Not quite, but my iPhone inadvertently made a strong case for medical checklists.
This past weekend, I was once again in Denver. Colorado is a great destination for those who love natural beauty and outdoor adventure. My own personal adventure involved a fierce competition between me and water. Which machismo activity was I engaged in?
- Level 5 white water rafting
- Slalom water skiing
- Cliff diving
- Hang gliding with water landing
- Sitting poolside with my iPad
I put the iPad down and crept into the pool slowly. Why do folks in the pool always beckon others in claiming the water temperature approaches hot tub levels, when it’s freezing? I’ve never been one to dive right in. I enter at a glacial pace. I dipped my toe in and in 10 short minutes, the water and I became as one. Then, the shock struck me with cold fury. Had Zeus pierced me with a lightning bolt, it would have been a mere pinprick in comparison. At that moment, I am standing in the pool with the water level at my navel. The iPad was resting safely on a nearby lounge chair. The iPhone, however, was in my pocket, an electronic submersible being bathed in chlorine.
While it took me 10 minutes to enter the pool, it took me 10 nanoseconds to exit it. The iPhone was dead. There were no breath sounds or pulse. I scanned the area for an AED (automated external defibrillator), not for the fibrillating phone, but for its terrified owner. ‘Get some rice’, my friend exhorted. I had heard of this fantasy where dead phones were resuscitated by lifesaving, hydrophilic rice. I sprinted to the hotel restaurant and received a large container of raw rice. I plunged the iPhone into the abyss and prayed for a miracle.
How could I be so careless? Humans make mistakes and I am a typical Homo sapiens. Who hasn’t locked their car keys inside their car, placed a food item in the fridge that needed to be frozen or left the umbrella in the car at the wrong time? Yes, to err is human, but drowning your iPhone seems downright inhuman. Indeed, if there were an eighth deadly sin…
Could this catastrophe have been avoided? What if I always performed a ritual prior to entering a pool, a lake or an ocean? What if I checked my bathing suit pockets every time before my toe hit the water? Had I done so, I would have discovered the iPhone before it became iDead. In other words, if I had a swimming checklist, my phone would still be alive today. If only I had considered this ‘app’ beforehand.
Medical checklists are red hot these days. These are procedures that doctors and nurses are encouraged or required to follow without exception to prevent human errors. The medical community has belatedly adopted this concept from the airline industry, where pilots proceed through an ordered checklist every time before take-off. Deviating from the ritual invites disaster, even though checklist adherence can become a mechanical process that can lose its meaning. (How closely do we listen to the flight attendants as they yawn through their safety presentations at the beginning of flights?) Checklists are being adopted in operating rooms throughout the country to reduce errors such as wrong sight surgeries and other preventable events.
Just this week, I read of two medical horrors that could have been prevented had checklists been followed.
- The prestigious UPMC in Pittsburgh has shut down their living kidney donor transplant program when several folks missed that a donor was positive for hepatitis C. Yes, this tainted kidney was transplanted into an unsuspecting recipient. Whoops!
- A Florida veteran is suing for a mere $30 million claiming he contracted hepatitis C from a colonoscopy performed at a VA hospital 2 years ago. It is well known that many cases of hepatitis C and other infections transmitted endoscopically occurred when standard scope cleaning procedures were breached.
My advice? When you’re ready to dive in from the deep end, or you are poised to begin a colonoscopy, think of the sage advice from the Christmas standard, Santa Claus is Coming to Town. Are you making a (check)list and checking it twice?