Doctor Rich:
Welcome back. I’m Doctor Rich. Today we’re going to review an episode of the new hit series The Resident. My team watched this video, and they asked me to react. They told me there’s something in this video that’s so shocking and unbelievable. They asked me to review it to see if this could actually happen.
Don’t have time to read this post? Watch the video here instead!
[Video begins playing. A man and woman are sitting together on a couch in a hospital consultation room.]
Male Patient:
I’m 85% sure I have cancer.
Patient’s Wife [jokingly]:
But then refused to make an appointment for six weeks. Kind of backwards, right?
Male Patient:
Doc, I hoped the pain would go away.
Dr. Pravesh [reassuringly]:
The number of people who walk in here thinking they have cancer versus the number of people who actually do?
Dr. Hawkins [enters the room with test results]:
Not cancer.
Patient’s Wife:
Thank God.
Dr. Hawkins:
That bike accident did more damage than you thought. You have an atrophied testicle.
Doctor Rich:
So this guy comes in, he thinks he has cancer because he’s got pain in the groin area. There is a balance between being a hypochondriac and having a healthy appreciation of your body (and concern that there’s something going wrong that you need to find out what’s up). So the main character comes in and says that he’s got an atrophied testicle from a bike accident. So the guy fell and had some kind of a problem.
Most likely this happens when the testicle twists and cuts off its own blood supply. And at that point, you can actually lose total function of that testicle, and sometimes it has to be removed. Now in my specialty, the same thing can happen with ovaries. An ovary can twist and cut off its own blood supply. It’s called ovarian torsion, usually because there’s a big cyst. So this is a risk factor. If you notice pain, don’t ignore it. Go see your doctor.
[Video resumes]
Male Patient:
Well, that doesn’t sound good. Will it just heal by itself?
Dr. Pravesh:
With this degree of atrophy and your continued pain, the recommended treatment is removal.
Male Patient:
Chopping my ball off? Oh, come on. Come on, guys. Will we still be able to have kids?
Dr. Pravesh:
Absolutely. You only need one healthy guy for that.
Doctor Rich:
And this is also a good point. The good Lord designed us with a lot of duplication. So you can give your friend a kidney, and as long as the other one works at least 20%, your body wouldn’t know the difference. You can lose a gonad, you can lose an ovary, you can lose a testicle. And as long as the other one is healthy, it has really no impact on your absolute fertility rates. Now the only downside is you no longer have a spare. So if something happens to the remaining ovary or testicle, then you’re out of luck.
[Video resumes. The patient, his wife, and Dr. Pravesh are looking at examples of prosthetic testicles.]
Dr. Pravesh:
Impressive, right? It has a thin silicone elastomer shell.
Male Patient:
Groovy!
Patient’s Wife:
So Doctor, will Ed’s package look the same, or…?
Dr. Pravesh:
Exactly the same.
Male Patient:
Well, mind if I choose this one here? [He holds up a very large prosthetic testicle.]
Patient’s Wife [rolling her eyes and laughing]:
God…
Dr. Pravesh:
Might actually throw off your anatomical balance.
Patient’s Wife [jokingly]:
So it’s kind of like bad wheel alignment. You’d be drifting to the left. You know, I have an idea! Why don’t I just get a triple D implant, but only in my right boob. That way we’d always be moving towards each other.
Doctor Rich:
So that actually brings up another point. So once you get some kind of cosmetic surgery (and probably the best example of this is a breast implant or a BBL [Brazilian butt lift]), you’re kind of stuck with that going forward. So a lot of thought needs to go into “How big is big enough, and how big is too big?” And of course, all implants can be exchanged — but not without another major surgical episode.
[The video cuts to the operating room. The attending nurse is reading the patient’s information. Dramatic classical music plays in the background.]
Nurse:
Edward Brooks, date of birth 8/13/82.
Dr. Mina Okafer:
Agree.
Nurse:
Attending Dr. Randolph Bell.
Dr. Okafer:
Yes, here for a left orchiectomy, no known allergies. Everyone agree?
OR Staff:
Correct.
Dr. Bell:
Timeout has concluded. Dr. Okafer, you may proceed.
Doctor Rich:
So I’m going to take a second here to talk about this. What they’re doing here is called a surgical timeout. So this is a very important and critical part of the surgical culture. During the surgical timeout, there is an absolute pause in the OR. All of the movement is stopped. The anesthesiologist, the surgeon, the circulating nurse, the scrub tech all have to identify themselves. The patient’s identified, the surgery is identified. And this is to ensure that everything proceeds according to plan.
Dr. Okafer:
Change this dumb music.
[Nurse changes music to rap.]
Did you pick this because I’m black?
Nurse:
I picked it because it’s awesome!
Doctor Rich:
So in every OR you got to pick the DJ. Typically, the doctor selects the type of music they want to listen to. I kind of give my team free reign unless it’s something that (for me) is intolerable. Otherwise, I think it’s good. It keeps the mood up. But you have to keep the volume at a point where everybody can communicate.
[In another OR, a medical emergency is happening during a surgery.]
Nurse:
Oh my God…
Dr. Bell:
Sharon, get Dr. Okafer!
Nurse:
Yes, doctor!
Dr. Bell:
Just keep it coming. More pressure, and get some suction in there! I can’t see a damn thing! Where the hell is Mina?!
Doctor Rich:
Well, that looks awful, but surgical complications can occur. Vascular complications are the most urgent and life-threatening. Any other injury to any other organ can be fixed on your own time schedule. But with acute blood loss, it has to be fixed now — and you need to call for backup. You need to call for somebody to help. And that’s appropriately what this guy did here.
[Nurse enters the OR where Dr. Okafer is starting surgery on the male patient with testicular atrophy.]
Nurse [to Dr. Okafer]:
Bradley’s passed out. York’s crashing. Bell needs you.
Anesthesiologist [to Dr. Okafer]:
The [patient’s] vitals are stable. Go.
Doctor Rich:
Now, in the course of elective surgery, it would be extremely rare that a surgeon would actually have to leave the surgery that they’re doing to go help another with a case. In virtually all cases, the surgeon would complete what they’re doing and make sure that patient is safe before going to another or to help another surgeon. The one probable exception to that is some kind of mass casualty circumstance — a big motor vehicle pile-up on a highway or some kind of shooting accident where there are multiple victims coming at the same time. And there are circumstances where you do have to triage who lives and who dies based on who is the people you can save and the people you can’t. But that’s not the example here. So this would be very rare that you’d have, during elective surgery, someone that is already under anesthesia, and then the surgeon has to leave.
[In the OR with the emergency situation]
Dr. Pravesh:
Shall I extubate Ed?
Dr. Bell:
Is he stable?
Dr. Pravesh:
Yes.
Dr. Bell:
Well, he’s not a priority. Put more quarters in the gas machine. Have him put a foley in here, then get back there with Christine.
[Dr. Okafer peeks back into her operating room, giving directions to the team.]
Dr. Okafer:
I need about thirty minutes to make headway with Christine. Place a foley for Ed, and re-prep in about twenty. Once Bell or Jude comes in, I’ll scrub out and finish here. [Dr. Okafer leaves.]
[Back in the OR with the emergency situation…]
Nurse:
Christine’s bleeding again. Systolic is dropping. I need Bell!
Nurse [to Dr. Bell in another OR]:
Mina needs Bell. Christine’s systolic is dropping. York’s colon perforation is not under control. Bell can’t leave.
Dr. Okafer:
There’s no time to wait for Jude.
Dr. Bell [yelling from the other OR]:
You know what to do. Prep for a graft. Dr. Okafer, you’ve got this!
[Video cuts to Dr. Okafer re-entering the male patient’s OR after finishing the emergency surgery.]
Dr. Okafer:
Has Ed been prepped?
Nurse:
Yes. Right after the foley. Should we do another time out?
Dr. Okafer:
No, he’s been under too long. Let’s get this over with. 15 blade… [Dr. begins cutting with the scalpel. A nurse rushes in.]
Nurse:
Christine’s pressure dropped, and we can’t get it back up even with the blood transfusion…
Doctor Rich:
Wow, that’s exciting. So I’m getting kind of palpitations just watching that. Vascular complications are really the most urgent in this circumstance. You really wouldn’t have the attending doctor in another room performing another surgery and a resident by themselves. So a doctor in training in most institutions (if not all), there’s safeguards that the attending surgeon doesn’t have to actually be in the OR the entire time. But they have to be immediately available. So I think this is a little bit dramatized for TV, but like I said, there are some emergency circumstances where there may be multiple surgeries going on and you have to do the best that you can.
[Video cuts to the male patient and his wife holding hands post-surgery. They both look very sad. The audio is from a medical board hearing.]
Medical Board Member [reading the incident report]:
A patient in his early thirties scheduled for a routine surgery, the removal of an atrophy testicle, only to have the healthy one excised.
Doctor Rich:
Oh…
Medical Board Member:
How do we explain this?
Doctor Rich:
Alright, so now this takes a pretty diabolical twist here. So multiple surgeries going on, everybody’s excited because there’s a vascular injury that requires immediate intervention. One of the patients didn’t survive, and then during the least urgent of all of the surgeries, the routine removal of a testicle, they were running back and forth, I guess. So they remove the wrong one, so he is only left with a bad one. And as I said earlier, you can remove one as long as you have one left. It doesn’t affect fertility, but then you don’t have a spare. So unfortunately in this case, they removed the wrong one. So this brings up a whole other issue of wrong-site surgery, which is considered a “never” event. You should never go in as a patient expecting to have surgery on your right leg only to have surgery on your left leg or your right brain and have surgery on your left brain.
Now unfortunately, wrong-site surgeries actually DO occur. The rate is about one in a hundred thousand surgeries, but with 40 to 50 million surgeries going on in the US every year, that’s about 500 wrong-site surgeries per year in America.
Now, there’s a governing body that monitors hospitals called the Joint Commission, and they have put together a series of safeguards and protocols — one of which we mentioned earlier, which is the surgical timeout. So prior to surgery, there’s a presurgical prep where all of that information is discussed. The patient, two identifiers, the site of the surgery, and then the affected or the abnormal leg is then marked. This is so that when the surgeon goes into the OR, that’s the reminder: This is the leg or the foot or the side of the head that you’re supposed to operate on. So pre-procedurally, the site is marked. Intraoperatively, there is an all-stop that happens in the OR, typically after patient’s been put to sleep, prepped, and draped. This is where (again) the patient is identified and the site is identified. And this is in reference to wrong-site surgery.
There’s also wrong-patient surgery. So sometimes there’s a lineup, and the surgeon comes in, and he does the entirely wrong surgery on a patient.
In fact, that was a recent surgical misadventure that made the headlines where a surgeon went in to operate, I believe, on the spleen and ended up taking out the liver. And of course you need a liver to survive, and I believe the patient expired in that case. So in that case, the surgeon wasn’t technically wrong-site, he just mistook the organ. Which… man! If you went through medical school and residency training to be a surgeon, you ought to know the difference between the spleen and a liver! Not least of which because the liver’s on the right and the spleen’s on the left side of the body.
[Still in the hearing]
Dr. Okafer:
I should have double-checked. It was my responsibility. I asked Nurse Moore to re-prep the surgical field. When she sanitized the surgical area, the incision mark was removed.
Doctor Rich:
Oh, okay…
Dr. Okafer:
When I returned to the OR One, Nurse Moore asked if we should do another timeout, and I said, “No, he’s been under too long.”
Doctor Rich:
So in this case, the pre-procedural marking was basically nullified because the re-prep removed the mark and the surgeon didn’t do another time out after leaving the room — which they should have done in the root cause analysis by the Joint Commission.
The three main reasons that wrong-site surgeries occur are communication failures, failure of leadership, and procedural non-compliance. So this is an interesting example where something like this could happen. And even though these are considered “never” events, they do happen, and this is why they happen. The risk factors are emergency cases, multiple surgeons, the pressure of time, unusual equipment or setup, room changes, obesity, and deformities.
So as promised, this was a shocking and unbelievable plot twist in this episode of The Resident. Unfortunately, it’s something that can and actually does happen even though it’s considered something that should never happen.
As a patient, if you are having surgery on a duplicate organ (the two sides of the brain, lungs, kidneys, gonads, limbs, hands, feet), make sure you discuss with your surgeon ahead of time that they should be marking the side that they’re supposed to be operating on once. So as a patient, make sure that the surgeon does that pre-procedural marking of the side. If your hospital is completely chaotic and you have an elective surgery, don’t be afraid to speak up and reschedule.
