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.