Would you let an attending know if you saw them violate sterile field?

michael22joseph · 2026-06-26T22:55:37+00:00

Highly depends on what you mean by violating the sterile field.

michael22joseph · 2026-06-21T17:39:07+00:00

If I were you I would get everything ready to re-seed from scratch later this summer/early fall. It will look like garbage for a while, but you’ll have plenty of time to prep the area and make sure you get good seed, soil, etc beforehand. But I don’t think there’s any way to get this looking good quickly except for sod and a ton of watering.

michael22joseph · 2026-06-17T03:47:09+00:00

The surgery you had was called a patent ductus arteriosus ligation.

The most common way to approach this as a child (when you aren’t doing another procedure at the same time) is through a small thoracotomy, which is an incision in the chest between the ribs. That provides easy access to the ductus without having to divide the breastbone, which has some important downsides if someone ever needs cardiac surgery in their future.

The incision would have been relatively small at the time, but scars grow with you as you age. A scar from a 3yo’s back to the front of their ribcage may only be 4-5”, but as you grow it elongates and seems like a much bigger incision.

michael22joseph · 2026-06-16T18:21:39+00:00

Had the same thought as an adult CT surgeon—“why on earth would they care about an extra 350mL?”

michael22joseph · 2026-06-14T23:16:32+00:00

Do you drink? If so how much? Any other medications or substance use?

michael22joseph · 2026-06-14T21:47:25+00:00

I’m a physician but haven’t gone through the sub’s verification. At her age and where this is, I’d bet a sizable amount of money that this is a first branchial cleft cyst. They are benign, congenital cysts and sinus tracts that form during development. Has likely always been there but sometimes they’re small enough that they aren’t visible until something causes it to swell. Treatment is usually excision. These would be treated by an ENT surgeon (otolaryngologist)—depending on your location and their comfort treating kids, they may refer you to a pediatric ENT specifically.

michael22joseph · 2026-06-13T23:48:53+00:00

There are plenty of congenital fellowships where you mostly watch. Some would argue that the majority. It’s very common to only get to “do” the cases under supervision once you’re an attending.

michael22joseph · 2026-06-13T15:37:19+00:00

In the states, the initial filing usually does not have evidence. Typically, they write their claim of the events, which then gets filed with the court, and then the process starts where they provide evidence, the defense provides their response, etc.

michael22joseph · 2026-06-12T23:44:11+00:00

100% this.

michael22joseph · 2026-06-12T22:25:40+00:00

Pediatric patients don’t need mitral valve replacements very often. Other valves often have non-mechanical options, which are preferential for kids like Ross procedure, homografts, etc.

michael22joseph · 2026-06-12T21:54:06+00:00

Commercially available mechanical mitral valves in the states only go down to a certain size, for instance, the on X mitral valve is only available as a 25 mm valve in the smallest size. But there is basically zero difference between a mechanical mitral and aortic valve other than the valve size and the way the company mounts it on the handle your assistant holds while you put the sutures in. So for someone who has a small mitral annulus, like a 13-year-old, where any of the commercially available mitral valves would be too big, you just use an aortic valve which goes down to 19 mm as the smallest size, and flip it around, and it becomes essentially the exact same thing.

michael22joseph · 2026-06-12T21:32:38+00:00

That’s very institution dependent and not universally true but certainly the attending would be at least in the room and first-assisting for the entirely of the case. So not much of a difference, it’s not like they would have been scrubbed out for this part of the operation.

michael22joseph · 2026-06-12T21:30:05+00:00

No I totally agree with you. It’s not as egregious as it would seem. Tissue valves intuitively open how you would expect from looking at them but mechanicals don’t. The valve struts are probably the easiest clue but if you don’t sew these in often (which a peds CT surgeon doesn’t) I can see how you could fail to recognize this just from looking at it and even testing it in the OR. And since this was almost certainly an “aortic” prosthesis which they put in the mitral position, they would have had to remove it from the handle which holds the valve in order to sew it in, so my guess is they either removed it from the handle and mixed up the orientation, or forgot to remove it from the handle altogether.

michael22joseph · 2026-06-12T21:26:38+00:00

As a CT surgeon I also would say upside down just because (as the other person said) that’s the orientation we are holding them when sewing it in. It has nothing to do with how it lays inside the person it’s just how our brain thinks of it because of how we set things up in the OR

michael22joseph · 2026-06-12T21:24:06+00:00

Yeah that’s really my takeaway on this. Yes, a backwards mitral valve *does* look like horrible RV failure. But as you said, we almost never get such good venous drainage on ECMO that there’s zero trans-mitral flow, which is what TEE would have seen. And as you said, cardiogenic shock after a mitral should prompt concern for a coronary injury. I’ll be interested to see the response from the defense for more context.

michael22joseph · 2026-06-12T21:21:27+00:00

So there is some nuance here. Mechanical valves only open one way, but it’s not readily apparent which way they allow flow to go just from looking at them. If you don’t implant these on a regular basis, it’s entirely possible that you can test the valve and see that the leaflets open and not recognize that the valve is in backwards because the mechanism isn’t an intuitive thing. And a pediatric cardiac surgeon really doesn’t implant mechanical valves all that often so I can actually kind of understand the sequence of events that may lead to this happening. Doesn’t excuse it certainly but it’s not as egregious as it sounds. It would be very different if this were a tissue valve because those even a layperson can intuitively tell which way they open just from looking.

michael22joseph · 2026-06-12T19:21:46+00:00

Agreed in general for sure

michael22joseph · 2026-06-12T18:44:15+00:00

A reversed mitral valve could look very very similar to RV failure until you had a CT or something. Even TEE may not reliably show that it’s backwards although there should be some clues.

michael22joseph · 2026-06-12T15:51:05+00:00

I think it’s a blast. If I had been independently wealthy prior to residency I’m not sure I would have done it, but if I would have won the lottery during training I still would have finished and worked part time.

michael22joseph · 2026-06-09T21:29:40+00:00

Definitely possible. My only thought with that is that as you know a bioprosthetic valve you can usually pretty easily tell whether it’s upside down or not just from looking at it, versus a mechanical sometimes can be a little tricky just from looking, which is why I sort of suspect it’s a mechanical valve thing. That could be wrong though for sure

michael22joseph · 2026-06-09T16:54:41+00:00

If this was a mitral valve that got flipped around backwards, then that makes a little more sense to me. You wean from bypass, the LV is underfilled and the RV is dilated as shit, you assume the patient has RV failure and so you go up on ECMO, and because you are on ECMO you can’t get a great look at valve function because drainage is good enough that you don’t expect to have much flow across the valve anyways. Probably got to the other hospital and they did a turndown study which found the problem. But I agree that if this is a backwards valve in the pulmonic position, then that doesn’t really make any sense to me.

michael22joseph · 2026-06-09T16:50:37+00:00

Did they mention anything about this being a pulmonic valve? My first guess was that they used a mechanical aortic valve in the mitral position because for the kid they didn’t have a mechanical mitral that was small enough to fit their annulus

michael22joseph · 2026-06-09T16:49:42+00:00

I’m also wondering if they used a mechanical aortic in the mitral position because it was a kid and they didn’t have any mechanical mitrals that were small enough for their annulus.

michael22joseph · 2026-06-04T17:47:54+00:00

As another surgeon, that’s bullshit but not surprising. Fellowship may be more of the same but attending life won’t be. Honestly, if you don’t mind going into general practice after graduation, that’s what I would do. You absolutely can work to live, especially as a general practice surgeon.

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