medical errors

The God in small things

Name the decisive war that Napoleon lost?

Most of us would answer Waterloo. In fact , Waterloo is almost a synonym for final comeuppance. The reality though is a little different. Napoleon actually won Waterloo. Yet, he managed to snatch defeat from the jaws of victory.

When Napoleon escaped from Elba in 1815 and the Hundred Day Campaign begun, the capitals of Europe instantly sprang to activity. The political uncertainty was profound , as everyone was well aware of Napoleon’s military genius. To put it mildly, the future of Europe and thus of the world was at stake. As fate would have it, it fell upon Colonel Cornelius Frazier,battalion commander of Wellington to face Napoleon. The British had cleverly planned to fight from high ground at Mont Saint-Jean. Napoleon was least bothered -he had the best of men, horses and lances -commanded by the mighty Napoleon himself. He decided to mount a deadly cavalry attack and separate the enemy forces from their cannons. Facing Napoleon’s marauding army, the British forces tried their best to avert disaster. There was only so much they could do and before long they started abandoning their cannons and ran for life. Napoleon beamed -he had defeated Wellington at Waterloo. He thought he would dine in Brussels that night.

I might have been writing this post in French, instead of English, had Napoleon’s men not forgotten a tiny detail. Those days, the cannons were muzzle loaded and were ‘triggered’ by placing flame in the touchhole. It was customary to destroy enemy cannons after capture by hammering a headless nail into the touchhole, making the cannon useless. Napoleon’s men had forgotten to bring that pack of nails!

As the battle raged on, the British realized the French blunder. This energized the British forces who thought they were staring at death. Eventually the British recaptured the cannons and the tide turned. Napoleon watched in horror as he lost the battle he had just won, all for want of a few nails. He had the best men and weapons, but that didn’t matter. A small detail, overlooked, changed the history of the world.

As doctors, we will see patients and we will make mistakes.Sometimes a mistake will cost the life of a patient. It may not change the history of the world, but it may snuff out the future of someone, who means the world to his loved ones. No one is immune to mistakes, but we take each mistake seriously and learn from them.

For instance,a mortality meeting is one such probe for mistakes. The kind of things we want to avoid. Learning from someone else’s mistakes is easier and less painful than learning from our own. I have made my lion’s share of mistakes. Thinking back, some were as disastrous as Napoleon’s nails and others much less so. But each one taught me that small things matter. As they say God is in the details, but so is the devil.

Our experience is the sum total of our successes and failures. We will only ever truly fail, if we fail to learn from our mistakes. In life or in medicine.