Checklists a-Manifesting

This time of year, we frequently hear these song lyrics: He’s making a list, checking it twice.

I say, “Wait, only twice? What kind of slacker are you, Santa?”

I have long been a fan of making lists. When I was younger, the lists were more of a catalog: the countries I had visited or wanted to visit, clothing items to buy that would complete my wardrobe (who was I kidding? It’s never completed!), guys I had dated. Now that I’ve reached middle age, the lists help me remember what I need and want to do. Yeah, kids, you read that right – I need a reminder sometimes of the things I want to do. That little reduction in memory capacity is waiting for you, too, when you reach middle age. (Hmm… I don’t like the term “middle age.” It sounds so much older than just saying my actual age of 45.)

I rely heavily on such checklists during recovery from my craniotomy, but they look a little different now. Initially, they actually looked different without one’s having to read them because my handwriting had gone all to hell (fine motor skills issue). Then, perhaps a week or two after surgery, I found it much more comfortable to write in very tiny letters. I’m not sure why; perhaps the smallness gave me more of a sense of control or maybe it just felt quieter¹ to write that way.

But even now, the content of my checklists is slightly different than before. While I’m still occasionally having problems with brain overload around things that involve a lot of executive functions, I have to break complex actions down into smaller steps. For example, instead of “make zucchini muffins,” which has been something I’ve meant to do since I got home from the hospital, I have “process zucchini” (meaning I have to either clean and chop/grate it or thaw it), then “assess condition of carrots,” “check for other ingredients,” “make shopping list,” etc. I used to be able to roll all of these steps together into one item—and soon I will be able to do so again—but now I find it less intimidating to break the steps down. This is, apparently, one of the “workarounds” that a neurocognitive therapist would suggest. (See post "The One Month Checkup")

Aside from Santa and recent craniotomy patients, do you know who else relies on checklists? Surgical teams. Their lists, however, accomplish more than producing zucchini muffins or determining whether young Bobby should get a toy robot or a lump of coal; their checklists save lives.

The 2009 bestseller The Checklist Manifesto: How to Get Things Right by surgeon Atul Gawande was recommended to me this past summer by a cousin of mine who works in the field of public health². Gawande was concerned that despite the expertise of everyone who works in an operating room, careless mistakes and oversights still happened that either led to complications, infections, or even death. He wanted to find a way to make something as complex as surgery a mistake-free zone (or as close to it as humans can get). He examined other fields, such as aviation and skyscraper construction projects, and noticed a reliance on checklists. They do not cover everything—a novice could not just grab a plane’s checklists and successfully fly the thing—but they cover the things that matter and the things that could easily be overlooked. So he created and honed a series of checklists for safe surgery. If I remember correctly, in one of the hospitals piloting the checklists, the surgical infection/complication rate plummeted by some ridiculously high percentage rate.

So around 7:00am, November 1^st, I was lying in my warm lavender marshmallow when a nurse came in with a form for me to sign in various spots. She got busy with another task, so I had an opportunity to look over the rest of the form. On the back there were four color-coded checklists. I wasn’t able to read them all—I think the nurse had started some “joy juice” in my IV line—but I did notice these items, which I recalled directly from Gawande’s book (I’m paraphrasing here):

·       Team members make introductions and know each other’s names
·       Antibiotic is administered before surgery

That first item may seem odd. A bit trivial-sounding, no? Well, no, it’s not. Gawande found that surgical teams that knew each other’s names and roles in the surgery were more likely to communicate with one another, correct their mistakes, and even question the top-dog surgeon about whether they contaminated their gloves or removed that tiny sponge before closing the patient up. Essentially, people are less likely to correct or question the actions of strangers.

I cannot tell you how relieved and happy I was to see these checklists. I noticed behaviors in my surgical team that I don’t recall observing when I had surgery in 1985 (two of them) and 1991. Things I noticed, which I believe were items on the first checklist on the far-left side of the page:

·       The anesthesiologist met with me before surgery! I had never talked to one before. Dr. Mullan had asked if I have a problem with anesthesia, which I do (nausea), so the anesthesiologist, Dr. Murray, noted that and explained how she’d layer the anesthetic to prevent nausea. “Do you ever get motion sickness?” Yes, I said, so she ordered a scopolamine patch for me to wear behind my ear for up to three days. I have a somewhat hazy but warm impression of her: big blue eyes and blonde hair peeking out from under her cap, patting my arm periodically in reassurance. I felt cared for, and aside from one little spot of urpiness (I refer to the "vomit bean" incident in post "Pain and Percocet"), I was not troubled by nausea.

·       Dr. Mullan came in to see if I had any questions, which I don’t think I did. (I opted not to ask him if he were really just a zombie hungry for my brains.) Then he took a Sharpie, apologized, and put his initials on my head near where the meningioma was. Another check on the list: Is the correct part of the body marked for surgery?

·       After he left, two surgical techs of some sort—I don’t remember their jobs, but I remember their names: Tim and Eric—came in and asked if Mullan had signed my head. Yes. They approached to verify that, but then seeing the density of my hair, asked, “Um, could you help us out here?” So I showed them the spot. Another tick on the checklist.

The surgery went well, clearly. However, caring for a patient outside of the OR is still a complex task, which is complicated by the revolving staff of nurses and ICU doctors. One doctor’s orders may be contradicted by another’s. (The doctor in the ICU strictly forbade my taking any birth control pills during my hospital stay, but I was cleared by someone else to take one the next evening when I moved to the regular floor.)

Another issue is that there is a standard protocol for dealing with post-operative patients, but sometimes the note that a particular patient shouldn’t follow that protocol exactly does not get passed along. For example, anesthesia tends to do a number on a patient’s ability to go number two. (Blogger “The Everywhereist” reported that she could not poo for four days.)

Constipation causes you to strain, thus creating pressure in a craniotomate's freshly cracked noggin, which is a no-no. Therefore, once you’re able to use the potty, you’re given Senokot and Metamucil, two different kinds of laxatives, to help move things along. 

But I don’t have a colon. I will never in my life need a stool softener or a laxative to help with normal, um … output. I mention this lack of colon to every medical professional I meet because:

1.     It’s a rather large organ to be missing;

2.     Twice in 1985, unfamiliar doctors tried to prep me for either an appendectomy or emergency abdominal surgery due to a seriously diseased colon—when I had neither organ! Imagine being thirteen years old and having to contradict a grown-ass man who happens to be a doctor about a medical procedure he thinks is necessary. Both instances were obviously mistakes – wrong patient and wrong X-ray films, respectively—but if they had just read my freakin’ chart!

3.      What is normal for me regarding elimination is not normal for you folks burdened with colons. For the colon-free, the words “diarrhea” and “constipation” are somewhat meaningless. We're kind of superhuman in that regard. Some of us also don't get sick very often or for very long because any illness that involves the gut just isn't in us for very long.

Once I was out of the ICU³, what did the nurses bring me – twice? Senokot and Metamucil. This was not a big problem because I could easily say, “I’m not taking those because I don’t have a colon and don’t need them,” but my concern was that somewhere on my med orders there should have been a note about this. Why was this not communicated to the next shift? I was still a bit groggy and was being given what seemed like a cornucopia of drugs –what if I hadn’t questioned what I was being given?

So there still are gaps in the complicated, complex arena of patient care, but things have improved and continue to improve. The next time you go in for surgery, ask if there's a checklist and don't be afraid to question their orders!

¹ Avoiding noisiness in all forms, including visual and informational noise, was important to me in the first two-three weeks after surgery. (See post “A Post-Craniotomy Media Diet”) In fact, I bought some fragrances from Black Phoenix Alchemy Lab just so I could receive the two free samples of holiday scents named “Stillness” and “Silence.” Yeah, the descriptions of the smell of the scents were good, but the names really hooked me. BPAL creates unusual scents, often based on literature, movies, or mythologies. There’s a line of scents based on works by Neil Gaiman, H. P. Lovecraft, Lewis Carroll, as well as Hellboy, Fraggle Rock, Sherlock Holmes, and role-playing games. Some of my favorites include Gnome, Bordello, and Shub-Niggurath (the Black Goat of the Woods with a Thousand Young), which happens to smell like Christmas cookies! Not such a fan of Embalming Fluid, though. 

² Some people erroneously think that “public health” means free clinics or other cheap healthcare for the disadvantaged, but it’s not that. Public health is the field that seeks to promote better health in communities or populations as a whole, as compared to the field of medicine which seeks to treat individual patients. Research in one field may affect actions or policies in the other, though. Think of the anti-smoking campaigns or blood pressure monitoring; public health experts were most likely involved in how much you see those things now. Please correct me if I’m off-base here, Oilcan.

³ One my nurses in the ICU was also colon-free! She was only the third person in 32 years I had met who was a member of “my tribe.” We swapped stories.