What could be the worst nightmare for the parents of a toddler?
In a small Austrian town in the Alps, a mother and father were strolling in the woods with their three-year-old daughter. The parents lost sight of the girl for a moment and that was all it took. She slipped into an icy fishpond. The parents frantically jumped in after her. But the pond was dark and it took them thirty minutes before they could find her at the pond bottom. Eight minutes later when the rescue team arrived, the girl’s condition wasn’t good. She was unresponsive with no pulse and no sign of breathing. Her pupils were dilated and unreactive to light, indicating cessation of brain function. She was gone.
But the emergency technicians didn’t give up. They flew her in a helicopter to the nearest hospital, where she was wheeled directly into an operating room. A surgical team immediately got her onto a heart-lung bypass machine. She had been lifeless for an hour and a half. By the two-hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. Since the debris and pond water severely damaged her lungs, they had to plug her to an artificial-lung system which required the surgeons to open her chest down the middle with a power saw and sew the lines directly into her aorta and her beating heart.
The surgical team moved the girl into ICU, with her chest still open and covered with sterile plastic foil. Through the day and night, the ICU team worked on suctioning the water and debris from her lungs with a fiberoptic bronchoscope. Over the next two days, all the girl’s organs recovered—her liver, her kidneys, her intestines, everything except her brain. She remained in the coma for more than a week. Then, slowly, she came back to life. First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But she underwent extensive outpatient therapy. By age five, she had recovered her faculties completely. Physical and neurological examinations were normal. She was like any little girl again.
This medical case study comes from Dr. Atul Gawande’s highly acclaimed book The Checklist Manifesto. He writes —
What makes this recovery astounding isn’t just the idea that someone could be brought back after two hours in a state that would once have been considered death. It’s also the idea that a group of people in a random hospital could manage to pull off something so enormously complicated.
To save this one child, scores of people had to carry out thousands of steps correctly: placing the heart-pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the exposed fluid in her brain; keeping a temperamental battery of machines up and running. For every drowned and pulseless child rescued, there are scores more who don’t make it—and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; someone fails to wash his hands, and an infection takes hold.
Today, we live in a world of extreme complexity. And this extreme complexity is the result of immense know how that we’ve accumulated over last few hundred years’ of scientific revolution. Unfortunately, this know-how has become unmanageable. The volume and the complexity of our knowledge have gone far beyond our individual ability to translate the benefits of that knowledge accurately and reliably. Knowledge has both saved us and burdened us.
So how did that team that fought day and night to save the life of the three-year-old girl in that small and ordinary community hospital in Austria manage to pull off such an extraordinary feat which involved dozens of complex procedures and maddening level of communication between people involved in the whole ordeal?
Their secret strategy was something so trivial that it would leave you baffled. They used Checklists.
In 1935 Boeing was demoing its latest bomber plane — Model 299 — to US army. After few seconds of takeoff, the plane crashed killing everyone except two people onboard. Subsequent investigation reports concluded that it was too much plane for a single pilot to fly. In other words, the plane controls had grown significantly more complex than its earlier versions. While trying to fly the plane the pilots forgot few basic steps which caused the accident.
Boeing realized that imparting more training to the pilots wasn’t the solution. So, they tried something different. Something far more simple and counterintuitive. They introduced a pilot’s checklist.
They made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots already know. They check that the brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked—dumb stuff. You wouldn’t think it would make that much difference. But with the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without a single accident.
Why did the checklist turn out to be such an effective solution?
In a complex environment, the primary challenge we face is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.
For example, a doctor forgets to check the pulse of the patient while trying to calm down his upset family member. Or a pilot forgets to extend the landing gear while trying to negotiate his preferences with air traffic controller.
In spite of all our training, skills, knowledge, and specialization, we still miss steps and make mistakes. Preventable mistakes.
Checklist work because they ensure that we don’t miss the obvious steps. They save us from avoidable failure by bringing our attention back to basics.
That’s what happened in that small Austrian hospital. When they got the first SOS from the little girl’s parents, the rescue squads and the hospital operators were ready with their checklists. Their checklist said that the rescue teams were to tell the hospital to prepare for possible cardiac bypass. They were supposed to inform the hospital even before they arrived on the scene, which gave enough preparation time to the hospital staff. According to the checklist, the hospital telephone operator worked down a list of people to notify them to have everything set up and standing by.
Checklists have proved unmistakably effective in improving the quality of decisions in fields as diverse as aviation and medicine. But there is one more field where checklists have found enthusiastic takers.
Charlie Munger — vice chairman at Berkshire Hathaway and Warren Buffett’s best buddy — is a big proponent of using checklists in investing. In fact, Munger sent a $20,000 check as a gift to Atul Gawande when he read his article on checklist.
Guy Spier, who paid $650,000 in an auction to have lunch with Warren Buffett, wrote in his book —
…the mind has a way of skipping over certain pieces of information—including rudimentary stuff like where I’ve left my keys. This also happens during the investment process. The checklist is invaluable because it redirects and challenges the investor’s wandering attention in a systematic manner. I sometimes use my checklist in the middle of the investing process to deepen my understanding of a company, but it’s most useful right at the end as a way of backstopping myself.
Put simply, the purpose of creating a checklist is to avoid obvious and predictable errors. Checklists facilitate analysis and rationality and eliminate the distractions that often cloud complex decisions. In other words, checklist acts as the final circuit breaker in a decision-making process.
I think a checklist is a way of managing our mind and guarding against our own follies.
In the end, a checklist is not a mere formula but a means of self-awareness.