The .Plan

This week’s New Yorker has an essay by Atul Gawande on the complexities of ICU care. He describes a former patient who was losing all of his organs, one by one.

I called his sister, who was his next of kin, and told her of the situation. “Do everything you can,” she said.

So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his throat. Another resident “lined him up.” She inserted a thin, two-inch-long needle and catheter through his upturned right wrist and into his radial artery, and then sewed the line to his skin with a silk suture. Next, she put in a central line—a twelve-inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to—inside his vena cava at the entrance to his heart—she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone.

We hooked a breathing tube up to a hose from a ventilator and set it to give him fourteen forced breaths of a hundred-per-cent oxygen every minute. We dialled the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood-pressure measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous-pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artificial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt in his body as well. He was, we liked to imagine, a simple machine in our hands.

But he wasn’t, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway eighteen-wheeler hurtling down a mountain.
–Atul Gawande, “The Checklist”, New Yorker, December 10, 2007 [emphasis added]