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”.
He must have been on something. The green syringe again no doubt.
You colonist failed catastrophically while performing surgery.
I would definitely want this V guy doing my surgery
,Damn, forget about the malpractice. If I ever get caught looking like that in my mugshot, deny my parole and tack on 10 more years.
I bet he feels absolutely gutted
That surgeon has some spleening to do…
Okay I’m so sleepy. I forgot what that grey bit in the middle of the liver is.
This has got to be from The Onion
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
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.
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.
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?”
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
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.
I soooo wanna know about the implied non-consensual operations…
It’s the doctor from The Human Centipede.
Music video version https://www.youtube.com/watch?v=GFokXnCCMf8
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
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.
… 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.
I wonder if the surgeon has dementia
“We accidentally replaced your heart with a baked potato. You have about 10 seconds to live.”
There’s always Russia.
Masses of Human: Spleen 30-230 g Liver avg. 1.5 kg male, and 1.2 kg female
smh
Just being a devil’s advocate here. If they are removing the spleen, it’s probably because there is something wrong with the spleen.
And I’ve seen splenomegaly cases where the spleen is bigger than the liver. Like almost twice as big.
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.
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
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?
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.
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.
“Not my job”
It could be dementia.
