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This is a book about failure: how it happens, how we learn from it, how we can do better. Although its focus is medicine, its message is for everybody. Against expectations, that turns out to be hugely, enthrallingly optimistic. Atul Gawande is a surgeon at the Brigham and Women’s hospital, Boston. He is also – and this could only happen in America - a staff writer on The New Yorker. He sees medicine from the inside, but with an outsider’s perspective. His book is riveting: packed with insights, its luminous prose lifting effortlessly off the page. It opens with a case that still haunts him: a Portuguese woman in her seventies whom he was assigned to look after in his final year as a medical student. She "didn’t feel too well", as the technical diagnosis has it, but showed no conventional signs of illness. The trainee Gawande ran the usual tests and waited to see what turned up. It was only thanks to the diligence of his supervisor, who had a hunch something was wrong, that his patient was saved from a resistant, fulminant pneumonia that erupted suddenly and unexpectedly and nearly killed her. Diligence is fundamental in medicine, first to recognise failure and then to learn from it. As examples, Gawande reports on efforts to eradicate polio in India, to cut military casualties in Iraq and to reduce infection rates in hospitals. None of this involves hi-tech medicine. Instead, it requires constant attention to details which, alone, appear insignificant but when added together can be epoch-changing—getting doctors to wash their hands, for instance. The story of war casualties is instructive. Over time, though fire-power has increased, lethality has decreased. In the American War of Independence, when soldiers faced bayonets and single-shot rifles, 42 per cent of those wounded died. By World War II, soldiers faced grenades, bombs, shells and machine guns, yet the death rate fell to 30 per cent. Vietnam and the first Iraq war saw only a small improvement — to 25 per cent. The military were desperate to do better, and the assumption was that success would come with new treatments and techniques. It didn’t. It came by increasing the speed with which casualties were treated, getting medical teams closer to the front. Civilian surgeons speak of the "golden hour" within which, if a trauma victim can be treated, there is a good chance of success. On the battlefield this becomes the "golden five minutes". Getting emergency life support to casualties in the field (basic aid like stemming blood loss), shipping them back for more extensive treatment and then flying the most seriously injured out for specialist surgery has saved innumerable lives. Among 609 American soldiers wounded in the two battles for Fallujah in 2004, just 10 per cent died. No breakthrough drug or revolutionary surgical technique could have achieved as much. This was about using basic medicine and applying it effectively. Gawande calls it a "stunning accomplishment". So is this book. It is essential reading for doctors and should be handed out with the antibiotics to all users of the NHS. It has already been described as a modern masterpiece—and so it is. —By arrangement with The Independent
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