Never events: Inexplicable surgical misadventures.

[Smurfette]

Accidental Hepatectomy

Saw this article today and cannot begin to understand how so many things went wrong (was it everyone else in the OR's first day? Who is in the room watching this happen?) and have a hard time believing this guy passed anatomy class and finished a surgical residency.

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[Apollyon]

When I took anatomy, one of the cadavers had a spleen as big as the liver - which probably contributed to his death - but, BUT, even as first semester med students, we recognized it for what it was - not a football, but a spleen, on the right side.

 

[anonperson]

Accidental Hepatectomy

Saw this article today and cannot begin to understand how so many things went wrong (was it everyone else in the OR's first day? Who is in the room watching this happen?) and have a hard time believing this guy passed anatomy class and finished a surgical residency.

Impaired physician? Drugs and/or alcohol?

Bizarre case.

Interesting that he's had issues like this before and still had privileges. The chair of the department must have really liked him.

Cases like this usually get brought up for review internally in a hospital.

 

[StIGMA]

serial killer/sociopath? Sounds like that neurosurgeon who maimed people intentionally

 

[Apollyon]

serial killer/sociopath? Sounds like that neurosurgeon who maimed people intentionally

Chris Duntsch. Now a permanent resident of the Graybar Hotel. You know, the Concrete Hilton.

 

[OtoHNS]

Reminds me of this (horrifying) ENT case:

Enucleation as Endoscopic Sinus Surgery Complication

Enucleation as a Complication of Endoscopic Sinus Surgery

Functional endoscopic sinus surgery (FESS) is a commonly performed procedure that has a risk of serious ophthalmic complications. We report a case of complete enucleation as a complication of FESS.

jamanetwork.com

 

[eyeeye_captain]

Reminds me of this (horrifying) ENT case:

Enucleation as Endoscopic Sinus Surgery Complication

Enucleation as a Complication of Endoscopic Sinus Surgery

Functional endoscopic sinus surgery (FESS) is a commonly performed procedure that has a risk of serious ophthalmic complications. We report a case of complete enucleation as a complication of FESS.

jamanetwork.com

I thought about this one as well. I don’t have access to the full text anymore, but the photos were gruesome.

 

[LucidSplash]

This will be an interesting one to follow. It certainly sounds egregious but also seems like there is a lot that is not clear from the information released by the family/family lawyer. I suspect there may be a lot we don’t know that could affect the perception of the case. Of course the hospital/surgeon are prevented from a response in public due to HIPAA. So likely will have to read the eventual court documents, and whatever information is released on the Florida BOM website regarding any actions taken against the surgeon, if any, before rendering an opinion.

And of course this is VERY likely to be settled out of court and we may never get the full story.

 

[Pir8DeacDoc]

Reminds me of this (horrifying) ENT case:

Enucleation as Endoscopic Sinus Surgery Complication

Enucleation as a Complication of Endoscopic Sinus Surgery

Functional endoscopic sinus surgery (FESS) is a commonly performed procedure that has a risk of serious ophthalmic complications. We report a case of complete enucleation as a complication of FESS.

jamanetwork.com

Without knowing specifics, we all fear getting into the orbit. And I think we've all seen orbital fat and figure out it was time to stop. But getting into the actual globe is a really wild misadventure.

 

[TheLesPaul]

Without knowing specifics, we all fear getting into the orbit. And I think we've all seen orbital fat and figure out it was time to stop. But getting into the actual globe is a really wild misadventure.

exactly. the MR is pretty easy to eat unknowingly with the microdebrider, but the ON and globe should feel qualitatively different

 

[dienekes88]

Was just sent this story. Scary.

 

[eyeeye_captain]

If we’re still hanging out near eyeballs, I got sent this one recently. Quick state board lookup and somehow the guy still has a license, only got a 30 day suspension.

TL;DR from the article: wrong side surgery, realizes it during the next case, takes the next patient’s now non-sterile instruments to recovery and operates on the correct eye there with the patient awake, then changed the consent.

Doctor operated on wrong eye, tried to fix mistake with no anesthesia, lawsuit says | abc7chicago.com

 

[HighPriest]

If we’re still hanging out near eyeballs, I got sent this one recently. Quick state board lookup and somehow the guy still has a license, only got a 30 day suspension.

TL;DR from the article: wrong side surgery, realizes it during the next case, takes the next patient’s now non-sterile instruments to recovery and operates on the correct eye there with the patient awake, then changed the consent.

Doctor operated on wrong eye, tried to fix mistake with no anesthesia, lawsuit says | abc7chicago.com

You know what the real problem is with this hole over dug myself in to? It ain’t deep enough. There’s gold at the bottom somewhere….

 

[WheezyBaby]

This will be an interesting one to follow. It certainly sounds egregious but also seems like there is a lot that is not clear from the information released by the family/family lawyer. I suspect there may be a lot we don’t know that could affect the perception of the case. Of course the hospital/surgeon are prevented from a response in public due to HIPAA. So likely will have to read the eventual court documents, and whatever information is released on the Florida BOM website regarding any actions taken against the surgeon, if any, before rendering an opinion.

And of course this is VERY likely to be settled out of court and we may never get the full story.

I'm trying to remember where another forum had this case, I think it was in the anesthesiology forum. In that thread, someone had shared what to my recollection was essentially the internal event review from the hospital, and it did not paint a much different story from what the articles described.