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Patient Dies After Doctor Allegedly Removes Wrong Organ · Murder Files Unsealed

0:00
Speaker 1: So imagine going to sleep for routine surgery. You're trusting
0:03
the the blindingly bright lights above you, the scrubbed in
0:07
professionals all around.
0:08
Speaker 2: You, Right, all those years of medical training hanging in
0:10
frames on the wall.
0:11
Speaker 1: Exactly, you believe that when you are completely unconscious and vulnerable,
0:17
the people operating on you are working with this flawless,
0:20
almost machine like precision, which is what we all expect. Yet, right,
0:23
you expect them to remove the small diseased organ that
0:27
they showed you on the scan. But now imagine the
0:30
surgeon makes an error so catastrophe, I mean, so completely
0:34
unfathomable that they remove an entirely different.
0:38
Speaker 2: Organ, and not just any organ, one of the largest,
0:40
most vital organs in your body.
0:41
Speaker 1: Yeah, and you end up bleeding to death on the
0:43
table while the rest of the medical team just they
0:46
just watch in silence. I mean, it sounds like a
0:47
horror movie trope.
0:48
Speaker 2: Oh absolutely, that sounds like dark fiction.
0:50
Speaker 1: But on August twenty first, twenty twenty four, in this
0:54
pristine Florida operating room, it actually became a fatal reality.
0:59
Speaker 2: It's just it's shatters that illusion of safety we all
1:02
carry when we walk through hospital doors. Because we are
1:05
we're conditioned to view modern medicine as this marvel of engineering.
1:10
Speaker 1: Right, like a mechanic fixing a car.
1:12
Speaker 2: Yeah, you identify the broken part, you take it out,
1:14
you stitch the patient up. But the reality is that
1:17
an operating room is this incredibly high stress environment. It's
1:21
governed not just by biology, but by human psychology.
1:24
Speaker 1: An extreme cognitive bias exactly.
1:27
Speaker 2: And deeply entrenched social hierarchies. So today we are dissecting
1:32
a case that really forces us to question every safeguard
1:35
we think exists in a modern hospital.
1:38
Speaker 1: We are unpacking the investigative reports, the court records, and
1:40
all these Florida Department of Health documents regarding a case
1:43
we're calling fatal anatomy, the fatal removal of the wrong organ,
1:47
the heavy one, it really is. And the mission for
1:50
this deep dive today is to understand exactly how a
1:53
highly trained, board certified surgeon could remove a massive liver
1:58
instead of.
1:58
Speaker 2: A physicized which biologically is wild.
2:02
Speaker 1: Wild doesn't even cover it. We need to explore the
2:05
incredibly complex anatomy of the human abdomen, the blinding nature
2:10
of confirmation bias, and this terrifying phenomenon of the authority
2:14
ingredient that literally silences entire teams of professionals.
2:19
Speaker 2: And ultimately what this means for your own safety, right
2:21
like the next time you are a loved one becomes
2:23
a patient exactly.
2:24
Speaker 1: So, to truly grasp the magnitude of the systemic failure here,
2:28
we have to start at the very beginning of the
2:30
patient's journey.
2:31
Speaker 2: Because long before that first incision was ever made, the
2:34
stage was basically being set by this really complex dynamic
2:38
of fear, trust, and medical authority.
2:41
Speaker 1: Okay, let's untack this. The patient at the center of
2:43
this whole tragedy is William Bryan. Everyone called him Bill.
2:47
He was a seventy year old retiree from Muscle Shoals, Alabama,
2:51
and in August of twenty twenty four, Bill and his
2:53
wife Beverly were spending some time near their rental property
2:56
in Miramar Beach, Florida.
2:57
Speaker 2: Which is gorgeous by the way.
2:59
Speaker 1: Oh yeah, if you picture the Florida Panhandle, you know,
3:01
the emerald greenwaters, the sugar white scent. It's a place
3:04
designed for relaxation, the ultimate escape, right, It's where you
3:08
go to escape stress. But Bill couldn't escape this severe
3:12
abdominal pain he was suddenly experiencing, and that.
3:15
Speaker 2: Pain is what led them to seek medical attention in
3:17
the first place. The subsequent imaging pointed to a severe
3:20
issue on the left side of his abdomen.
3:23
Speaker 1: What did the doctors actually find.
3:25
Speaker 2: Well. While strict privacy laws do shield the minute details
3:28
of his daily charts, the state investigative records reveal his
3:32
doctors identified two really critical issues. First was significant splen omegally,
3:38
which is just the medical term for a massively enlarged
3:41
spleen okay. And the second, the second and arguably the
3:45
more alarming finding, was the suspicion of a splinic artery aneurism.
3:49
Speaker 1: Okay, I want to make sure we understand the mechanics
3:51
of that, because the word aneurysm carries a lot of weight, right,
3:54
Like an artery is essentially a high pressure hose carrying
3:57
blood away from the heart.
3:58
Speaker 2: That's a great way to put it.
3:59
Speaker 1: Yeah, So an aneurysm means the wall of that hose
4:02
has become weak and it's ballooning outward, right.
4:05
Speaker 2: That is the perfect way to visualize it. These blood
4:08
vessels have muscular walls designed to handle the immense pressure
4:11
of your heart pumping. But if a section of that
4:14
splending artery weakens, the constant pressure of the blood basically
4:18
forces that weak section to bulge.
4:20
Speaker 1: Outward like a weak spot on a bicycle tire.
4:23
Speaker 2: Exactly like that. And if that bulge continues to stretch,
4:26
it can eventually rupture. And if a major abdominal artery ruptures,
4:30
the patient experiences massive immediate internal hemorrhaging.
4:35
Speaker 1: Which is an absolute life threatening surgical emergency. Yes, you
4:40
do not have much time if that happens, which totally
4:42
explains the incredible pressure Bill and Beverly must have felt.
4:46
But here's the detail that makes this entire story so
4:49
much more tragic. To me. Bill did not want the surgery.
4:52
Speaker 2: He was incredibly reluctant.
4:53
Speaker 1: Yeah, and Beverly wasn't just a worried spouse sitting in
4:56
the corner taking notes. She was a nurse, which is huge, right.
5:00
She understood the inherent baseline risks of putting a seventy
5:03
year old man under general anesthesia for major abdominal surgery.
5:07
Speaker 2: Her background is a nurse really is a crucial lens
5:10
through which to view this whole thing. She knew that
5:13
there's basically no such thing as a miner abdominal surgery.
5:17
Speaker 1: Because the moment you open the human.
5:18
Speaker 2: Body, you introduce the risk of severe infection, deep vein, thrombosis,
5:23
pulmonary embolism's adverse reactions to the anesthetic. I mean, the
5:27
list goes on.
5:28
Speaker 1: And given Bill's age, Beverly and Bill strongly advocated for
5:32
conservative management. They wanted to monitor the situation, manage his pain,
5:37
and see if they could avoid cutting him open entirely.
5:39
Speaker 2: Which is a completely reasonable approach, right.
5:42
Speaker 1: So I struggle to understand how you go from a
5:45
unified front of let's wait and see to literally signing
5:49
a consent form and getting wheeled into an operating room.
5:52
I mean, if the patient is resisting and the wife
5:54
is a medical professional who knows how dangerous this is
5:57
what actually breaks that resistance down.
6:00
Speaker 2: It is the overwhelming psychological weight of the worst case
6:03
scenario presentation, meaning what exactly, well we all place this enormous,
6:07
almost subconscious trust in the authority of a physician in
6:11
a white coat. And according to the investigative records in
6:14
the family's accounts, the surgical team, which was led by
6:17
doctor Thomas J. Sheechnovski, they frame this not as a choice,
6:21
but as a ticking time bomb.
6:23
Speaker 1: Oh wow.
6:24
Speaker 2: Yeah, they essentially communicated that if Bill left the hospital
6:27
without having his spleen removed, that aneurism could burst at
6:30
any moment.
6:31
Speaker 1: Leading to sudden, unavoidable death.
6:34
Speaker 2: Exactly.
6:34
Speaker 1: So it's essentially medical coercion through fear, I mean, not
6:37
malicious coercion necessarily, but a presentation of the facts that
6:41
removes any feeling of actual choice.
6:43
Speaker 2: That's a really good way to frame it.
6:45
Speaker 1: Because when a surgeon stands at the foot of your
6:46
bed and says, if you go home, you might bleed
6:48
to death in your living room, your primitive brain just
6:51
takes over the fear of that immediate catastrophic outcome, just
6:55
overgrides the logical desire to seek a second opinion or wait.
6:58
Speaker 2: And sadly that dynamic plays out in hospitals thousands of
7:02
times a day. Patients signed consent forms not because they're
7:06
enthusiastic about the procedure, but because they are terrified of
7:09
the alternative.
7:10
Speaker 1: Yeah, so their hesitation was basically overridden. Bill consented to
7:15
a laparoscopic splenectomy, which is the surgical removal of the spleen,
7:19
and the procedure was scheduled for August twenty first, twenty
7:22
twenty four at Ascension Sacred Heart Emerald Coast Hospital.
7:26
Speaker 2: Let's talk about the setting in the surgeon for a second,
7:28
because the context really matters here. Yeah, please, Ascension Sacred
7:31
Heart Emerald Coast isn't some massive, chaotic urban trauma center.
7:36
It's a seventy six bed facility in resort town, Okay,
7:39
and it's part of a massive, heavily resourced national health system. Plus,
7:44
doctor Schreknovski was forty four years old. He was a
7:47
board certifiled general surgeon who graduated from Midwestern University Chicago
7:51
College of Osteopathic Medicine back in two.
7:54
Speaker 1: Thousand and nine, so he had been practicing for well
7:56
over a decade.
7:57
Speaker 2: Exactly. On paper, everything about the external set up looked
8:00
completely standard. You have a seasoned surgeon, a modern facility,
8:03
and a common procedure. The environment projected total competence.
8:07
Speaker 1: But as we know, the physical reality inside Bill Brian's
8:10
abdomen was about to be profoundly misinterpreted. And this is
8:14
where the story shifts from a routine hospital visit into
8:17
something truly truly baffling. Because doctor Chichnovsky didn't remove the spleen.
8:23
Speaker 2: No, he did not.
8:24
Speaker 1: He removed Bill's liver, and in the process of tearing
8:27
that liver out of the body, he severed the major
8:30
blood vessels connecting it to the heart, causing Bill to
8:33
bleed to death right there on the operating table.
8:35
Speaker 2: The sheer scale of that anatomical error is I mean,
8:39
it's difficult for the medical community, even process I can imagine,
8:43
to truly understand how impossible this mistake should be. We
8:46
have to explore the biological reality of what these two
8:49
organs actually are, how they function, and where they actually
8:52
sit inside the human body.
8:54
Speaker 1: I've been trying to visualize this, and honestly, the only
8:56
way I can wrap my head around it is to
8:58
look at the physical disparity. Like mistaking the spleen for
9:01
the liver. Isn't like confusing a lemon for a lime
9:04
and a crowded produce bin.
9:05
Speaker 2: No, not at all.
9:06
Speaker 1: It's like mistaking a fist sized plum sitting on the
9:09
far left edge of a table for a massive, multi lobed,
9:13
four pound watermelon sitting on the far right edge.
9:16
Speaker 2: That analogy captures the physical dimensions perfectly, but honestly, even
9:21
that doesn't account for the biological plumbing.
9:23
Speaker 1: Let's break down the actual anatomy then, starting with the intended.
9:26
Speaker 2: Target, the spleen.
9:28
Speaker 1: Okay, so the spleen is located in the left upper
9:30
quadront of the abdomen. It is tucked really high up,
9:33
essentially hiding beneath the rib cage and right below the
9:37
left side of the diaphragm.
9:38
Speaker 2: And how big is it normally.
9:40
Speaker 1: In a healthy adult, it's roughly the size of a fist,
9:43
maybe like a small avocado.
9:44
Speaker 2: And what does the spleen actually do? Like, why is
9:48
it there?
9:48
Speaker 1: It is primarily a lymphoid organ. Its main job is
9:52
to filter your blood. It recycles old red blood cells,
9:55
it stores platelets, and it houses white blood cells to
9:58
help fight off infection.
9:59
Speaker 2: Okay, so it's a filter exactly.
10:01
Speaker 1: And because its job is to filter blood, it is
10:03
incredibly vascular, which gives it a very distinct, deep purplish
10:07
red color, and the plumbing relatively straightforward. It is supplied
10:11
by the splinic artery, which brings oxygenated blood in, and
10:14
the splanic vein, which carries the filtered blood away. Both
10:18
of these vessels branch off from a larger central hub
10:20
called the celiac trunk. So, just to recap, we have
10:23
the left side of the body high up under the ribs,
10:26
fist sized, deep, purple, simple input output plumbing.
10:30
Speaker 2: Got it.
10:31
Speaker 1: Now, compare that to the liver.
10:32
Speaker 2: The liver is the absolute behemoth of the abdominal cavity.
10:35
I mean, it completely dominates the right upper quadrant. It
10:38
is the largest solid internal organ in the human body.
10:42
Speaker 1: Wow. So how much does it weigh?
10:44
Speaker 2: Well, the spleen might weigh a few ounces. A healthy
10:47
adult liver weighs around one point five kilograms. That's roughly
10:50
three point three pounds.
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Speaker 1: Geez over three pounds.
10:53
Speaker 2: Yeah. Visually it is brownish red, and unlike the smooth,
10:58
unified surface of the spleen, the liver is highly lobular.
11:02
It is divided into two main lobes, the right and
11:04
the left, and two smaller lobes.
11:06
Speaker 1: But the liver isn't just floating free in there, right,
11:08
I mean, if it weighs over three pounds, it has
11:10
to be secured to the body somehow or it would
11:12
just bounce around.
11:13
Speaker 2: This is a critical point. The liver is essentially bolted
11:16
to the diaphragm and the abdominal wall by these thick,
11:19
heavy duty fibrous bands called ligaments bolted down. Basically, yeah,
11:24
you have the false form ligament running right down the middle,
11:26
the coronary ligament attaching it to the diaphragm, and the
11:29
triangular ligaments anchoring the sides. To remove a liver, a
11:33
surgeon has to physically slice through these massive structural anchors.
11:38
A surgeon pulling on a liver would feel an immense
11:41
mechanical resistance that simply does not exist when manipulating a spleen.
11:46
Speaker 1: And the plumbing for the liver is entirely different too. Right.
11:49
Isn't just a simple artery in a vein?
11:51
Speaker 2: Oh? No? The liver's vascular supply is one of the
11:54
most complex intersections in the human body. It has a
11:57
dual blood supply.
11:59
Speaker 1: Meaning it gets blood budd from two different sources.
12:01
Speaker 2: Exactly. It receives oxygen rich blood from the hypatoic artery,
12:05
but it also receives massive volumes of nutrient rich, deoxygenated
12:09
blood directly from the digestive tract via the portal vein. Wow.
12:13
And once the liver processes all that blood, it drains
12:16
it through the hepatic veins.
12:18
Speaker 1: And where do those hepatic veins go?
12:20
Speaker 2: They empty directly into the inferior of VENICAVO or the IVC. Yes, yeah,
12:24
the IVC is the massive central highway of the circulatory system.
12:28
It is a giant vein that runs vertically up the
12:31
back of the abdomen, carrying almost all the deoxygenated blood
12:34
from the lower half of your body directly into the
12:37
right atrium of the heart.
12:38
Speaker 1: So the liver is really tapped into the mainline.
12:40
Speaker 2: The liver is intimately wrapped around the IVC.
12:43
Speaker 1: Okay, so let's pause and look at the reality. Here.
12:46
We have the spleen left side, purple, fist size, simple
12:50
vessels hanging relatively loose, and we have the liver right side,
12:55
brown three plus pounds, four distinct lobes, bolted to the
12:59
diaphragm with thick ligaments and tapped directly into the largest
13:02
vein in the human body.
13:03
Speaker 2: A massive difference.
13:05
Speaker 1: So how on Earth does a surgeon look at a
13:06
CT scan, open a patient up and confuse the.
13:09
Speaker 2: Two medical experts and forensic radiologists have debated this exact
13:13
question for months. I mean, they have desperately tried to
13:16
find any physiological explanation, any trick of the anatomy that
13:19
could explain the initial confusion.
13:21
Speaker 1: Did they find anything?
13:22
Speaker 2: Well, the theory that has gained the most traction involves
13:25
a rare anatomical variant known as a beavertail liver morphology.
13:29
Speaker 1: Beavertail liver I have to assume that means a piece
13:32
of the liver is elongated and flat like a beaver's tail, exactly.
13:36
Speaker 2: In a small percentage of the population. The left lobe
13:39
of the liver grows abnormally long. It stretches all the
13:42
way across the mid line of the abdomen, completely crossing
13:45
over to the left side, and physically wraps itself around
13:49
the spleen.
13:49
Speaker 1: Wait really, so, if a surgeon inserts a tiny camera
13:52
into left side of the abdomen looking for the spleen,
13:55
the very first thing they might encounter is this rogue
13:57
elongated piece of the liver exactly where the spleen should be.
14:02
Speaker 2: Yes, if Bill Bryan possessed a beaver tail liver variant,
14:05
it would explain why doctor Schiknowski initially saw liver tissue
14:09
in the left upper quadrant.
14:10
Speaker 1: Okay, that actually makes some sense visually.
14:12
Speaker 2: But we also have to consider the preoperative imaging. The
14:15
CT and MRI scans reportedly described a massively enlarged spleen
14:21
measuring around thirty centimeters.
14:22
Speaker 1: Thirty centimeters that's over a foot long.
14:24
Speaker 2: Yeah, a spleen that size would be monstrous. It would
14:27
expand past the midline of the body into the center
14:29
of the abdomen.
14:30
Speaker 1: But the scans also showed hemo peratonium right, which means
14:34
there was already free floating blood inside the abdominal cavity.
14:37
Speaker 2: Correct. So put yourself in the mind of the surgeon.
14:40
Before the first incision is even made, he has looked
14:44
at a scan that he believes shows a giant, one
14:46
foot long spleen. He knows there is blood pooling in
14:50
the abdomen which completely obscures the normal anatomical landmarks. He
14:55
has built a mental model of what he is going
14:57
to see, and this brings us to one of the
14:59
most dangerous psychological phenomena in high stakes environments, confirmation bias. Right.
15:05
Speaker 1: Confirmation bias is essentially the brain's filtering mechanism. Like, when
15:10
we strongly believe something is true, our brain unconsciously highlights
15:14
any evidence that supports our belief, and it actively ignores
15:18
or rationalizes away any evidence that contradicts it.
15:20
Speaker 2: Our brains are desperate for cognitive shortcuts, especially under stress.
15:25
Doctor Schechnovsky expected to see a massive dark organ packing
15:28
up the middle and the left side of the aptomen,
15:30
and then he looked inside right when he inserted the
15:32
camera and saw a massive, dark, blood covered organ which
15:36
was actually the liver. His brain didn't say, wait, this
15:39
texture is wrong, this is the liver.
15:41
Speaker 1: His brain said, ah, there is the giant spleen the
15:43
ct scan warned me about.
15:45
Speaker 2: Exactly the visual cues were forced to align with his
15:48
expectation rather than objective reality.
15:51
Speaker 1: Okay, I can understand confirmation bias. For like the first
15:54
five minutes, I can see how an elongated piece of
15:57
liver covered in blood viewed through a two D camera
15:59
monitor could trick the eye initially, sure, but how does
16:03
that psychological trap sustain itself over the course of a
16:07
major extended operation. I mean, a surgeon has his hands
16:10
inside the body, he is cutting ligaments. How does the
16:13
illusion not break?
16:15
Speaker 2: It's terrifying, But this takes us to the actual sequence
16:18
of events in the OAR, which is where things descend
16:21
into absolute chaos. Let's get into it to understand the
16:24
mechanical escalation of this disaster. We really have to look
16:26
at the surgical technique itself. The operation began laparoscopically. This
16:30
is what we call minimally invasive surgery. Instead of slicing
16:33
the abdomen wide open, the surgeon makes three or four
16:36
tiny incisions, usually about a half inch long. Through these
16:40
incisions they insert hollow metal tubes called tree cars.
16:44
Speaker 1: And you can't just stick instruments into a flat stomach
16:47
because all the organs are resting against each other. You
16:49
have to create space to.
16:51
Speaker 2: Work, right. So through one of those trocars, they pump
16:54
the abdominal cavity full of carbon dioxide gas.
16:58
Speaker 1: Oh wow, so they inflate it.
17:00
Speaker 2: Yeah. This process called insufflation inflats the belly like a
17:04
tight balloon. It lists the abdominal wall away from the organs,
17:07
creating a hollow dome that makes sense. Inside that dome,
17:11
the surgeon inserts a high definition camera with a light
17:13
on the end, and these long, thin instruments that operate
17:16
sort of like chopsticks with tiny scissors and graspers on
17:19
the tips.
17:20
Speaker 1: This means doctor Shacknofsky isn't looking down at the patient.
17:23
He's standing next to the patient, but his eyes are
17:26
glued to a flat television monitor across the room. He
17:30
is navigating a three D space using a two D image,
17:33
and that.
17:34
Speaker 2: Loss of depth perception is critical. When you look through
17:37
a laparoscopic camera, the internal landscape is flattened. Scale and
17:42
distance are incredibly difficult to judge.
17:44
Speaker 1: Especially if this is messy.
17:45
Speaker 2: In there exactly and almost immediately upon inserting the camera,
17:50
the operative reports indicate that doctor Schiknovsky encountered severe difficulties.
17:55
The anatomy was incredibly distorted. The camera revealed dense adhesions.
18:00
Speaker 1: Adhesions are essentially internal scar tissue, right like bands of
18:03
tough fibrous tissue that act like super glue, sticking organs
18:07
together that shouldn't be connected.
18:08
Speaker 2: That's right. They often form after prior inflammations or minor
18:12
internal bleeds. These adhesions were webbing the organs together, further
18:17
obscuring the anatomy.
18:18
Speaker 1: That sounds like a nightmare to navigate it is.
18:20
Speaker 2: And on top of that, he noted a highly distended,
18:22
swollen colon blocking his view. And as he tried to
18:25
navigate through this messy, confusing landscape, the bleeding started.
18:29
Speaker 1: Oh no, the.
18:31
Speaker 2: Pool of blood in the abdomen began to rise, clouding
18:33
the camera lens and completely hiding the critical landmarks.
18:36
Speaker 1: Okay, stop right there, because this is a massive pivot point.
18:40
I'm imagining like a pilot flying into a thick storm
18:44
cloud where the instruments start failing.
18:46
Speaker 2: Very similar.
18:47
Speaker 1: If a surgeon is looking at a monitor seeing unexpected
18:50
scar tissue, a swollen colon, and rising blood that obscures
18:54
his vision, what is the textbook standard of care protocol
18:59
in that exact set?
19:00
Speaker 2: The absolute golden rule of surgery is if you cannot
19:04
clearly identify the anatomy, you do not cut. You stop it,
19:07
just stop. You pause for clarity. You suction out the blood,
19:11
You irrigate the area with saline to watch away the clots,
19:13
and you try to reorient yourself. If the laparoscopic view
19:17
is compromised, you stop the procedure and call for a
19:19
more senior partner or a specialized I had abiliary surgeon
19:22
to scrub in and give a second opinion.
19:24
Speaker 1: But the investigative report shows Schechnofsky didn't pause. He didn't
19:28
ask a nurse to page another surgeon for a consult.
19:31
He kept pushing forward into the blind spots.
19:34
Speaker 2: He continued dissecting blindly through the bloody tissue, and as
19:37
the bleeding inevitably worsened because he couldn't see what he
19:39
was cutting, he realized he had lost control of the
19:42
laparoscopic environment.
19:43
Speaker 1: So what did he do?
19:45
Speaker 2: He made the decision to convert to an open procedure.
19:48
Speaker 1: Now, converting to an open procedure is a massive escalation.
19:52
It is the surgical equivalent of pulling the emergency brake.
19:55
Speaker 2: It absolutely is.
19:56
Speaker 1: It means abandoning the tiny keyhole incisions, releasing the carbon
20:00
dioxide gas, taking a scalpel, and slicing a massive incision
20:05
straight down the middle of the patient's abdomen so the
20:08
surgeon can plunge his hands directly into the body cavity.
20:11
Speaker 2: Converting to open is supposed to provide immediate clarity. Suddenly
20:16
you have a three D view. You can feel the
20:18
organs with your hands. You can assess weight, texture, and
20:21
ligament attachments.
20:23
Speaker 1: It should have been the moment the illusion broke. It
20:25
should have been the moment he touched that massive, lobular,
20:28
three pound organ and realized, my god, I'm holding the liver.
20:31
Speaker 2: But the nightmare only accelerates from here. According to the investigation.
20:36
Once the abdomen was laid open, Schignowsky did not pause
20:39
to reidentify the anatomy.
20:41
Speaker 1: You're kidding.
20:42
Speaker 2: Instead, amidst the pooling blood, he grabbed a surgical stapling
20:46
device and fired it blindly into the abdomen to control
20:49
what he believed was a hemorrhaging splenic artery.
20:52
Speaker 1: This is I mean, this is where the medical community
20:54
reviewing this case simply gasps.
20:56
Speaker 2: It's horrifying.
20:58
Speaker 1: Let's break down the mechanics of a surgical staple, because
21:00
it's not a desktop swing line. Firing this device blindly,
21:05
that's not just putting a staple into tissue. It's like
21:08
using a pair of industrial bolt cutters on a massive
21:11
bundle of live wires when you can't even see the wires.
21:14
Speaker 2: That is a highly accurate mechanical comparison. A surgical stapler
21:18
is a heavy, sophisticated piece of equipment. When a surgeon
21:22
positions it around a blood vessel and squeezes the handle,
21:25
the device does three things simultaneously.
21:28
Speaker 1: Okay, what does it do?
21:29
Speaker 2: First it clamps down with immense pressure, crushing the tissue flat.
21:34
Then a razor sharp blade slides down the middle, completely
21:37
severing whatever is inside the jaws, and the third thing
21:40
At the exact same microsecond, it fires multiple staggered rows
21:44
of titanium staples on both sides of the cut, permanently
21:47
sealing the severed end shut. It is designed to cleanly
21:50
and permanently divide major.
21:51
Speaker 1: Anatomy, and he fired it blindly into a cool of blood.
21:55
He couldn't see what was inside the jaws of the device.
21:57
He just clamped down and pulled the trigger.
21:59
Speaker 2: That's why what happened.
22:00
Speaker 1: How does a rational, trained human being do something so reckless.
22:05
Speaker 2: This brings us back to the psychology of the operating room, specifically,
22:09
the sunk cost fallacy combined with extreme physiological stress.
22:13
Speaker 1: The sunk cost fallacy, that's the human tendency to continue
22:16
down a doomed path because of the time, effort and
22:20
narrative you've already invested in it.
22:21
Speaker 2: Exactly, Chicknowsky had already committed to the narrative. This is
22:25
a giant ruptured spleen, and I am in a race
22:28
against time to get it out before the patient bleeds
22:31
to death.
22:32
Speaker 1: So he genuinely believed he was saving Bill's life in
22:35
that moment.
22:35
Speaker 2: Yes, under that extreme stress, the autonomic nervous system just
22:40
takes over the fight or flight response floods the brain
22:43
with adrenaline and cortisol. In this state, cognitive processing dramatically narrows.
22:48
It's called tunnel vision. The brain literally stops processing peripheral information,
22:53
the texture of the organ, the weight, the attachments, and
22:56
focuses entirely on the perceived immediate threat, the bleeding. He
23:00
thought he was stapling the splinic artery to stop a hemorrhage.
23:03
Speaker 1: But he wasn't anywhere near the splenic artery. The organ
23:07
he had in his hands, the organ he was blindly
23:09
firing bolt cutters into was the liver.
23:12
Speaker 2: When he fired that stapler, the jaws clamped down not
23:16
on the splintic vessels, but on the liver's major vascular highway.
23:19
He divided the hepatic inflow, the outflow, and most catastrophically,
23:24
the stapler caught and severed the inferior vnicava.
23:28
Speaker 1: The IVC. We established earlier that this is the massive
23:31
central vein, returning all the blood from the entire lower
23:35
half of the body straight to the heart. What is
23:37
the physiological reality of severing the IVC without clamping it
23:41
off first?
23:41
Speaker 2: It is sudden uncontrollable catastrophic exanguinationes bleeding out instantly. The
23:46
IBC operates under immense volume. If you sever it, the
23:49
patient's entire blood supply begins emptying directly into the open
23:52
adominal cavity like a fire hydrate that has been sheared
23:55
off at the base. Oh my god, you cannot simply
23:57
put your finger over it to stop it. The bloodline
24:00
is so rapid and so massive that the heart essentially
24:02
runs dry within seconds.
24:04
Speaker 1: The moment that stapler fired and sliced through the IVC,
24:08
the physiological chaos inside Bill Bryan's body instantly triggered a
24:12
wave of psychological and social chaos among the rest of
24:15
the surgical team.
24:16
Speaker 2: Because we have to remember doctor Chichnovsky was not alone
24:19
in that room, right.
24:20
Speaker 1: An operating room is a crowded place. There is an
24:24
anesthesiologist monitoring the vitals. There is a scrub nurse handing
24:28
over the instruments. There is a circulating nurse managing the room.
24:32
Speaker 2: The investigative reports describe absolute, terrifying pandemonium erupting the second
24:38
the stapler was fired.
24:39
Speaker 1: Because the anesthesiology team is sitting behind the drape at
24:42
the patient's head right. They're looking at the monitors. Suddenly
24:45
the blood pressure plummets from normal to virtually zero in
24:48
a matter of heart beats.
24:50
Speaker 2: They immediately initiate emergency resuscitation protocols. They're calling a code blue.
24:55
They activate the massive transfusion protocol, screaming for coolers of
24:59
oh negative blood to be rushed into the room.
25:01
Speaker 1: It must have been just pure panic.
25:02
Speaker 2: They are pushing vase opressors, which are drugs designed to
25:06
artificially clamp down the blood vessels to keep the brain alive.
25:09
The monitors are screaming with alarms, but there is no
25:13
blood left to pump.
25:14
Speaker 1: Bill Bryan slips into profound cardiac arrest right there on
25:17
the table, and the team begins desperately performing CPR.
25:21
Speaker 2: And amidst this absolute horror, with alarms blaring, blood pooling
25:25
uncontrollably in a team performing chess compressions, Schicknowsky physically tears
25:29
the organ out of the body.
25:31
Speaker 1: He literally tears it out.
25:32
Speaker 2: He lifts this massive, brownish red, multi lobed three pounds structure,
25:37
walks over to the sterile, stainless steel surgical back table,
25:40
drops it down, and announces to the room that he
25:43
has successfully removed the spleen.
25:45
Speaker 1: This specific moment in the timeline is I mean, this
25:48
is the crux of the entire investigation, because what happens
25:51
next is a chilling indictment of medical culture.
25:54
Speaker 2: Here really is.
25:54
Speaker 1: The silence, the paralyzing, deadly silence.
25:58
Speaker 2: Following the incident, investigators for the Florida Department of Health
26:01
arrived and systematically interviewed every single medical professional who was
26:05
present in that operating room.
26:06
Speaker 1: And what did they say.
26:07
Speaker 2: Multiple staff members admitted a terrifying truth. When Shchikoski placed
26:12
that organ on the table, they looked at it. They
26:14
saw the four lobes, they saw the size, they saw
26:16
a color, and they knew They instantly recognized that it
26:19
was a liver.
26:20
Speaker 1: You're telling me there are trained nurses and medical technicians
26:23
looking at a liver, knowing full well it's a liver,
26:26
while a man is coding on the table, and they
26:29
said nothing.
26:30
Speaker 2: They remained completely silent.
26:32
Speaker 1: I just I can't wrap my head around that.
26:34
Speaker 2: The horror of the situation is compounded by the fact
26:36
that one individual in the room, the clinical staff member
26:40
whose specific job was specimen handling, took a plastic biohazard container,
26:46
placed the massive liver inside it, took a marker and
26:50
labeled the container's.
26:51
Speaker 1: Spleen, even though they knew it wasn't.
26:53
Speaker 2: Exactly as doctor Sheiknowski instructed, despite knowing in their own
26:57
mind that it was a liver.
26:58
Speaker 1: I am struggling to process this. How does a room
27:01
full of highly educated, dedicated medical professionals see a massive
27:05
liver here a doctor call it is spleen, watch a
27:08
patient actively bleeding to death, and fundamentally refuse to speak
27:12
the truth out loud. What psychological force is strong enough
27:16
to gag an entire room during a fatal emergency.
27:19
Speaker 2: It is a deeply studied sociological and organizational concept known
27:23
as the authority gradient.
27:24
Speaker 1: The authority gradient.
27:25
Speaker 2: Yeah. In the culture of medicine, and particularly in the
27:28
high stakes theater of surgery, there is a rigid, historical,
27:32
almost militaristic hierarchy. The surgeon is the captain of the ship.
27:36
Their authority is absolute, their word is law.
27:39
Speaker 1: Okay. So the gradient part.
27:40
Speaker 2: The gradient describes the psychological distance between the highest ranking
27:44
person in the room, the surgeon, and the subordinates the
27:47
nurses and texts.
27:48
Speaker 1: So when that gradient is steep, the psychological distance is.
27:51
Speaker 2: Vast precisely when the gradient escape subordinates feel it is
27:55
culturally and professionally unacceptable to question or contradict the leader,
27:59
even when they possess undeniable visual proof that the leader
28:03
is making a fatal error.
28:04
Speaker 1: They just assume the doctor knows best.
28:06
Speaker 2: They assume the leader must know something they don't, or
28:09
they fear the immediate wrath of challenging someone who holds
28:12
their career in their hands.
28:13
Speaker 1: It's the catastrophic failure of psychological safety. Yes, exactly, because
28:17
psychological safety is the foundational belief within a team that
28:22
you will not be punished, humiliated, or fired for speaking
28:25
up with an idea, a question, a concern, or pointing
28:29
out a mistake.
28:30
Speaker 2: But in that operating room, during an active code blue,
28:33
with a patient's chest open, blood everywhere and alarms blaring, ye,
28:37
the sheer terror of confronting an intense adrenaline fueled surgeon
28:42
silenced the entire room.
28:44
Speaker 1: And this isn't a new phenomenon. It's a known deadly
28:47
glitch and human hierarchical systems. The aviation industry actually confronted
28:51
this exact sociological nightmare decades ago, didn't they?
28:54
Speaker 2: They did in the nineteen seventies, aviation regulators realized that
28:58
perfectly functional airplanes were flying into the sides of mountains
29:01
because junior copilots were too terrified of senior, authoritative captains
29:06
to speak up and say, captain, our altitude is too low.
29:09
Speaker 1: The Teneriff Airport disaster in nineteen seventy seven is the
29:12
prime example, isn't it. Two massive seven four sevens collided
29:16
on a runway, killing five hundred and eighty three people,
29:19
largely because a flight engineer was too intimidated to forcefully
29:22
stop a senior captain from taking off without clearance.
29:25
Speaker 2: Exactly after Tenerief, aviation invented crew resource management or CRM.
29:31
CRM completely restructured the hierarchy of the cockpit in aviation. Today,
29:35
a copilot is not just encouraged to challenge the captain,
29:38
they are explicitly trained and mandated to do so right.
29:42
Speaker 1: They have specific scripts they must use. If a captain
29:45
makes a strange maneuver, the copilot doesn't just clear their
29:48
throat nervously.
29:49
Speaker 2: No, they go.
29:49
Speaker 1: They are trained to say, captain, I am concerned about
29:52
this heading, and if the captain ignores them, they escalate
29:54
the language Captain I'm uncomfortable, Captain, I am taking control
29:58
of the aircraft.
29:59
Speaker 2: And medicine has spent the last twenty years desperately trying
30:02
to adopt Aviation's CRM principles. They want nurses to feel
30:06
empowered to say, doctor, I need clarity on this anatomy.
30:08
This structure looks like a liver, not a spleen.
30:11
Speaker 1: But as the silence in Bill Bryan's operating room tragically demonstrates,
30:15
having a theoretical safety policy written in a hospital handbook
30:19
is entirely different from breaking through centuries of cultural conditioning
30:24
in the terrifying, chaotic heat of an act of surgical emergency.
30:28
Speaker 2: A completely different reality in the moment.
30:29
Speaker 1: I want to connect this to you, the person listening
30:32
right now, because it is really easy to judge the
30:34
people in that room. But think about your own life.
30:37
Think about a time at your workplace where you knew
30:40
with absolute certainty that a boss, a senior manager, or
30:43
a CEO was making a massive, costly mistake. We have
30:46
all been there, right, But the culture of your office,
30:49
the steep authority ingredient, or simply the fear of being
30:52
humiliated in front of your peers, made it impossible for
30:55
you to speak up, You bit your tongue. You let
30:57
the mistake happen.
30:58
Speaker 2: It happens every day.
31:00
Speaker 1: Now, take that exact feeling of workplace paralysis that not
31:03
in your stomach, and imagine that instead of a bad
31:05
marketing campaign or a flawed spreadsheet, a human life is
31:09
literally draining away on a steel table in front of you.
31:13
That is the paralyzing reality distorting power of the authority gradient.
31:17
Speaker 2: The silence ruled the room. The team performed CPR, they
31:21
pushed the blood transfusions, but it was medically feudle. You
31:25
cannot resuscitate a patient who has a severed inferior venaicavo
31:29
without clamping it, and Shignotsky had not clamped it.
31:31
Speaker 1: So Bill Brand died.
31:33
Speaker 2: He died from exanguination catastrophic blood loss within hours of
31:37
the initial incision.
31:38
Speaker 1: The surgery ends, the heart monitors turned off, the blood
31:41
soaked drapes are pulled back. But the silence couldn't last forever. No,
31:45
it couldn't, because outside those double doors, sitting in a
31:48
waiting room chair is Beverly Bryan, and a surgeon has
31:52
to scrub out, take off his bloody gown, walk down
31:54
the hallway and explain to a woman why her husband,
31:57
who walked into the hospital for a procedure they said
32:00
would save his life, is now lying dead on a table.
32:03
Speaker 2: And according to the deeply detailed Department of Health reports.
32:06
Chechnovsky sits down with Beverley, and the explanation he provides
32:10
is staggering.
32:11
Speaker 1: What does he tell her?
32:12
Speaker 2: He tells her that the surgery descended into a nightmare
32:14
because Bill's spleen was grossly abnormal. He claims the spleen
32:18
was four times its normal.
32:19
Speaker 1: Size, which we know is supposedly on the scams, but
32:22
still right.
32:23
Speaker 2: But more shockingly, he tells her that the spleen had
32:26
literally migrated to the opposite side of the body what
32:29
and that the massive bleeding was caused by this splinning
32:32
artery aneurysm naturally rupturing during the procedure.
32:35
Speaker 1: He tells her the spleen migrated.
32:37
Speaker 2: That is what the reports state, and if we connect
32:41
this to the broader medical and anatomical reality, that explanation
32:45
is not just a creative misinterpretation of a chaotic event.
32:48
Speaker 1: It's an outright lie.
32:50
Speaker 2: Medical experts and the family's attorneys have categorized that statement
32:54
as a profound anatomical impossibility.
32:56
Speaker 1: Because spleens don't have legs. They are attached to a
32:59
vascular pet of call.
33:00
Speaker 2: Exactly, spleens do not simply detach from their arterial blood supply,
33:05
wander across the abdominal cavity and resettle on the right
33:08
side of the body underneath the diaphragm. The explanation defies
33:12
the basic laws of human biology.
33:14
Speaker 1: It is an alleged deception that is breathtaking in its audacity.
33:18
And he didn't just verbally tell the grieving widow this story.
33:22
He allegedly codified it into the official hospital record.
33:25
Speaker 2: He did.
33:25
Speaker 1: The investigative reports state that when Schachnovsky dictated his official
33:29
operative report, the legal document detailing the surgery step by step,
33:34
he completely omitted any mention of the massive vascular injury
33:38
to the inferior vinakava.
33:40
Speaker 2: And he officially identified the organ he removed as a
33:43
grossly enlarged spleen.
33:45
Speaker 1: Prosecutors and medical reviewers later described this documentation as an
33:49
active attempt to convince the room and the permanent medical
33:52
record of a narrative that completely contradicted the physical reality
33:56
of what had just occurred.
33:57
Speaker 2: It's a staggering cover up.
33:59
Speaker 1: I am stuck on the shiite illogical nature of this
34:01
cover up. Did he think this lie was actually going
34:03
to hold up? We aren't living in the eighteen hundreds
34:05
where you can just throw an extracted organ into an incinerator.
34:08
Speaker 2: No, everything is tracked now, right.
34:10
Speaker 1: In a modern American hospital, every single piece of tissue
34:14
removed from a human body, whether it's a massive organ
34:17
or a tiny skin mall goes directly to the pathology lab.
34:21
It is a mandatory, inescapable legal protocol.
34:24
Speaker 2: You are exactly right. The tissue goes into a preservative fluid,
34:27
usually formaline, and is sent down to a pathologist who
34:30
slices it, stains it, and puts it under a microscope
34:33
to examine the cellular structure.
34:35
Speaker 1: So did he somehow believe the pathologist was just gonna
34:38
glance at a three pound multi lobed liver sitting in
34:42
a bucket, see the word spleen scrawled on the lid
34:45
and sharpie, and just stamp it approved.
34:49
Speaker 2: We can really only speculate on his exact state of
34:51
mind in those hours following the death, but psychological experts
34:54
who study medical errors point to the profound psychology of
34:58
denial that occurs after a never of.
35:00
Speaker 1: A never event.
35:01
Speaker 2: Yeah, a never event is an error so catastrophic and
35:04
so preventable that it is supposed to be impossible. When
35:08
a highly trained professional commits one, the human mind can
35:11
literally fracture. It's the blind panic of the cover up.
35:14
Speaker 1: The brain refuses to accept the reality of what the
35:16
hands just did.
35:17
Speaker 2: Yes. Some behavioral psychologists suggest he might have been so
35:21
deeply entrenched in his initial confirmation bias, the belief that
35:24
he was dealing with a massive spleen, that his brain
35:27
was still desperately clinging to that narrative to protect his
35:30
own ego insanity Wow. Alternatively, a more cynical interpretation is
35:35
that he knew exactly what he did, and he was
35:37
simply trying to bide time, hoping that the chaos of
35:40
the massive hemorrhage and the code bleue would somehow obscure
35:44
the precise sequence of his fatal errors during a later review.
35:48
Speaker 1: But the truth always comes out under the bright light
35:50
of a microscope, because the very next day the pathology
35:53
lab processes the tissue, and the resulting pathology report is
35:57
the ultimate smoking gun of this higher devastating tragedy.
36:01
Speaker 2: That report changed to everything.
36:03
Speaker 1: The plastic container arrives at the lab. It is clearly
36:05
labeled spleen, but the pathologist opens it, examines the tissue,
36:09
and writes the official report. It reads, tissue designated spleen
36:13
excision liver with mild chronic portal inflammation. No splinic tissue identified.
36:18
Speaker 2: Liver with portal inflammation. The cellular structure of a liver
36:23
is entirely distinct from a spleen. The pathologist didn't even
36:27
need a microscope to see the error, but the cellular
36:30
analysis confirmed it beyond the shadow of a doubt.
36:33
Speaker 1: I bet they were stunned.
36:34
Speaker 2: The pathologist actually had to pick up the phone and
36:37
call doctor Sheknovsky directly to discuss these findings.
36:40
Speaker 1: Imagine being a pathologist and having to make that phone
36:43
call to a surgeon. Doctor, I'm looking at the specimen
36:46
you sent down from yesterday's fatal surgery. You labeled it spleen.
36:50
It's a liver. That is the exact moment the entire
36:53
fabricated narrative instantly unraveled.
36:56
Speaker 2: The pathology report forces the truth into the light. Beverly Bryant,
37:00
who was initially sitting in her grief mourning what she
37:03
believed was the unavoidable tragedy of a ruptured aneurysm in
37:06
an old man. Suddenly learns through the subsequent legal and
37:10
medical review that her husband's death was not an act.
37:12
Speaker 1: Of nature, It was an act of gross, unimaginable surgical incompetence.
37:16
Speaker 2: She realizes her husband was essentially killed on.
37:18
Speaker 1: The table, so she immediately hires a prominent attorney, Joe'sarzar.
37:23
They demand the pathology report, they demand the autopsy, and
37:26
the autopsy confirms the final devastating detail.
37:30
Speaker 2: When the medical examiner opened Bill Bryan's body, they found
37:33
his actual spleen still perfectly intact.
37:36
Speaker 1: Sitting exactly where it was supposed to be in the
37:38
left upper quadrant of his abdomen.
37:40
Speaker 2: It was completely untouched save for a minor harmless cyst.
37:43
Speaker 1: The family released a public statement that cut through all
37:46
the medical jargon. They simply pointed out the obvious reality.
37:50
Typical human anatomy dictates that the liver naturally exists on
37:54
the opposite side of the abdominal cavity, and it is
37:56
several times larger than the spleen.
37:58
Speaker 2: And once that pathology to report and the autopsy results
38:01
hit the hospital administration's desks, and the families lawyers file
38:05
their notices. The state government is legally forced to step in.
38:09
Speaker 1: And what the investigators for the Florida Department of Health
38:11
found when they began digging into doctor Sheechnovsky's files was
38:14
that the horrific death of Bill Bryan was not an
38:17
isolated freak incident.
38:19
Speaker 2: No, it wasn't. It was the terrifying climax of a
38:22
documented pattern of catastrophic behavior.
38:24
Speaker 1: Which brings us to the legal and professional reckoning which
38:28
escalated with unprecedented speed. On September twenty fourth, twenty twenty four,
38:33
just a month after the surgery, Florida's Surgeon General, doctor
38:37
Joseph A. Ledappo, signed a twenty one page emergency suspension order.
38:42
Speaker 2: That is a massive deal.
38:43
Speaker 1: I've read excerpts of that order and it is a brutal,
38:46
uncompromising document. Emergency suspensions of medical licenses are incredibly rare.
38:52
Medical boards usually move at a glacial pace, preferring long
38:55
investigations and hearings.
38:57
Speaker 2: Right They usually want to take their time.
38:58
Speaker 1: But this document tripped doctor Schuchnovsky of his medical license immediately.
39:03
It explicitly cited his blatant disregard for the truth regarding
39:07
the falsified operative report, and it stated in stark legal
39:11
terms that his continued practice constitutes an immediate, serious danger
39:14
to the health, safety, or welfare of the citizens of
39:17
the State of Florida.
39:18
Speaker 2: The high burden of proof required for an emergency suspension
39:22
was met not just because of the shocking nature of
39:24
Bill Bryan's case, but because the Department of Health's investigation
39:27
pulled back the curtain on prior deeply concerning red flags
39:31
that the hospital system had seemingly failed to act upon.
39:34
Speaker 1: Right, the investigators found a history we learn about a
39:38
woman named Dorothy Dorsett in twenty twenty three, just a
39:41
year prior. She was a seven year old patient who
39:44
died just days after doctor Sheeknovsky performed a procedure to
39:48
remove a digestive tract tumor.
39:50
Speaker 2: Her family had already raised massive red flags and major
39:53
concerns about his surgical competence.
39:55
Speaker 1: And even more shockingly, the investigation unearthed another documented allegation
40:00
from his past case files. In a previous surgery, Schiknofsky
40:04
was scheduled to perform an adrenalectomy right and adrenalectomy is
40:07
the removal of an adrenal gland. Right, Those are the
40:09
tiny glands that sit like little hats right on top
40:12
of your kidneys.
40:12
Speaker 2: Exactly. They are small, distinct endocrine glands. But according to
40:17
the allegations on Earth by the State, instead of removing
40:19
the adrenal gland, Schikanowski allegedly removed a portion of the
40:22
patient's pancreas.
40:23
Speaker 1: He mixed up the adrenal gland and the pancreas just
40:26
like he mixed up the spleen and the liver. Yes,
40:28
this shatters the idea that the beaver tail, a liver
40:31
anomaly in Bill Bryan's case, was a one off stroke
40:34
of bad luck. This reveals a fundamental, terrifying inability to
40:37
safely navigate human anatomy.
40:40
Speaker 2: And this documented history of anatomical confusion is why the
40:44
justice system decided to escalate this case far beyond the
40:48
realm of standard civil medical malpractice.
40:50
Speaker 1: Because medical malpractice usually involves a tragic mistake made in
40:54
good faith exactly.
40:55
Speaker 2: But on April fourteenth, twenty twenty six, a Walton County
40:59
grand jury convened, reviewed the evidence, and handed down a
41:03
criminal indictment. They charged doctor Chichnovsky with one count of
41:07
second degree manslaughter.
41:08
Speaker 1: Second degree manslaughter is a severe felony charge. It carries
41:12
a penalty of up to fifteen years in prison.
41:15
Speaker 2: It is exceptionally rare for a surgeon to face criminal
41:18
charges for an act committed in the operating room. In Florida.
41:22
To convict a doctor of second degree manslaughter, prosecutors cannot
41:25
just prove that a mistake was made. They must prove culpable.
41:28
Speaker 1: Negligence, meaning what exactly they have.
41:30
Speaker 2: To demonstrate a reckless indifference to human life.
41:33
Speaker 1: So the legal threshold is essentially proving that the doctor's
41:36
actions were so wildly outside the bounds of standard medical
41:39
practice that they became a criminal act rather than a
41:42
clinical error.
41:43
Speaker 2: Yes, the charging documents explicitly cite his blind firing of
41:47
the stapling device into a pool of blood, which directly
41:50
resulted in the catastrophic transaction of the inferior venicaba and
41:54
the subsequent exanguination.
41:55
Speaker 1: Blind firing is the key, right.
41:58
Speaker 2: Furthermore, the state called out the shock and the chaos
42:01
that Schacknovsky claimed prevented him from properly identifying the organ,
42:05
arguing that a competent surgeon is trained to manage chaos
42:08
by stopping, not by blindly tearing mass of organs out
42:12
of the body.
42:12
Speaker 1: So we have a grieving family, a disgraced surgeon facing
42:16
fifteen years in prison, and a medical team traumatized by
42:19
their own silence. How do we contextualize a systemic failure
42:23
of this magnitude in a healthcare system that we all
42:26
inevitably have to rely on.
42:28
Speaker 2: We have to zoom out and look at the concept
42:29
of never events. The National Quality Forum and the Agency
42:33
for Healthcare Research and Quality established the term never events
42:36
to define medical errors that are so egregious, so fundamentally preventable,
42:40
that they should literally never occur in a well functioning
42:44
modern hospital.
42:44
Speaker 1: Give me some examples.
42:46
Speaker 2: The classic examples include amputating the wrong leg, performing surgery
42:50
on the wrong patient entirely, or as in this case,
42:53
removing the wrong organ.
42:54
Speaker 1: But despite the name never events happen, the data shows
42:59
they happen with terrified regularity.
43:01
Speaker 2: They do happen. Current medical data estimates they occur in
43:04
roughly one in ten thousand to one in one hundred thousand.
43:07
Speaker 1: Procedures, which sounds rare.
43:09
Speaker 2: But when millions of surgeries are performed a year, that
43:12
translates to thousands of devastating errors to prevent them, Organizations
43:17
like the Joint Commission, the body that it credits hospitals
43:21
implemented strict mandatory protocols.
43:23
Speaker 1: If you've had surgery recently, you've probably experienced the Universal Protocol.
43:28
It's when the preopt nurse comes in with a thick
43:30
black marker and literally draws a big X and their
43:33
initials on your right knee so the surgeon doesn't accidentally
43:35
replace your left knee.
43:36
Speaker 2: That is called site marking, and it's highly effective for
43:39
external appendages. But you obviously cannot take a sharpie and
43:42
mark an internal organ on a CT scan. True, so
43:45
for internal surgeries, the most critical safeguard of the Universal
43:48
Protocol is the surgical timeout.
43:50
Speaker 1: How does a timeout actually work? In practice?
43:53
Speaker 2: Right before the surgeon asks for the scalpel to make
43:56
the very first incision, the entire operating room is manned
44:00
to stop. The music is turned off, the side conversations.
44:04
Speaker 1: End, complete silence.
44:05
Speaker 2: The surgeon, the anesthesiologist, and the circulating nurses must verbally
44:09
confirm aloud using a checklist. We have patient Bill Bryan.
44:14
We are here to perform a laparoscopic splenectomy. We have
44:17
the correct imaging displayed on the monitors. We have emergency
44:20
blood cross smashed and ready. Does everyone agree? Every team
44:23
member must verbally say yes.
44:26
Speaker 1: But a timeout wouldn't have prevented Bill Bryan's death because
44:29
at eight am when they did the timeout, everyone in
44:31
the room fundamentally agreed they were there to remove the spleen.
44:34
Speaker 2: Exactly.
44:35
Speaker 1: The catastrophic failure didn't happen before the surgery. It happened
44:38
during the surgery and the heat of the moment, when
44:40
the anatomy looked wrong and the bleeding started.
44:43
Speaker 2: Which is exactly why the data shows that over seventy
44:45
percent of surgical sentinel events, these catastrophic fail outcomes are
44:50
ultimately traced back not to a lack of technical skill,
44:53
but to communication failures during the procedure.
44:56
Speaker 1: That makes total sense.
44:57
Speaker 2: When the camera went in and the anatomy was distorted
44:59
by adhesions, when the bleeding started, when the decision was
45:02
made to blindly fire a stapler, or when the massive
45:06
lobular liver was placed on the back table. At any
45:08
of those specific junctures, a functional team communication dynamic could
45:12
have stopped the momentum.
45:14
Speaker 1: Just someone saying wait.
45:15
Speaker 2: The Joint Commission data consistently proves that surgical teams with
45:19
high psychological safety, teams that act like airline crews have
45:23
vastly lower mortality rates.
45:25
Speaker 1: This also forces us to look at the hospital itself.
45:28
Ascension Sacred Heart has to face massive systemic questions here.
45:33
How is a surgeon who allegedly mistook a pancreas for
45:36
an adrenal gland in a previous case allowed to maintain
45:39
operating privileges for complex abdominal procedures.
45:42
Speaker 2: That is the crux of the intense civil litigation that
45:45
the Brian family is currently pursuing alongside the criminal prosecution.
45:49
It exposes the dark underbelly of hospital administration.
45:53
Speaker 1: What you mean?
45:53
Speaker 2: Hospitals have to balance the financial need for high surgical
45:56
volume against their primary ethical duty, which is credentialing and
46:01
peer review.
46:02
Speaker 1: Explain how a peer review board works. If a surgeon
46:05
makes a mistake, who polices them?
46:07
Speaker 2: Hospitals have internal morbidity and mortality committees often called M
46:11
and M conferences. When a patient dies or suffers a
46:14
severe complication, the surgeons are supposed to present the case
46:17
to their peers for review.
46:19
Speaker 1: Okay, that sounds good in theory.
46:21
Speaker 2: But these reviews are often shrouded in intense secrecy protected
46:25
by laws designed to encourage honest medical discussion without fear
46:29
of immediate lawsuits. However, this secrecy can sometimes be warped
46:34
to protect the hospital's reputation rather than protect future patients.
46:38
Speaker 1: If massive red flags were raised after the pancreas incident
46:41
or after the tragic death of Dorothy Dorsett, the hospital's
46:45
credentialing board had a duty to intervene. They could have
46:48
revoked his privileges, mandated that he only operate with a
46:51
senior partner scrubbing in, or restricted him to minor procedures Exactly.
46:56
Speaker 2: This case exposes the terrifying tension between a hospital's relifeis
47:00
on independent surgeons who bring in revenue, and their absolute
47:03
duty to build guardrails that protect patients from incompetent practitioners.
47:07
Speaker 1: The failure of that peer review system is what allowed
47:10
doctor Schuchnovsky to walk into an operating room on August
47:14
twenty first, twenty twenty four. It is as we wrap
47:17
up this deep dive, I want to bring the focus
47:19
back to you, the listener, because spending an hour dissecting
47:22
a systemic fatal medical failure can leave you feeling completely powerless.
47:28
It is terrifying to realize that the system is this fragile.
47:31
But what are the actual actionable takeaways here? If you
47:35
are a loved one are facing a major surgery tomorrow,
47:38
what can you physically do to protect yourself?
47:40
Speaker 2: The very first and most important takeaway is to fiercely
47:43
validate and listen to your own instincts. Bill Bryan was reluctant.
47:46
His wife Beverly, with all her nursing experience, was reluctant.
47:50
Speaker 1: They knew something was off.
47:51
Speaker 2: Patient reluctance is not just anxiety. It is often a
47:54
highly valid warning sign that you need more information. If
47:57
you feel rushed, if you feel pressured, or if a
47:59
doctor leaning heavily on worst case scenario fear tactics to
48:03
secure your signature on a consent form, you have the
48:05
absolute legal and moral right to hit the brakes.
48:08
Speaker 1: You can always pause, You can always demand a second opinion.
48:11
Speaker 2: Always get an independent second opinion for any major surgery,
48:15
preferably from a completely different hospital system. Second, you must
48:19
take ownership of your consent forms. Do not just blindly
48:23
sign the.
48:23
Speaker 1: iPad screen, read the fine print, read.
48:25
Speaker 2: The documents, look the surgeon in the eye, and ask
48:28
highly specific questions, doctor, what are your specific personal complication
48:33
rates for this exact procedure over the last five years?
48:37
Have you ever had a sentinel.
48:38
Speaker 1: Event that feels incredibly confrontational to ask a doctor?
48:42
Speaker 2: It does because of the authority gradient we discussed, but
48:45
you're hiring them to perform a life altering service. Third,
48:49
never go to a surgical consultation alone. Bring a fiercely
48:53
vocal advocate with you, a spouse, a child, of friends,
48:56
someone whose only job is to take notes, ask the
48:58
hard questions and not be intimidated by the white coat.
49:01
Speaker 1: I love that.
49:02
Speaker 2: And finally, you can and should ask about the hospital
49:05
safety culture. You can ask the charged nurse on the floor,
49:09
how does this specific hospital handle safety reporting? Do the
49:12
nurses here feel empowered to hit the pause button if
49:15
something looks wrong?
49:16
Speaker 1: You essentially have to act as your own ultimate advocate,
49:20
because as advanced, high tech and sterilized as the medical
49:23
system is, it is still ultimately run by deeply flawed, biased,
49:28
and fallible human beings.
49:30
Speaker 2: Following the indictment, Beverly Brian issued a heartbreaking public plea
49:34
to anyone who would listen. She said, protect yourselves in
49:37
the hospital. She learned in the most devastating way imaginable
49:42
that an Ivy League degree or a board certification on
49:45
the wall does not guarantee infallibility.
49:47
Speaker 1: This entire case, from the beautiful Resort Town hospital room
49:51
to the frantic chaos of the Code blue to the
49:53
cold reality of the grand jury indictment, is a profound,
49:57
multi layered tragedy. Bill Bryan w as a man who
50:00
trusted the system.
50:01
Speaker 2: He really did.
50:01
Speaker 1: He trusted the credentials, He trusted the beeping monitors and
50:04
the pristine's sterile environment. He was put to sleep, believing
50:07
that he was in the hands of experts and that
50:09
he would wake up healed.
50:10
Speaker 2: As Beverly so powerfully and heartbreakingly summarized the reality of
50:14
that day my husband died while helpless on the operating
50:18
room table. It is a sobering, devastating reminder that all
50:23
the high tech equipment in the world, the high definition
50:26
laparoscopic cameras, the complex titanium staplers, the advanced three dMRI imaging,
50:32
none of it can override human fallibility, the blindness of
50:36
cognitive bias, and the deadly toxic silence of a frightened room.
50:40
Speaker 1: We deeply want to believe that when we crossed the
50:42
threshold into a hospital. The strict protocols, the surgical checklists,
50:46
and the years of medical school guarantee our safety. We
50:49
desperately want that absolute engineering level precision when we were
50:52
at our most vulnerable.
50:53
Speaker 2: Yeah, we do.
50:54
Speaker 1: But I want to leave you with a final thought today,
50:56
something to moul over. Long after you take your head
50:58
froms off, what happens. One of the most dangerous, unpredictable
51:01
instrument inside an operating room isn't the scalpel or the stapler,
51:05
but the human ego. If you're lying unconscious on that
51:08
cold steel table, bleeding in the dark, who in that
51:11
room would be brave enough to break the silence and
51:13
save your life?
51:14
Speaker 2: That's the real question.
51:15
Speaker 1: Thank you for joining us on this deep dive. Stay
51:18
curious and stay vigilant.