selves besides what is instilled in them through professional training. It is one thing to hold the line against another doctor on the basis of science—
for example, by invoking the rate of anesthetic induction on one lung. It is another thing to fret about an obscure event that has been reported only a few times before in the medical literature. Doctors risk becoming the butt of jokes if they sound too many warning bells about rare events or diseases that theoretically might occur. They are accused of “chasing zebras.” Nevertheless, zebras do exist. Sometimes a doctor must insist that a zebra does, in fact, lurk nearby. But to do so a doctor needs natural inner strength. No scientific equation can fortify a doctor when he or she declares the imminent presence of a zebra. A doctor needs natural determi-
nation and a backbone—something that I lacked in those days.
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I also let Dr. G have his way because I wanted to prove to him that I
was no Chicken Little. The desire to be macho exists to some degree in
every man, but it is especially prominent in doctors like Dr. G, who pride themselves on being tough guys and adventurers. These doctors know
that medicine has changed over the years, but how it has changed has
affected their imaginations in a strange way. As medicine grows more
rule bound and protocol oriented, these doctors feel cribbed and confined; they long to flout established guidelines, to become pioneers and travel
the open highway once again. For them, rules and protocols are for
nurses—medicine’s version of the prudent and cautious middle class. It is not the physician of the past who serves as an invariable reference point for these swashbucklers but the frontiersman—hence, these doctors are
often called “cowboys.” They love danger; they love the thrill of taking
risks. Their risk taking is really quite cowardly, for the real risk is to the patient. Tell them afterward that they were trusting to luck and they will laugh, “We got away with it,” reflecting a desire on their part to be seen as adorably reckless cowboys.
Few things are more dangerous in medicine than a cowboy eager to
get back to his office or go home. An impatient cowboy must be resisted
at all costs. But I didn’t resist. I didn’t like confrontation, and I didn’t like being called a chicken.
Dr. G positioned himself at the head of the table. I removed the boy’s
breathing tube. Dr. G reached into the airway with a long instrument,
grabbed the morsel of food, which turned out to be a peanut, and pulled.
At about the level of the boy’s vocal cords the peanut shattered into two pieces and fell back, blocking both airways. Dr. G tried to extract one of the pieces but failed. He quickly removed his instrument to let me ventilate the boy with bag and mask, but the boy’s lungs were now totally
obstructed on both sides.
I was furious with myself. Then, as the boy’s lips turned blue, fear
sucked at my heart. The peanut was choking the boy’s little life.
I pressed the mask against the boy’s face to create a tighter seal, but
the air I squeezed in with my right hand simply went into the boy’s
stomach. I kept squeezing the bag, until sense and experience howled
inside my mind, prodding the blood in my brain to start moving again and
do something different. I thought about looking into the boy’s throat with my laryngoscope to snare some of the food; yet I knew this was pointless, as the food was below the vocal cords and beyond the level of conven-
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tional vision. I was out of options. I hurriedly gave the airway back to the Dr. G and told him that mask ventilation was futile. We had to clear the
boy’s airway below the vocal cords.
Dr. G threw back the boy’s head with all the force and resolution of a
man desperate to exonerate himself from a charge of murder. He jammed
the snare into the boy’s throat with his shaking hand.
“Jesus Christ!” the cowboy shouted. “Jesus fuckin’ Christ!”
Hope lay in extracting some of the peanut and nowhere else. Dr. G
worked furiously, scraping, grabbing, and poking, each time realizing
mournfully that he had not carried out his intention.
The boy’s arms lay flung out on armboards, his palms, now gray like
marble, turned upward and open, as if they were begging. I ordered the
nurse to retrieve the saw so that we could cut open the boy’s chest and
slice open the delicate airways to remove the bits of peanut under direct vision—a horrible and likely futile maneuver, as the boy would probably
suffer irreparable brain damage by the time we got in. I tore off the drape and exposed the white chest skin suffused with the color of lilac. I imagined the cabbage-like scrunch of the rending bone that the saw would
produce as it cut through and felt lightheaded.
The whole room was infected by a capitulatory mood. Then, through
sheer luck, Dr. G removed a piece of peanut. Five seconds later I violent-ly pressed the mask against the boy’s face and ventilated one lung. The
boy pinked up, the warm color coming across his face like the feeble light of dawn after a long, dark night. Two minutes later I handed the airway
back to the surgeon, who calmly removed the second piece of nut, this
time with the table tilted to one side.
I glanced around the room, dazed and restive, my pupils dilated. In-
struments scattered on the floor were coated with blood and sputum. I
looked at them with respect and thanks, as though they were the real
soldiers, dead on the field, deserving of medals for big deeds, for hero-
ism. The nurse asked me something, but her words failed to penetrate my
consciousness. The nurse asked me again, “How long before the boy
wakes up?” I gazed at her, my eyes still aflame with the light of battle, but said nothing.
The nurse called the recovery room to say the patient would be com-
ing out soon. Without emotion she gave the nurse on the other end of the
line the name of the procedure: “removal of foreign body from trachea.”
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She noted that general anesthesia had been used and also that the patient had an intravenous.
And what had really happened? Two doctors had clashed in a contest
of egos, with a fair-haired young boy bruised and battered in the process, until the breath of death was in the air, at which point both doctors,
mortally terrified, and feeling the pinching chill of malpractice, worked together and luckily saved the situation. They finished with their arms as heavy as lead, despising themselves.
And they called it the third case of the day.
We wheeled the young boy past the clerk encaged in the command
center. At that moment I had a terrible longing to be like him, relaxed and comfortable, neither terrifying to other people nor afraid himself, going home every day with a clean conscience and unaware that what he did for
a living never needed to be done by anybody.
“You did a good job in the emergency room. Why did you listen to
that surgeon?” I asked myself.
But what is done is done. A doctor learns early on that life flows only
one way and in one groove. After he or she makes a medical decision, the
roads not taken, like innumerable streams breaking off from the main
current, flow on visibly for some distance and scatter over the plain of
existence. It is even possible to imagine heading back, choosing one of
those streams, and following its winding course. But
over time the
streams dwindle into rivulets, and the doctor realizes that only one channel of life, the channel forged by his or her decision, flows richly and
fully. Eventually the rivulets, tiny symbols of what might have been, dry up altogether.
How could this near catastrophe have been averted? It is tempting to
blame Dr. G’s impatience, especially since impatience in health care
seems to be on the rise. Some primary care doctors today, for example,
are forced to restrict their patient visits to eleven minutes. 1 Surgery shows a similar trend. A community hospital’s surgical schedule in the 1960s
often had large gaps between cases. Today, cases are stacked tightly, with fifteen-minute turnover time. The rush even penetrates anesthesia research, as most recent advances have been time-saving ones—for exam-
ple, new anesthetic gases that exit the body quickly, allowing for faster
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wake-up, and non-narcotic pain substitutes that shorten recovery room
time, thereby improving efficiency at that end of the assembly line.
Overspecialization has also increased, fostering physician impatience
in a second way. Theoretically, a medical degree lets doctors practice any medical field. Doctors stay in their own specialties today because they
can’t get the necessary malpractice insurance coverage. Still, as late as the 1980s, it was not uncommon for doctors to cross over—for example,
ENT surgeons to practice a little general surgery, or obstetricians to practice a little anesthesiology. Not only does this no longer happen, but
within the specialties themselves doctors also increasingly confine them-
selves to a narrow slice of activity. The rarefied concerns of one group of doctors inevitably become foreign to another. This makes doctors impatient with one another.
Yet impatience is simply a factor to be reckoned with in human af-
fairs. To prevent a catastrophe, a doctor must confront impatience head
on. I had failed to do this with Dr. G.
Some people in medicine pin their hopes on less confrontational ap-
proaches. A few hospitals, for example, mount traffic lights on their walls to police against rude behavior. The green light registers when people
nearby talk in normal conversational voices; raised voices trigger the
orange light; the red light flashes with frank yelling, warning the aggressor to back off. Yet the red light doesn’t solve the impatient doctor problem. An impatient doctor can cut corners or call someone a “chicken” in a normal conversational tone as well as in a loud voice. There are soft-spoken cowboys.
Another innovation designed to do everything but confront the impa-
tient doctor head on is the “time-out.” During a time-out, hospital personnel stop what they are doing and go through a safety checklist. The time-
out does a good job of making sure the surgical site is correct, or that
antibiotics have been given prior to the start of a procedure. But the time-out is useless as a check on an impatient cowboy who wants to get back to his office or go home.
In theory, a cowboy’s reckless behavior should be flushed out at the
end of the time-out, when the nurse gets to the question—first posed to
the surgeon, and then to the anesthesiologist—“Do you have any general
concerns?” It is the moment when the sensible doctor might tell the
impatient doctor that the risks being taken are too great, and that a different path should be taken. Yet the response to this question is uniformly
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silence, or, at most, “No.” Indeed, at no time have I ever heard a surgeon respond in the affirmative to this question, nor have I, the anesthesiologist, ever done so; nor has any surgeon or anesthesiologist I know ever
done so. About minor concerns we remain silent, as announcing them
accomplishes nothing but make everyone in the operating room uneasy.
In regard to major concerns, the surgeon and I will have already discussed them in advance, before the time-out, so there is no reason to air them
again. If a passive doctor fails to stand up to an impatient doctor when
discussing them—that is, if he hasn’t already pushed back in private—he
is even less likely do so during a very public time-out. If he does, he is simply telling the operating room that he was too spineless to voice his
concerns at the appropriate time, when he was one-on-one with the sur-
geon, or that he voiced his concerns but failed to carry his point, in which case now he was being sour grapes and a tattletale.
In medicine, war is sometimes necessary. A doctor must learn to fight.
He or she must accept the risk of being bloodied in that fight, being called bad things, and having another doctor hate him or her as a consequence.
Even stalemate is safer than compromise with an impatient cowboy. Two
doctors fight one another, but they still need each other; each needs the skills the other lacks. If a doctor cannot win a war, he or she can at least stand firm and do nothing. For example, an anesthesiologist may not
carry the day with a cowboy surgeon, but he or she does not have to start the anesthetic.
So long as the medical profession downplays the problem of the impa-
tient cowboy, catastrophes will continue to happen along this front. Medical training programs tend to look at conflict as an unnatural state of
affairs, or, when conflict does occur, something to be peacefully resolved.
This is wrong thinking. Conflict is a part of nature.
A medical school dean once told me that he preferred students who
were the sons and daughters of delicatessen owners rather than of aca-
demics. Delicatessen owners, he observed, have street smarts, gumption,
and an understanding that life is one long fight, qualities they often pass on to their children. Academics, however, live in environments where
conflict is rare and scary, and where life is easy because others before
them already fought for their better life. Familiar with hard reality, the children of delicatessen owners are more likely to stand up to cowboys,
he said, while the children of academics are more likely to shrink when
confronted with the darker and cruder sides of life.
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We arrived in the recovery room. Upon discovering it was full and
unable to accept new patients, Dr. G, already in a bad mood to begin with, flew into a temper. “What do you mean there’s no spot? I’ve got three
more cases!” he shouted.
The room shivered in fear. Nurses darted around frantically like bats
around a house, trying to prove how busy they were and how the crunch
had been unavoidable. With no one volunteering to take responsibility,
Dr. G raged. Housekeepers leaning on their mops gathered around the
entrance to see what the ruckus was all about. Several residents came by, bunching together out of safety, as if they were in the proximity of a
dangerous animal.
Even the clerk in the command center wandered over from his com-
fortable chair to see what was happening. He wore surgical scrubs
adorned with several badges. He looked like a doctor. But he was not a
doctor. When Dr. G glared at him and demanded, “What are you looking
at?” the clerk scurried back to the safety of his cage.
By the time the nurses had found an open spot, the boy was awake and
thrashing about—so much that he pulled out his intravenous line. I
wanted to put a new one in. Although
the boy was breathing comfortably,
I feared pulmonary complications later on, as repeated surgical manipula-
tions can injure an airway, while peanuts can provoke an intense inflam-
matory response in the lung. I thought having an intravenous in place
would be safer. But putting an intravenous in an awake and unhappy
eight-year-old is a hellish maneuver that requires numerous staff mem-
bers to hold the child down. Dr. G eyed the two ENT residents on his
team. Both looked doubtful and resistant, and eager to avoid hard work.
Since he wouldn’t have to deal with any airway complications in the
recovery room (I would), Dr. G waved his hand dismissively and said,
“Don’t worry about it. The child doesn’t need it.” The two residents
sighed with relief.
But this time—this time—there would be conflict. “No, he needs an
IV,” I explained. “And he’s going to get one.” My response was simple,
straightforward, uncomplicated, and honest. Dr. G glared at me. Another
test of wills loomed. But this time he sensed I was not my usual submis-
sive self, and rather than challenge me, he walked away. It was not a
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formal surrender, but when compared with events in the operating room,
it’s as if I had twisted his arm behind his back until he fell on his knees.
One of the residents rolled his eyes and called me a “jerk” while
holding down the child’s arms. He complained about having to get back
to his clinic. The other resident shook his head while holding onto the
child’s legs, calling the whole thing unnecessary. I had made myself a
terrible nuisance. But while they disapproved of my decision, they did not refuse me the right to have it carried out. I was unbiased and without self-interest; my honesty in assigning the task could not be questioned. These elementary virtues made me powerful.
People sometimes say doctors act like dictators. They do so to criticize
doctors. But a dictator gains power through being frugal and incorrupt-
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