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”.
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.
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.
Firing a doctor they hired is a bad look for them, so they try to avoid it at all costs.
why was the hospital protecting this guy so much?
Because lawyers will now look into his history and the lawsuits will be huge.
This is just medicine
Massive doctor shortage maybe? Either way this is unacceptable and on them.
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.
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.
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.
Trump is probably getting the papers ready for the new general surgeon he just found
"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
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.
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.
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.
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.
That surgeon has some spleening to do…
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
Americans should be so lucky!
As someone living in Florida I’m not surprised. The doctors down here almost killed me three times and I’ve only been here since 2019. The situation is fucking appalling.
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.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.
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.
“We accidentally replaced your heart with a baked potato. You have about 10 seconds to live.”
