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”.
You colonist failed catastrophically while performing surgery.
He must have been on something. The green syringe again no doubt.
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.
I soooo wanna know about the implied non-consensual operations…
There has been, as I recall, all sorts of fucked up nonsense, usually involving minorities and women. Go in for one thing and oh whoops, you’re sterile now! A lot of insane shit like that. People going to the doctor’s to figure out a problem with an organ they didn’t realize that they no longer have, that kinda bullshit.
It’s the doctor from The Human Centipede.
Music video version https://www.youtube.com/watch?v=GFokXnCCMf8
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.
That surgeon has some spleening to do…
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.
Apparently you should have failed your medical board exam. How TF did he pass it?
Reading the report that was posted last time this was discussed it was equally the fault of the hospital as it was the doctors. Apparently he had a bunch of botched surgeries before this one, he was sent to a Continuing Medical Education (CME) program where he failed his evaluation, and he was allowed to take it again after the hospital intervened and he came back to work.
The hospital had reporting systems that nurses and tech were supposed to use to report issues such as these, nobody did even though after they were interviewed they said they had concerns about that specific doctor such as him being late to scheduled operations and other issues. Some nurses stated that they would not bring family to the hospital if they knew that specific doctor was on rotation. The operation where he killed this guy also started late in the afternoon and the doctor didn’t perform a splenectomy before this one.
The operation report was also quite surreal. Apparently they started the surgery laparoscopically but then the doctor decided to convert it into a normal surgery because he couldn’t see properly. Once they opened the guy the nurses noticed that he had an enlarged colon that was blocking most of the surgical field and this was not mentioned in the post-op report even once. Then the doctor started cutting and caused a hemorrhage that made what visibility there was even worse. He continued the operation and removed what he called the spleen. Most of the operating tech immediately noticed it wasn’t the spleen since even an enlarged spleen doesn’t usually get over 800 grams. The thing he pulled out was almost 2 kilograms. Also apparently a different surgeon walked into the room and pointed at the organ on the table and asked what that is. The doctor said: “It’s the spleen.” to which the other surgeon retorted: “That’s no fucking spleen” before storming out. Then they sent it to a pathologist which said that he didn’t even need to put it under the microscope to see that it wasn’t a spleen.
The coroner that did the autopsy of the dead man stated that the spleen was untouched in the place where it should be but the liver has been surgically resected with the surgeon cutting through the portal vein without any evidence of clamping.
Edit: Here is the report if anyone wants to look through it themselves.
https://zarzaurlaw.com/wp-content/uploads/2024/10/AHCA-Report-1.pdf
why was the hospital protecting this guy so much? The fact that Nurses would prevent family members from going to the hospital if this guy was on rotation is telling. He must have a shit ton of info on board members or something.
Massive doctor shortage maybe? Either way this is unacceptable and on them.
Honestly no idea. This is his previous history with botched surgery, and the actions taken by the hospital, quoted from the report:
From May 2023 to August 2023, the hospital identified a total of 3 surgical errors. All 3 errors involved Surgeon A (this is the guy in the news story).
In May 2023, Surgeon A removed part of a patient’s pancreas instead of the intended adrenal gland. Surgeon A had not performed adrenalectomies at the facility. Corrective actions included to immediately stop scheduling adrenalectomies, counseling surgeons on the use of surgical markers and proctoring at least 5 cases. Proctoring was not competed because the hospital no longer performs adrenalectomies.
In August 2023, a patient was identified to have a bowel perforation following a partial colectomy performed by Surgeon A. Patient died from infection complications. Corrective actions included referral to the Credentialing committee for potential actions. However, per Credentialing Manager interview, this is not one of the Credentialing committee functions.
In August 2024, Surgeon A performed a splenectomy on Patient #1(this is the one from the news story). Surgeon A removed the patient’s liver instead, resulting in hemorrhage and death. Surgeon A had not performed a splenectormy at this hospital in over 3 years, since July 2021. The Hospital suspended Surgeon A’s privileges and initiated an investigation.
Interviews with 8 sampled operating room staff found 6 staff with concerns regarding surgical practices by Surgeon A. These concerns were reported to the Operating Room Manager and/or Operating Room Director, but no further action was initiated. Staff interviews identified 2 additional patients with possible surgical errors by Surgeon A that had not been investigated. Surgeon A was observed to sever the common bile duct on a Patient during a Cholecystectomy in April 2024 and sever a ureter on another Patient during a partial colectomy in July 2024 resulting in an Urologist being called to the operating room for repairs during the surgery of that Patient.
Quotes taken from: https://zarzaurlaw.com/wp-content/uploads/2024/10/AHCA-Report-1.pdf starting on page 19.
The only one here I can understand happening is bowel perforation. That can happen, so much so, that they generally waiver you for such things. But we don’t know how bad it was and considering his shit surgical history, the patient dying from infection, Fuck this guy.
Nah, this is normal in the medical world. You think the Thin Blue Line is bad, you should see doctors cover each other’s shit. It’s one of the reasons their insurance is so high.
you should see doctors cover each other’s shit
and throw the nearest nurse under the bus.
why was the hospital protecting this guy so much?
Because lawyers will now look into his history and the lawsuits will be huge.
Firing a doctor they hired is a bad look for them, so they try to avoid it at all costs.
This is just medicine
The hospital had reporting systems that nurses and tech were supposed to use to report issues such as these, nobody did
Retaliation is very real in the medical system.
I gave family in the medical industry. They frequently share how hospitals protect expensive doctors/specialists.
Yeah I did technical support for a hospital and everyone was terrified of pissing doctors off because you absolutely would be sided against if they complained about you. I can’t imagine how much worse that situation is for the nurses that had to work with them every day.
I want to hear the nurses’ testimonies at the trial.
I hope they sue the hospital into the ground
There are so many people who are good at their jobs and have imposter syndrome. If anyone should have it, it is probably this person.
I bet he feels absolutely gutted
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
Jesus fucking Christ… America is just a big fucking scam.
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
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
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
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.
That poor person. 😢
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.
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.
Americans should be so lucky!
"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.
I read that and thought “dude, you DID fail him”
The level of service was less than optimal
It’s at least going on the comment card
I would definitely want this V guy doing my surgery
,- He is only 44
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.
“We accidentally replaced your heart with a baked potato. You have about 10 seconds to live.”
Not the onion. How. How do you mistake the spleen and the liver? How drunk was this surgeon?
Not the onion.
Not the spleen either.
I first thought it was an onion headline.
