate immediately fell to 1 percent—incontrovertible proof, it would seem, that he was right. Yet elsewhere, doctors’ practices did not change. Some colleagues were even offended by his claims; it was impossible to them that doctors could be killing their patients. Far from being hailed, Semmelweis was ultimately dismissed from his job. Semmelweis’s story has come down to us as Exhibit A in the case for the obstinacy and blindness of physicians. But the story was more complicated. The trouble was partly that nineteenth-century physicians faced multiple, seemingly equally powerful explanations for puerperal fever. There was, for example, a strong belief that miasmas of the air in hospitals were the cause. And Semmelweis strangely refused to either publish an explanation of the logic behind his theory or prove it with a convincing experiment in animals. Instead, he took the calls for proof as a personal insult and attacked his detractors viciously. “You, Herr Professor, have been a partner in this massacre,” he wrote to one University of Vienna obstetrician who questioned his theory. To a colleague in Wurzburg he wrote, “Should you, Herr Hofrath, without having disproved my doctrine, continue to teach your pupils [against it], I declare before God and the world that you are a murderer and the ‘History of Childbed Fever’ would not be unjust to you if it memorialized you as a medical Nero.” His own staff turned against him. In Pest, where he relocated after losing his post in 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 17 On Washing Hands 17 Vienna, he would stand next to the sink and berate anyone who forgot to scrub his or her hands. People began to purposely evade, sometimes even sabotage, his hand-washing regimen. Semmelweis was a genius, but he was also a lunatic, and that made him a failed genius. It was another twenty years before Joseph Lister offered his clearer, more persuasive, and more respectful plea for antisepsis in surgery in the British medical journal Lancet. One hundred and forty years of doctors’ plagues later, however, you have to wonder whether what’s needed to stop them is precisely a lunatic. Consider what Yokoe and Marino are up against. No part of human skin is spared from bacteria. Bacterial counts on the hands range from five thousand to five million colony-forming units per square centimeter. The hair, underarms, and groin harbor greater concentrations. On the hands, deep skin crevices trap 10 to 20 percent of the flora, making removal difficult, even with scrubbing, and sterilization impossible. The worst place is under the fingernails. Hence the recent CDC guidelines requiring hospital personnel to keep their nails trimmed to less than a quarter of an inch and to remove artificial nails. Plain soaps do, at best, a middling job of disinfecting. Their detergents remove loose dirt and grime, but fifteen seconds of washing reduces bacterial counts by only about an order of magnitude. Semmelweis recognized that ordinary soap was not enough and used a chlorine solution to achieve disinfection. Today’s antibacterial soaps contain chemicals such as chlorhexidine to disrupt microbial membranes and proteins. Even with the right soap, however, proper hand washing requires a strict procedure. First, you must remove your watch, 31915_ch01.001-275.qxd 18 2/1/08 3:06 PM Page 18 Better rings, and other jewelry (which are notorious for trapping bacteria). Next, you wet your hands in warm tap water. Dispense the soap and lather all surfaces, including the lower one-third of the arms, for the full duration recommended by the manufacturer (usually fifteen to thirty seconds). Rinse off for thirty full seconds. Dry completely with a clean, disposable towel. Then use the towel to turn the tap off. Repeat after any new contact with a patient. Almost no one adheres to this procedure. It seems impossible. On morning rounds, our residents check in on twenty patients in an hour. The nurses in our intensive care units typically have a similar number of contacts with patients requiring hand washing in between. Even if you get the whole cleansing process down to a minute per patient, that’s still a third of staff time spent just washing hands. Such frequent hand washing can also irritate the skin, which can produce a dermatitis, which itself increases bacterial counts. Less irritating than soap, alcohol rinses and gels have been in use in Europe for almost two decades but for some reason only recently caught on in the United States. They take far less time to use—only about fifteen seconds or so to rub a gel over the hands and fingers and let it air-dry. Dispensers can be put at the bedside more easily than a sink. And at alcohol concentrations of 50 to 95 percent, they are more effective at killing organisms, too. (Interestingly, pure alcohol is not as effective—at least some water is required to denature microbial proteins.) Still, it took Yokoe over a year to get our staff to accept the 60 percent alcohol gel we have recently adopted. Its introduction was first blocked because of the staff ’s fears that it 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 19 On Washing Hands 19 would produce noxious building air. (It didn’t.) Next came worries that, despite evidence to the contrary, it would be more irritating to the skin. So a product with aloe was brought in. People complained about the smell. So the aloe was taken out. Then some of the nursing staff refused to use the gel after rumors spread that it would reduce fertility. The rumors died only after the infection-control unit circulated evidence that the alcohol is not systemically absorbed and a hospital fertility specialist endorsed the use of the gel. With the gel finally in wide use, the compliance rates for proper hand hygiene improved substantially: from around 40 percent to 70 percent. But—and this is the troubling finding— hospital infection rates did not drop one iota. Our 70 percent compliance just wasn’t good enough. If 30 percent of the time people didn’t wash their hands, that still left plenty of opportunity to keep transmitting infections. Indeed, the rates of resistant Staphylococcus and Enterococcus infections continued to rise. Yokoe receives the daily tabulations. I checked with her one day not long ago, and sixty-three of our seven hundred hospital patients were colonized or infected with MRSA (the shorthand for methicillin-resistant Staphylococcus aureus) and another twenty-two had acquired VRE (vancomycin-resistant Enterococcus)—unfortunately, typical rates of infection for American hospitals. Rising infection rates from superresistant bacteria have become the norm around the world. The first outbreak of VRE did not occur until 1988, when a renal dialysis unit in England became infested. By 1990, the bacteria had been carried abroad, and four in one thousand American ICU patients had become infected. By 1997, a stunning 23 percent of ICU pa- 31915_ch01.001-275.qxd 20 2/1/08 3:06 PM Page 20 Better tients were infected. When the virus for SARS—severe acute respiratory syndrome—appeared in China in 2003 and spread within weeks to almost ten thousand people in two dozen countries across the world (10 percent of whom were killed), the primary vector for transmission was the hands of health care workers. What will happen if (or rather, when) an even more dangerous organism appears—avian flu, say, or a new, more virulent bacteria? “It will be a disaster,” Yokoe says. Anything short of a Semmelweis-like obsession with hand washing has begun to seem inadequate. Yokoe, Marino, and their colleagues have now resorted to doing random spot checks on the floors. On a surgical intensive care unit, they showed me what they do. They walk in unannounced. They go directly into patients’ rooms. They check for unattended spills, toilets that have not been cleaned, faucets that drip, empty gel dispensers, overflowing needle boxes, inadequate supplies of gloves and gowns. They check whether the nurses are wearing gloves when they handle patients’ wound dressings and catheters, which are ready portals for infection. And of course, they watch to see whether everyone is washing up before patient contact. Neither hesitates to confront people, though they try to be gentle about it. (“Did you forget to gel your hands?” is a favored line.) Staff members have come to recognize them. I watched a gloved and gowned nurse come out of a patient’s room, pick up the patient’s chart (which is not supposed to be touched by dirty hands), see Marino, and immediately stop short. “I didn’t touch anything in the room! I’m clean!” she blurted out. Yokoe and Marino hate this aspect of the job. They don’t want to be infection cops. It’s no fun, and it’s not necessarily 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 21 On Washing Hands 21 effective, either. With twelve patient floors and four different patient pods per floor, they can’t stand watch the way Semmelweis did, scowling over the lone sink on his unit. And they risk having the staff revolt as his staff did against him. But what other options remain? I flipped through back issues of the Journal of Hospital Infection and Infection Control and Hospital Epidemiology, two leading journals in the field, and the articles are a sad litany of failed experiments to change our contaminating ways. The great hoped-for solution has been a soap or a hand rinse that would keep skin disinfected for hours and make it easy for all of us to be good. But none has been found. The situation has prompted one expert to propose—only half jokingly—that the best approach may be to give up on hand washing and get people to stop touching patients altogether. We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right—one after the other, no slipups, no goofs, everyone pitching in. We are used to thinking of doctoring as a solitary, intellectual task. But making medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands. It is striking to consider how different the history of the operating room after Lister has been from that of the hospital floor after Semmelweis. In the operating room, no one pretends that even 90 percent compliance with scrubbing is good enough. If a single doctor or nurse fails to wash up before coming to the operating table, we are horrified—and certainly not shocked if the patient develops an infection a few days later. Since Lister we have gone even further in our expectations. 31915_ch01.001-275.qxd 22 2/1/08 3:06 PM Page 22 Better We now make sure to use sterile gloves and gowns, masks over our mouths, caps over our hair. We apply antiseptics to the patient’s skin and lay down sterile drapes. We put our instruments through steam heat sterilizers or, if any are too delicate to tolerate the autoclave, through chemical sterilizers. We have reinvented almost every detail of the operating room for the sake of antisepsis. We have gone so far as to add an extra person to the team, known as the circulating nurse, whose central job is, essentially, to keep the team antiseptic. Every time an unanticipated instrument is needed for a patient, the team can’t stand around waiting for one member to break scrub, pull the thing off a shelf, wash up, and return. So the circulator was invented. Circulators get the extra sponges and instruments, handle the telephone calls, do the paperwork, get help when it’s needed. And every time they do, they’re not just making the case go more smoothly. They are keeping the patient uninfected. By their very existence, they make sterility a priority in every case. Stopping the epidemics spreading in our hospitals is not a problem of ignorance—of not having the know-how about what to do. It is a problem of compliance—a failure of an individual to apply that know-how correctly. But achieving compliance is hard. Why, after 140 years, the meticulousness of the operating room has not spread beyond its double doors is a mystery. But the people who are most careful in the surgical theater are frequently the very ones who are least careful on the hospital ward. I know because I have realized I am one of them. I generally try to be as scrupulous about washing my hands when I am outside the operating room as I am inside. And I do pretty well, if I say so myself. But then I blow it. It 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 23 On Washing Hands 23 happens almost every day. I walk into a patient’s hospital room, and I’m thinking about what I have to tell him concerning his operation, or about his family, who might be standing there looking worried, or about the funny little joke a resident just told me, and I completely forget about getting a squirt of that gel into my palms, no matter how many laminated reminder signs have been hung on the walls. Sometimes I do remember, but before I can find the dispenser, the patient puts his hand out in greeting and I think it too strange not to go ahead and take it. On occasion I even think, Screw it—I’m late, I have to get a move on, and what difference does it really make what I do this one time? A few years ago, Paul O’Neill, the former secretary of the Treasury and CEO of the aluminum giant Alcoa, agreed to take over as head of a regional health care initiative in Pittsburgh, Pennsylvania. And he made solving the problem of hospital infections one of his top priorities. To show it could be solved, he arranged for a young industrial engineer named Peter Perreiah to be put on a single forty-bed surgical unit at a Pittsburgh veterans hospital. When he met with the unit’s staff, a doctor who worked on the project told me, “Peter didn’t ask, ‘Why don’t you wash your hands?’ He asked, ‘Why can’t you?’ ” By far the most common answer was time. So, as an engineer, he went about fixing the things that burned up the staff ’s time. He came up with a just-in-time supply system that kept not only gowns and gloves at the bedside but also gauze and tape and other things the staff needed, so they didn’t have to go back and forth out of the room to search for them. Rather than make everyone clean their stethoscopes, notorious carriers of infection, between patients, he arranged 31915_ch01.001-275.qxd 24 2/1/08 3:06 PM Page 24 Better for each patient room to have a designated stethoscope on the wall. He helped make dozens of simplifying changes that reduced both the opportunities for spread of infection and the difficulties of staying clean. He made each hospital room work more like an operating room, in other words. He also arranged for a nasal culture to be taken from every patient upon admission, whether the patient seemed infected or not. That way the staff knew which patients carried resistant bacteria and could preemptively use more stringent precautions for them— “search-and-destroy” the strategy is sometimes called. Infection rates for MRSA—the hospital contagion responsible for more deaths than any other—fell almost 90 percent, from four to six infections per month to about that many in an entire year. Two years later, however, despite encouragement and exhortation, the ideas had spread to only one other unit in the hospital. Those other units didn’t have Perreiah. And when he left the original unit for a different project elsewhere, performance on that unit began to slide, too. O’Neill quit as head of the health care initiative in frustration with its lack of progress. Nothing fundamental had changed. The belief that something could change did not die, however. Jon Lloyd, a surgeon who had helped Perreiah on the project, continued to puzzle over what to do, and he happened across an article about a Save the Children program to reduce malnutrition in Vietnam. The story seemed to Lloyd to have a lesson for Pittsburgh. The antistarvation program, run by Tufts University nutritionist Jerry Sternin and his wife, Monique, had given up on bringing outside solutions to villages with malnourished children. Over and over, that strategy had failed. Although the know-how to reduce malnutrition 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 25 On Washing Hands 25 was long established—methods to raise more nourishing foods and more effectively feed hungry children—most people proved reluctant to change such fundamental matters as what they fed their children and when just because outsiders said so. The Sternins therefore focused on finding solutions from insiders. They asked small groups of poor villagers to identify who among them had the best-nourished children—who among them had demonstrated what the Sternins termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing. Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea, for example; giving them several small feedings each day rather than one or two big ones; adding sweet potato greens to the children’s rice despite its being considered a low-class food. And the ideas began to spread. They took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped 65 to 85 percent in every village the Sternins had been to. Lloyd was bitten by the positive deviance idea—the idea of building on capabilities people already had rather than telling them how they had to change. By March 2005, he and Perreiah persuaded the veterans hospital leadership in Pittsburgh to try the positive deviance approach with hospital infections. Lloyd even convinced the Sternins to join in. Together they held a series of thirty-minute, small group discussions with health care workers at every level: food service 31915_ch01.001-275.qxd 26 2/1/08 3:06 PM Page 26 Better workers, janitors, nurses, doctors, patients themselves. The team began each meeting saying, in essence, “We’re here because of the hospital infection problem and we want to know what you know about how to solve it.” There were no directives, no charts with what the experts thought should be done. “If we had any dogma going in,” Jerry Sternin says, “it was: Thou shalt not try to fix anything.” Ideas came pouring out. People told of places where hand-gel dispensers were missing, ways to keep gowns and gloves from running out of supply, nurses who always seemed able to wash their hands and even taught patients to wash their hands, too. Many people said it was the first time anyone had ever asked them what to do. The norms began to shift. When forty new hand-gel dispensers arrived, staff members took charge of putting them up in the right places. Nurses who would never speak up when a doctor failed to wash his or her hands began to do so after learning of other nurses who did. Eight therapists who thought wearing gloves with patients was silly were persuaded by two of their colleagues that it was no big deal. The ideas were not terribly new. “After the eighth group, we began to hear the same things over and over,” Sternin says. “But we kept going even if it was group number thirty-three for us, because it was the first time those people had been heard, the first time they had a chance to innovate for themselves.” The team made sure to publicize the ideas and the small victories on the hospital Web site and in newsletters. The team also carried out detailed surveillance—taking nasal cultures from every hospital patient upon admission and upon discharge. They posted the monthly results unit by unit. One 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 27 On Washing Hands 27 year into the experiment—and after years without widespread progress—the entire hospital saw its MRSA wound infection rates drop to zero. The Robert Wood Johnson Foundation and the Jewish Healthcare Foundation recently launched a multimilliondollar initiative to implement this approach in ten more hospitals across the country. Lloyd cautions that it remains to be seen whether the Pittsburgh results will last. It also remains to be seen if the success can be duplicated nationally. But nothing else has worked, and this is the most fascinating idea anyone has had to solve the problem in a century. At one point during my tour with Yokoe and Marino, we walked through a regular hospital unit. And I finally began to see the ward the way they do. Flowing in and out of the patients’ rooms were physical therapists, patient care assistants, nurses, nutritionists, residents, students. Some were good about washing. Some were not. Yokoe pointed out that three of the eight rooms had bright yellow precaution signs because of patients inside with MRSA or VRE. Only then did I realize we were on the floor of one of my own patients. One of those signs hung on his door. He was sixty-two years old and had been in the hospital for almost three weeks. He had arrived in shock from another hospital, where an operation had gone awry. I performed an emergency splenectomy for him and then had to go back in again when the bleeding still didn’t stop. He had an open abdominal wound and could not eat. He had to receive his nutrition intravenously. He was recovering, though. 31915_ch01.001-275.qxd 28 2/1/08 3:06 PM Page 28 Better Three days after admission, he was out of the intensive care unit. Initial surveillance cultures were completely negative for resistant organisms. New cultures ten days after admission, however, came back positive for both MRSA and VRE. A few days after that, he developed fevers up to 102 degrees. His blood pressure began dropping. His heart rate climbed. He was septic. His central line—his lifeline for nutrition—had become infected, and we had to take it out. Until that moment, when I stood there looking at the sign on his door, it had not occurred to me that I might have given him that infection. But the truth is I may have. One of us certainly did. 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 29 The Mop-Up P eople underestimate the importance of diligence as a virtue. No doubt this has something to do with how supremely mundane it seems. It is defined as “the constant and earnest effort to accomplish what is undertaken.” There is a flavor of simplistic relentlessness to it. And if it were an individual’s primary goal in life, that life would indeed seem narrow and unambitious. Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible, expectation for performance and human behavior. Yet some in medicine have delivered on that expectation on an almost 31915_ch01.001-275.qxd 30 2/1/08 3:06 PM Page 30 Better unimaginable scale. The campaign to eradicate polio in India is just such an instance. The index case was an eleven-month-old boy with thick black hair his mother liked to comb forward so that the bangs rimmed his round face. His family lives in the southern Indian state of Karnataka, in a village called Upparahalla, along the Tungabhadra River. Dry mountains of teetering rocks can be seen in three directions from the village. It has no running water and little electricity. The boy’s mother is illiterate; the father can read only road signs. They are farm laborers, and they live with their three children in a single-room hut of thatch and mud. But the children are well nourished. The mother wears gold and silver earrings. Once in a while, they travel. In April 2003, the family took a trip north to see relatives. Shortly after they returned, on May 1, the boy developed high fevers and racking bouts of nausea and vomiting. His parents took him to a nearby clinic, where a doctor gave him an antibiotic injection. Two days later, the fevers subsided, but he became unable to move either of his legs. In a panic, the parents took him back to the doctor, who sent him to the district hospital in Bellary, about forty miles away. As the day progressed, the weakness spread through the boy’s body. His breathing grew shallow and labored. He lay flat and motionless on his hospital cot. A doctor at the hospital, following standard procedure in cases of sudden childhood paralysis, phoned a surveillance medical officer with the World Health Organization in Bangalore, the capital of Karnataka. The medical officer made sure 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 31 The Mop-Up 31 that stool specimens were taken and sent for culture to a national laboratory in Mumbai (as Bombay is now called). On June 24, the laboratory results finally came back. A young technical officer with WHO in New Delhi got the call; it was a confirmed case of polio, a disease thought to have been eliminated from southern India, and it set off an alarm. The World Health Organization is nearly two decades into its campaign to eradicate polio from the world. If the campaign succeeds, it may be mankind’s single most ambitious accomplishment. But this is a big if. International organizations are fond of grand-sounding pledges to rid the planet of this or that menace. They nearly always fail, however. The world is too vast and too various to submit to dictates from on high. Consider the other attempts that have been made to eliminate individual diseases. In 1909, the newly established Rockefeller Foundation launched the first global eradication campaign, an effort to end hookworm disease, using antihelminthic drugs, in fifty-two countries. It didn’t work. Today, a billion people—a sixth of the world’s population—are infected with hookworm, an intestinal parasite that feeds on human blood. A seventeen-year campaign against yellow fever, led by the Rockefeller Foundation and the United States armed services, had to be abandoned in 1932 when yellow fever was found to have a reservoir outside human beings. (The yellow fever virus persists in mosquitoes’ eggs.) In 1955, WHO and UNICEF began a campaign to end yaws, an infectious disease that causes painful, purulent skin ulcers; workers screened 160 million people in sixty-one countries for the disease and treated every case they found with penicillin. A 31915_ch01.001-275.qxd 32 2/1/08 3:06 PM Page 32 Better dozen years later, the campaign was dropped when it turned out that silent, subclinical infections were continuing to propagate the disease. Billions of dollars were spent in the fifties and sixties to eradicate malaria; today the disease afflicts more than 300 million people a year. After a century of effort, the only successful attempt at eradication of a global disease has been the battle against smallpox—a mammoth undertaking that was, just the same, decidedly simpler than the campaign against polio. Smallpox, with its distinctive blisters and vesicles, could be readily and quickly identified; the moment a case appeared, a team could be dispatched to immunize everyone the victim might have come into contact with. That strategy, known as “ring immunization,” eradicated the disease by 1979. Polio infections are far harder to identify. For every person who is paralyzed, between two hundred and a thousand infected people come down with little more than a stomach flu—and they remain silently contagious for several weeks after the symptoms abate. Nor is every case of childhood paralysis polio, and it usually takes weeks for stool specimens to be obtained, delivered to a laboratory, and properly tested for the disease. By the time one case has been identified, scores more people have been infected. As a result, the area targeted for polio immunization must be far larger than that for smallpox. And whereas people needed to be vaccinated against smallpox only once for immediate protection, a single dose of polio vaccine does not always take—children with diarrheal illnesses tend to pass the oral vaccine straight through. So a repeat round of immunization is required within four to six weeks. In logistical 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 33 The Mop-Up 33 terms, it’s the difference between extinguishing a candle flame and putting out a forest fire. Despite the obstacles, however, the campaign against polio has made immense progress. Routine vaccination had made polio uncommon in the West, but cases continued to occur in the United States, Canada, and Europe into the 1980s, and the disease remained endemic in large portions of the world. In 1988, more than 350,000 people developed paralytic polio, and at least 70 million were infected with the virus. By 2001, only 498 cases were identified. The whole of the Americas, Europe, and the western Pacific, along with nearly all of Africa and Asia, are currently free of the disease. In each year since 2001, however, just as the disease was on the verge of being wiped out, an outbreak has flared in some country in Asia or Africa, spilled across borders, and threatened to bring polio roaring back. In 2002, India was that country. Outbreaks in the north produced sixteen hundred polio cases. Four-fifths of all the world’s cases occurred there that year. Nonetheless, the belief was that the disease had been isolated to a handful of northern states. Then, in 2003, a boy in south India developed polio—the first case in the state of Karnataka in almost three years. If the disease expanded from there, the campaign would be all but over. On June 25, less than twenty-four hours after the report of the Karnataka polio case came in, Sunil Bahl, a WHO physician and technical officer in the Delhi office, sent an e-mail to key people at WHO, at UNICEF, and in the Indian government. It 31915_ch01.001-275.qxd 34 2/1/08 3:06 PM Page 34 Better was his job to provide the initial assessment of the facts on the ground. “The case is in an area that has a history of being the worst in Karnataka,” he wrote; it had poor routines of immunization and the most polio cases in the early years of the campaign. “Risk of establishment of virus in the area high, unless quick wide and strong measures in the form of a wide mop-up are taken.” A “mop-up” is WHO lingo for a targeted campaign to immunize all susceptible children surrounding a new case. It’s what is done in an area that has been rendered polio-free through routine immunization but is facing a new infection that threatens to bring the disease back. The campaigns are carried out rapidly, in just three days, to ensure that the vaccine saturates a population and to make it easier to recruit volunteers. Sunil Bahl sent around a map of the proposed area for the mop-up operation. It covered fifty thousand square miles. Working around the summer holidays and festivals, government officials selected July 27 for the start of the first immunization round. The second round would follow a month later. Brian Wheeler, a thirty-five-year-old Texan who was the chief operations officer for WHO’s polio program in India, explained the logistics to me. The Indian government would have to recruit and organize teams of medical workers and volunteers, he said. They would have to be trained in how to administer the vaccine and provided with transportation, vaccine, and insulated coolers and ice packs to keep the vaccine cold. And they would have to fan out and vaccinate every child under five years of age. Anything less than 90 percent coverage of the target population—the percentage 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 35 The Mop-Up 35 needed to shut down transmission—would be considered a failure. I asked him how many people that would involve. He checked his budget sheet. The plan, he said, was to employ thirty-seven thousand vaccinators and four thousand health care supervisors, rent two thousand vehicles, supply more than eighteen thousand insulated vaccine carriers, and have the workers go door to door to vaccinate 4.2 million children. In three days. Polio is a disease that strikes children almost exclusively— more than 80 percent of paralysis cases occur in children under age five. It is caused by an intestinal virus; the virus must be ingested to bring about an infection. Once inside the gut, it passes through the lining and takes up residence in nearby lymph nodes. There it multiplies, produces fevers and stomach upset, and passes back into the feces. Those infected can contaminate their clothing, bathing sites, and supplies of drinking water and thereby spread the disease. (The virus can survive as long as sixty days outside the body.) Poliovirus infects only a few kinds of nerve cells, but what it infects it destroys. In the most dreaded cases, the virus spreads from the bloodstream into the neurons of the brain stem, the cells that allow you to breathe and swallow. To stay alive, a person has to be fed through a tube and ventilated by machine. The nerve cells most commonly attacked, though, are the anterior horn cells of the spinal cord, which control the arms, the legs, and the abdominal muscles. Often, so 31915_ch01.001-275.qxd 36 2/1/08 3:06 PM Page 36 Better many neurons are destroyed that muscle function is eliminated altogether. Tendon reflexes disappear. Limbs hang limp and useless. The first effective vaccine for polio was introduced in 1955, after the largest clinical trial in history. ( Jonas Salk’s vaccine, made from killed poliovirus, was given to 440,000 children; 210,000 received a placebo injection, and more than a million served as unvaccinated controls.) Five years later, Albert Sabin published the results of an alternative polio vaccine he had used in an immunization campaign in Toluca, Mexico, a city of a hundred thousand people, where a polio outbreak was in progress. His was an oral vaccine, easier to administer than Salk’s injected one. It was also a live vaccine, containing weakened but intact poliovirus, and so it could produce not only immunity but also a mild contagious infection that would spread the immunity to others. In just four days, Sabin’s team managed to vaccinate more than 80 percent of the children under the age of eleven—26,000 children in all. It was a blitzkrieg assault. Within weeks, polio had disappeared from the city. This approach, Sabin argued, could be used to eliminate polio from entire countries, even the world. The only leader in the West who took him up on the idea was Fidel Castro. In 1962, Castro’s Committee for the Defense of the Revolution organized 82,366 local committees to carry out a succession of weeklong house-to-house national immunization campaigns using the Sabin vaccine. In 1963, only one case of polio occurred in Cuba. Despite those results, Sabin’s grand idea did not catch on until 1985, when the Pan American Health Organization 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 37 The Mop-Up 37 launched an initiative to eradicate polio from the Americas. (Six years later, Luis Fermin Tenorio, a two-year-old boy in the town of Pichinaki, Peru, became the last polio victim in the Americas.) In 1988, spurred by the campaign’s growing success, WHO committed itself to eradicating polio from the world. That year, Rotary International pledged a quarter of a billion dollars for the effort. (It has since provided 350 million dollars more.) UNICEF agreed to organize the worldwide production and distribution of vaccine. And the United States made the campaign one of the CDC’s core initiatives, supplying both expertise and considerable additional funding. The centerpiece of the effort has been what are called national immunization days—three-day periods when all children under five in a country are immunized, regardless of whether they have received immunization before. In one week in 1997, 250 million children were vaccinated simultaneously in China, India, Bhutan, Pakistan, Bangladesh, Thailand, Vietnam, and Burma. National immunization days have reached as many as half a billion children at one time—almost a tenth of the world’s population. Through such efforts—and a reliable network of monitors to detect outbreaks—the WHO campaign has brought the incidence of polio in the world to less than 1 percent of what it used to be. The striking thing is that WHO doesn’t really have the authority to do any of this. It can’t tell governments what to do. It hires no vaccinators, distributes no vaccine. It is a small Geneva bureaucracy run by several hundred international delegates whose annual votes tell the organization what to do but not how to do it. In India, a nation of a billion people, WHO employs 250 physicians around the country to work on polio 31915_ch01.001-275.qxd 38 2/1/08 3:06 PM Page 38 Better monitoring. The only substantial resource that WHO has cultivated is information and expertise. I didn’t understand how this could suffice. Then I went to Karnataka. For the three days of the mop-up, I traveled through Karnataka with Pankaj Bhatnagar, a WHO pediatrician whose job was to see that the operation was properly executed. He is in his forties, with a slight paunch and an easy, genial manner. The work can be a tricky business, he explained as we waited in Delhi for our flight south. WHO distributes much of the money for mop-up operations. UNICEF provides the vaccines. Rotary of India prints the banners and advocates locally for the cause. But the operation itself is run by people none of these organizations control: government health officials who must hire the thousands of vaccinators, train them properly, and send them from house to house. We took a plane to Bangalore, then traveled eight hours overnight by train to Bellary, a crowded, dusty town that is the district seat for Upparahalla. At a small, strange hotel there (it had a safari theme), Pankaj convened the members of his team over breakfast. To monitor the immunization of four million children, he had just four people: three young medical officers and himself. They were the only ones available who spoke Kanada, the local language. The medical officers finished their breakfast of idli and dosa and lit up cigarettes (in India, it seems, half the doctors who work in public health smoke), and then Pankaj asked for a status report. Since the index case was identified, he was told, four more cases of confirmed polio had appeared in the region, 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 39 The Mop-Up 39 including another child in Upparahalla, and four “hot” cases were awaiting confirmatory testing. Of the thirteen districts targeted for mop-ups, Bellary accounted for all but one of the cases. “Then we must concentrate our monitoring in this district,” Pankaj said. “This is now the place with the most intense transmission of polio in the world.” Another doctor pulled out some figures on the area. Bellary district, he told Pankaj, has a population of 2,965,459, with 542 villages and nine urban towns. Fifty-two percent of the males and 74 percent of the females are illiterate. There are just ninety-nine doctors in the district public health system. He turned to a map. The polio cases, he said, were clustered in a triangle of villages around Siriguppa, a small, slum-ridden town about forty miles away. Pankaj made his assignments. For the mop-up, he would check on progress in at least Upparahalla, a village called Sirigere where polio had appeared, the two urban areas with hot cases, and a mine in Chitradurga, where vaccinators might have particular difficulties gaining entry because the housing was on the property of a private company. He assigned the remaining villages to the others and asked them to follow up behind him for a second check in Upparahalla and the urban areas. The group then split up. By eight thirty in the morning, Pankaj and I were on the road. We had a rented four-wheel-drive Toyota and a betel-nutchewing driver who waited until we were an hour down a pitted road to tell us that the battery was dead. Whenever the 31915_ch01.001-275.qxd 40 2/1/08 3:06 PM Page 40 Better engine was turned off, he said, we’d need to push-start the car. Pankaj thought this was funny. The terrain outside the windows was baked by the hot sun, and the hills were desert-lizard brown. The monsoon had failed to come this year. Only the few fields that had drip irrigation looked green. It took us about two hours to travel the thirty-five miles to Sirigere, a village of mud-walled huts jammed up against one another. There was garbage in the alleyways, and dust-faced children were playing everywhere. Pankaj had the driver stop at a group of dwellings seemingly at random. Marked in chalk on each door was a number, a “P,” and that day’s date. The number was the house number. The “P” meant that the vaccinators had come, identified all the children under the age of five who lived in the house, and vaccinated them—that very day, according to the date marked. Pankaj took out a pad of paper and strode over to one of the huts. He asked the young woman at the door how many children lived there. One, she said. He asked to see the child. When she found him, Pankaj took his hand and noted the black ink mark on the nail bed of his little finger—it’s how the vaccinators tag the children who have received polio drops. Was any other child in the fields? Away at a relative’s? No, she said. He asked if her boy had received routine immunizations before today. No, she said. Had she heard about the polio case in town? She had. Had she heard about the vaccination team before the workers arrived at the door? She had not. He thanked her and wrote all the information down on a form before moving on. Several houses later, Pankaj said that, so far, the workers 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 41 The Mop-Up 41 had done their job. But he was disturbed that no one knew the vaccinators were coming that day. In addition to putting up banners (we’d seen a couple hanging as we came into the village), workers were supposed to use “miking” to reach the illiterate—auto-rickshaws with loudspeakers playing tapes announcing the upcoming campaign. Without that warning, some people would turn away the vaccinators knocking on their doors. Going around to a few more huts, we bumped into a vaccination team—a social welfare worker wearing sandals, a blue sari, and a flower in her hair, and a younger, collegestudent volunteer with a flower in her hair, too, and a square blue cold box of vaccine slung over her shoulder. They were standing in front of a hut they’d marked with an “X” instead of a “P”—the woman of the house had said that three children lived there, but one was absent and could not be vaccinated. Pankaj asked the vaccinators to open their cold box. He checked the freezer packs inside—still frozen, despite the heat. He inspected the individual vaccine vials—still fresh. There was a gray-and-white target sign on each vial. Did they know what it meant? That the vaccine was still good, they said. What does it look like when the vaccine expires? The white inside the target turns gray or black, they said. Right answer. Pankaj moved on. We went to the home of the village’s recent polio case. The girl was eighteen months old and silent. The mother, pregnant and with a three-year-old boy clinging to her side, laid her down on her back so that we could examine her. Neither leg would move. Lifting each one, I felt no resistance in 31915_ch01.001-275.qxd 42 2/1/08 3:06 PM Page 42 Better the child’s hips, her knees, her ankles. Only four weeks had passed since she was stricken. She almost certainly was still contagious. Pankaj found three children visiting the house. He checked each of their hands. None had received polio drops yet. We gave the four-wheel drive a push and made our way to Sirigere’s primary health center, a few miles outside the village. It was a drab, unpainted, three-room concrete building. The center’s medical officer met us at the door. About forty years old, with ironed slacks, a buttoned short-sleeve shirt, and the only college education in the area, he seemed eager to have our company. He offered tea and tried to make small talk. But Pankaj was all business. “May I see your microplan?” he asked before we had even sat down. He was referring to the block-by-block plan drawn up by each local officer. It is the key to how the operation is organized. The medical officer’s microplan was a sheaf of ragged paper, with marker-drawn maps and penciled-in tables. The first page said that he had recruited twenty-two teams of two vaccinators each to cover a population of 34,144 people. “How do you know this population estimate is right?” Pankaj asked. The officer replied that he’d done a house-to-house survey. Pankaj looked at the map—the villages in the area were spread out over more than ten miles. “How do you distribute the vaccine to the vaccinators who are far away?” By vehicle, the officer said. “How many vehicles do you have?” Two, he said. “What are the vehicles?” One was an ambulance. The other was a rented car. “And how does the supervisor get out to the 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 43 The Mop-Up 43 field?” There was a pause. The officer shuffled through the microplan. More silence. He did not know. Pankaj went on. Twenty-two teams would require about a hundred ice packs per day, or three hundred ice packs altogether. “Why did you budget for only a hundred and fifty ice packs?” We are freezing them overnight for the next day, the officer explained. “Where?” He showed Pankaj his deep freezer. Pankaj opened it up and pulled out the thermometer, which revealed that the temperature was above freezing. The electricity goes out, the officer explained. “What is your plan for that?” He had a generator. But when pressed to show it he was forced to admit that it wasn’t really working, either. Pankaj is not a physically imposing man. He has a boyish mop of thick black hair, parted almost down the center, and sometimes it sticks up. He has programed his cell phone to play the James Bond theme when it rings. When we’re driving, he points out the monkeys we pass. He makes jokes. He laughs with his head tilted back. But in the field his demeanor is grave and taciturn. He doesn’t tell people if their answers are good or bad. He keeps everyone on edge. I had an impulse to tell the medical officer that he was doing okay. But Pankaj seemed to make a point of saying nothing to fill the silences. In Siriguppa, where two of the hot cases had appeared, we walked the neighborhoods with another medical officer. Siriguppa is a dense, urbanized town of windowless concreteblock tenements, rusting corrugated-metal lean-tos, and some forty-three thousand people. We had to fight our way through narrow streets crowded with water buffalo, motorcycles, braying goats, and fruit sellers. There was electricity here, I noticed, running through wires that drooped from scattered 31915_ch01.001-275.qxd 44 2/1/08 3:06 PM Page 44 Better utility poles, and the sound of televisions poured out from some of the houses. The two hot cases, we found, were in a small Muslim enclave that had sprouted up a few months earlier. Going door to door, Pankaj learned that almost none of the enclave’s children had received routine immunizations. Some of the families seemed suspicious of us, answering questions tersely or trying to avoid us altogether. We found one boy whom the vaccinators had missed. Pankaj was concerned other children might have been hidden. The previous year, rumors had circulated among Muslims that the Indian government was giving different drops to their male children in order to make them infertile. The rumors were thought to have been quashed by an education campaign and greater Muslim involvement in the immunization program. But one had to wonder. Later, walking with a local doctor and a vaccination team through a village called Balkundi, we came to the home of a small, pretty woman who had rings on her toes and a baby held loosely on her hip. Another child, a boy of about three, stood nearby, staring at our little crowd. Neither child had been vaccinated, so Pankaj asked if we could give them the polio drops. No, she said. She did not appear angry or afraid. Pankaj asked if she knew that a case of polio had appeared in her neighborhood. Yes, she said. But she still didn’t want the drops given. Why? She would not say. Pankaj said OK, thanked her for her time, and moved on to the next house. “That’s it?” I asked. “Yes,” he said. The local doctor had stayed behind, however, and when 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 45 The Mop-Up 45 we looked back he was shouting at the mother: “Are you stupid? Your children will become paralyzed. They will die.” It was the one time I saw Pankaj angry. He walked back and confronted the doctor. “Why are you shouting?” Pankaj demanded. “Before, she was listening, at least. But now? She’s not going to listen anymore.” “She is illiterate!” the doctor shot back, embarrassed to be rebuked so openly. “She doesn’t know what is right for her child!” “What does that matter?” Pankaj replied. “Your shouting doesn’t help anything. And neither will a story going around that we are forcing drops on people.” So far, few were refusing the drops, and that was good enough, he told me later. A single nasty rumor could destroy the whole operation. One difficult question came up repeatedly—from local doctors, from villagers, from workers trudging house to house. The question was: Why? Why this huge polio campaign when what we need is—fill in the blank here—clean water (diarrheal illness kills 500,000 Indian children per year), better nutrition (half of children under three have stunted growth), working septic systems (which would help prevent polio as well as other diseases), irrigation (so a single rainless season would not impoverish farming families)? We saw neighborhoods that had had outbreaks of malaria, tuberculosis, cholera. But no one important had come to visit in years. Now one case of polio occurs and the infantry marches in? There are some stock answers. We can do it all, goes one. 31915_ch01.001-275.qxd 46 2/1/08 3:06 PM Page 46 Better We can eradicate polio and do better on the other fronts. In reality, though, choices are made. For that whole week, for instance, doctors in northern Karnataka had all but shut down their primary health clinics in order to carry out the polio vaccination work. Pankaj relies on a somewhat more persuasive line of argument: that ending polio is in itself worthwhile. In one village, I watched a resident demand to know why the government and WHO weren’t combating malnutrition there instead. There was only so much they could do, Pankaj said. “And if you’re starving, becoming paralyzed certainly isn’t going to help.” Still, you could make the same claim for almost any human problem that you decide to tackle—blindness or cancer or, for that matter, kidney stones. (“If you’re starving, kidney pain certainly isn’t going to help.”) And then there is the issue of money. So far the campaign has cost three billion dollars worldwide, more than six hundred dollars a case. To put that in perspective, the Indian government’s total budget for health care in 2003 came to four dollars per person. Stopping the very last case of polio, one official told me, might cost as much as two hundred million dollars. Even if the campaign succeeds in the eradication of polio, it is entirely possible that more lives would be saved in the future if the money were spent on, say, building proper sewage systems or improving basic health services. What’s more, success is by no means assured. WHO has had to extend its target date for eradication from 2000 to 2002 to 2005 and now is having to extend it again. In these last years of the campaign, more and more money has been spent chas- 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 47 The Mop-Up 47 ing the few hundred cases that keep popping up. A certain weariness is bound to settle in. Around twenty-four million children are born in India each year, creating a new pool of potential polio victims the size of Venezuela’s entire population. Just to stay caught up, a mammoth campaign to immunize every child under the age of five has to be planned each year. The truth is, no cost-benefit calculus can assure us just now that the money is well spent. Yet for all these reservations, the campaign has averted an estimated five million cases of paralytic polio thus far—a momentous achievement in itself. And although erasing the disease from the world is a grand, perhaps even absurd ambition, it remains a feasible task and one of the few things we as a civilization can do that would benefit mankind forever. The eradication of smallpox will last as an enduring gift to all who are to come, and now, perhaps, the eradication of polio can, too. But this means we must actually get down to that final polio case. Otherwise, the efforts of the hundreds of thousands of volunteers, and the billions spent will have amounted to nothing—or maybe worse than nothing. To fail at this venture would put into question the very ideal of eradication. Beneath the ideal is the gruelingly unglamorous and uncertain work. If the eradication of polio is our monument, it is a monument to the perfection of performance—to showing what can be achieved by diligent attention to detail coupled with great ambition. There is a system, and it has eradicated polio in countries with far worse conditions than I was seeing in India—for example, in Bangladesh, in Vietnam, in Rwanda, in Zimbabwe. Polio was eradicated from Angola in the midst of a civil war. An outbreak in Kandahar in 2002 was halted by 31915_ch01.001-275.qxd 48 2/1/08 3:06 PM Page 48 Better a WHO-led mop-up operation despite the Afghan war. In 2006, new mop-ups took place in northern Nigeria, where polio remains endemic and periodically spills into neighboring countries. In India, Pankaj told me, there have been campaigns on camels in the Thar Desert of Rajasthan, in jeeps among the tribal communities of the Jharkhand forests, on power boats through flooded regions of Assam and Meghalaya, on Navy cruisers traveling to remote islands in the Bay of Bengal. During our own mop-up, we covered about a thousand miles in the three days of going town to town. Pankaj worked his mobile phone almost constantly. Armed with the information he provided, state officials arranged deliveries from ice factories to teams at risk of running short of ice packs and extended the mop-up by an additional day in one area where the local officer had severely underestimated the population to be vaccinated. Four miles outside the village of Balkundi, we came upon a cluster of makeshift shanties for migrant laborers, not seen on any maps. When we checked the children, though, they all had the vaccinators’ ink marks on their pinkies. At Chitradurga, we found the mines in decay, but state officials had made sure that the company gave the vaccinators access to the workers’ compound. With some searching, we discovered a few children here and there. Every one of them had received the vaccine, too. By the end of the mop-up, UNICEF officials had distributed more than five million doses of fresh vaccine through the thirteen districts. Television, radio, and local newspapers had been blanketed with public service announcements. Rotary of India had printed and delivered 25,000 banners, 6,000 posters, 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 49 The Mop-Up 49 and more than 650,000 handbills. And 4 million of the targeted 4.2 million children had been successfully vaccinated. In 2005, India had just sixty-six new cases of polio. Pankaj and his colleagues believe that they’re finally closing in on their goal of eradication in India. And as India goes, so might the world. Still, there is no denying the dimensions of what Pankaj and his colleagues are up against. Pankaj says that he has seen more than a thousand cases of polio in his career as a pediatrician. When we drove through the villages and towns, he could pick out polio victims at a glance. They were everywhere, I began to realize: the beggar with two emaciated legs folded under him, rolling by on a wooden cart; the man dragging his leg like a club down the street; the passerby with a contracted arm tucked against his side. On the second day of the mop-up, we reached Upparahalla, the village where the Karnataka outbreak had started. The first, index case of polio was now a fourteen-month-old boy with a healthy, almost muscular thickness about his upper body; after the first few days of his infection, his breathing had returned to normal. But when his mother put him down on his stomach you could see that his legs were withered. With the exercises the nurses had taught her to do with him, he had regained enough movement in his left leg to be able to crawl, but his right leg dragged limply behind him. Making our way around the open sewage in Upparahalla, the mud-covered pigs, the cows resting curled up like 31915_ch01.001-275.qxd 50 2/1/08 3:06 PM Page 50 Better cats with their heads on their hooves, we found the neighbor girl who had come down with polio after the boy. She was eighteen months old, with a big, worried face, perfect white teeth, and short, spiky hair. She was wearing small gold earrings and a yellow-and-brown checked dress. She squirmed in her mother’s arms, but her legs only dangled beneath her dress. Her mother wore an impassive expression as she stood before us in the sun, holding her paralyzed child. Pankaj gently asked her if the girl had ever received polio drops—perhaps she’d got the vaccine but it had not taken. The mother said that a health worker had come around with polio drops a few weeks before her daughter became sick. But she had heard from other villagers that children were getting fevers from the drops. So she refused the vaccination. A look of profound sadness now swept over her. She had not understood, she said, staring down at the ground. Eventually, Pankaj continued onward, checking on the vaccinators going door to door. Then, when he was finished, we left. The road heading out of the village was a red dirt track and we rattled over it with our wheels in the ruts that the bullock carts had made. “What will you do when polio is finally gone?” I asked Pankaj. “Well, there is always measles,” he said. 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 51 Casualties of War E ach Tuesday, the U.S. Department of Defense provides an online update of American military casualties from the wars in Iraq and Afghanistan. According to this update, as of December 8, 2006, a total of 26,547 service members had suffered battle injuries. Of these, 2,662 died; 10,839 lived but could not return to duty; and 13,085 were less severely wounded and returned to duty within seventy-two hours. These figures represent, by a considerable margin, the largest burden of casualties our military medical personnel have had to cope with since the Vietnam War. When U.S. combat deaths in Iraq reached the twothousand mark in September 2005, the event captured worldwide attention. Combat deaths are seen as a measure of the 31915_ch01.001-275.qxd 52 2/1/08 3:06 PM Page 52 Better magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities. Both, however, are weak proxies. Little recognized is how fundamentally important the medical system is—and not just the enemy’s weaponry—in determining whether or not someone dies. U.S. homicide rates, for example, have dropped in recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with firearms, have more than tripled during that period. A key mitigating factor appears to be the trauma care provided: more people may be getting shot, but doctors are saving even more of them. Mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today. We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In the Revolutionary War, American soldiers faced bayonets and single-shot rifles, and 42 percent of the battle wounded died. In World War II, American soldiers were hit with grenades, bombs, shells, and machine guns, yet only 30 percent of the wounded died. By the Korean War, the weaponry was certainly no less terrible, but the mortality rate for combat-injured soldiers fell to 25 percent. Over the next half century, we saw little further progress. Through the Vietnam War (with its 153,303 combat wounded and 47,424 combat dead) and even the 1990–91 Persian Gulf War (with its 467 wounded and 147 dead), mortality rates for the battle injured remained at 24 percent. Our technology to save the wounded seemed to have barely kept up with the technology inflicting the wounds. The military wanted desperately to find ways to do bet- 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 53 Casualties of War 53 ter. The most promising approach was to focus on discovering new treatments and technologies. In the previous century, that was where progress had been found—in the discovery of new anesthetic agents and vascular surgery techniques for World War I soldiers, in the development of better burn treatments, blood transfusion methods, and penicillin for World War II soldiers, in the availability of a broad range of antibiotics for Korean War soldiers. The United States accordingly invested hundreds of millions of dollars in numerous new possibilities: the development of blood substitutes and freezedried plasma (for infusion when fresh blood is not available), gene therapies for traumatic wounds, medications to halt lung injury, miniaturized systems to monitor and transmit the vital signs of soldiers in the field. Few if any of these have yet come to fruition, however, and none were responsible for what we have seen in the current wars in Iraq and Afghanistan: a marked, indeed historic, reduction in the lethality of battle wounds. Although more U.S. soldiers have been wounded in combat in the current war than in the Revolutionary War, the War of 1812, and the Spanish-American War combined, and more than in the first four years of military involvement in Vietnam, we have had substantially fewer deaths. Just 10 percent of wounded American soldiers have died. How military medical teams have achieved this is important to think about. They have done it despite having no fundamentally new technologies or treatments since the Persian Gulf War. And they have done it despite difficulties with the supply of medical personnel. For its entire worldwide mission, the army had only about 120 general surgeons available 31915_ch01.001-275.qxd 54 2/1/08 3:06 PM Page 54 Better on active duty and two hundred in the reserves in 2005. To support the 130,000 to 150,000 troops fighting in Iraq, it has been able to put no more than thirty to fifty general surgeons and ten to fifteen orthopedic surgeons on the ground. And these surgeons and their teams have been up against devastating injuries. I got a sense of the extent of the injuries during a visit to Walter Reed Army Medical Center in Washington, D.C., in the fall of 2004, when I was invited to sit in on what the doctors call their “War Rounds.” Every Thursday, the Walter Reed surgeons hold a telephone conference with army surgeons in Baghdad to review the American casualties received in Washington. The case list for discussion the day I visited included one gunshot wound, one antitank-mine injury, one grenade injury, three rocket-propelled-grenade injuries, four mortar injuries, eight improvised explosive device (IED) injuries, and seven with no cause of injury noted. None of these soldiers was more than twenty-five years of age. The least seriously wounded was a nineteen-year-old who had sustained extensive blast and penetrating injuries to his face and neck from a mine. Other cases included a soldier with a partial hand amputation; one with a massive blast injury that amputated his right leg at the hip, a through-knee amputation of his left leg, and an open pelvic wound; one with bullet wounds to his left kidney and colon; one with bullet wounds under his arm requiring axillary artery and vein reconstruction; and one with a shattered spleen, a degloving scalp laceration, and a throughand-through tongue laceration. These are terrible and formidable injuries. Nonetheless, all were saved. * * * 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 55 Casualties of War 55 If the answer to how was not to be found in new technologies, it did not seem to reside in any special skills of military doctors, either. George Peoples is a forty-two-year-old surgical oncologist who was my chief resident when I was a surgical intern. In October 2001, after the September 11 attacks on the World Trade Center and the Pentagon, he led the first surgical team into Afghanistan. He returned after service there only to be sent to Iraq, in March 2003, with ground forces invading from Kuwait through the desert to Baghdad. He had gone to the U.S. Military Academy at West Point for college, Johns Hopkins Medical School in Baltimore, Brigham and Women’s Hospital in Boston for surgical residency, and then M. D. Anderson Cancer Center in Houston for a cancer surgery fellowship. He owed the army eighteen years of service when he finally finished his training, and neither I nor anyone I know ever heard him bemoan that commitment. In 1998, he was assigned to Walter Reed, where he soon became chief of surgical oncology. Peoples was known in training for three things: his unflappability, his intellect (he had published seventeen papers on work toward a breast cancer vaccine before he finished his training), and the five children he and his wife had during his residency. He was not known, however, for any particular expertise in trauma surgery. Before being deployed, he hadn’t seen a gunshot wound since residency, and even then, he never saw anything like the injuries he saw in Iraq. His practice at Walter Reed centered on breast surgery. Yet in Iraq, he and his team managed to save historic numbers of wounded. “How is this possible?” I asked him. I asked his colleagues, too. I asked everyone I met who had worked on medical teams in the war. And what they described revealed an intriguing 31915_ch01.001-275.qxd 56 2/1/08 3:06 PM Page 56 Better effort to do something we in civilian medicine do spottily at best: to make a science of performance, to investigate and improve how well they use the knowledge and technologies they already have at hand. The doctors told me of simple, almost banal changes that produced enormous improvements. One such change involved Kevlar vests, for example. There is nothing new about Kevlar. It has been around since the late 1970s. Urban police forces began using Kevlar vests in the early 1980s. American troops had them during the Persian Gulf War. A sixteen-pound Kevlar flak vest will protect a person’s “body core”—the heart, the lungs, the abdominal organs—from blasts, blunt force trauma, and penetrating injuries. But researchers examining wound registries from the Persian Gulf War found that wounded soldiers had been coming in to medical facilities without their Kevlar on. They hadn’t been wearing their vests. So orders were handed down holding commanders responsible for ensuring that their soldiers always wore the vests—however much they might complain about how hot or heavy or uncomfortable the vests were. Once the soldiers began wearing them more consistently, the percentage killed on the battlefield dropped instantly. A second, key discovery came in much the same way, by looking more carefully at how the system was performing. Colonel Ronald Bellamy, a surgeon with the army’s Borden Institute, examined the statistics of the Vietnam War and found that helicopter evacuation had reduced the transport time for injured soldiers to hospital care from an average of over eleven hours in World War II to under an hour. And once they got to surgical care, only 3 percent died. Yet 24 percent of wounded soldiers died in all, and that was because transport time to sur- 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 57 Casualties of War 57 gical care under an hour still wasn’t fast enough. Civilian surgeons talk of having a “Golden Hour” during which most trauma victims can be saved if treatment is started. But battlefield injuries are so much more severe—the blood loss in particular—that wounded soldiers have only a “Golden Five Minutes,” Bellamy reported. Vests could extend those five minutes. But the recent emphasis on leaner, faster-moving military units moving much farther ahead of supply lines and medical facilities was only going to make evacuation to medical care more difficult and time-consuming. Outcomes for the wounded were in danger of getting worse rather than better. The army therefore turned to an approach that had been used in isolated instances going back as far as World War II: something called Forward Surgical Teams (FSTs). These are small teams, consisting of just twenty people: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, plus medics and other support personnel. In Iraq and Afghanistan, they travel in six Humvees directly behind the troops, right out onto the battlefield. They carry three lightweight, Deployable Rapid-Assembly Shelter (“drash”) tents that attach to one another to form a nine-hundredsquare-foot hospital facility. Supplies to immediately resuscitate and operate on the wounded are in five black nylon backpacks: an ICU pack, a surgical-technician pack, an anesthesia pack, a general-surgery pack, and an orthopedic pack. They hold sterile instruments, anesthesia equipment, medicines, drapes, gowns, catheters, and a handheld unit that allows clinicians to measure a complete blood count, electrolytes, or blood gases with a drop of blood. FSTs also carry a small ultrasound machine, portable monitors, transport venti- 31915_ch01.001-275.qxd 58 2/1/08 3:06 PM Page 58 Better lators, an oxygen concentrator providing up to 50 percent pure oxygen, twenty units of packed red blood cells for transfusion, and six roll-up stretchers with litter stands. All of this is ordinary medical equipment. The teams must forgo many technologies normally available to a surgeon, such as angiography and radiography equipment. (Orthopedic surgeons, for example, have to detect fractures by feel.) But they can go from rolling to having a fully functioning hospital with two operating tables and four ventilator-equipped recovery beds in under sixty minutes. Peoples led the 274th FST, which traveled 1,100 miles with troops during the invasion of Iraq. The team set up in Nasiriyah, Najaf, Karbala, and points along the way in the southern desert, then in Mosul in the north, and finally in Baghdad. According to its logs, the unit cared for 132 U.S. and 74 Iraqi casualties (22 of the Iraqis were combatants, 52 civilians) over those initial weeks. Some days were quiet, others overwhelming. On one day in Nasiriyah, the team received ten critically wounded soldiers, among them one with rightlower-extremity shrapnel injuries; one with gunshot wounds to the stomach, small bowel, and liver; another with gunshot wounds to the gallbladder, liver, and transverse colon; one with shrapnel in the neck, chest, and back; one with a gunshot wound through the rectum; and two with extremity gunshot wounds. The next day, fifteen more casualties arrived. Peoples described to me how radically the new system changed the way he and his team took care of the wounded. On the arrival of the wounded, they carried out the standard Advanced Trauma Life Support protocols that all civilian trauma teams follow. However, because of the high propor- 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 59 Casualties of War 59 tion of penetrating wounds—80 percent of casualties seen by the 274th FST had gunshot wounds, shrapnel injuries, or blast injuries—lifesaving operative management is required far more frequently than in civilian trauma centers. The FST’s limited supplies provided only for a short period of operative care for a soldier and no more than six hours of postoperative intensive care. So the unit’s members focused on damage control, not definitive repair. They packed off liver injuries with gauze pads to stop the bleeding, put temporary plastic tubes in bleeding arteries to shunt the blood past the laceration, stapled off perforated bowel, washed out dirty wounds—whatever was necessary to control contamination and stop hemorrhage. They sought to keep their operations under two hours in length. Then, having stabilized the injuries, they shipped the soldier off—often still anesthetized, on a ventilator, the abdominal wound packed with gauze and left open, bowel loops not yet connected, blood vessels still needing repair—to another team at the next level of care. They had available to them two Combat Support Hospitals (or CSHs—“CaSHes”—as they call them) in four locations for that next level of care. These are 248-bed hospitals typically with six operating tables, some specialty surgery services, and radiology and laboratory facilities. Mobile hospitals as well, they arrive in modular units by air, tractor trailer, or ship and can be fully functional in twenty-four to forty-eight hours. Even at the CSH level, the goal is not necessarily definitive repair. The maximal length of stay is intended to be three days. Wounded American soldiers requiring longer care are transferred to what’s called a level IV hospital—one was established in Kuwait and one in Rota, Spain, but the main one is in 31915_ch01.001-275.qxd 60 2/1/08 3:06 PM Page 60 Better Landstuhl, Germany. Those expected to require more than thirty days of treatment are transferred home, mainly to Walter Reed or to Brooke Army Medical Center in San Antonio, Texas. Iraqi prisoners and civilians, however, remain in the CSHs through recovery. The system took some getting used to. Surgeons at every level initially tended to hold on to their patients, either believing that they could provide definitive care themselves or not trusting that the next level could do so. (“Trust no one” is the mantra we all learn to live by in surgical training.) According to statistics from Walter Reed, during …
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