Okay I'm so sleepy. I forgot what that grey bit in the middle of the liver is.
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And that’s basically it!
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
This has got to be from The Onion
"We accidentally replaced your heart with a baked potato. You have about 10 seconds to live."
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.
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.
"Not my job"
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.
He got his medical degree from the same school as Dr. Nick Riviera.
Hollywood Upstairs Medical School.
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
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.
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!
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.
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
I hope they sue the hospital into the ground
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.
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.
This is just medicine
why was the hospital protecting this guy so much?
Because lawyers will now look into his history and the lawsuits will be huge.
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.
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.
