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?”
The article is kinda shit and gives no information but usually there would be multiple eyes on the patient. You have at minimum the rotating nurse (not scrubbed in,) the scrub tech (sterile and knows every step of the operation,) the anesthesiologist or CRNA (wouldn’t have a good view of the site), and a resident or PA assisting. There would have been eyes on the patient, which is what makes it so confusing. Maybe the surgeon was intimidating and nobody felt they could speak up against him?
https://www.namd.org/journal-of-medicine/3293-surgeon-removed-liver-instead-of-spleen-family-says.html This article is better than the one in the post but doesn’t answer the big question, which is how many people had eyes on the patient?!?!? It’s difficult for me to believe that a surgeon with experience could make this kind of mistake without inebriation being a factor. The article describes the organ removed as “grossly” obviously a liver, grossly in this case meaning you can see it with your eyes and don’t need special tools. I can’t imagine making this mistake and I’m not even a surgeon I just went to med school. Absolutely insane case and I wonder how many other people this doctor harmed.
That entire “don’t ever want to second guess them” was put upside down with airplane captains where they are.trained to communicate and not be afraid to speak up when they see a problem, lest we have a other Tenerife incident
Yeah there’s a reason they have kinda long checklists when doing operations.
People have had the wrong leg cut off etc. Although that’s perhaps a more understandably a bureaucratic mistake instead of a surgeon mistaking a liver for a spleen. But granted, I’ve never cut into the human body so even though they’re pretty distinct in graphics, once covered in blood and whatnot they might not look so different. Idk. But I think he should have.
Yep the main driver is that people didn’t need to fly, it’s an option, so they had incentives to make it look safe (just being safe is very hard but not enough).
While most surgeries are not really optional and the only incentives are profit by hospitals. What are you going to do, not have surgery?
Totally agree and this has been discussed a lot. We learn about the Swiss cheese model https://en.wikipedia.org/wiki/Swiss_cheese_model, I’ve read The Checklist Manifesto, we talk a lot in med school about listening to nurses and scrub techs and pharmacists…it goes on.
I’ve sat in on a lot of morbidity and mortality rounds. If there’s an adverse event it’s reviewed, and yes it can be very embarrassing for the people involved. We had a breast cancer patient who needed more exploration involving the axillary lymph nodes and an artery got nicked and vascular had to be called, and the next day she was bleeding significantly and had to be brought back to the OR with me, as the med student, holding pressure on her armpit. She lived. A few days later both attending surgeons (breast and vascular) had to do the Morbidity and Mortality in front of the whole hospital, and it felt like a movie.This should be investigated exactly how you said but there is no way that surgeon was sober. Unless the patient’s anatomy was crazy weird, there’s no way that was an honest mistake.
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.
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!
Trump is probably getting the papers ready for the new general surgeon he just found
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
… comparing this surgeon’s patient survival rate to that of other surgeons should determine whether he is to blame.
If his patients are significantly more likely to die than on average, it is probably the surgeon’s fault. If he has a pristine record, on the other hand, it was probably beyond his control.
That would go poorly if he tends to operate on riskier patients. Would definitely have to compare with other surgeons that have a similar patient risk.
Absolutely. A good study would account for confounding variables. Even the best surgeons make mistakes that lead to death; they are only human.
…society doesn’t want to create a situation where surgeons refuse to operate for fear of making a mistake.
What colour is a spleen typically? Even doubled in size a spleen can’t be as big as a liver that’s distinctly shaped, takes up much of the body cavity, and known to have a reddish brown colour that’s fairly distinct.
"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.
Americans should be so lucky!
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
That surgeon has some spleening to do…
Florida man …
TIL Some Florida Men are also surgeons. I mean, in retrospect, it always had to be true, I’d just never really thought about it before.
Oh wow… a whole bunch of Florida Men are rocket scientists… I think my brain just broke.
Not the
OnionSpleen.Wow, yeah, that sounds really hard. How’s his family taking it? Must be like a super bummer for everyone.
Also sucks for the patient too I guess, wonder how he’s feeling…
I bet he feels absolutely gutted
There’s always Russia.
Maybe don’t be a shit surgeon then, this asshole should be charged with willful homicide.
It would be negligent homicide, and as another described, the hospital is at least as criminally can civilly liable as this surgeon.
Okay I’m so sleepy. I forgot what that grey bit in the middle of the liver is.
