Smith spent the next two weeks in the intensive care unit and survived. And was grateful for how hard so many people worked to save his life, Gawande recalled.
But the hospital team missed a crucial step. The spleen functions as part of the immune system to fight bacteria, and when it is removed, patients have to have vaccines to protect against infection.
"The surgical team thought the ICU should have given it and the ICU thought the surgeon should have done it and both thought the primary care provider should have remembered. Maybe they all just forgot. But it didn't happen," Gawande said.
Two years later, Smith was on the beach with his family when he got an ordinary strep infection that landed him in the intensive care unit at the tether of his life.
"He survived, but not before losing all his fingers and all his toes, his livelihood, and the ability to care for his family and simply be the person he wanted to be. It was, he said, the worst vacation ever."
Then Gawande clicked the next slide. There was Smith, sitting on a curb, without those portions of his limbs.
As much as the doctors and healthcare executives in the audience sat in rapt attention, that wasn't Gawande's punchline.
"The damning thing wasn't that this happened. The damning thing was that no one learned anything from it. The story is repeated. We had the exact same thing happen in my hospital, with a worse outcome. And it's happening all over the country. We missed this basic unglamorous step about half the time when the spleen gets removed. Why?"
A Rhodes Scholar, MacArthur Genius award winner, Harvard Medical School Graduate, and author of books about healthcare and topical essays that are frequently published in the New Yorker, Gawande has emerged as a healthcare rock star.