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Who is the Captain of the Ship in the operating room, the surgeon or the anesthesiologist? The Captain of the Ship doctrine was a 20th century legal doctrine which held that, in an operating room, the surgeon was “liable for all actions conducted in the course of the operation.” The Captain of the Ship doctrine was first introduced into law by the case of McConnell v Williams in Pennsylvania in 1949. In this case, an obstetrician asked an intern to be his assistant for a childbirth. After the baby was delivered, the obstetrician turned the child over to the intern for the purpose of tying the umbilical cord and applying a solution of silver nitrate into the infant’s eyes. The intern squirted the solution once into the child’s left eye and twice into the right eye, which resulted in too much solution into the right eye. The intern failed to irrigate the eye. The child lost sight in the right eye, and the family sued. The plaintiffs sought a deeper pocket than the intern to sue for the eye injury, and the obstetrician was a deeper pocket. One problem was that the obstetrician had never hired and had never paid the intern, who received a regular paycheck from the hospital. The obstetrician was not the employer of the intern, but the Pennsylvania court ruled that under the law, a servant could have different masters at different times. The obstetrician testified that his responsibility to attend to the baby included the time until the baby was turned over to the family doctor, so consequently the negligence occurred during the obstetrician’s treatment of the patient. As well, the selection of the intern’s duties was the obstetrician’s choice. Finally, the defendant obstetrician testified that he “had complete control of the operating room and of every person within it while the operation was in progress.” His answer was that the intern was bound to carry out the obstetrician’s orders. If the surgeon had the right of control and the right to give orders which the negligent intern was obligated to carry out, then under classical tests of agency the surgeon was liable for the harm. The court ruled that “responsibility is commensurate with authority.” The court pointed to an area of maritime law as support. They claimed the surgeon was “in the same complete charge of those who are present and assisting him as is the captain of a ship over all on board, and that such supreme control is indeed essential in view of the high degree of protection towhich an anesthetized, unconscious patient is entitled.” The obstetrician testified about his control with the same confidence one expects of the Captain of a Ship, that his orders will be carried out by everyone in the operating room. The intern and everyone in the room was under his control, and the intern and everyone in the operating room was bound to carry out his orders.
This image of operating room hierarchy has disappeared since the 1940s. The operating room team today consists of multiple professionals working in collaboration, including the surgeon, the scrub tech, the circulating nurse, and the anesthesia MD or CRNA. These members, each competent in his or her own right, work together as a team. The surgeon is dependent on the other team members to provide anesthesia, to count sponges, and to do numerous other activities that the surgeon could not possibly be responsible for while performing the surgery. It may be true that surgeons like the dramatic notion that they are the Captain of the Ship, but this Captain of the Ship philosophy has now died out as courts understand that surgeons are not able to control everything that occurs in the operating room. The operating team is a collaborative and cooperative venture. Each member participates and contributes their own expertise and talents.
At my medical school in the Midwest in the 1970s, many of the anesthesiologists were foreign medical graduates who had less confidence and advanced knowledge than the surgeons. Many surgeons chose to lord over the anesthesia attendings with verbal abuse and a condescending attitude. In present day hospitals and surgery centers, anesthesiology is a proud, high-earning specialty sought after by medical students and worthy of equal status with surgeons in the operating rooms. While the surgeon is performing the scheduled surgical procedure, the anesthesiologist is responsible for maintaining the cardiac, respiratory, and neurologic well-being of the patient, supervising the vital signs of heart rate, blood pressure, oxygen saturation, respiration, and temperature, and administering the potent general anesthetic medications.
Surgeons are experts in surgery and anesthesiology providers are experts in anesthesia care. Surgeons do not control anesthesiologists, surgeons do not prescribe the anesthesia plan, and surgeons do not manage anesthesia complications. In the operating room, surgical complications may include bleeding, damage to normal tissues, misdiagnosis, or iatrogenic mistakes regarding scalpels, sutures, or surgical devices. Surgeons are educated, experienced, and equipped to assess and treat these issues. Anesthesia complications may include airway complications, mismanagement of vital sign abnormalities, or iatrogenic mistakes with catheters, needles, or injectable medications. Anesthesiologists are educated, experienced, and equipped to assess and treat these issues.
Airway, breathing, and cardiac emergencies occur in operating rooms, and if they do, the anesthesiologist is at the front line of the patient’s defense. If a patient’s airway is lost before, during, or after an anesthetic, permanent brain damage may occur in as little as five minutes. Should an airway disaster occur, the anesthesiologist will be working frantically to remedy a dire anesthesia airway emergency. The surgeon will typically be an observer during this ordeal. Anesthesiologists are experts in placing an endotracheal tube, which is the immediate lifeline to oxygenating a patient in need. What about a tracheostomy? It’s long been an expectation that if an emergency surgical airway is needed to save a patient’s life, then a surgeon should apply a scalpel to the patient’s neck stat to insert a breathing tube. In current practice, the fastest surgical airway in an emergency is a cricothyrotomy, a procedure every anesthesiologist is taught to perform in seconds if a “can’t intubate/can’t oxygenate” hypoxic emergency occurs. In a true “can’t intubate/can’t oxygenate” hypoxic emergency, there’s no time to page an ear, nose, and throat surgeon, and there’s no time for a non-airway surgeon to try to remember how to cut down on the tracheal rings of the patient’s windpipe. An anesthesiologist can perform a lifesaving Bougie-assisted cricothyrotomy and insert an anesthesia endotracheal tube into the trachea in the neck in seconds.
The anesthesiologist may not be wearing a Captain’s hat, but he or she is the most important member of the operating room cast if an airway disaster occurs.
The surgeon and the anesthesiologist are Co-Captains of the Ship in the operating room. The two doctors share responsibility and respect, with the mutual goal of an excellent outcome for their patient.
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I trained under a cardiac surgeon who would turn to the residents and say “ I am the captain of the ship and we are sailing in a sea of fools.” The title of this article brings back a lot of memories.
John,
Yours is a classic story!
One time I had a lap sponge left in a patient with my documentation and the nursing staff of “sponge, needle and instrument counts correct X2”. The hospital Risk Management person said to me “you are the captain of the ship”, to which I replied, “Yes, and if the captain contracts out to have the barnacles cleaned off the bottom of the ship and is told twice by the contract company that it is clean, is it the captain’s responsibility to put on a mask and snorkel and go check for barnacles?” I then proceeded to tell the family what happened, took the patient back to remove the lap pad, and the hospital settled out of court without my connection at all.
Joseph,
Great story! Thanks for sharing.
Rick
The surgeon may be the captain of the ship, but the anesthesiologist is the captain of the *sinking* ship.
Walter,
You are so correct!
Rick
Having performed adult and pediatric cardiac surgery, suffice it to say that not all anesthesiologists are sufficiently trained and experienced for all such cases. For example, I witnessed bolus protamine administration to treat systemic hypertension coming off pump. This resulted in cardiac standstill and an ultimate LVAD. I also witnessed a CRNA during a cardiac case reconnecting an IV that had fallen on the floor without disinfecting the connection sites. The clean separation of responsibility suggested in this post is unrealistic in other than the few exalted institutions.
Matthew,
Interesting to hear of your experiences and viewpoint. Clearly you’ve worked with anesthesia professionals who you felt weren’t qualified for leadership or for captaining any ship. My hope is that across American more than a few exalted institutions are staffed with fine anesthesiologists. I get what you’re saying — I’ve worked with surgeons I wouldn’t refer a patient to myself. Thanks for writing. Rick
“Surgeons are experts in surgery and anesthesiology providers are experts in anesthesia care. Surgeons do not control anesthesiologists, surgeons do not prescribe the anesthesia plan, and surgeons do not manage anesthesia complications….In current practice, the fastest surgical airway in an emergency is a cricothyrotomy, a procedure every anesthesiologist is taught to perform in seconds if a “can’t intubate/can’t oxygenate” hypoxic emergency occurs.”
Having been an academic cardiothoracic surgeon and CVTS Chief at a major metropolitan county hospital, I take a different view on the “surgeons do not manage anesthesia complications” comment. I’ve never, ever witnessed an anesthesiologist perform a cricothyroidotomy; I’ve done 17 surgical cricothyroidotomies in my career. You’ll need more than a wire & a bougie, you’ll need dilators as well (such as the Blue Rhino system or the Avalon percutaneous ecmo dilator kit). I’ve never heard of an anesthesia resident even being taught to perform one. A protamine reaction of sufficient severity requires return to cardiopulmonary bypass support. A central line misadventure resulting in a dilator injury to the common carotid artery or the subclavian artery requires a surgeon, not an anesthesiologist, to repair it. A membranous trachea injury caused by a bougie, a lung transplant bronchial anastomosis perforated by a bougie, a PA catheter floated too far out into the periphery of the lung causing massive hemoptysis (or even a hemothorax) requires a surgeon, not an anesthesiologist, to manage.
Dr.Novak, you look like a youthful, attractive anesthesiologist with a head full of nice dark hair…& though I might envy that, there’s a saying in life: You can’t expect gray hairs on young shoulders. I think a gray-haired Dr. Novak will throw in a few nuances to your current statements. Good luck
Michael,
Thank you for your comments. I have tremendous respect for cardiovascular surgeons such as yourself, and their skill set, as I was a CV anesthesiologist for 15 years.
The teaching of front of neck access by scalpel, bougie, endotracheal tube is now a mainstream airway management skill for all anesthesiologists, and best requires no kit (which is invariably not available). The technique is referenced and described in my column at
https://theanesthesiaconsultant.com/2018/11/07/front-of-neck-access/
Regarding gray hair, alas I have an old picture on some of my internet content. I have 40 years of anesthetics under my belt, and I too am convinced that gray hair, or white hair, is great on airline pilots, CV surgeons, and anesthesiologists!
Rick
I have been working for 42 years as a cardiothoracic surgeon. I have seen good, great and poor CT surgeons and CT anesthesiologists. They definitely share the goal of a perfect patient’s outcome.
However, I always said that the most important person in the OR is the patient and the person most responsible for the patient’s life is the surgeon.
The patient comes to surgeons, the anesthesiologists are consultants for the administration of anesthesia.
The anesthesiologist disappears most of the time after surgery and does not see the patient anymore unless is part of the critical care team. In the night is the surgeon who comes back to check on the postop and sleeps there if it is needed.
The surgeon has a commitment to the patient till the patient dies or the surgeon retires. The anesthesiologist does not.
I have taken teeth dislodged during intubation out of a bronchus and I have been the one coordinating care with the ENT specialist when the arytenoid cartilage was dislodged during intubation. I also managed patients with laceration of the membranous portion of the trachea created by a difficult double lumen intubation. Not to mention patients that start moving during a distal anastomosis, etc, etc.
As every surgeon, I had my share of complications but I don’t remember once when the anesthesiologist took care of my complications.
I worked also with a great anesthesiologist who could perform a TEE on a neonate during Norwood stage I for HLHS. However, I’ve never seen an anesthesiologist staying in the OR during the entire case. They take many breaks and are replaced by another anesthesiologist or, more commonly, by a CRNA. Contrary to many anesthesiologists and surgeons who are in the OR only during the critical phase of the procedure, I always stayed in the OR from opening to closure and I never run two ORs at the same time.
Dr. Aru,
Thanks for your fine comments. You are clearly a dedicated and outstanding CT surgeon–a specialty as demanding as they come. Your experiences are not universal. When you write, “I’ve never seen an anesthesiologist staying in the OR during the entire case,” it’s contrary to the experience of our practice in California where we’ve been staying in the OR for the entire case for the past 40 years in our physician-only anesthesia practice. When you write, “I don’t remember once when the anesthesiologist took care of my complications,” that may be true for cardiac surgery complications, but in other specialties I’m aware of many cases in which OR complications caused by the surgeon, the anesthesia care, or just fate, are solved and resolved by the anesthesiologist, who of course does not do the surgery, but is chiefly responsible for the patient’s Airway Breathing and Circulation.
You are absolutely accurate in that the surgeon is tied to the patient long term, while the anesthesiologist can walk away from an uncomplicated case after the PACU stay concludes.
Thanks for writing.
Rick