Left Coast Justin's Reviews > Complications: A Surgeon's Notes on an Imperfect Science

"Emesis" is a pretty little word, two palindromes side-by-side, but until I read this book I could never quite find the proper words to describe the actual process: "intensely aversive".

Dr. Gawande occupies a rarified Valhalla of people who understand medicine, who understand public policy and who understand how to write. You want facts? Got 'em:

She was in what physicians call the "prodomal phase of emesis." Salivation increases, sometimes torrentially. The pupils dilate. The heart begins to race. The blood vessels in the skin constrict, increasing pallor.

While all this is going on, the stomach develops abnormal electrical activity, which prevents it from emptying and causes it to relax. The esaphagus contracts, pulling the upper portion of the stomach from the abdomen, through the diaphragm, and into the chest...Then, in a single movement, known as the "retrograde giant contraction," the upper small intestine evacuates its contents backward into the stomach in preparation for vomiting...In the expulsive phase, the diaphragm and stomach undergo a massive, prolonged contraction, generating intense pressure in the stomach; when the esophogus relaxes, it's as if someone had taken the plug off a fire hydrant.

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The above citation was edited considerably for length. So why all this recounting of such an "intensively aversive" experience at all? Who wants to think about this stuff? Well, some women have such a problem with morning sickness during pregnancy that it threatens not only the embryo's life but the mothers as well. And part of the job of the doctor is to figure out exactly how to deal with this problem, which can be far from simple. After all, you don't want to poison the embryo with strong, potentially toxic medicines; hypersensitivity to toxins appears to be the root cause of morning sickness in the first place.

I've read a lot of medical memoirs, and encountered surprisingly few accounts of morning sickness. Generally the stories deal with emergency C-Sections, roadside surprises and the like. The fact that the author chooses to dwell at length on what is, for many women, the most awful part of pregnancy testifies that he actually listens to his patients, and takes their fear and suffering seriously.

Regarding public policy, Gawande is a well-known speaker and patient advocate, and writes clearly and well about things we could do to improve patient care (getting bad doctors away from patients, for example) and also about the impossibility of doctors knowing exactly what to do in any given situation. This puts part of the public policy back on the public: We're very complicated creatures, and we need to stop expecting miracles.

Unlike some of his other books (The Checklist Manifesto, for example), this was really a collection of unrelated essays and didn't quite hang together as well. But it was still packed with nice writing, fascinating science and humane stories. Recommended.