The Present Illness

Surgeon Takes Out Liver by "Accident"?!

• Alyssa Burgart & Arghavan Salles • Season 1 • Episode 31

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0:00 | 58:04

Surgeons need to know anatomy; Voting is good; SCOTUS conflicts of interest; pediatric society hosts unscientific panel on trans kids

Death during surgery:

  • Summary of “accidental” liver removal
  • State medical board order suspending Shaknovsky’s license
  • Investigation into the hospital/interviews of Shaknovsky and staff
  • Arghavan’s video going over the anatomy
  • Arghavan’s video going over the operative report


Unscientific Conference Panel:


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Credits

  • Production by Arghavan Salles & Alyssa Burgart
  • Editing by Alyssa Burgart
  • Theme Music by Joseph Uphoff
  • Social Media by Arghavan Salles
SPEAKER_01

The specimen that he handed to the OR staff was a liver. And he told them to label it as a spleen. But it was a liver, as confirmed by pathology. But even the people in the room knew, I mean, the spleen and the liver do not look the same. Hey there, fellow nerds. Welcome to another episode of The Present Illness, the podcast where two physicians try to make sense of a world that is very febrile, uh, maybe even with a pustule or two, uh, and definitely underdiagnosed. I'm Arga Von Salas, a surgeon scientist, and your friendly neighborhood doom scroller and residence.

SPEAKER_02

And I'm Alyssa Berghard, an anesthesiologist and bioethicist who tracks news and health law like their EKGs, full of spikes and surprises. The present illness is where we dig into public health, politics, culture, and ethics with a scalpel in one hand and a meme in the other. We're glad you're here. And as a noted to new listeners, we often talk about topics that are intense, they can be a lot. Um, so you may not want to listen to it with your little ones.

SPEAKER_01

Big thanks to everyone listening and extra love to our subscribers and those who follow us on various platforms online. And a special warm welcome to anyone who just stumbled in from the gutting of the Voting Rights Act by the Supreme Court.

SPEAKER_02

The Supreme Court's really making me mad.

SPEAKER_01

It's not new, unfortunately, but this is their latest attack. I mean, they've been trying to dismantle the Voting Rights Act for a long time. And this is, it feels like the last nail in the coffin, if you will. Um, because this decision had to do uh with section two. Um, and the whole idea of the Voting Rights Act, right, is that people have equal ability to vote for the politicians that they prefer. And the idea was to eliminate discrimination in voting. And it all started with this is not our main topic, Bridget, but just for folks listening, it all started with the case out of Louisiana, where um only one out of six districts in Louisiana were majority black voters, even the one-third of the population of Louisiana, roughly, is um black people. And so um a group had brought a lawsuit saying this is discriminatory against black people. And so there was another version of the map that was made that created a second district that was majority, uh, that consisted of majority black voters. And then this other group of they called themselves quote, non-African American voters, um, they brought a lawsuit saying that this was discriminatory. The fact that they created this new map with these two districts that had a majority uh of voters who were black was racial discrimination because you can't create a district based on race. That was their argument. And they took that case all the way up to the Supreme Court, and the Supreme Court um astoundingly and devastatingly agreed with them. And so they said basically you can make a district off of anything you want. It could be off of political affiliation, it could be off of anything, but it cannot be related to race. And of course, the idea that they were using here was the the litigants, uh, the the people who brought the case was that there is a lot of correlation between race and political affiliation. And so what they wanted essentially was for there to be proof that this was not based on race, but that it was based on politics. But since they're so highly correlated, um, the justices concluded that they didn't prove that. Um, basically, I'm not a lawyer, I'm just summarizing what I've what I've read about it. Um, but the impact of this decision is that the 2024 map in Louisiana with those two districts that had majority black voters, that map was deemed unconstitutional by the Supreme Court. And so um that's gonna have a huge impact. And as I said, they their conclusion is that you can use anything you want to decide your district except for race. And the whole idea of this, you know, gerrymandering around race and excluding, like dividing black voters into these various odd-shaped districts is to dilute the vote of black voters, right? So that was part of what the Voting Rights Act was meant to um prohibit from happening. But now, because of this decision, uh Justice Kagan writes in her um descent that now, if anyone wants to bring a case about dilution of votes for minority groups, they will have to prove that there was intent to do this based on race in order to prove that their vote is being diluted. It's not just that the vote is being diluted, but it's that it was done intentionally. And Clarence Thomas said something that I found really distressing uh in breaking news. Um, this is what Clarence Thomas exactly said. He said the Supreme Court should never have interpreted section two of the Voting Rights Act of 1965 to effectively give racial groups, I think this is a quote from that act, uh, an entitlement to roughly proportional representation.

SPEAKER_02

Yeah, and you know, this it's a wonderful time to be reminded that the Supreme Court and Claire, you know, Tom Clarence Thomas is not the only one of the justices who has massive conflicts of interest, who has clearly profited immensely off of their role. Um, and there's a piece that I read recently from uh Christopher Armitage um on the Chief Justice John Roberts, and how his wife has accepted over$20 million as a she like recruits people to work for law firms. And so she'll take like people who are leaving government roles or leaving um high profile roles, and then she'll find them these like bespoke placements in fancy law firms. And for years he never disclosed that he had this conflict, even though the ethics rules of when you need to disclose a conflict absolutely say that you need to. So, you know, the the Supreme, the the people who are making these decisions on the Supreme Court are not being held to any sort of standard. There's no way to enforce any of the ethics rulings that, of course, John Roberts created ethics rules that are unenforceable, shocker. Um so I'll I'll put a link to that, uh, those details as well into the the show notes because I think it's really important for people to understand like not only are these bad decisions that don't make sense and that hurt the American public, they're being made by people who are making themselves flagrantly rich, uh, enriching themselves through their roles and not telling the public about their major conflicts of interest that are directly in relation to the people who are arguing these cases.

SPEAKER_01

Yeah, absolutely. Anyway, so this is a clear and blatant attack on black and brown people in this country. That is a slap in the face to everyone who was involved in the civil rights movement, who, I mean, people literally died to advance civil rights in this country. And these were really hard-fought wins. Um, and the Supreme Court yesterday said, yeah, who cares? Screw you. Um, and it's a rolling back of rights for many, many decades back. Um, of course, this is exactly what the folks behind Project 2025 wanted. So it's a, I think it's a very sad and shameful day in America.

SPEAKER_02

Well, I'm gonna put a also in the show notes a link to Slate magazine had a really great series on Clarence Thomas and like his his entire life, like his rise to power, decisions that he's made, conflicts that have been present. Um, it's on their podcast called Slow Burn. Yeah. So I'll put a I'll put a link to that in the show notes as well. That's great. Thank you. I'll uh well, Argivon, what are we gonna talk about today?

SPEAKER_01

Okay. Folks may have heard about this case a couple of years ago, but it's back in the news, and um, it is so astounding that I've been talking to as many people as I can about it because I I just want someone to figure it out. And uh it's not not been me, I haven't been able to figure it out. It's this um uh really tragic case in Florida where in 2024 the surgeon had taken a patient, surgeon's name is Thomas Jacknowsky, had taken a patient, a 70-year-old man, uh, to the operating room, supposedly to take out this man's spleen and instead removed the liver, and the patient died from bleeding in the operating room. Um and the even when the news first came out of this case in 2024, I talked about it, I made a couple of videos about it. I I could not understand it then, and I still do not understand it now, but we do have more information now than we had then. So the basic gist of the story is that this uh patient had come to this hospital. The patient is not from Florida, I believe he was from Alabama. He was in Florida, he was having left-sided abdominal pain. This spleen sits on the left for non-medical medical folks listening. So he has left-sided abdominal pain, and they admitted him to the hospital because he has a CT scan that showed an enlarged spleen, supposedly. I've not seen these images, obviously, but the operative report filed by Thomas Shachnowsky said that the patient had an enlarged spleen and there was apparently some small amount of hemoperitoneum, meaning blood in the abdominal cavity. And then they kept the patient in the hospital for monitoring to see how his pain, what would happen with his pain and what, you know, whether he was going to have further bleeding. And the patient very much wanted to go back home to Alabama, and the surgeon was recommending the spleen to be removed. Um, and this went for on for a couple of days, and the patient's hemoglobin blood count was dropping. I don't know to what extent, that's not stated as far as I can recall in the operative report. Um, he was, but he was having decreases in his blood count and he continued to have abdominal pain. So basically, the surgeon convinced the patient to have surgery there. And I already told you the basic just of what happened in the operating room, but we now have more information because at the time when I covered this in fall 2024, I had his operative report, but we didn't know much else. His operative report says kind of what you might expect for a spleen removal, which is called the splenectomy. He says the patient had this problem, you know, we took him to the operating room and we started laparoscopically and then uh like with uh little incisions and then couldn't see. He says that he couldn't see because of blood and he had to convert to open, making a larger incision. And that there was he again, this is his version of the story that there was an aneurysm, so an enlargement of the artery going to the spleen, the splenic artery, and that he says he put a clamp on it, and that when he took the clamp off to staple across to divide that that artery, that the artery, the sorry, the aneurysm ruptured, and that's when he couldn't see, and he just tried his best to get the spleen out quickly so that he could try to save this patient's life. Um, the patient already was coating by the time he was supposedly trying to take out the spleen. So that's what we knew as his version at that time. But the specimen that he handed to the OR staff was a liver. And he told them to label it as a spleen, but it was a liver, as confirmed by pathology. But even the people in the room knew, I mean, the the spleen and the liver do not look the same. They are not in the same location in the body, they do not have the same anatomy. But let's talk about that in a minute because I just want to say because my face is saying a lot.

SPEAKER_02

I mean, those of you who are on the podcast, you're listening and you don't understand that, like as a liver transplant anesthesiologist, I remember this case when it first happened, and I'm relivering it, reliving it with you now. And I there is no explanation for this besides incompetence.

SPEAKER_01

Like I didn't know. Well, here I think there is. It's just psychopathy or sociopathy. I do you know what I'm saying? Like, I there's not an explanation that makes sense for a rational, competent person, but I don't know. And I mentioned I'm talking about this because this is what I've really been trying to grapple with. Like, is this a case of a person in the surgeon who is, as you say, just incompetent and truly didn't know that he was taking out a liver? I I don't even know how that's possible. But like, is it like that? Was he incapacitated due to substances? Even that, like, I don't know.

SPEAKER_02

Let's say how drunk would I have to be to not be able to tell the difference between a spleen and a liver. They're literally on different sides of the body. They do not look the same, they do not feel the same, they do not have the same texture. It's like, yeah, even if you have like an inflamed spleen, and I've seen some inflamed spleens, they don't look like livers.

SPEAKER_01

No, absolutely not. And so I don't know, that's one theory that folks have is that he was on some sort of substances. But I have the same feeling you do. It's like, what substance could make me think that the liver is the spleen or that the spleen is the liver? Like, I don't, I can't, I don't know of one, but maybe he was having a psychotic episode and convinced himself that the liver was the spleen. Um, or this is my latest theory is that he did it on purpose and he was wondering if he could get away with it, or maybe thought that he could get away with it. I don't have evidence to support that theory, by the way. It's just what I'm thinking, and what made me really think that is I want to um share with you what the medical examiner said, which um for the autopsy. He said, or they said, the autopsy confirmed there was no liver. The liver was perfectly dissected off the diaphragm. As a forensic pathologist, that is one of the hardest things to learn to do. Quote, essentially the liver was autopsied out of that man, end quote. There was no evidence of cross clamping, no sutures, no evidence of cautery. The inferior vena cava was clearly dissected by the surgeon. Everything surrounding this liver was completely untouched. The spleen showed no evidence of aneurysm, no rupture, and no evidence the spleen was touched.

SPEAKER_02

So also, the inferior vena cava is a really, really big vessel. It's so important. So for people who um who have not become as intimately familiar with the inferior vena cava as you and I, it is the biggest blood vessel that is returning blood to your heart. It is the superior one is above your heart, sending things into your right atrium of your heart, the inferior vena cava, the livers attached to it, and then goes up into the heart and dumps blood back in. It's literally the delivery system for every bit of blood from the lower part of your body. Yeah. It's big.

SPEAKER_01

It is. And this idea that it was like so cleanly dissected, that's what got me thinking maybe it was intentional. Because it's one thing. So again, the the story that is told in the operative report is that there was blood everywhere, you couldn't see anything, um, just tried to get the spleen out. And again, the spleen is on the left side. So why would you be working on the right side if you thought you were getting the spleen out? I don't know. But that was the story. But now I read this other document where they talked to multiple staff members at the hospital, including multiple people who were in that room. And they started out laparoscopically. I, that's what I trained in was minerally invasive surgery. The patient was laying on his back. That is not the position you put someone in for a laparoscopic laparoscopic spleen removal. You put someone on their left side. Sorry, the right side, so the left side is up, so that you know, all the other organs kind of fall away from the spleen. It helps the pos to have them in that position. So if you were gonna do a laparoscopic splenectomy, why would you put the patient supine on their back? That doesn't make sense to me, unless you never intended to do a splenectomy and you were planning to do something else.

SPEAKER_02

Yeah, and the other thing that um I find deeply unsettling about like the culture in which this must have taken place, where like if everyone in the room was like, bro, that's a liver, why was no one else called?

SPEAKER_01

Yeah, so this is a question. Okay, here's what I I've gained a little more insight on that, because like that's totally reasonable thing to wonder. Like, aren't people in the room seeing that he's operating on the left side instead of operating on the right side? So let me just go back and say, so he starts out laparoscopically, and what is reported by many people who were in the room is that actually the problem was that the colon was quite large. So he couldn't see because of the colon, not because of blood. And because the colon was so dilated, he converted to open. He says he couldn't see even at that time because of blood, but the staff in the room are like, because on if it dyslaparoscopic, everyone sees what's on the screen. And they're like, no, it was that the colon was enlarged. There's no mention of enlarged colon in the operative reports. The colon was enlarged, they couldn't see, so they converted to open. And then the staff be clear. The operative report is a fantasy.

SPEAKER_02

Oh, yeah. Yeah. Yeah. Just for folks, like there's a there's nothing believable in the operative report.

SPEAKER_01

Right. It tells a very different story from what seems to have happened in reality. So once they convert to open, the staff say that he pretty much blindly fired a stapler, and that's when the bleeding started. That's what the multiple staff members say that he put a stapler into the abdomen, fired it, and that's when massive bleeding started. And then the patient coded. And so the anesthesia team was busy performing CPR and they were like getting blood and all of that to try to keep up while he was supposedly taking out this spleen. In the meantime, a lot of uh, at least a couple of the staff said they couldn't see what was happening. Um, because I've had other people say, you know, like on my videos, well, why didn't the staff say anything? I it is not clear to me that they knew while it was happening what was happening because there was a lot of blood and this guy was just doing whatever he was doing. But I do have a question around like where he was standing and where you saw his hands working. Like we all know, again, the spleen is on the left and this and the liver's on the right. So I feel like they must have at least seen that he was working on the right. But to your point about the culture in the room, um, it's clear they didn't feel comfortable speaking up. But they did call other people. So they called additional staff in to help, and they also called another surgeon to come in. But I don't know when they called that surgeon, but that surgeon wasn't there until after the specimen was out, and that surgeon supposedly said, This is a liver, and the operating surgeon said, It's a spleen. And then this other surgeon left, is what it says in the notes that I saw. They also called the CMO, the chief medical officer of the hospital. I have, I have never seen a chief medical officer come into the operating room. I don't know if you have. Um, so that was strange and unusual to me. Some CMOs are surgeons, but those are the times I've seen it. All right. If they're like interested in a case or something, maybe I don't know. But um anyway, so they did call some people, is what I'm trying to say. But the exact timing of when that happened, we don't know exactly how fast he was doing whatever he was doing to get this liver out. But certainly once the liver was out of the body, multiple people, as you can imagine in the room were like, that's a liver. Um well, okay.

SPEAKER_02

And just and I also, just for for clarity here, like you cannot live without a liver. Right. You can, I mean, and but I think a lot of people don't know that, right? Like we think like, oh, our heart, your heart, your lungs, your brain, those are like they're so glamorous. Everybody knows how important they are. Everyone loves them, wants them to be in good health. And like the liver, you're like, well, you know, it can get damaged. But like you literally cannot survive without a liver. And so to keep someone alive without a liver, for example, you know, and there's very rare cases, like if you're you do a transplant and an organ fails dramatically, sometimes you have to remove it. It's very difficult to keep that person alive for hours to days while you wait for hopefully another liver transplant to be available. Like your liver is doing is the reason that you can clot your blood. It detoxifies a bunch of things from your from your body alongside your kidneys. Like it's important for doing so many functions. You need it for digestion. You need it for like there's so many, the liver. It's, I mean, I'm I'm biased. I love the liver. You can live without a spleen, but you can't live without a liver. Right. And it is I it is telling to me whatever the culture was in this place. And apparently staff had made complaints about him in the past. I don't know if those had not been taken seriously.

SPEAKER_01

Well, okay, let's talk about that for a second, because the folks who were interviewed in this document that I saw, which is I think part of some investigation of the hospital. So there's obviously an issue here with this surgeon who has just been indicted. That's why we're talking about it now, because even though this case happened in 2024, he was just indicted. Um the document that I saw asked these various staff members, nurses, and surgical techs about this man. And what they multiple of them said was that if they or someone they knew was sick, they would check if he was on call before they would come to that hospital. Um, that he was known to be a quote unquote bad surgeon. Um But the document that I saw says none of these people that they talked to for this um actually had reported him. They just kind of like did the best they could to deal with him. Um which is so it's just like an open secret. Kind of but okay, here's the thing. Let's talk about the supposed the complications, not supposed the complications that he has had before this, the surgeon. So one was um that I see people talk about a lot is that he had been doing an adrenalctomy and had taken out part of a person's pancreas. Now the pancreas and the adrenal gland are very close to each other. I don't think it is well, it's certainly not unheard of to have taken out some pancreatic tissue while you're doing an adrenalctomy. Like that's not obviously it's not desirable, it's not ideal, but they're right next to each other, and that could certainly happen. Um so people, I'm mentioning that because a lot of people are using that as evidence that he had like taken out the wrong thing before, and it is the wrong thing, but it's also right there, and mistakes are made, and also we don't know the anatomy of that patient. You know, surgery's hard. I'll just say that as a surgeon. Surgery is hard. Um, and complications do occur. So that's one. Another one is he had um divided a common bile duct, uh, there was a common bile duct injury during a gallbladder removal surgery. That is a rare but known complication of gallbladder surgery. So is it ideal? No. But does that mean he's necessarily incompetent that that happened one time that we know of in his career? I I don't think so. Like again, that happens. Um, the third one that comes up in some of this paperwork is that there was a time he was doing an inguinal hernia repair, a laparoscopic inguinal hernia repair for a patient, and he was supposed to be working on one side and he ended up fixing both sides because he noticed that the patient had a hernia on the other side. Um without knowing what conversations he had with that patient in advance of the surgery, I can't say whether that was appropriate or not. I mean, I've definitely had patients where I asked them, like, if I find a hernia on the other side, would you like me to repair it while I'm there? And they'll say yes. And so he may very well have had that conversation. Um, but obviously we don't know. So those are the things I've seen mentioned. Um, none of those ones are clearly like either sociopathic, psychopathic, or uh extremely incompetent or signs of that to me. Um, they seem like more in the normal realm of what happens in surgery. Now, for the patient who did the ingle and hernia on both sides, if he never had that conversation with that patient and just like surprised did that surgery on the other side, obviously that would be a violation of that patient's autonomy, but we don't know that that's what happened. So it's hard for me to say that's what it was. Um, but the point is there was this at least idea that this was not a good surgeon, and yet he continued to practice there, and people just made sure that they and the people in their family um were never there.

SPEAKER_02

I also think that taking aside this particular case that has gotten him indicted, which is so egregious, there is no explanation. Um, you know, this is one of the challenges is that medical culture demands self-regulation. Now, it's not the only kind of regulation. There's obviously a lot of other regulations that come from the state and come from the federal government. Hospitals have policies, but this is also part of where the reporting systems that hospitals have in a functioning culture, you should be able to report when you see something that you think might be dangerous so that it creates is there if there's a pattern, right? We should want people to see it. Now, there are lots of things that influence who feels comfortable using those reporting systems and who does not. Yeah. And we know that those reporting systems can also be used, uh, they can be weaponized against people because they're disliked for some reason, because there's, you know, so I think the people who are reviewing the data that comes in through those reporting systems have to become very thoughtful about recognizing legitimate versus potentially questionable reports and what is a pattern versus what was a one-off situation. And so when I think again about this culture, if these folks are saying, like, well, we we never would let him operate on anybody we like, um, that's also a very stressful, morally distressing experience. And that means that you had people who were so consistently in that state about this person that it had become normalized. So anyway, I'm very curious to see what comes out. I really do hope we're able to learn more about this case because it's this, it's terrifying, right? Like if you're somebody, you're this poor family, they were traveling and you get sick, they felt pressured. I mean, that was the other thing is like, I don't know, I don't like to pressure anybody to do anything. I think that's a bad idea. I think that, you know, certainly we have patients sometimes who are afraid of an intervention. And so we do our best to help understand where they're coming from and give them the information they need and the support that they need to reach a decision. Um, but anytime somebody is convinced to do something when they've been really opposed, that's always risky in general. Because like if anything goes wrong, like I would just feel so even more responsible than I feel on a regular basis.

SPEAKER_01

Yeah, yeah, because you convince someone to do something that they didn't want to do. I I totally agree. Um, there are a couple other things about the the case that I just want to talk about um because they're part they help, I think, explain why it's so, so confusing. So one is when I read that forensic pathologist's comments and saying that the spleen hadn't even been touched, that was that made me um think about the case a little bit differently. Because it's one thing if you're trying to take the spleen out and you get into bleeding and you really can't see and somehow you get disoriented. I mean, I'm still not like really understanding, but like that's one thing. But it sounds like if if this pathologist said the spleen was not even touched, I mean, the things that you have to do to take out a spleen, it's not actually super complicated. It's a it's a surgery you take very, very seriously because about 20% of your blood flow goes to the spleen. And so if you have a problem when you're dividing the vessels that go into and out of the spleen, the there can be really devastating consequences. So it's a serious, serious surgery, but it's not technically super duper challenging. You there's a connection to the stomach, there's a connection to the colon. So you have to take out all of those connections and you have to dissect around the vessels, and then you have to divide the vessels, and that's the part where you like, you know, want to make sure that your stapler is in the right spot and there's no malfunction so that you know the patient doesn't you don't just to be clear, you don't randomly just go like shooting staples like you're in a gun show. Yeah, you don't like throw in a stapler and fire any old way. Um, so yeah, so you want to be really careful at that time, and that's the most stressful part of that case, but it's not like a million things going on because the spleen, it just has usually one vessel going in and then a couple vessels coming out, and they're all in the same place.

SPEAKER_02

Um, and and so and on the anesthesia side, it's not a case where I'm like, oh gosh, oh gosh, a splenectomy. Right. I'm like, uh, it's a splenectomy. Like, I know what to do. And it's not usually very dramatic. Correct.

SPEAKER_01

And so the the again, if the story were as he says it is, which is that he was trying to take out the spleen, but then got into this bleeding, you would have expected at least those attachments to have been taken down, like the connection between the spleen and the stomach, the connection between the colon and the and the spleen, but none of that was touched. So it's like that's what makes me think this was some um either like a psychosis episode or somehow intentional, because how do you not even try to get the spleen out if that's what you consented the patient for?

SPEAKER_02

How do you not go to the correct side of the body? Listen, I understand that sometimes, you know, your right is the patient's left, your left is the patient's right. But like when you've done that every single day for your entire career, like you get used to. You should know which side of the body the spleen is on. So for example, like when I first, when I just saw the headline, when I just saw the headline, I thought, huh, I wonder if this patient had heterotaxy, which is where your organs are literally due to a congenital condition, they are on the opposite sides of the body. We see that in our pediatric practice. There's lots of things you need to do differently. But then I started reading and I was like, this person had no heterotaxy. No.

SPEAKER_01

I mean, look, we all went through these same thoughts, like, oh, was it the other side? But okay, even if, even if that were the case, that the patient had Cytus inversus or whatever, the spleen. I just told you kind of what the anatomy of the spleen is, like in terms of the vasculature. The liver, you have chordal vein, you've got the IVC behind it, you've got the bile ducts, you've got the hepatic artery, you've got a lot of different things happening around the liver because it's a much more complicated organ than the spleen. So even if somehow you got confused, you're right and you're left, I don't know, like they don't look the same. They don't have the same things coming into and out of them. And they're not even shaped the same. As you said, the textures are like, I don't understand it.

SPEAKER_02

And like, you know, not that everyone like I'm and I'm for those of you who are on uh listening, I'm holding up a picture of Netter, my favorite anatomy book. And like, hello liver, big so many blood vessels. Oh blood vessel from the spleen. Spleen so small, so small. Even when it's inflamed, it doesn't look like a liver.

SPEAKER_01

No, it definitely does not. And you saw, can you hold that up again real quick? Yeah, yeah, yeah. For folks uh who can't see, uh uh, because you're listening, um, there's a really large, I mean, there's large vasculature going into the liver, and there's like a nice little splenic. I think this one's showing veins, this uh picture that you're on.

SPEAKER_02

Yeah, this one's a vein picture. You want to see the arteries?

SPEAKER_01

Well, a little, sure, yes, let's look at the arteries as well. Um, but there my point is as a surgeon, when you're taking out an organ, you have to think about all the things that organ is attached to. So when you're taking out a liver, yes, there are, as the forensic pathologist described, like attachments to the diaphragm, but the IVC is right behind it and the hepatic veins are coming off the IVC into the liver. All of that would have to be divided to get the liver out. The um gallbladder, if this patient already had a gallbladder removed, so that wouldn't apply in this case. But if there's a gallbladder, you have to remove that. Um, you have to divide the bile duct, you have to divide the hepatic artery, you have to divide the portal vein. You know, it's a lot more structures that you have to deal with in different locations relative to the organ. So just when you're thinking as a surgeon about the steps to an operation, there's many more steps. Like, you know, I was part of organ transplant teams and procurements. So, you know, we go to where a patient has a an organ donor is ready for their organs to be donated. And part of, you know, I've seen what that process is for the liver to be removed. You're obviously part of liver transplants all the time for your job. It's a totally different procedure. You cannot accidentally take out the liver. And so this is why it's just so um hard to wrap our heads around.

SPEAKER_02

Just because I said I would show you the arteries for show our audience, the arteries.

SPEAKER_01

Yeah. So there you can see the aorta that's sitting there behind the stomach. Um, and then you see the splenic artery coming from the spleen all the way, uh, or from the aorta, really, going to the spleen. And then you see the hepatic artery going up into the liver. You see the gallbladder and the bile duct. Uh, for those who are who are listening, those are the structures that we're looking at in this photo. Um, and this will all be in our YouTube video if folks want to actually see the picture. Thank you for holding that up. So that they're just totally different organs. The process to take them out is totally different. And another thing I didn't mention is that this case they started at like 5:30 in the afternoon, um, which is not an ideal time to be doing, even if it's the splenectomy, like a standard splenectomy, it's really not an ideal time because if you do get into bleeding, you want to have people around who can help. You want to have like normal daytime staffing. Um, and apparently multiple people had gone to the hospital and expressed concern about this case even happening. So there's a nurse who said she um expressed her concerns, concerns preoperatively and said that the majority of staff and anesthesia and the CRNA all voiced their opinion and didn't think we should be doing this procedure. Um, she said, this nurse said that she didn't think the surgeon was a great surgeon and didn't think it would end well. Um, and she said splenectomies can go bad very fast. And starting the surgery at 5 30 wasn't smart. Um anyway, so there was that too that people had expressed concerns about whether this procedure should even be done there or even at that time. Um anyway, I I don't, you know, we weren't there. We obviously don't know, but a couple other things I'll say are that he left the operating room. So the patient died even I think maybe before he had the liver out, I'm not totally sure, but pretty quickly.

SPEAKER_02

And um well, yeah, you're gonna die pretty quickly when so much of your blood flow has no is not going back to your heart where it wrongs because somebody has cut off your IVC.

SPEAKER_01

Um, and so the patient, so the surgeon left the room, but her multiple staff members came back to the room three different times to reassert that it was the spleen, that the specimen was the spleen, and that there had been a splenic artery in your zone that had ruptured. So that's not the behavior of someone who like let's say it wasn't somehow accident. Again, I don't know how that's possible, but let's say it even was. A person who has done something that catastrophic doesn't come back and keep reasserting their version of the truth or whatever they however they experienced reality.

SPEAKER_02

No, they're busy like crying in a closet, talking to the family, like starting to document what happened because you know you're gonna get sued at that point. Yes. This case will get an incredible amount of sc of scrutiny, which it should. Yeah. You know that you're likely, if you don't get sued, you're in your and this a lot of this depends on who how your uh malpractice insurance works. Either your hospital is gonna get sued or you're gonna get sued as an individual, or everyone in the room is gonna get sued. Um and so we're all very cognizant when something has happened to that, like be very accurate in your documentation. Do not go back and change anything after the fact, do not go back in time and change anything because it is very suspicious. Because people will understandably who are trying to make sense of everything afterwards, will think that you've modified your documentation to somehow justify the outcome. Um so yeah, the I this guy like coming back to like you guys know what to say, right? Wink wink. Come on.

SPEAKER_01

Yeah, basically three times. That's very strange behavior. I mean, I've never seen anything like that.

SPEAKER_02

Once is strange behavior. Once is strange behavior.

SPEAKER_01

Absolutely.

SPEAKER_02

That's weird. Absolutely. So what happened? Also, we're also dysfunctional, like emotionally dysfunctional for so many of us that work in operating rooms. That like, I would say talking with friends across the country for what it's very unusual for people to die in the operating room for one. That is very, very unusual. This is that is not a typical thing to happen. Many people will go through their entire career and never have a patient die on the operating room table if they're not doing transplant, like hard surgery, super high-risk procedures. Um, but like it's not unusual for people to just sort of like not talk about it because we're so emotionally dysfunctional. Nobody even knows how to have a conversation like a normal person. Because there's all this accounting that has to happen. You have to count all the blood products you gave. You have to make sure that all these like documents all say the things they need to say. And you know that once you leave the room to like communicate with the family or communicate, you know, you got to escalate it to all sorts of people.

SPEAKER_01

Um no one wants to go back after that. Yeah. It's it's very strange. So so this all happens, and then pretty quickly, the state of Florida, who does not have a surgeon general, who I think is necessarily always looking out for the public health of the state, um, his name, Ladapo. Yeah. He um he they did revoke his license pretty quickly after that, as they should have. Um, I believe he also had a license in New York that also got revoked. Um and then since that time, so that was fall of 2024, surgery was in August of 2024, and most of these other developments were in the fall of 2024. Um, now there's been this case um that's been working its way through the legal system, and he's been recently indicted. Um, and so we'll see what comes out of that. The um patient's widow has said that she just really doesn't want anything like this to happen to anyone else again, and that is her motivation for pursuing justice here. Um and yeah, it'll be interesting to see if anybody has some really great theory that ties it all together. Like, let us know. Because I I've talked to a lot of surgeons about this. I was just at a surgical conference and I asked a number of people what they think. And um, it's not like you and I are missing anything. Nobody else knows either. Everyone is everyone is perplexed, very perplexed by this um, by this case, by the way the surgeon acted, the fact that it even happened in the first place. It's yeah, very hard to put together a story that makes sense. Oh, I'll just say one more thing, which is that a number of people online have been asking if he was trying to like steal the liver for organ procurement. And I really don't think that because he doesn't have control. The surgeon is scrubbed at the time of surgery, right? And so once you pass the specimen off, it becomes the it gets put into a container, it's not sterile anymore. You're typically still doing your surgery. It's it's very difficult logistically for a surgeon to steal an organ that he had just taken out.

SPEAKER_02

First of all, I understand with the long history of unethical practices in transplantation, body snatching, all of these things, I can absolutely understand why people are worried about that. Um, but for a transplant to be effective, uh a liver trans, a liver, you basically need to either put it directly onto a specialized pump um that can continue to give it oxygen and nutrients until it can be implanted in another person, or it needs to go directly onto um basically goes on ice. You have to flush it with all sorts of things. There's all sorts of things that like you would have to perfusion, uh mix or whatever. You you would have to know what you were doing, and you would have to have somebody from, you know, an organ has to be assigned to somebody.

SPEAKER_01

Yeah, and you'd have a you'd have to have a team helping you with these things. You wouldn't be able to do it by yourself. So I agree, I totally understand why people are asking that, but it's just not feasible, really, for for someone to do that.

SPEAKER_02

I also like I feel bad. So right the reason he had a license in New York is because he did his residency training at Hackensack University Medical Center. And I feel bad for them. Like, what a it makes them look really bad that this guy graduated from their program.

SPEAKER_01

Well, you know, that's a conversation for another time, but I was just at the surgical education meeting and one of the um sessions was about failure to rescue in surgical education. So, what do you do with a trainee who's not doing well? And how do you figure out if they can do better, what support they need to do better, or you know, how do you decide who to not graduate from your program? But there's lots of conversations happening about that, as there have been, you know, at least the entirety of my career. But anyway, yeah, it's a it's a tragedy, and my heart goes out to his wife, especially. I'm sure she also didn't want him to have the surgery. You know, they wanted to be home. Um and this was the obviously the worst possible outcome.

SPEAKER_02

Well, thanks so much for covering that case. I remember when it first was in the news, I'm glad to see that he's been indicted. Um, I really hope that whatever comes out of the legal proceedings that are that are going to happen, I really hope that we see and can learn more about how do you really prevent this from happening again? Because um this all happens in a in an ecosystem. We're we're we're we're running we're running long, typical of us. We had we get so excited talking about things, but I did just want to um alert folks who maybe haven't seen there was a bunch of drama last week, actually last weekend, at uh the Pediatric Academic Societies meeting, which was in Boston. This is a huge academic meeting. It's called people will call it PAS. It's where there's a bunch of different pediatric academic organizations, like for different organ systems, different subspecialties, and they all come together and do this huge like it's a very much a research meeting, usually has about 7,000 people attend. It's a big deal to have your work accepted at PAS. Big scandal last week because it became clear that a panel had been accepted. It was the only panel exclusively dedicated to the health of trans kids. And it was entirely populated by people who are all connected with a group called the Society for Evidence-Based Gender Medicine or SEGEM. This organization has been called by a hate group by the Southern Southern Poverty Law Center. We've talked before about documents that have come out of the Trump administration really attacking trans kids. These are the same kinds of people who are on that, some of them the exact same people. Moti Gorin, who was one of the authors of the HHS report that we've talked about. So Aaron in the Morning, which is a newsletter that's run uh by a trans journalist, broke the story that this was on the that this was on the PAS uh schedule. And this ended up getting a lot of advocacy work done uh both externally by some uh trans youth advocates as well as internally from people who were at the meeting. I was not at the meeting, um, but I was hearing about it from folks, um, especially you know, people that I talk about uh trans kids and trans kids ethics issues with. So the petit there was a petition that was trying to get this session canceled. The session ultimately was not canceled. What was interesting is I was able to see on the session listing, it actually was directing people to all the other sessions that would talk about trans kids' health or about LGBTQ issues or other things that were uh presumably actually based in scientific evidence and the care and dignity of our patients. Um anyway, I'm very curious to see what comes out of this because I think that people who want to bring very specific opinions to academic medical set uh medical conferences can be very skilled at coding the submission in a way that is very effective at shielding what the topics will actually say. And I don't know, I don't know how the ecosystem works for PAS, but like there's other groups that I have done reviews for of submissions and usually they're uh they're blinded, so you don't know who has submitted them. Um but I really hope after this that there is a real reckoning within PAS as well as in other academic uh society meetings, to be like, hey, uh what is our process for escalating, just making sure that certain topics have extra scrutiny? It turns out that PAS's requirement for disclosing conflicts of interest was very bare bones. And that probably made it possible for several of the speakers. They didn't have to disclose some of the things like their association with SEGM. So, and that means that people could get CME credit for attending this like panel full of anti-trans people. So, very interesting. I'll put some links in the show notes for folks who want to learn more. Um, I'm gonna follow, I'm gonna follow this and see kind of what else comes of it.

SPEAKER_01

Yeah. I mean, thank you for sharing that. It does make me wonder about their process and whether they'll revisit their process for selecting these panels. Because it's one thing to have, I suppose, a conversation with people from different perspectives. But when you've got a whole panel of people who are whose positions are in contradiction to what the science tells us.

SPEAKER_02

Um, and they called it a scientific, they they claimed in the title that it was like a scientific review. And there was no endocrinologists on it, like there were no people who actually are the science. That's relevant. So anyway, I agree. I'm I'm very curious what's going to come from this from a process standpoint so that this doesn't happen again. Cause I I imagine that people at PAS were horrified and embarrassed, and you know, makes them look really bad.

SPEAKER_01

Yeah. Although, yeah, I don't know. We're we're stuck in this very weird academic freedom, freedom of speech space right now, where saying things that are um not real, like not evidence-based, not science-based, is somehow more welcome in some spaces than talking about science and evidence-based things. I'm sure that's not the case for PAS in general. I'm just saying there's much more acceptability now uh for things that are really just not scientific and are quite frankly harmful, um, in this case to a very marginalized group and a marginalized and vulnerable group of people. Um, so yeah, it is surprising to see that in that kind of venue. But hopefully there will be, you know, some reflection on how this came to be and um not to not to say no one should be allowed to speak, but that there should be a clear guidance.

SPEAKER_02

Yeah, I think that some I think there's a lot of good things about blind peer review for making sure you have variety, making sure you don't just have the same people presenting at a conference all the time because they're already famous or whatever. But I do think that you do need to have an extra level of scrutiny around topics that we know people will try to game the system to get in. Yeah. And it also makes me wonder what other panels, if there were any other panels that were to talk about the care of transgender children, were not accepted, but this one was accepted. And that's likely, I I doubt they're ever gonna share that. Right. Um, but it makes it certainly makes me curious who who was allowed in versus who was allowed out using the current system and what can be done to prevent further harm. Yeah, I agree. So um we should do our take to and call me in the morning. Okay, great. Why don't you go first? Um, well, one, I have a paper that just came out and I love when a paper gets published. It makes me very excited. Thank you. Um uh it's called Refusals to Provide Anesthesia for Abortion Care: Reconsidering Conscientious Objection Claims Amongst Anesthesiologists. So I got to write this with uh my friend Jacob Meeb, who is an incredible junior OB anesthesiologist at Northwestern University, and Katie Watson, who is a brilliant uh feminist legal scholar and bioethicist also at Northwestern. She wrote the book Scarlet A, which talks about uh having more nuanced conversations about abortion um in the United States. And it's a fabulous book for anybody who's uh interested. It almost seems kind of cute because it's from before the Dobbs era, but I still think it's really, really relevant. Um, so anyway, I was proud to work with them. I was proud to upshot. Tell us about it. What's the you know, couple line summary? That first, I think that there's a lot of people who are physicians who are not religious. They don't identify as having a religious affiliation, they don't have strong opinions about abortion or medical aid and dying or other things. And so they don't know that conscientious objection exists. And that's been fascinating to me. Um, having been raised Catholic, trained in a Catholic hospital system, I was very aware of what conscientious objection was when it was used. Usually it's used um to prevent people from getting clinicians who say, Oh, I don't want to participate in abortion because it's gonna, you know, deeply damage my sense of self. But what we found from talking to obstetrician gynecologists is they're like, hey, the people who are stopping us from doing abortions are not OBGYNs. The people who are stopping us are anesthesiologists. And so we really wanted to think more deeply about that. And there's some arguments that anesthesiologists um reportedly have been making that are claiming to be a conscientious objection, but they're actually something else. It's actually feeling icky about abortions, or it's actually that um they have legal concerns, which are is just a different thing. And so we need to have better processes. And so um we pulled together the literature on how to write a good conscientious objection policy so that your policy is not um, first of all, putting patients at harm, because if you have a conscientious objection, if there's an emergency, you should still be providing care to that patient. You cannot cause harm to a patient by refusing to provide care. Um, that is not something that's protected. Um, but there's a bunch of states that are trying to enhance their um conscientious objection protections for clinicians. There's uh federal government is trying to make it so that basically a doctor could just say they don't want to do anything for anybody. Um and so we wanted to really provide some nuance around this issue. We're not saying that conscientious objection shouldn't exist, um, but we're talking about how do you protect patients and how do you not overly burden the people who are willing to provide care? Because that's a whole other issue.

SPEAKER_01

Yeah. Well, it's so important. Thank you for working on that and congratulations on education. Thank you. Um the thing I was gonna say, look at us being so very nerdy this week. Um the thing that was that brought me joy this week uh was being at that surgical education meeting. This is a conference I've gone to the first time I went to it was when I was a medical student. So for many years. Um I I skipped a couple years in the pandemic and and that early part of the pandemic um period. But um it's such a lovely community of people. And you know how it is when you go to conferences and you see people who you've been colleagues with uh who are not at your institution, but you see them at these meetings year after year and you really develop um real meaningful relationships with folks. It's always lovely to see. And at that particular meeting, because it's a because it's a surgical education meeting, just a lot of really thoughtful people who spend a lot of time thinking about not just patient care, but also how do we provide the appropriate spaces for our learners, how do we teach, how do we assess? Um, I just feel like they're really, really thoughtful folks. Um, so it was lovely for that reason. Um and the president, the outgoing president of the organization um is a woman named Dr. Amy Gardner, a PhD psychologist. And her presidential address, she did something that is not super common, which is she brought her baby on stage with her and she um sat down with her baby and did most of or some of the talk. At some point her husband relieved her because uh there were issues with the microphone. But the reason that I thought was worth mentioning is that she did it not because she didn't have childcare, right? We've seen legislators, for example, women legislators who've had to take their baby with them. I I know a lot of people have seen that as like an empowering thing. I have not. I personally think that's a failure of our system if you don't have other support and you have to take your baby onto a parliamentary floor. Um, but this was an intentional choice. Her whole family was there. Her husband clearly was capable of watching the baby because he did uh for the latter portion of the talk. But she made this statement about being a woman leader and being a mom and doing them both at the same time that I just thought was really powerful because of the fact that you knew it wasn't because she didn't have childcare. Also, there was free on-site childcare for this conference. So many ways come a long way.

SPEAKER_02

Huh? Yeah. We've come a long way to have actual childcare at conferences. I mean, the amount of the degree to which that was entirely taboo and considered completely ridiculous 10 years ago is, you know, I'm glad that's changed.

SPEAKER_01

Me too. Um, so anyway, I thought it was I I love that she used her time in that way um while talking about other things, but like the message was very clear. Um, and so I appreciated it and made me feel um proud to be part of that organization and to see um how successful she's been. So yeah, that was my uh thing that brought me joy this week. Not really transferable to our audience, but uh I have a picture up on my blue sky, so I'll link to that if folks want to check it out. That's it for this week's episode. Uh, if you didn't like what you heard, this has been the Clavicular podcast. If you liked it, don't forget to subscribe to The Present Illness, leave us a review or rating, growth, um, and tell other folks to listen as well.

SPEAKER_02

We know that you all have better taste in podcasts. So we know that you're gonna follow us on TikTok, Instagram, and YouTube. We're at the Present Illness. You can stay on top of all of our TPI-related news.

SPEAKER_01

We will, as always, be back next week uh with more headlines, hot takes, and zoom scrolling. Hopefully next week we'll have more laughs. Uh this week with uh mostly downer. I mean, it's always mostly downer, but we usually have more laps. It's hard to joke about someone losing their life in the operating room. We don't want to joke about that, yeah.

SPEAKER_02

Um, until then, agitate, hydrate, take a nap, and we'll see you next time on the present illness. Production by Argivon Salas and Alyssa Bergart, editing by Alyssa Bergart, social media by Argivon Salas, and original music by Joseph Uphoff. Don't take medical advice from random people on a podcast. This shows for informational purposes. It's meant to be fun. It's clearly not medical advice. Take your medical questions to a qualified professional.

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Alyssa Burgart, MD, MA

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Arghavan Salles, MD, PhD

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