Thomas Shaknovsky botched the surgery of William Bryan, 70, who died on the operating table
According to Shaknovksy’s deposition, after removing Bryan’s liver, the surgeon instructed a nurse to label the organ as a “spleen” – and he also identified it as a spleen in Bryan’s postoperative notes. Shaknovsky later said he had been “mentally compromised” at the time of Bryan’s death, explaining that he was “devastated, demoralized, crying over his passing, felt that I failed him”.
Though this was an idiocity, I think we need to be careful with just blaming the surgeon and that’s it.
Errors like this usually happen because of a chain of various circumstances and other little mistakes, like with airplane crashes.
I think it would be much better that we treat these sort of incidents like airplane crashes. Investigate everything that went wrong, all causes, without focussing on guilt during the investigation. Guilt can be determined from the results of that, but primarily I want that we get data on how this happened in the first place, and what we can do to avoid this from happening again. This strategy was highly successful in aviation, I’d like to see that applied here too because too much shit still goes too much wrong in healthcare
It’s been a while since I’ve operated on anyone (consentually, at least). I know some doctors can be so arrogant that you don’t ever want to second-guess them or correct them for fear of bring berated. Aren’t there other people directly over the patient who might butt in and say “hey, are you sure that’s the right part?”
because most commenters here only seem to be reading the headline: according to the surgeon, the patient started heavily bleeding first, and as he was trying to find/stop the bleeding, that’s when the mixup happened:
Shaknovsky’s deposition testimony described the chaos in the operating room after Bryan began bleeding extensively, causing his heart to stop. Medical staff performed chest compressions, and Shaknovsky attempted to find where the bleeding was coming from.
“I couldn’t tell the difference because I was so upset,” he said, referring to the organ he mistakenly identified.
“It was like a overflown sink that’s clogged up, and I am looking for a fork at the bottom, trying to feel and find the bleed, and I was not able to do so,” Shaknovsky said. He added: “After 20 minutes of struggling – desperately trying – to save his life, that’s when the wrong-site event took place.
As to why he didn’t notice the obviously wrong size of the organ:
Despite a spleen typically being significantly smaller than a liver, Shaknovsky said he believed Bryan’s spleen was “double the size of what is normal” because of a mass on it. Beverly Bryan’s lawsuit, however, states that a medical examiner told her that her husband’s spleen was anatomically “nearly normal”, according to NBC.
edit: more context in this comment: https://lemmy.world/post/46739636/23694470
Okay I’m so sleepy. I forgot what that grey bit in the middle of the liver is.
“We accidentally replaced your heart with a baked potato. You have about 10 seconds to live.”
This has got to be from The Onion
Americans should be so lucky!
I wonder if the surgeon has dementia
Masses of Human: Spleen 30-230 g Liver avg. 1.5 kg male, and 1.2 kg female
smh
Seriously.
Also, left and right. Like they shift a bit but not that much. My spleen got lost too (radiology, not surgery, longer story involving indium than I want to tell in text) but if you think a liver is an inflamed spleen you better have identified that the inflamed spleen is the size of a liver first.
Also don’t they have a different number of tubes coming offa them? This is not my area of anatomy specialty.
Different in so many ways, it’s criminal.
Ok that’s insane, was he drunk or something? But mainly I wanna know what the surg techs and nurses were thinking. Like, wouldn’t you see he was working on the wrong side of the abdomen? Investigate everyone in that operating room IMO
Like, wouldn’t you see he was working on the wrong side of the abdomen? Investigate everyone in that operating room IMO
According to the article the patient was actively bleeding to death at the time, so he (and everyone else) was frantically trying to save his life:
“It was like a overflown sink that’s clogged up, and I am looking for a fork at the bottom, trying to feel and find the bleed, and I was not able to do so,” Shaknovsky said. He added: “After 20 minutes of struggling – desperately trying – to save his life, that’s when the wrong-site event took place.
There was a post about this case a month or two ago on Lemmy. I can’t find the link right now, I’m sorry. But in there, someone had posted a link to the case files for the court. You could see summaries of testimony from multiple nurses and scrub techs. The short version was that many of them had strong reservations about the surgeon prior to this case due to other errors. When this case happened, they were all pretty certain it was not the spleen immediately.
Did nobody try to stop him?
do that and you lose your job. Surgeons are infamous vindictive cunts.
I would be willing to lose my job it it meant saving someones life
My dude, I run into people who wanted to have that “I’m willing to lose my job over this” fight in the hospital a few times over something that would kill me. And they were on the killing me side. And I know they were willing to take it to losing their job because they did.
I’m not sure if you mean this generally before the case happened, or if you meant, did nobody try to stop him during the case?
I think before the case, there were a lot of people who were uneasy with him because of the types of mistakes he was making, although these were generally smaller, less serious mistakes. I think there had been some scrutiny of his practice, but I don’t recall the details.
During the case, it sounded like there was a complication with bleeding which partially obscured visibility in the operative field. The people in the room knew that the case was not going well because of the bleeding, but it wasn’t until he actually pulled the liver out of the patient that anyone realized how wrong things had gone.
Different surgeon removes wrong leg.
in every case, there was a team of people in the surgery.
Yes there’s always a team in the room. I was only stating that in this case it seemed like from the court summary, the other team members knew there was a problem with bleeding but were unaware he was resecting the liver until he pulled it out of the patient. It sounded like because of the excessive blood they simply couldn’t see well.
“Not my job”
It could be dementia.
Trump is probably getting the papers ready for the new general surgeon he just found
There’s always Russia.
"felt that I failed him”
Aww don’t be too hard on yourself.
He was devastated, but not as devastated as the guy on the operating table.
The House of Pod did an episode about this, the host is a doctor and one of his guests for this episode is a surgeon and educator. Some good perspective on how this could happen and exactly how giant of a fuck up it was: https://shows.acast.com/the-house-of-pod-a-medical-podcast/episodes/bonus-sode-revisiting-the-mistakenly-removed-liver
He got his medical degree from the same school as Dr. Nick Riviera.
Hollywood Upstairs Medical School.
Florida’s medical regulations allow “bad” or negligent doctors to continue practicing through a combination of strict malpractice lawsuit limitations, weak disciplinary measures, and high hurdles for patient victims. Key factors include the “three strikes” rule, which rarely triggers license revocation, severe restrictions on filing lawsuits, and a “free kill” law that limits wrongful death liability.
That’s basically the function of most state medical licensing boards. They primarily act as lobbying organizations on behalf of their members to limit civil/legal liability, and to bring a sense of internal regulatory action. My state license costs thousands of dollars a year and is necessary to practice, but all they do is ask me once a year if I’ve committed any crimes or are currently addicted to any illicit substances.
A bunch of physicians like to bitch about malpractice suits making the field difficult to work in, but in reality you really almost have to be acting maliciously to lose a case. For example the last guy in my city to have lost a malpractice case in my field was years ago, and it was because he forgot to order a titanium rod for spinal fusion and installed the shaft of a stainless steel screwdriver instead. Like… Yeah buddy, you should be in jail.
Self-regulation is not regulation at all.
Yeap, the state medical boards appear as if the state is actually an outside regulatory agency. In reality the boards are almost always organized and run by a group of physicians and medical providers associated with larger hospital networks.
Holy shit
Disgraced doctors that can’t be hired for insurance reasons get hired by health insurance to deny claims too, as per propublica. I think one of their examples was a doctor from florida too.
I think it’s this one: https://www.propublica.org/article/mental-health-insurance-denials-unitedhealthcare-cigna-doctors
But regulation bad!!! We can’t just create a society of trust through enforceable guarantees! That would be a nightmare… worse, it would be SOCIALISM!
