Bart Writer, 56, died shortly after undergoing cataract surgery at Colorado’s InSight Surgery Center on February 3, 2023. The reason? The two doctors performing the operation were distracted by playing “music bingo” and failed to notice that he had stopped breathing.
A lawsuit filed by his widow claimed that the “the distraction of the music bingo game … contributed to the operating room staff’s failure to monitor Mr. Writer’s vital signs during the procedure” and ultimately led to his death. The game involved listening to ’70s and ’80s songs and linking band names to the letters B-I-N-G-O. Dr. Carl Stark Johnson, the surgeon, and Dr. Michael Urban, the anesthesiologist, regularly played the game during operations and admitted this in their depositions.
The lawsuit was settled, but now the two doctors swear the distraction had nothing to do with their patient’s death. Well, to be more specific, the two doctors are blaming each other. Johnson, who has performed over 25,000 cataract surgeries, blames Urban for silencing critical monitoring alarms without informing the surgical team. “I know that he wasn’t paying attention to the vital signs and doing his job,” he said. Urban, who is now practicing in Oregon, stands by his care and disputes Johnson’s version of events.
Writer, meanwhile, like Generalissimo Francisco Franco, is still dead.
Questions: Why is that surgery center still treating patients? Why hasn’t it been razed for a parking lot?
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Pointer: JutGory
Ethics Alarms 
The reality is that the surgeons and other doctors rule the roost. The environment is set by their behavior, bad or good. Attempts to raise concerns about disruptive behaviors and habits of surgeons in particular to administrators will have them run to their calculators to determine how much money is this surgeon pulling in, thus allowing them broad range to do what ever they want in spite of complaints of the lower staff.
long gone are the days when the focus of the or team is always on the patient. It unfortunately is focused on the satisfaction of meeting the quirks of the moneymaker.
He wants to play acid rock, head banging music at 20x normal conversation decibels? Let it be. He has booked four profitable surgeries . Impeding communication between staff members and disregard for the safety alarms be damned.
Pretty much “The King’s Pass”
No complaint has been filed with the state medical licensing agency???
This kind of horrific event illustrates why moving toward fully robotic surgery for something very routine like cataract removal would likely benefit patients.
Surgeons are paid very high wages and have high social status. Their position in the hierarchy generates all kinds of problems, some of which deacondan86 has described.
The high status and salary also tends to obscure the fact that for certain types of pretty simple surgeries, it can be highly repetitive, boring, and mind-numbing (cataract surgeries are highly routine and according to the interwebs take 15-30 minutes). So the surgical teams may well be doing 10 or more of these a day, day in, day out. It’s repetitive factory work for highly educated intelligent professionals, basically.
Hence there is job design problem. People who are supposed to watch surveillance cameras at night also have the problem that there just isn’t much to look at, their mind wanders, they listen to music or seek other distractions, and become pretty much useless at their jobs and don’t notice anything.
Please note I am NOT JUSTIFYING, NOT EXCUSING, NOT DISAGREEING that this was a horrific event and the surgeons are absolutely to blame for their behavior. Silencing monitoring alarms (in service of their little game, apparently) shows just how callous and unethical (and in this case deadly) there behavior was. They are ABSOLUTELY TO BLAME!
I am looking at the context, and addressing the natural question: How could it possibly come about that surgeons are playing music games while performing surgery???????? Are they insane? I don’t think so. It was a profoundly stupid choice to cope with a boring repetitive job.
I have had many colonoscopies (which take 30-60 minutes typically), most without anaesthesia (which most people agree to), so I am atypically fully awake and aware. The doctor and support staff spend 90% of the time chatting about all kinds of random topics, with maybe 10% job related communication (generally when they see a polyp, which breaks up the boredom). This helped me realize just how inherently uneventful and routine (and likely very boring) it is to actually DO this procedure.
Chatting is clearly a MUCH safer form of distraction so they don’t fall asleep at the wheel than playing loud music! I’m pretty sure they would actually notice if some kind of alarm went off because I stopped breathing….
I’d agree in that almost any activity can fall into a routine if one does it enough times.
For surgeons, it’s not that their demanding training is to teach them how to cut and tie. Fishermen and sailors can cut and tie knots. The surgeon is trained to recognize when things are going wrong and what to do to fix them when that happens. Almost any medical procedure has some risk involved.
A doctor’s training is designed so that, when things go wrong, he or she can do more than run around in a circle, flinging his arms in the air, and screaming in panic. I can pretty much accomplish those things, if i put my mind to it.
I have no problem with doctors talking during a procedure — as long as it doesn’t distract them from noticing that my blood has turned green, or I’m frothing at the mouth.
On the other hand, turning off alarms? That falls under res ipsa loquitur.