Abnormal fatigue on the part of a senior surgeon in the Department of Thoracic Surgery at Sheba Hospital led to the death of 68-year-old Shmuel Sachs, according to an investigative report by the Health Ministry's investigative committee that was first exposed by Israel Hayom.
The report also reveals a disturbing series of failures and omissions that preceded the tragic outcome on July 19, 2020 in the largest thoracic surgery department in Israel.
Suspicion of gross negligence. Sheba Hospital, Photo: Gideon Markowitz
According to the report, the senior surgeon was exhausted from the burden of surgery and in a state of extreme mental and physical fatigue. In the surgery, which was intended to remove a lung lobe, an unusual, severe and extremely rare malfunction occurred that has not been documented until now in Israel and around the world, and caused the death of Sachs - a cut using a staple gun in the main artery in the human body, from which the arteries branch in the bloodstream.
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Until now, in the media and public discourse, workload has always been associated with specialized doctors as part of struggles to shorten the hours on duty. This is the first time that the Ministry of Health's investigation has fully revealed the connection between abnormal workload and severe accumulated fatigue among senior doctors and specialists and errors and malfunctions that may lead to the death of patients in planned non-urgent surgeries they perform.
The glitch in the surgery was discovered only after the fact
The Ministry of Health's commission of inquiry determined in its investigation that it is calling on the Ministry of Health, for the first time ever, to apply to surgeons in Israel work norms similar to those of pilots with regard to workload and sleep hours.
"Just as it would be inconceivable for anyone to send a pilot on a planned operational mission without sleep as a basic condition," they stated. "There is room to apply such appropriate norms to surgeons as well."
However, the investigation report was submitted back in November 2022 to the Health Ministry's Medical Professions Ombudsman, Dr. Boaz Lev, but despite the recommendations of the committee that investigated the affair, no new guidelines were issued to hospitals regarding the workload and sleep hours of doctors, especially senior surgical doctors.
The late Shmuel Sacks was diagnosed with a malignant disease in the left lobe of the lung and he was hospitalized for a mastectomy. The surgery was performed by a senior surgeon in the Department of Thoracic Surgery at Sheba Hospital, a department where about 600 surgeries are performed annually for adults, children and babies and is considered the leading and best department in the field of chest surgery in Israel.
According to the hospital's data, mortality rates in the department are also very low on a global scale, and the most complex and complicated surgeries in the field are performed in Israel.
No new guidelines have been issued to hospitals regarding doctors' workload and sleep hours. Breast surgery at Sheba, photo: Coco
Zacks' surgery was performed by a senior doctor in the department together with a specialized doctor, and was the third of the surgical team that day. The surgery began at 18:40 and ended at 22:16 as part of hesitation surgeries that take place in all hospitals in Israel, in which the medical and nursing staff receive additional payment for procedures that take place outside of normal working hours.
The surgery was performed using the thoracoscopic method (using small and isolated incisions in the surgical area through which a video camera and instruments are inserted) and during it significant and unusual bleeding was discovered. The senior nurse was preparing to undergo open surgery, but the surgeon in charge testified that he had managed to control the bleeding and that "nothing unusual was seen on the surgical field."
Zacks was transferred to recovery in serious condition, on a ventilator and anesthetized. His condition worsened and he died two days later in the respiratory intensive care unit without doctors being able to understand or diagnose what had happened. The mistake was discovered only in an autopsy performed at the Ministry of Health's Forensic Pathological Institute.
Big load - an opening for trouble even for the most skilled
The review committee noted that Sachs' surgery was "inherently complex and defined by skilled thoracic surgeons as the most complex lobe-resection of all existing lobe-resections" and that "the testimony of family members emphasized that the surgeon looked tired to them when he left the previous surgery and that they asked him whether it was not appropriate to postpone the operation to another date."
The surgeon testified before the committee that he "does not recall abnormal fatigue on that day and therefore in order not to harm the patient, who was already fasting and mentally preparing for the operation, proceeded as planned."
At the same time, the surgeon noted that "the burden placed on him as a central player holding the reins in a large center like Sheba is exceptional and according to his testimony the burden placed on him in his position certainly leads to accumulated fatigue, but was it extreme fatigue that day that affected his abilities in the operating room? We'll never know."
The committee stated that the senior doctor "reiterated that the burden placed on him as a surgeon is very great and it is clear to all that cyclical work in this format is an opening for trouble that may occur even in the most skilled hands."
"What's more," they wrote. "Given that the surgeon uses a surgical technique that at the time of the operation he was the only one in Israel skilled in, as a leading surgical method in his department, all the surgeries performed in this format were performed by him, a situation that created an unreasonable burden on his shoulders."
An eclipse whose causes are unclear
The committee further emphasized that the mistake did not occur maliciously and "constitutes a defect on the part of the surgeon, the causes of which are not clear to the surgeon's staff and the committee members, and given that the surgeon is highly experienced and has operated on hundreds of cases using the same technique, this is not a lack of professionalism."
"The only possible cause of the momentary disorientation in the surgical space is the extreme fatigue he suffered," they added. "The committee also finds it necessary to emphasize that among all the members of the treating team, there is no one who regrets the tragic event more than the senior surgeon."
Shmuel Sachs z"l (reproduction),
The committee emphasized: "When the work day of a senior surgeon begins in the early morning and ends late at night as usual, with all responsibility, physical and mental, resting on his shoulders, in our assessment, this is a loophole that calls for a thief, i.e., an opening for mishaps to occur."
The committee further determined that the most complex surgery planned for that day, the one with the greatest potential for complications, such as the surgery of the late Shmuel Sacks, should be scheduled first on the day of the operation, and that the assignment of the surgery as the last one that evening was "fundamentally wrong."
The committee concluded that the hospital management should examine, supervise and control the load of surgeries in the departments, and certainly in the smaller surgical departments such as thoracic surgery or vascular surgery, where fewer doctors are employed than the general departments. All this "given the fact that the main goal of every hospital, both public and private, is to bring relief to its patients, and needless to say, the economic profit that accompanies this is an adsorption."
The committee recommended that a surgical plan be drawn up in a format in which the more complex surgical procedures would be performed in the early hours of the working day, with all members of the surgical team at their best, and further stated that "in circumstances where the patient deteriorated unexpectedly very close to the date of the operation, it is appropriate for the surgeon to physically stay within the walls of the hospital and actively assist in the patient's care."
"We demand that the Ministry of Health act decisively"
Zacks' family is represented by attorneys Michael Elnatan and Amikam Harlap of Amikam Harlap & Co. law firm.
Attorney Elnatan said, "The Health Ministry's investigation into the death of Shmuel Sacks z"l following a horrific mistake in the surgery revealed very serious systemic and personal failures, and we demand that the Ministry of Health not settle for discovering only the serious findings, but act with determination not only to prevent similar incidents at Sheba Hospital, the largest hospital in Israel, but in the entire health system."
The family is represented by Adv. Michael Elnatan and Adv. Amikam Harlap of Amikam Harlap & Co. Law Offices. Photo: Yehoshua Yosef
Attorney Harlap said, "This was the first time that the Ministry of Health discovered the connection between fatal malfunctions in medical treatment and the excessive burden placed on senior doctors, which causes them exhaustion and fatigue that impair their functioning in performing surgeries and patients. The Ministry of Health must not leave these conclusions in a drawer, but act urgently and decisively so that these phenomena do not recur at Sheba and in all hospitals in Israel."
Sheba Hospital: "A Very Unusual Case"
Sheba Hospital said in response to the findings of the Ministry of Health's investigation: "The Ministry of Health's examination committee noted all along the excellence of Sheba's chest surgery department and the high standards it meets. The incident, which occurred about three years ago, is highly unusual."
"Since then, Sheba Medical Center has taken a series of steps to ensure that such incidents do not recur. Moreover, the committee's recommendations were adopted. Sheba Medical Center is constantly working with all relevant entities in full transparency – as it always does. We share in the family's grief."
The Ministry of Health said: "We share in the family's grief. The committee's report was passed on to the family about eight months ago, when Health Ministry officials were in personal and direct contact with them, explaining the report and its implications. This is a tragic, highly unusual case that was thoroughly examined by a committee appointed by the Ombudsman."
"The Ministry of Health is continuing to clarify the incident and the process of drawing the necessary conclusions following the committee's findings," they added, noting that "the Commission is holding talks and consultations with the professionals and parties involved in the incident and will formulate its recommendations accordingly."
"Doctors should not operate when they are exhausted and tired"
The family of Shmulik Sacks, his wife Yael and children Sharon and Guy, issued a joint response on behalf of the family: "Our father Shmulik was our hero. We are shocked and saddened by his sudden death after an operation that should have been relatively simple because it was performed using advanced and minimally invasive technology."
Overwhelmed and pained. The widow and children of the late Sachs, photo: Coco
They added: "The facts speak for themselves and point to gross negligence on the part of the hospital and the surgeon. Although the operation was not urgent or life-threatening, the head of the department insisted on performing it late after a busy day's work."
"After the operation, he went home and left a patient anesthetized, on a ventilator and in a rapidly deteriorating physical condition without really knowing what had gone wrong. It pains us that the outcome could have ended differently."
"It's been three years," the family said. "To date, Sheba Hospital and the surgeon have not seen fit to contact us and explain to us the cause of death. We received the answers about what happened from Dr. Boaz Lev and from the examination committee appointed by the Ministry of Health, based on data collected, including from Dr. Andrei Kotick, the pathologist from the Abu Kabir Medical Institute, who performed the autopsy."
"Pilots don't fly when they're tired"
"These bodies wrote in-depth reports, opened our eyes and exposed us to the terrible negligence that occurred during the surgery when it turned out that during the operation, the surgeon damaged the aorta without noticing, blocked the artery with a clamp, and all the complications that happened immediately afterwards were the result of a lack of blood supply to vital body organs such as the liver and kidneys. Until his death, the medical staff did not identify the root of the problem, which, as stated, became clear only at autopsy."
"It's important for us to publish our personal and painful story, so that medical teams working around the clock don't take risks and don't go into surgery exhausted, just like pilots don't fly when they're tired."
"It's about human life," the family cries out their pain. "It is possible that if the operation had been performed at a reasonable time, and with alertness, the surgeon would have identified that he had damaged the main artery and was able to save Dad. The hospital was obliged to respect the family's decision to autopsy outside the hospital in order to get to the truth."
"Had it not been for our insistence on the matter, we might still be left without an answer as to what caused our father's unexpected death."
In conclusion, the family members of the late Sachs say: "The hospital has many conclusions that must be implemented in the system for the future so that more people will not experience what our family experienced and paid the heaviest price. In conclusion, we would like to commend and thank the support and sensitivity of the Pathological Institute and the Ministry of Health, which gave us some light in the darkness."
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