Authors: Atul Gawande
Mr. Jolly had come into the hospital for treatment of a wound infection in his legs. But he soon developed congestive heart failure, causing fluid to back up into his lungs. Breathing became steadily harder for him, until we had to put him in the ICU, intubate him, and place him on a ventilator. A two-day admission turned into two weeks. With a regimen of diuretics and a change in heart medications, however, his heart failure reversed, and his lungs recovered. And one bright Sunday morning he was reclining in bed, breathing
on his own
, watching the morning shows on the TV set that hung from the ceiling. “You’re doing marvelously,” I said. I told him we would transfer him out of intensive care by the afternoon. He would probably be home in a couple of days.
Two hours later, a code-blue emergency call went out on the overhead speakers. When I got to the ICU and saw the nurse hunched over Mr. Jolly, doing chest compressions, I blurted out an angry curse. He’d been fine, the nurse explained, just watching TV, when suddenly he sat upright with a look of shock and then fell back, unresponsive. At first, he was asystolic—no heart rhythm on the monitor—and then the rhythm came back, but he had no pulse. A crowd of staffers set to work. I had him intubated, gave him fluids and epinephrine, had someone call the attending surgeon at home, someone else check the morning lab test results. An X-ray technician shot a portable chest film.
I mentally ran through possible causes. There were not many. A collapsed lung, but I heard good breath sounds with my stethoscope, and when his X ray came back the lungs looked fine. A massive blood loss, but his abdomen wasn’t swelling, and his decline happened so quickly that bleeding just didn’t make sense. Extreme acidity of the blood could do it, but his lab tests were fine. Then there was cardiac tamponade—bleeding into the sac that contains the heart. I took a six-inch spinal needle on a syringe, pushed it through the skin below the breastbone, and advanced it to the heart sac. I found no bleeding. That left only one possibility: a pulmonary embolism—a blood clot that flips into the lung and instantly wedges off all blood flow. And nothing could be done about that.
I went out and spoke to the attending surgeon by phone and then to the chief resident, who had just arrived. An embolism was the only logical explanation, they agreed. I went back into the room and stopped the code. “Time of death: 10:23
A.M.
,” I announced. I phoned his wife at home, told her that things had taken a turn for the worse, and asked her to come in.
This shouldn’t have happened; I was sure of it. I scanned the records for clues. Then I found one. In a lab test done the day before, the patient’s clotting had seemed slow, which wasn’t serious, but an ICU physician had decided to correct it with vitamin K. A frequent side effect of vitamin K is blood clots. I was furious. Giving the vitamin
was completely unnecessary—just fixing a number on a lab test. Both the chief resident and I lit into the physician. We all but accused him of killing the patient.
When Mrs. Jolly arrived, we took her to a family room where it was quiet and calm. I could see from her face that she’d already surmised the worst. His heart had stopped suddenly, we told her, because of a pulmonary embolism. We said the medicines we gave him may have contributed to it. I took her in to see him and left her with him. After a while, she came out, her hands trembling and her face stained with tears. Then, remarkably, she thanked us. We had kept him for her all these years, she said. Maybe so, but neither of us felt any pride about what had just happened.
I asked her the required question. I told her that we wanted to perform an autopsy and needed her permission. We thought we already knew what had happened, but an autopsy would confirm it, I said. She considered my request for a moment. If an autopsy would help us, she finally said, then we could do it. I said, as I was supposed to, that it would. I wasn’t sure I believed it.
I wasn’t assigned to the operating room the following morning, so I went down to observe the autopsy. When I arrived, Mr. Jolly was already laid out on the dissecting table, his arms splayed, skin flayed back, chest exposed, abdomen open. I put on a gown, gloves, and a mask, and went up close. The assistant began buzzing through the ribs on the left side with the electric saw, and immediately blood started seeping out, as dark and viscous as crankcase oil. Puzzled, I helped him lift open the rib cage. The left side of the chest was full of blood. I felt along the pulmonary arteries for a hardened, embolized clot, but there was none. He hadn’t had an embolism after all. We suctioned out three liters of blood, lifted the left lung, and the answer appeared before our eyes. The thoracic aorta was almost three times larger than it should have been, and there was a half-inch hole in it. The man had ruptured an aortic aneurysm and had bled to death almost instantly.
In the days afterward, I apologized to the physician I’d reamed out over the vitamin, and pondered how we had managed to miss the diagnosis. I looked through the patient’s old X rays and now saw a shadowy outline of what must have been his aneurysm. But none of us, not even the radiologists, had caught it. Even if we had caught it, we wouldn’t have dared to do anything about it until weeks after treating his infection and heart failure, and that would have been too late. It disturbed me, however, to have felt so confident about what had happened that day and to have been so wrong.
The most perplexing thing was his final chest X ray, the one we had taken during the code blue. With all that blood filling the chest, I should have seen at least a haze over the left side. But when I pulled the film out to look again, there was nothing.
How often do autopsies turn up a major misdiagnosis in the cause of death? I would have guessed this happened rarely, in 1 or 2 percent of cases at most. According to three studies done in 1998 and 1999, however, the figure is about 40 percent. A large review of autopsy studies concluded that in about a third of the misdiagnoses the patients would have been expected to live if proper treatment had been administered. George Lundberg, a pathologist and former editor of the
Journal of the American Medical Association
, has done more than anyone to call attention to these figures. He points out the most surprising fact of all: the rates at which misdiagnosis is detected in autopsy studies have not improved since at least 1938.
With all the recent advances in imaging and diagnostics, it’s hard to accept that we not only get the diagnosis wrong in two out of five of our patients who die but that we have also failed to improve over time. To see if this could really be true, doctors at Harvard put together a simple study. They went back into their hospital records to see how often autopsies picked up missed diagnoses in 1960 and 1970, before the advent of CT, ultrasound, nuclear scanning, and other technologies, and then in 1980, after those technologies became widely used. The researchers found no improvement. Regardless of
the decade, physicians missed a quarter of fatal infections, a third of heart attacks, and almost two-thirds of pulmonary emboli in their patients who died.
In most cases, it wasn’t technology that failed. Rather, the physicians did not consider the correct diagnosis in the first place. The perfect test or scan may have been available, but the physicians never ordered it.
In a 1976 essay, the philosophers Samuel Gorovitz and Alasdair MacIntyre explored the nature of fallibility. Why would a meteorologist, say, fail to correctly predict where a hurricane was going to make landfall? They saw three possible reasons. One was ignorance: perhaps science affords only a limited understanding of how hurricanes behave. A second reason was ineptitude: the knowledge is available, but the weatherman fails to apply it correctly. Both of these are surmountable sources of error. We believe that science will overcome ignorance, and that training and technology will overcome ineptitude. The third possible cause of error the philosophers posited, however, was an insurmountable kind, one they termed “necessary fallibility.”
There may be some kinds of knowledge that science and technology will never deliver, Gorovitz and MacIntyre argued. When we ask science to move beyond explaining how things (say, hurricanes) generally behave to predicting exactly how a particular thing (say, Thursday’s storm off the South Carolina coast) will behave, we may be asking it to do more than it can. No hurricane is quite like any other hurricane. Although all hurricanes follow predictable laws of behavior, each one is continuously shaped by myriad uncontrollable, accidental factors in the environment. To say precisely how one specific hurricane will behave would require a complete understanding of the world in all its particulars—in other words, omniscience.
It’s not that it’s impossible to predict anything; plenty of things are completely predictable. Gorovitz and MacIntyre give the example of a random ice cube in a fire. Ice cubes are so simple and so alike
that you can predict with complete assurance that an ice cube will melt. But when it comes to inferring exactly what is going on in a particular person, are people more like ice cubes or like hurricanes?
Right now, at about midnight, I am seeing a patient in the emergency room, and I want to say that she is an ice cube. That is, I believe I can understand what’s going on with her, that I can discern all her relevant properties. I believe I can help her.
Charlotte Duveen, as we will call her, is forty-nine years old, and for two days she has had abdominal pain. I begin observing her from the moment I walk through the curtains into her room. She is sitting cross-legged in the chair next to her stretcher and greets me with a cheerful, tobacco-beaten voice. She does not look sick. No clutching the belly. No gasping for words. Her color is good—neither flushed nor pale. Her shoulder-length brown hair has been brushed, her red lipstick neatly applied.
She tells me the pain started out crampy, like a gas pain. But then, during the course of the day, it became sharp and focused, and as she says this she points to a spot in the lower right part of her abdomen. She has developed diarrhea. She constantly feels as if she has to urinate. She doesn’t have a fever. She is not nauseated. Actually, she is hungry. She tells me that she ate a hot dog at Fen-way Park two days ago and visited the exotic birds at the zoo a few days before that, and she asks if either might have anything to do with this. She has two grown children. Her last period was three months ago. She smokes half a pack a day. She used to use heroin but says she’s clean now. She once had hepatitis. She has never had surgery.
I feel her abdomen. It could be anything, I think: food poisoning, a virus, appendicitis, a urinary-tract infection, an ovarian cyst, a pregnancy. Her abdomen is soft, without distension, and there is an area of particular tenderness in the lower right quadrant. When I press there, I feel her muscles harden reflexively beneath my fingers. On the pelvic exam, her ovaries feel normal. I order some lab tests.
Her white blood cell count comes back elevated. Her urinalysis is normal. A pregnancy test is negative. I order an abdominal CT scan.
I am sure I can figure out what’s wrong with her, but, if you think about it, that’s a curious faith. I have never seen this woman before in my life, and yet I presume that she is like the others I’ve examined. Is it true? None of my other patients, admittedly, were forty-nine-year-old women who had had hepatitis and a drug habit, had recently been to the zoo and eaten a Fenway frank, and had come in with two days of mild lower-right-quadrant pain. Yet I still believe. Every day, we take people to surgery and open their abdomens, and, broadly speaking, we know what we will find: not eels or tiny chattering machines or a pool of blue liquid but coils of bowel, a liver to one side, a stomach to the other, a bladder down below. There are, of course, differences—an adhesion in one patient, an infection in another—but we have catalogued and sorted them by the thousands, making a statistical profile of mankind.
I am leaning toward appendicitis. The pain is in the right place. The timing of her symptoms, her exam, and her white blood cell count all fit with what I’ve seen before. She’s hungry, however; she’s walking around, not looking sick, and this seems unusual. I go to the radiology reading room and stand in the dark, looking over the radiologist’s shoulder at the images of Duveen’s abdomen flashing up on the monitor. He points to the appendix, wormlike, thick, surrounded by gray, streaky fat. It’s appendicitis, he says confidently. I call the attending surgeon on duty and tell him what we’ve found. “Book the OR,” he says. We’re going to do an appendectomy.
This one is as sure as we get. Yet I’ve worked on similar cases in which we opened the patient up and found a normal appendix. Surgery itself is a kind of autopsy. “Autopsy” literally means “to see for oneself,” and, despite our knowledge and technology, when we look we’re often unprepared for what we find. Sometimes it turns out that we had missed a clue along the way, made a genuine mistake. Sometimes we turn out wrong despite doing everything right.
Whether with living patients or dead, however, we cannot know until we look. Even in the case of Mr. Sykes, I now wonder whether we put our stitches in correctly, or whether the bleeding had come from somewhere else entirely. Doctors are no longer asking such questions. Equally troubling, people seem happy to let us off the hook. In 1995, the United States National Center for Health Statistics stopped collecting autopsy statistics altogether. We can no longer even say how rare autopsies have become.
From what I’ve learned looking inside people, I’ve decided human beings are somewhere between a hurricane and an ice cube: in some respects, permanently mysterious, but in others—with enough science and careful probing—entirely scrutable. It would be as foolish to think we have reached the limits of human knowledge as it is to think we could ever know everything. There is still room enough to get better, to ask questions of even the dead, to learn from knowing when our simple certainties are wrong.
O
ne by one, between 1949 and 1968, each of the ten children born to Marie Noe, a Philadelphia woman, died. One was stillborn. One died at the hospital just after birth. But eight others expired at home, just infants, in their cribs, where Noe said she found them blue and either limp or gasping. Doctors, including some of the most respected pathologists of the time, could find no explanation for the eight crib deaths—autopsies had in fact been done in every case. Foul play was strongly considered, but no evidence for it was found. Later, the medical community would come to recognize that thousands of seemingly healthy infants died inexplicably in their beds each year, a circumstance given the name Sudden Infant Death Syndrome, or SIDS, and the cases were attributed to this.