How checklist improves productivity in Delhi hospital

In his book, “Checklist Manifesto”, Atul Gawande of Harvard Medical School explains how a simple tool such as a ‘checklist’ can eliminate errors and prevent accidents and deaths. Gawande had helped WHO in developing a ‘safe surgery’ check list,  which was later implemented in different pilot sites all over the world.

While visiting the pilot sites, Gawande came across surgeries being performed in so many different kinds of settings. This is how he describes a charity hospital in Delhi:

The volume of patients they were asked to care for in this city of thirteen million people was beyond comprehension. The hospital had seven fully trained anesthetists, for instance, but they had to perform twenty thousand operations a year. To provide a sense of how ludicrous this is, our New Zealand pilot hospital employed ninety-two anesthetists to manage a similar magnitude of surgery. Yet for all the equipment shortages, power outages, waiting lists, fourteen hour days, I heard less unhappiness and complaining from the surgical staff in Delhi than in many American hospitals I’ve been to"

Twenty thousand operations per year handled by seven anesthetics means an average of eight operations per anesthetist for every single day of the year. That’s amazing. I wonder what their technique is. Do they use hammers? The check list for the anesthetist will simply read:

1) Sterilise hammer.

2) Put on surgical gloves.

3) Lift hammer from the table

4) Give a solid whack on the patient’s head.

5) Move to next operating table.

One shining moment....

A friend, in one of his introspective moods, told me, “Raj, let’s be honest. What have you and I achieved in this world? Have we done anything of any significance to anyone? When one of us dies, our entire life story will be summed up thus: “He was born, he lived and then he died” What else is there to write?

In that respect, Edith Shain is better off than either of  us. She suddenly became a celebrity, decades after World War II, asserting that she was the nurse kissed by a sailor in Life magazine’s memorable photograph of V-J Day in Times Square. That was her solitary moment of fame. She died last week. Here tombstone can read, “She was born, she worked as a nurse, she kissed a sailor and died”.

Or take the case of character actor Mac Mohan who died last month. He may have acted in 175 movies, but he is remembered only for his role of Gabbar Singh's sidekick Sambha in Ramesh Sippy's blockbuster "Sholay". That was his only claim to fame. His epitaph can read, “He was born, he was Gabbar Singh’s sidekick, then he died”.

I remember reading a news item many years back about a lift operator in a hotel. Apparently, a leading actress was staying in the hotel and got into the lift. The operator seized the moment to give her a hug. He was reported and was handed over to the police. Now, the poor operator could have gone up and down in his lift a million times and ended his career with nothing to report. But he had sterling stuff in him. ‘Carpe diem’, he shouted while grabbing his opportunity and..the actress. So, when he dies, his obituary can read, “ He was born, he operated lifts, he hugged a leading actress, then he died”. How many of us can claim to have such an impressive CV?

Belief in oneself

After being 8-14 down in the first game, Saina Nehwal fought back and won the finals of the Singapore Open yesterday. Later, she told a reporter, “At 8-14, I was nervous. Then I believed in myself and told myself to play my best and give my 100 percent. That worked for me”. When she won the finals of the Indian Open in Chennai last week, despite being a game down, she said the same thing about believing in ‘herself’.

Saina certainly comes across as a determined person and has demonstrated her grittiness on quite a few occasions when the chips were down.

But then, every sportsperson is trained to behave the same way. Her Chinese competitor must also have been told by her coach, “If you have a 14-8 lead, don’t relax. Go for the kill. And finish your opponent”.

If every competitor believes in herself, plays her best and gives off her 100 percent, as she is trained and mentally conditioned to do, then no match will come to an end. It will stretch on and on, with neither of the players giving in. The one who is leading will bring out her killer instinct, while the one who is trailing will show her fighting spirit, with both ‘believing in themselves’.

But then matches do end and someone does emerge the victor. In this case, was Saina’s 100 percent better than her opponent’s 100 percent? Or was Saina’s belief in ‘herself’ stronger than her opponent’s belief in ‘herself’?

Probably the simpler explanation is that history is written by the winner. The quotes that make it to the headlines are those of the winner’s. So, whenever Saina won she would have been quoted as saying that she believed in herself. And we remember those quotes.

The times that she lost, she wouldn’t have been quoted as saying, “I lost because I didn’t believe in myself”. Or, “I gave only 80% today”.

With reporters screaming for sound bytes, the ‘winner’ is expected to come up with a quotable punch line offering a clear explanation for her victory. It couldn’t have happened by chance. Surely, there was a plan in place and which was executed well? So, the poor sportsperson is forced to come up with these lines whether he or she believes in them or not.


Update 27/6/10: Well, by winning three events in a row, the latest being the Indonesian Open, Saina has demonstrated that her belief in herself is not misplaced. I like her 'quiet' determination, of the non-flamboyant, Rahul Dravid variety. May more such people succeed.

How pleasure works

Aware of my violent reaction if a song not composed by A.R.Rahman is played in my presence, my daughters try to test my loyalty by playing out an unfamiliar number and checking if I like it. If I happen to like the song and it turns out that it is not a Rahman song, or if I dislike a song that turns out to be Rahman’s, I am ticked off sharply.

Despite inheriting some great genes, these kids simply have no clue how the brain works. For their benefit, I am reproducing a quote from a book “ How Pleasure Works” by Yale psychologist Paul Bloom. (source).

As the founder and CEO of Perrier North America, it was important for Bruce Nevins to convey to people how good his product tastes. It was a bad day for him, then, when he was on a live radio show and asked to pick out the Perrier from a selection of seven cups of water. He got it on the fifth try.

There is nothing wrong with his taste buds. In blind taste tests, with waters at equal temperature, it is almost impossible to tell the difference between tap water and luxury bottled waters.

I would bet, though, that once Nevins left the radio show and went back to his life, he still thought that Perrier tasted really good - the radio test didn't prove otherwise. If so, he would be right. That is, someone who prefers the taste of Perrier to other waters but fails a blind taste test is not dishonest or confused. Perrier does taste great. It's just that to appreciate its great taste, you have to know that it is Perrier.

Got it, girls? To appreciate Rahman’s great music, you have to know that the song was composed by Rahman.

My country is the greatest.

An article by Priya Ramani on ‘our pseudo-nationalism’ got her a lot of hate mail and generated quite a buzz in the Twitter world. She wrote:

Recently I’ve become increasingly convinced that I’m not an Indian….. I have no furious loyalties to the Baganapalli or Alphonso. In fact, I can think of at least six fruits that I prefer to the mango. I have never eaten an entire paan or a pot of mishti doi (though I have tried both) and I don’t spit in public or private (except for that one time I tried a meetha paan)…. I don’t understand that other national obsession, cricket, either. White is not my favourite skin colour. I don’t read Chetan Bhagat or Paulo Coelho. I feel depressed every time I wear a salwar-kameez

I don’t think we’re the greatest people on earth. I don’t understand our sense of fake pride and nationalism. That whole chest-thumping Jai Ho phase? I never got it. Most of the insightful books and films/documentaries about India have been written/made by outsiders.

I agree with her about the chest-thumping and the constant proclamation of patriotism that we keep indulging in. When Sachin scores runs, he is not doing it for himself, but is sweating it out for his motherland. When Amitabh is acting, the last thought on his mind is money; he is working for the greater glory of the country and to keep the country’s flag flying high. Every morning these guys wake up and feel the need to say something profoundly patriotic on their blogs or tweats. (“My caste? I am an Indian”).

As Shaw put it, patriotism is the unreasonable belief that your country is the best merely because you were born in it. Being born in India was a random genetic event. Just accept it as a fact and move on. You don’t have to be proud of it, nor have to regret it.

Culpable negligence

Swaminathan Aiyer argues that the Indian Railways has caused more deaths than the Bhopal disaster and yet the public has not displayed the same degree of concern:

Consider Mumbai’s suburban rail services. Activist Chetan Kothari used the Right to Information Act to get data on people killed in Mumbai by the Central and Western Railway, which run through the city. Answer: 20,706 people have been killed in the last five years. This is six times as high as Bhopal’s 3,787 immediate fatalities and higher than even the long-term fatalities estimated at 15,000-20,000.

.. Union Carbide was lambasted for not using the best technology available to avert risks and deaths. But do we castigate the railways for not investing in the best safety technologies, and creating barriers to stop people from crossing the tracks? Union Carbide was slated for negligence in a shutdown plant. But the railways continue to be negligent year after year in a running organization that runs down people.

Many of us howled for justice after Bhopal. Many demanded the arrest of Union Carbide chief Anderson. Those convicted last week included Keshub Mahindra, the non-executive chairman with a largely ceremonial position. How many of us have demanded even the dismissal, let alone conviction, of the railway staff, Railway Board members or railway minister for the continuing holocaust in Mumbai? The non-executive head of the railways is, formally, the President of India. Has anybody demanded that Pratibha Patil be prosecuted for continuing railway deaths?

The Bhopal incident is certainly one of the worst and most tragic the world has seen. But, I also feel sorry for the plant engineers or managers at the Bhopal plant, who were convicted after a trial that ran for 25 years. What happened at Bhopal was an accident and not an act of terror with an intention to kill. But, the law says that negligence that leads to death is an offence. It believes that ‘punishment’ will act as a deterrent and reinforce the message that when safety of public is at stake one is obliged to be extremely vigilant.

But why scream for the head of Anderson alone? As any person who has undergone a basic course in Quality management will tell you, every accident can be traced back to human error. The Mangalore air crash was not an act of God, but caused due to negligence somewhere in the process. Did we ask for the arrest of the Chairman of Air India? The crane collapse at the Metro Railway site was a preventable accident. Did any Chairman get arrested for negligence? Each time we can demonstrate and prove that someone was guilty of an act of commission or omission.

As Aiyar concludes:

NGOs and the media suffer from a terrible double standard. They will pounce on negligence by a multinational, and rightly so. But they act as though the public sector has a licence to kill. That is disgraceful.

God and religion

The Crest Edition of today’s Times of India carries a series of articles probing the subject, “Does God exist?”. The usual arguments, for and against, have been put forward. Depending on one’s pre-disposition, one can find the material to agree with or disagree.

But the subject brought to mind some brilliant articles that I had come across in the website of “Edge, The World Question Centre”. Every year, Edge poses a question and invites experts from different fields to respond to that. The question asked in 2006 was, “What is your dangerous idea?” and some of the responses centred around God and religion.

Some excerpts:

In his article “Science must destroy religion”, Sam Harris, neuroscientist, warned that ‘religious tolerance” could help propogate absurd ideas and that it was as dangerous as religious war.

Despite the ecumenical efforts of many well-intentioned people, irreconcilable religious commitments still inspire an appalling amount of human conflict.

In response to this situation, most sensible people advocate something called "religious tolerance." While religious tolerance is surely better than religious war, tolerance is not without its liabilities. Our fear of provoking religious hatred has rendered us incapable of criticizing ideas that are now patently absurd and increasingly maladaptive. It has also obliged us to lie to ourselves — repeatedly and at the highest levels — about the compatibility between religious faith and scientific rationality.

 But Robert Provine, psychologist, talked about the futility of trying to resolve religious conflict.

Resolution of religious conflict is impossible because there is no empirical test of the ghostly, and many theologians prey, intentionally or not, upon the fears, superstitions, irrationality, and herd tendencies that are our species' neurobehavioral endowment. Religious fundamentalism inflames conflict and prevents solution—the more extreme and irrational one's position, the stronger one's faith, and, when possessing absolute truth, compromise is not an option

Scott Atran, anthropologist, feels that science must learn a few methods from religion if it has to win the battle.

Science treats humans and intentions only as incidental elements in the universe, whereas for religion they are central. Science is not particularly well-suited to deal with people's existential anxieties, including death, deception, sudden catastrophe, loneliness or longing for love or justice. It cannot tell us what we ought to do, only what we can do. Religion thrives because it addresses people's deepest emotional yearnings and society's foundational moral needs. Religion is the hope that science is missing.

Finally, Jesse Bering, Institute of Cognitive studies, says that it is impossible for Science to get rid of the concept of God and religion. It is something hardwired in our brains and made permanent by natural selection.

No matter how far our thoughts shall vault into the eternal sky of scientific progress, no matter how dazzling the effects of this progress, God will always bite through his muzzle and banish us from the starry night of humanistic ideals. 

Science is an endless series of binding and rebinding his breath; there will never be a day when God does not speak for the majority. There will never be a day even when he does not whisper in the most godless of scientists' ears. This is because God is not an idea, nor a cultural invention, not an 'opiate of the masses' or any such thing; God is a way of thinking that was rendered permanent by natural selection. God too is a biological appendage; until we acknowledge this fact for what it is, until we rear our children with this knowledge, he will continue to howl his discontent for all of time

A proof that the Hindus had the Binomial Theorem

The manuscript, “Asiatic Research or Transactions of The Society Instituted in Bengal for inquiring into the History and Antiquities, the Arts, Sciences and Literature of Asia – Volume II “, published in the year 1799, has a chapter, “ A Proof that the Hindus had the Binomial Theorem” ( page 487) by Mr Reuben Burrow.

An extract:

With respect to the Binomial Theorem, the application of it to fractional indices will perhaps remain for ever the exclusive property of Newton, but the following question and its solution evidently show that the Hindoos understood it in whole numbers to the full as well as Briggs, and much better than Pascal. Dr. Hutton, in a valuable edition of Sherwin’s tables, has lately done justice to Briggs; but Mr. Whitchell, who some years before pointed out Briggs as the undoubted inventor of the differential method, said he had found some indications of the Binomial Theorem in much older authors. The method however by which that great man investigated the powers independent of each other is exactly the same as that in the following translation from the Sanscrit.

" A Raja's palace had eight doors; now these doors may either be opened by one at a time, or by two at a time, or by three at a time, and so on through the whole, till at last all are opened together. It is required to tell the numbers of times that this can be done ?

" Set down the number of the doors, and proceed in order, gradually decreasing by one to unity, " and then in a contrary order, as follows :

8 7 6 5 4 3 2 1

1 2 3 4 5 6 7 8

" Divide the first number eight by the unit beneath it, and the quotient eight shows the number of times that the doors can be opened by one at a time. Multiply this last eight by the next term seven, and divide the product by the two beneath it, and the result twenty-eight is the number of times that two different doors may be opened ; multiply the last found twenty-eight by the next figure six, and divide the product by the three beneath it, and the quotient fifty-six shows the number of times that three different doors may be opened. Again, this fifty-six multiplied by the next five, and divided by the four beneath it, is seventy, the number of times that four different doors may be opened. In the same manner fifty-six is the number of fives that can be opened : twenty-eight the number of times that six can be opened: eight the number of times that seven can be opened ; and lastly, one is the number of times the whole may be opened together; and the sum of all the different times is 255."

The demonstration is evident to mathematicians; for as the second term's coefficient in a general equation shows the sum of the roots, therefore, in the n power of 1+1 where every root is unity, the coefficient shows the different ones that can be taken in n things : also, because the third term's coefficient is the sum of the products of all the different twos of the roots, therefore when each root is unity the products of each two roots will be unity, and therefore the number of units, or the coefficient itself, shows the number of different twos that can be taken in n things. Again, because the fourth term is the sum of the products of the different threes that can be taken among the roots, therefore, when each root is unity, the product of each three will be unity, and therefore every unit in the fourth will show a product of three different roots, and consequently the coefficient itself shows all the different threes that can be taken in n things; and so for the rest.

Positive energy

“The positive energy of all my devotees saved my life” said godman Sri Ravishankar after the miraculous ‘incident’ in which a bullet missed him by a few minutes and a few kilometers.

Most charlatans and quacks resort to such terms as ‘energy’ and ‘ vibrations” to give their dubious teachings a scientific spin, but Sri Ravishankar is refreshingly different. He knows his thermodynamics. When he says ‘positive energy’, he knows what the term connotes.

Eric Schrödinger ( “What is life?) and later Eric Schneider ("Life as a manifestation of second law of thermodynamics") had postulated that the sole purpose of life was to disperse energy. Virtually all organisms, including human beings, are sunlight transmogrified waypoints in the flow of energy. They do so not by burning brightly and disappearing, like a fire torching a forest, but through stable metabolic cycles that store chemical energy and continually reduce the solar gradient. ( source).

Albert Einstein famously derived the equation that established the relationship between energy and mass. Applying the equation, Sri Ravishankar could easily calculate that the bullet weighing around 10grams, fired from a distance of 750 metres can be deflected by a few kilometres, by the collective energy exuded by millions of his sunlight-transmogrifying devotees.

What a man!

An open letter to my daughters

Dear Daughters,

I always thought that you Millenials (those born between 1982 and 2002), with your ubiquitous iPods and 24/7 e-mail access, were spoiled and pampered whiners whose self-esteem had been overstoked by anxiously over-involved parents like us and who were granted undeserved As from teachers. All this has made your generation profoundly narcissistic and made you unmanageable later in life. You’ve become over-confident, nay irrationally exuberant and are headed for a major crash. So I concluded.

Apparently, that’s not true. ( source)

Though your lack of humility is hard to digest, I understand that you are not necessarily maladapted. On the contrary with your inexhaustible well of positive self-regard, your refusal to have your horizons defined by the limitations of our era, you may end up being far more resilient than those of our generation.

Yes, we certainly knew how to shape you, didn’t we?