"Complications" by Atul Gawande

Recently I’ve been reading (something I don’t get the chance to do a lot of the time!) a book called “Complications” by Atul Gawande. I had Awards Evening vouchers (I won Key Stage 4 awards for Contribution to my House, getting good GSCE grades and Computing) that I had to buy a book with for my prize. This book was recommended on many sites for prospective medical students and so I bought it! It’s written by a surgical resident in the US and contains many key ideas to being a doctor, which are presented through his personal anecdotes. It’s a brilliant book – very well written by anyone’s standards – and especially good for people interested in medicine. I’d recommend it to anyone!

In this book, many interesting and complex conditions and medical treatments are discussed. These include blushing and how this can be prevented by a surgical operation, the feeling of nausea, how and why people feel pain, operations to force people to lose weight, biopsies and more. The book also focussed on aspects of being a doctor, other than the actual conditions, such as when “good doctors go bad” and the possible role of robots in future.

I’ll start with a few of the conditions I found particularly interesting:

 Necrotizing Fasciitis

This is a condition I read about in the last chapter of the book (and is the freshest in my mind!), but I remember being especially fascinated by this lethal bacterial infection, partly because it’s so hard to diagnose and that we don’t know that much about it. This is caused by A Streptococcus, the bacterium that normally causes nothing more than a strep throat. However, some strains have evolved to become far more dangerous – such as this one. It is not known where exactly the bacteria come from, especially seeing as how cases of necrotizing fasciitis have developed from reported scratches (on any part of the body), after surgery, abrasions and even from punches on the arms. What I found most frightening is there are cases where no cause for infection has been found.

So what can this terrifying bacterium do? Well the press have nicknamed it the “flesh-eating bacteria” and this isn’t untrue! It invades deep under the skin (unlike cellulitis, which necrotizing fasciitis is often misdiagnosed as) and consumes any tissue it finds at a rapid rate. This leaves the tissue grey, foul and gangrenous. Without early surgical intervention, fatalities are shockingly common! Thankfully, this is a rather rare condition; however that also means it is often misdiagnosed. When the diagnosis of necrotizing fasciitis is confirmed from a sample of the infected area, the patient is taken into surgery, where all the infected tissue must be removed. This often means that limbs have to be amputated. In the case in the book – the lady with the infection went into surgery and survived with only the muscle in her leg removed. She went back to work in an office eventually and after a while could walk as well.

Sudden Infant Death Syndrome (SIDS)

This condition was particularly interesting to me because it’s another mystery to medicine. SIDS is a condition where babies die with no apparent cause of death. In a similar way that types of autism can be diagnosed as “Pervasive Development Disorder – Not Otherwise Specified”, SIDS is another diagnosis essentially meaning “we don’t really know”. In a case in the book, eight babies from one mother were diagnosed with SIDS. It is described how the pathologists can find no cause of death and so put “Undetermined” in the report. It reminded me of a case I read about in the news a few years ago, where a healthy young man dropped dead suddenly – a condition that is very rare and seems to cause people to suddenly die. This mystery fascinates me, although eventually the woman in the book admitted to counts of first degree murder by smothering her children in their sleep. In this case, there was a logical, fairly simple answer, but how do we know this is always the case?

Moving more on to the experiences Gawande showed in the book: one that particularly caught my attention, and is also fairly disturbing, is how common Anxiety and Depression Disorders are among doctors. A frightening  proportion of doctors (according to Gawande’s statistics) have disorders such as Depression and alcoholism. This of course could make them unsafe to treat patients and in “Complications”, Gawande tells of a doctor he knew who started off as a fantastic surgeon, but exhaustion and Depression ended up in him losing his licence.

Gawande also talks about diagnosis and the difficulties in diagnosing. The process is meant to be a purely factual one and he went on to say how the treatment for a patient should be decided by a mathematical process that determines the likelihoods of the possible outcomes of the diagnosis and of each treatment, however he said doctors have to make decisions in the heat of the moment, when a patient walks in, when something goes wrong in an operation or when a patient takes a sudden turn for the worse. They use their gut instinct; however Gawande also said how this can be influenced. For example, in the case of necrotizing fasciitis (see above), Gawande had experienced a case of this fatal bacterium merely weeks before. He described it as one of the worse cases he’s ever seen, the patient ended up dying after his organs started failing after they operated to remove the infected tissue that had consumed much of his tissue on the left side of his torso – the back and shoulder muscle, the abdomen, etc. This previous case had meant that the diagnosis was fresh in his mind and also something he didn’t want to see again. Had this previous patient not have been admitted, Gawande thinks he may have missed the correct diagnosis on the woman who eventually survived.

This book explores many issues of being a doctor and I would thoroughly recommend it to anyone, whether they’re interested in medicine or not!

In other news, today I attended my second training session with the Red Cross. We’ve covered how to lead sessions to peers and I’ve volunteered to train younger year groups in First Aid – I look forward to posting about this training and the sessions I end up running!