Monday, 18 December 2017

Branding

Oh, boy. We have a bit of a doozy here. As you all know this blog is mainly about stupid people doing stupid things. Sometimes, however, it is about smart people doing stupid things (namely me, if I do say so myself). This is one of those times. Except that this time, the smart person gloriously isn't me at all. Have no fear, it is still about a smart person, a surgeon even, having done a very stupid thing.

Indeed this story is about Simon Bramhall, a rather famous British transplant surgeon who gained fame in 2010 by transplanting a liver that was being transported by a plane that crashed. They managed to salvage the organ and he transplanted it successfully. I think we can all agree that that is a Very Good Thing.

But in 2013 Simon did a Very Stupid Thing. He was performing a liver transplant on February 9, when for some inexplicable reason he decided to burn his initials "SB" onto the surface of the organ he was transplanting. Before you start yelling, "Oh come on, he couldn't have done that. It was probably just misinterpreted. What type of egomaniac would do that?" Bramhall would, that's who. The instrument he used was an argon beam coagulator which is designed to effect (yes, 'effect') haemostasis on the surface of a bleeding organ, and yes he branded his initials onto the liver. Keep in mind this was a very superficial injury that he inflicted, one that would be expected to heal very quickly.

If that doesn't sound too bad, have no fear, because it gets worse. He did the exact same thing 7 months later, again branding his initials on a transplanted liver. Again, anyone who understands how livers heal knows that these marks should disappear quickly and completely. Unfortunately, they did not on one of these two patients. Another surgeon re-operating on one of the patients some time later noted "SB" still visible on the surface of the liver, and Dr. Bramhall was busted.

Dr. Bramhall was suspended initially, and he resigned from the hospital the next year. Further, he was arrested and charged with both assault occasioning actual bodily harm (to which he pleaded not guilty), and assault by beating, to which he admitted and was convicted.

Wait wait, assault by beating? How is that possible?

Right, I was as confused as you at first. It seems that the prosecutor didn't know exactly how to charge him, because this past week he stated that there was just no legal precedent for this type of injury. (Seriously, what the hell would you charge him with? Arson? I have no idea. This is one of approximately 2,490 reasons why I'm not a lawyer.) Regardless, the prosecutor did state that Bramhall's admission of guilt indicates that he admits that "what he did was not just ethically wrong but criminally wrong". Sentencing is scheduled for January 2018. I suspect the judge is just as clueless about how to punish him appropriately.

Bramhall was also issued a formal warning earlier this year from the General Medical Counsel which said regarding his behaviour, "It risks bringing the profession into disrepute and it must not be repeated. Whilst this failing in itself is not so serious as to require any restriction on Mr Bramhall’s registration, it is necessary in response to issue this formal warning."

And that is where I vehemently disagree.

In my opinion Bramhall deserves to be struck off the record, to lose his licence to practice. This falls so far outside the bounds of the normal, ethical, responsible behaviour of a physician that something more drastic than a proverbial slap on the wrist is in order. Bad behaviour by surgeons used to be tolerated, and everyone would just look the other way whenever it happened. Harassing nurses, inappropriate comments, throwing instruments, yelling at students, demeaning residents, and other assorted temper tantrums were commonplace in the operating theatre until recently. Nowadays, however, these sorts of outbursts are no longer permissible. Surgeons are now reprimanded and punished for bad behaviour.

But knowingly and purposefully injuring a patient?

Inexcusable.

I have heard the counterargument that no real harm was done, so it isn't that big a deal. Really? Is that a logical argument? Then by that same logic we should just allow people to drive drunk as long as they don't injure anyone, because no harm is done. Right? Right?

No, not right. Not right at all.

However, not everyone agrees with me. In fact, when he was suspended in 2014 one of his former patients said, "Even if he did put his initials on a transplanted liver, is it really that bad? I wouldn’t have cared if he did it to me. The man saved my life." It's true though, right? The liver heals very quickly, and even if it doesn't heal completely, having a scar on the organ won't affect its function one bit. So it's not a big deal, right?

Wrong. I've written before about the trust that patients put in their doctors, but especially their surgeons. Imagine the amount of faith people must have to allow themselves to be put completely to sleep, completely vulnerable, absolutely at our mercy, and trust that we not only do our best to put them back together but do it with dignity and respect.

Dr. Bramhall violated that dignity. He violated that trust. Not just one, twice.

I don't know if it was a momentary lapse of reason (twice), sociopathy, or simply a massive ego that led Bramhall to do what he did. Yeah, I'll be the first to admit that many surgeons have massive egos (yours truly excluded, of course). But quite frankly, I don't care a whit. I couldn't give a rattus rattus' posterior, because after pondering this since the moment this story broke, I've come to the realisation that there is literally not a single legitimate excuse in the world that would permit a surgeon to brand a patient like this. Not one.

Not one.

34 comments:

  1. I believe proper procedure is to leave a post-it note beside the liver.

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  2. I wonder how many other people have initials carved into their body parts? Maybe I had initials carved into my knee joint when I had surgery. You would think though that other people in the operating room would’ve seen the surgeon doing this and said something about it. I would’ve reported it.

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  3. by that same logic we should just allow people to drive drunk as long as they don't injure anyone, because no harm is done. Right? Right?

    Yes, right. In fact we already allow it, because the vast majority of people who drive drunk without injuring anyone are never apprehended. If we really cared, we'd do more than the very, very sparse spot checks we do now.

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  4. Ok, first the facetious answer: He should have used the patient's initials. Who doesn't want a monogrammed liver??

    Seriously though, I'm not sure whether this falls under assault or rape. Taking advantage of a vulnerable individual is more than just the legal equivalent of a beating (or a threat; to my understanding the beating is battery). It is taking advantage of that patient's trust (yeah, I know I'm repeating Doc nearly verbatim) and could leave them with emotional scars down the road.

    Throw the book at him. Legal dictionaries are nice and heavy. Should make a visible impact.

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  5. I can't believe the British legal system let this guy off with just a WARNING?? Burning his initials into someone's liver was assault at the very least. If he'd done that here in the states, the jerk would have lost his license & possibly ended up in jail.

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    1. That was the GMC. He hasn't been sentenced yet for his criminal charge.

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  6. I don’t disagree with you Doc Bastard, but let’s consider ‘burnout’. Quite literally, unfortunately. As a health care professional I can profess that we are stretched thinner than tissue paper. Surgeons are stretched the thinnest. Many of us are feeling an enormous amount of pressure, and many are leaving the profession. We spend our days taking care of patients that are not only extremely complicated, but many have associated behavioral health issues making them even more difficult to care for. Who takes care of us? Do we immediately take away his license? This is his life’s work. Should he be punished...yes. Counseled...definitely. But should he be given another chance? Maybe...

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    1. I would rather see any person amend their bad behavior, but there is also the question of whether there is a breach of trust involved. there are those who get a wakeup call and never make the same mistake again, and there are those who slip back into old habits. obviously I'd prefer the former, but I also want to prevent the latter from doing harm to somebody.

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    2. Sandra - I appreciate your view but this surgeons actions have no relationship with burnout. It's pure ego and smacks of narcissism to burn your initials into a human beings organ. Doc Bastard is 100% correct. His behavior cannot be excused - he should lose his license and quite frankly, spend a little time in jail. What he did is battery - he physically injured another human being. His actions are inexcusable. I'm also a healthcare professional for 38 years so I've seen my share of surgeons acting like arrogant pricks, demeaning peers and support staff and purposely intimidating patients who dare push back on the docs 'orders'. This surgeons actions actually don't surprise me. I'm encouraged by Doc Bastards words indicating that surgeons/doctors are finally being held accountable for their words and actions. Hopefully, the team approach to care will continue to build positive respectful relationships between team members. The patient this surgeon seared deserved to be respected by all caring for him and that didn't happen.

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  7. Um. I've never received an organ transplant. If I did I might feel differently. But I think I'd be so grateful to get a new liver that it would be OK with me. The problem is, since this surgeon clearly has something the matter with him, what's the next thing he's likely to do??

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  8. Try googling urologist Bonzani. Also scary.

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  9. graffiti? vandalism?

    the truly scary and wrong thing is if you look in the right places, you would probably find people who would pay well to get tattoos and brand marks on their insides.

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  10. I myself know exactly what its like to undergo major surgery, 5 different surgeries in fact for cancer. Not to mention the 3 c-sections decades earlier. What I can't know or even imagine is going through the wait for an organ,then getting it going through surgery only to find out y new problem with my new liver is because my sjgeon is an egoistical asshole. And that I will or might die after everything because of him. How horrible, hopefully he gets put in prison for 6 months or so and looses his License permanently.

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  11. I apologize for this off topic.
    I was having a bimble through Facebook catching up on who is doing what and claiming what and i thought i would pop in to the Jahi McMath fb page to see what delusional crap they have posted.

    The last post was a video posted Nov. 23 showing her hand moving etc.
    The usual comments show up including a few who think Jahi is breathing on her own.

    What is really happening are Lazarus signs (reflexes) this time with a nice close up of her right hand which shows contracted fingers moving , well twitching slightly, and then moving off the doll, well sliding, since the hand is on a slope and then being moved back. There appears to be darkening areas on her visible finger joints and nothing else of her is visible (i wonder why)
    I haven't heard any more about the court case where they are going to decide if she is alive or not.

    https://www.facebook.com/eno.inyang.712/videos/871457579683142/

    I still wonder if she 'stops breathing' or her heart gives up if thery will start CPR and call 911 and demand they continue CPR etc?

    That would be one call i would pay to be a fly on the wall to hear.

    Happy Christmas one and all xx

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    1. it bears mentioning that another medical futility group looked up the doll, and found out the doll has a motor inside that makes the doll move.

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    2. Ah, Thanks Ken.
      Shenanigans are still ongoing then.
      Still it is one up from the wire under the blankets gambit.

      Are they still resisting independent and complete tests on Jahi that would prove once and for all that she is still dead, no doubt citing some such claim as it would harm her if they did the apnoea test or, failing that, having any tests to test for reflexes, blood samples, heck even scans could cause her severe discomfort or pain, you know, pretty much anything that might reveal the truth?

      They have gone pretty quiet on her FB page but since Christmas is coming up, expect posts, videos etc and preferred deity will perform some great miracle on Jahi and will be a form of rebirth.
      Given the way some of their supporters prattle on can i expect to hear of Jahi having a virgin birth and the new messiah is born, sarcastic i know but having read the comments of some of their supporters, i would not be surprised.

      Wasn't there a court case in Oct and they were going to decide then what was to happen?

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    3. You good people know my policy on off-topic comments. There is a not-so-slim chance that there will be an update on this very topic in the near future, so please save your speculation for then.

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    4. My apologies Doc. I'll head to my naughty corner with some mince pies and a rather nice hungarian mundana 2001.

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  12. Hi Doc. Your post reminded me of something I've been wanting to ask. Why do surgeons sometimes leave tags at sites where they removed organs? I'm missing some parts (gallbladder, a portion of liver, and intestinal resection). Twenty years later, when I got an abdominal x-ray in another country, the radiologist discovered that they left markers in places where things were removed. The radiologist recognized what they were, but thought it was unusual. Nothing harmful or nefarious. I'm just curious if it really is unusual and why they might have done that.

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    1. They were probably clips that were used to ligate the cystic duct and artery during gallbladder surgery. They aren't markers per se, but they are easily recognised due to their typical shape, size, and location.

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  13. What I want to ponder is technical problem of just who Bramhall assaulted. If person dies with liver to be donated, and then liver is branded before transplantation, I would describe that indignity done to a corpse. If branding done after transplant I might say that assault is on patient getting new organ. But does patient own two livers at that point? What about the diseased one that is headed off to be sliced in a pathology lab? Does the pathology lab liver actually belong to some human at that point?
    Personally as a patient, I see Bramhall actions as bad but not horrid. Same legal seriousness as some guy scratching initials in the paint of a new car.

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    1. Except this isn't a car, this is a precious donated organ being implanted into a human being. And there is absolutely no medical reason to do what he did. If he had simply gotten carried away with marking an organ that needed marking (ie a biopsy specimen), I could let this go. But this, no.

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  14. Other commenters raise some good points but the key issue I think is CONSENT! Also, PURPOSE! There is no good medical reason to brand anyone's internal organs unless you're using the argon-laser-thingy for it's actual coagulatey purpose, so don't bloody do it. Also I didn't give you permission to brand my liver for funsies. Anyone who asks me who gave me the liver, I'll tell them, it was you you magical surgeon! What makes me creeped out the most is that nobody else was going to SEE this branding, except perhaps the others in the theatre who watched it happen and did nothing, maybe they're all part of a secret branding club. So this surgeon would just be cheering himself on inside his own head. He's already going to get plenty of good press and high fives, but nope that's not enough. Huge egomaniac. I couldn't believe that what got him caught out was someone else going back in, not actually a witness. Ughhhh. Slightly surprised he didn't just piss inside the guys abdomen, that would have been easier.

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  15. Well, for starters.... eventually the medical examiner will eventually see the branding during their eventual autopsy.

    I dont know. I’m torn on this. I’ve had umpteen surgeries some serious, some elective, and I don’t care. Just save my life. Thank the donor. Thank the surgeon. Thank God. Thank the fact my body will heal eventually and cover the branding of his initials in my new liver I am oh so grateful for. And if my body doesn’t big effing deal. So he’s an ego maniac. Have you ever met a brain surgeon? I have. They are the almighty God complex of surgeons. I’d hate them if I didn’t need them at one point. So basically what I’m saying is if I have some sort of brain surgeon initials on the plate covering where my skull use to be, then who cares? I’m tumorless. And being that my brain surgeon was a total prick but a smart prick, I wouldn’t doubt it one bit. But that’s just me

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  16. Egomanic--correct. However, I disagree that he knowingly did harm to his patients. He probably 100% thought the organs would heal completely. He did it just for giggles, because he had the power, because he thought there was no serious harm done. I woke up after a root canal with a long cut inside my cheek. Inevitable or did the doctor just not care that much to be careful because he knew I was under anesthetic? Who knows and ultimately doctors have a lot of responsibility and power in operating and they would only be "found out" if they do something stupid and identifiable like brand their initials into an organ.

    Also I have known worse things doctors have done to patients... so for my own sanity things like these don't really register as outrageous.

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  17. I'm torn on this one. Obviously it was a stupid thing to do, but not reckless - he knew that it would do no harm.

    It certainly needs some form of professional censure.. but consider this: If he is never allowed to operate again, will the person who replaces him be as good? Or the operations not done at all? In either of these cases, the result of the punishment is that patients will die who otherwise would have lived.

    Now, my personal beef - when I had a minor operation (nerve biopsy in my leg), I was left with an internal bleed and large hematoma in my thigh, which was extravagantly painful.. no one got punished for that, and I would have swapped it for having someone's initials branded onto my leg any day.

    There is also the consideration that circumcision - irreversible, function altering cosmetic surgery performed without consent - is still performed as a matter of routine, without the doctors involved being immediately struck off. Again not strictly comparable, but if our ethics permit that then it is hypocritical to complain about a more minor matter, such as this case.

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  18. I don't feel that the test of "did no ultimate harm" is the right one here. There are plenty of things that could be done to a patient under general anaesthetic that they might neither know of nor suffer any lasting effect from but which would be obviously unethical and in many cases illegal.

    What if a doctor shaved your head while you were under and they were supposed to be operating on your foot? No lasting damage is done and no injury at all is caused but it would be deeply creepy to wake up and find that someone had been messing with you in ways you could not have anticipated.

    The key point has to be the doc's one of trust - you trust that the surgeon will always act in your best interest while you are under. That does not mean that they won't ever do anything unexpected because they may find something unexpected to deal with. We also have to allow that wrong decisions may be made, no matter how experienced or well trained anybody is. However, you can expect that whatever they do will be what they perceived to be in your best interest at that moment. Branding his initials into a liver cannot have been thought to be in the patient's best interest and so is obviously wrong and that must have been obvious at the time.

    If I was the GMC (it's probably just as well I'm not). I would require than any future surgery he conducted be observed and recorded. We have had the debate here before about the risks of litigation due to hindsight analysis of recordings but here it's quite obvious that a record of his behaviour should be kept. As a aside, I would mention that if his surgery had been recorded before we might be able to work out just how often he has done this - is it really only twice?

    Ugi

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  19. As a former OR RN, I'm not surprised by this surgeon's act. Saddened but not surprised. Definitely not all, but some of the surgeons I've had the dubious pleasure to work with would do something like this as an "ego stroke" more than anything. Again, not all (in fact there are some fantastic surgeons where I worked and I assume that's the case in most ORs), but the abuse to the staff by some is going unchecked. We write 'em up, and they get a talking to, and the next few months are a different kind of tense until they pop off and lob a feces covered EEA stapler at your head because they perfed a bowel. These are the ppl that I could see pulling a jackass move just like that. I'm happy to report that many surgeons I worked with are fantastic, even enthusiastic teachers. But the ones that are not...wow. There is a reason I am no longer an OR nurse, even though I found it fascinating. There is a reason my hospital is always short on OR staff. I'm a pediatric nurse now, and the biggest risk I run now is being bitten by an unruly kid. I'm okay with that!

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  20. Ok we found out about the second one because some surgeon was in there later and saw the marks. How did we find out about the first one? Furthermore, how many more are there that we never found out about???

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  21. I won my bet, uncle has a bad chest infection and is on antibiotics again.

    Merry Christmas and a peaceful, happy, healthy and prosperous new year to Doc Bastard and the family Bastard and all the readers and commentators here.
    Thank you for an entertaining year of stories, posts and comments.
    May the coming year be as fruitful and entertaining.

    Tania xx

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  22. At least the good doc showed some discretion and did not write out his full name with the laser. I once worked with a surgeon that had a vanity license plate on his BMW that read "I CUT." He was a bit of a jerk, but just about a old time surgeons had their quirks. Abuse was part of the surgical culture and I learned how to duck a flying instrument in short order.

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  23. (Seriously, what the hell would you charge him with?)

    Vandalism?

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  24. What about graffiti offences as he was tagging the patient's liver?
    Misdemeanor or a felony?

    Banksy is a graffiti artist yet people pay millions for his work.
    Could the patient's liver be worth a small fortune in the future?
    The surgical version of Banksy, patients organs being tagged and then on the death of the patient removed and preserved, then displayed in some art gallery the same as some tattoos are preserved and displayed.

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    Replies
    1. art theft would be a really bad thing.

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