Saturday, July 24, 2004

Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes by Robert M. Wachter and Kaveh G. Shojania, both M.D.s themselves, is not nearly as sensationalistic as the title might imply. It is instead a fascinating exploration how how medical mistakes happen and what might be done to reduce the number of them, both from the medical and the patient ends.

People tend to look at medical personnel as either experts on subjects far too complex for the everyday human, or money-grubbing butchers. Internal Bleeding portrays doctors, nurses, pharmacists, and others in medical fields as exactly what they are: human beings with no special powers except training. The case studies they discuss are detailed without blame for individuals (in most cases), but they point out exactly where systems fail -- for example how the various procedures that are supposed to ensure June Morrison and Joan Morris don't get mixed up in the hospital, or that the wrong leg of diabetic Willie King doesn't get amputated (a case of personal interest to me as I live a few blocks from the hospital where it happened, and indeed once spent most of a night retching in their emergency room), or that the blood type of a transplant patient Jesica Santilan matches those of the organs she received in her transplant, all failed from a long series of separate human errors. Wachter and Shojania also have realistic (if sometimes expensive, as they admit) suggestions for hospitals, clinics, nursing homes, etc., to avoid these mistakes; suggestions that are not the type of safety rules that get routinely ignored (such as the rules that certain dangerous drugs be kept in locked cabinets, exactly where they aren't accessible when needed immediately for a flatlining patient).

They also provide a chapter and several appendices of things patients can do for themselves -- for example, making sure they know what drug in what dosage is being prescribed for them before leaving the doctor, so as to avoid the situation of Ramon Vasquez, whose pharmacist misread the handwritten prescription and gave him the wrong heart drug. (He was supposed to get 80 milligrams of Isordil daily; instead, he took 80 milligrams daily of Plendil, which is normally prescribed at 10 millligrams per day.) A similar case happened to a friend of mine, whose prescription was filled with some completely different drug from that intended; however, Ben knew what he was supposed to be taking and so caught the error. I think this book does an excellent job of showing people the need to be careful and aware of what's going on in their own medical care without being scary and inducing a fear of any and all medical help.

Friday, July 02, 2004

Richard Clarke's Against All Enemies: Inside America's War on Terror is an illuminating look at the U.S. government's response to terrorism. Clarke worked for the Reagan, Bush Sr., Clinton, and Bush Jr. administrations; presumably he's pretty good at his work to have lasted and kept getting promoted through 20 years under both major parties. However, George W. Bush's administration's response to September 11, 2001, disappointed him, as it will anyone who reads this behind-the-scenes look at officials (Secretary Donald Rumsfeld) who "complained that there were no decent targets for bombing in Afghanistan and that we should consider bombing Iraq instead, which, he said, had better targets." (Clarke compares this to "invading Mexico after the Japanese attacked Pearl Harbor.")

Clarke explains much of the recent history of Islamic fundamentalism in the Middle East, starting with the 1979 Soviet invasion of Afghanistan and the revolution in Iran which replaced the U.S.-friendly Shah with the Ayatollah Khomeini. Most Americans at the time focused on these events only as they immediately affected the Cold War balance of power and the U.S. (the Iranian hostage crisis, for example) and not how the changing politics in these largely Muslim countries affected the attitudes toward the U.S. of a huge block of people. U.S. military forces being moved into the Persian Gulf area in the 1980s did not help matters, even though the Reagan administration felt it necessary to counter the possibility of Soviet forces doing the same. U.S. forces were placed in Lebanon to try and help stabilize the country during the partially Iran-instigated turmoil, but were withdrawn after car bombings of a Marine barracks and the U.S. embassy killed several hundred people. In the eyes of the bombers and many others, this was proof that terrorism worked as desired against the U.S. Clarke tracks the shifting alliances through 25 years which included continued Afghan fighting, the Iran/Iraq war, the Iraqi takeover and expulsion from Kuwait, and the results of U.S.-Israeli cooperation. He gives his opinions about about which things the U.S. did were good and which made things worse in the long run. Whether or not one agrees with his opinions, his behind-the-scenes looks at international politics are fascinating.

'"Well, something just exploded. We don't know if it was a bomb, sir. The World Trade Center," a young Navy officer replied. "I know you handle terrorism, sir, and we're supposed to tell you when something happens that might be terrorism, but do you want to know when things happen in the United States too? Do you guys handle domestic crises too?" The notion that might occur in the United States was completely new to us then.'
Clarke, then working for the National Security Council, calls the government Situation Room on the day of the 1993 World Trade Center bombing.
This seems to have been just the beginning of difficulties in figuring out who was responsible for doing what during crises affecting the U.S. This as well as money -- "There was not one fund for counterterrorism, but several department budgets. We sought to fund programs in the Department of Energy, the Health and Human Services Department, the Defense Department, the Justice Department, the Federal Emergency Management Agency, and other departments whose Congressional appropriators did not see 'their' agencies as being counterterrorist departments." -- seem to have been great difficulties in 1990s attempts to be on guard against terrorism.

Clarke has a tendency to say "we" did this or that, and one is often not sure if it's the U.S. government, the agency he's working for, or even an informal group of people he'd put together. It's easy to feel that he's saying he was personally involved in every single thing he's discussing, which he may or may not have meant to imply. However, the personal look at individuals he worked with, particularly presidents (Clinton and Bush Jr.) makes the names and faces from the news a lot more human.

When he talks about the George W. Bush administration, Clarke gets much firmer in saying that the wrong things were done and that Iraq was not the place to focus. And though I believed that already, this book gave me a lot more evidence that the top levels of W.'s administration ignored what the people working for them were trying to tell them. Maybe Clarke's ideas on what can be done to better the existing mess would work, maybe not. But both the government and the people voting for that government need information to work with, and this book provides a lot.