A young vascular surgeon arrives at the operating room (theatre) for the first case of the day, a bypass of an obstructed femoral artery in a 65 year old smoker. The operation is planned to avert an amputation; there is early gangrene visible on the patient's great toe.

After all the safety checks have been complied, a nurse advises the surgeon that the "C arm" fluoroscope equipment is not available. The operative suite has two. One is in use in another room and the other stopped functioning the day prior. Fluoroscopic and ultrasound evaluation of newly installed vascular grafts are considered standard of care exams to be certain that the actual sewing has been accomplished without mishap. The vascular anastomosis that passes both tests has a higher chance of long term usefulness.

The surgeon ponders a series of choices. Should she cancel the case? Wait until the other room's equipment is available? Forge ahead, using older techniques for evaluation of the graft and her handiwork?

The operating room supervisor advises the surgeon that waiting for the other equipment is not an option. Mindful that cancelling cases and not using her "block time" will result in future loss of her right to this room at this time, the surgeon decides to "shoot an old fashioned arteriogram," using a dye injected directly into the graft while using standard x-ray equipment to take a "one shot" view of the work.

Things don't go well. The first film is over exposed. The next is mis-positioned so that the area in question is missing from the film entirely. Ultimately the anesthetist suggests that the use of additional dye in the face of the patient's precarious renal function is foolhardy. A week later, after the bypass graft has clotted, the patient's leg is amputated.

A new captain at a major airline arrives for the first flight of the day to find that the wheel well fire detection system on his Boeing 737 is inoperative. The airplane has spent the night at an "out station;" airline maintenance is not available to repair the system. Like the surgeon, the new captain has to make a decision about whether it is safe to depart.

Unlike the surgeon, though, the captain is not left by himself to make the decision. He and the first office consult the MEL, or minimum equipment list. The airlines and the manufacturer have thought about such contingencies and have come to some agreed upon assessments as to risk. In this case, it is deemed permissible to take off as long as the captain actually touches the brake housing to be sure it is cool and places a placard in the cockpit so that the entire crew is aware that the fire alerting system is inoperative. In addition, there is a note that states the crew might consider leaving the landing gear deployed after take off to ensure cooling. There is a calculation as to how much extra fuel this might require. After a telephone discussion with dispatch and maintenance, it is agreed: the flight is good to go.

Why is it that aviation has thought about these various contingencies, even if they are rare, and medicine hasn't, even if such disruptions are commonplace. Why can't we have minimum equipment lists and knowledgeable senior surgeons poised to help by phone instead of leaving each lonely surgeon to make judgments without decision support? Sometimes, even more than a leg is at stake.