I’m still in shock over the story of an Alabama man who died after a Florida surgeon removed his liver instead of his spleen.
First things first - you can live without a spleen. You can’t live without a liver. They look nothing the same, are on opposite sides of the body and have different vascular structures.
I find it hard to believe this could ever happen by accident unless the physician was severely impaired or acting out of malice.
Why did no one else in the operating room speak out? Surely everyone in that room knew he was touching the liver as opposed to the spleen.
This - for me - is the most troubling part of this disaster. Hospitals (and especially operating rooms) are not environments that encourage speaking up. They encourage falling in line and not challenging authority. It can make things very unsafe for patients - and it’s one of the reasons I say that a disabled patient should never be left alone in the hospital. They need an advocate at all times.
Unfortunately in surgery you can’t have an advocate. You’re 100% at the mercy of the people in the room. You’re unconscious, paralyzed and in their control. You have to trust them to take care of you. Why didn’t anyone speak up?
I don’t know the answers - and I’m not sure we will ever know. I do know that as patients we have to put our full trust in our medical team - and that’s a hard thing to do when you’ve experienced medical trauma or you hear stories like this.
Hospitals reward people who fall in line and obey the chain of command. Surgeons often have a God like complex and take great offence to anyone (patients, advocates or other staff) questioning their judgement.
So people simply don't question them.
The problem is that some people NEED to be questioned. Chain of command shouldn't matter when a literal life is on the line.
We all make mistakes - it's part of being human. The stakes are just much higher in medicine and especially in surgery
We need to start changing the culture to one of collaboration. Patients should be permitted to be partners in their own care.
Their expertise in their conditions and their body welcomed and listened to.
Other healthcare workers like nurses, social workers, respiratory therapists,
physiotherapists and dieticians should be brought to the table and treated as equals.
They should be encouraged to speak up if they feel their patient may be harmed.
Advocates should be welcomed & encouraged at all steps in the healthcare journey. Too often we hear of disabled patients being separated from their advocate and this should NEVER happen.
We need someone watching out for us at all times - especially if we might be unconscious
In a perfect world I would love to see all chronic illness patients given an advocate at the time of diagnosis. Someone like a disability doula who's job it is to help them navigate the complex medical system, keep them safe from harm and help them adapt to their disabilities
I recognize that's unlikely to be funded anytime soon - but there would be SO much value in a service like that - for patients AND physicians.
Until then - I ask that everyone who works in healthcare remember that your patient is scared, vulnerable and in need of protection
If you see something amiss - say something.
If they're upset - listen to them. Wear a mask for them! If they request a mask be placed on them when they're unconscious ... honour that request.
Don't be the person who violates their trust and bodily autonomy
Lastly - if you're a patient - try and make sure you always have an advocate. I recognize this isn't an option for everyone... but if it's at all possible please have someone with you. If not you could phone or video a friend, ask for social work, nurse manager or chaplain
Anything you can do to get an extra set of eyes and ears in the room will increase odds of a good outcome.
My heart is with the family of the man who lost his life to this reckless mistake & with everyone who's suffered due to a medical error or neglect. We must do better.
I would encourage anyone who questions HOW this can happen to watch or listen to Dr Death - the story of Christopher Duntsch. He was a Texas neurosurgeon who maimed and killed countless patients and the hospitals and medical board allowed it to continue until the legal system stopped him. It’s a chilling tale of how wrong things can go when organizations protect their reputation over their patients.
Full article on the William Bryan’s death here: https://globalnews.ca/news/10732577/florida-surgeon-removed-liver-spleen-dr-shaknovsky/
