Docs' fun and games in the OR allegedly leads to patient's death, lawsuit
Industry Buzz
Even if it’s not conscious, any change in pulse rate or tone should cause a little lurch in your stomach. And the BP cycle tone should draw you immediately. I wasn’t there so I don’t know the full details, but not paying attention to vitals is kind of absurd if that’s how it went down.
—Anesthesiologist @freakindon on Reddit
In February 2023, a routine cataract surgery resulted in the death of 56-year-old Bart Writer.[]
According to a now-settled lawsuit, the surgical team members—namely the surgeon, Carl Stark Johnson, MD, and the anesthesiologist, Michael Urban, MD—were playing a game called “music bingo” during the procedure. (Music bingo, as described in the case, involved naming musical artists or songs as letters, to fill a bingo card while songs were played from Urban’s cell phone.) This game was allegedly regularly played during what were considered simple or routine surgeries.
Is the OR a place for fun and games?
According to notes obtained from the surgery center, abnormal vital signs were noticed approximately 11 minutes into Writer’s cataract surgery.
By then, key alarms had reportedly been turned off or muted, and because Writer was covered and staff claimed they couldn’t immediately detect signs of oxygen deprivation (such as skin turning blue), the patient’s condition went unnoticed until it was too late.
“We learned from the nurses and from the depositions that it wasn’t unusual for them to turn off the audible alarms,” Writer’s wife, Chris, said.
By the time Writer was transferred to a nearby medical center, he had died of cardiac arrest.
Commenting on the case in the r/anesthesiology Reddit thread, @freakindon (an anesthesiologist), wrote, "Even if it’s not conscious, any change in pulse rate or tone should cause a little lurch in your stomach. And the BP cycle tone should draw you immediately. I wasn’t there so I don’t know the full details, but not paying attention to vitals is kind of absurd if that’s how it went down."
Surgical, ethical, and legal stakes
For medical professionals, there are several layers to this case worth unpacking: human factors, standard of care, alarm protocols, intraoperative distractions, and patient safety.
1. Distraction in the OR
Physicians and anesthetists are trained to monitor multiple data streams: physiologic monitors, alarms, and observational cues. Engaging in non‐clinical games—even those considered harmless—introduces cognitive load and can distract from monitoring critical signals.
The fact that the team reportedly turned off audible alarms suggests a breakdown in protocols designed to ensure that signs of patient distress are caught early—a red flag from both a safety and professional standards perspective.
2. Alarm management and monitoring
Some alarms are very sensitive, while others are nuisance alarms—turning them off altogether, however, is dangerous.
Draping, a standard practice involving covering a patient’s skin for sterility and exposure concerns, but also reduces visual cues, heightening surgeons’ reliance on alarms and vigilant monitoring. If alarms are silenced, medical professionals can become blind to early signs like cyanosis.
3. Duty of care and standard practices
Cataract surgery is common, with millions performed each year in the US. Despite its frequency and perceived “routine” nature, cataract surgery demands the same vigilance as any other surgical procedure.
Team communication: Anesthesiologists, surgeons, and nursing staff should have clear roles and contingencies in case of emergency.
4. Risk vs habit
“Music bingo” was allegedly a routine feature of intraoperative culture for the pair of doctors named in the lawsuit, suggesting a pattern of behavior that possibly undermined risk awareness.
Just because a practice is routine doesn’t mean it’s safe, particularly when patient physiology can change swiftly—especially under sedation or anesthesia.