Is the surgeon still "captain of the ship"?

A Kentucky appeals court ruled that a surgeon was not responsible for a burn caused by an instrument that had been removed from an autoclave and placed on an anesthetized patient's abdomen.

According to an article in Outpatient Surgery, the surgeon was not in the room when the injury occurred and only discovered it when he was about to begin the procedure.

An insufflator valve had been sterilized and was apparently still hot when an unknown hospital staff member put it down on the patient's exposed skin. [An insufflator is a machine that is used to pump CO2 through tubing into the abdomen for laparoscopic surgery.] When the doctor saw the mild second-degree burn, he asked what happened, but "but no one in the OR claimed any knowledge or responsibility."

The hospital had settled the suit on behalf of its staff, but the surgeon, who as a private practitioner had his own malpractice insurance, held out. The original lower court ruling dismissing the suit against him had been based on the plaintiff's lawyer's failure to prove that the surgeon was responsible for the actions of the hospital staff.

In December 2012, I wrote a post stating my opinion that activities such as counting the sponges during an operation were not the responsibility of the surgeon. Many who commented on the post were highly indignant that I could suggest such a thing.

I wrote another post last year on the subject in response to another surgeon's blog entitled "Everything's my fault: How a surgeon says I'm sorry." I felt that many things that happened to patients were beyond the control of the surgeon. Most of the comments agreed with me.

I keep hearing that medical care has become a team sport. If that's true, then the surgeon, like everyone else, is simply a member of the team. People on teams have different roles and must execute properly for the team to succeed.

One of the most interesting things about the case in question was that none of the OR team members had any idea how that hot insufflator valve found its way to the patient's abdomen.

One thing we know for sure, at least in Kentucky, is that a surgeon is not legally responsible for everything that happens to a patient in the operating room, particularly when he is not even present.

Is this decision the first nail in the coffin of the "captain of the ship" doctrine?

Are surgeons responsible for everything that happens to their patients?

Several months ago, a post called "Everything's my fault: How a surgeon says I'm sorry" appeared on KevinMD. It was written by a plastic surgeon who feels that no matter goes wrong with a patient, surgeons should never blame anyone else.

She gave some examples such as the lab losing a specimen, a chest x-ray that was ordered and not done, a patient eating something when he was not to be fed, and a surgeon having to cancel a case because the patient's blood pressure was elevated. She felt that all of these incidents should be owned by the patient's surgeon.

I agree that if I order a chest x-ray and find out later it wasn't done, I would accept the responsibility to have made sure it was done. I have always believed that you should not order a test if you aren't going to do something with the result.

But if the lab loses a specimen or a patient who was not supposed to eat does so, how is that my fault?

"Thousands" of errors made by surgeons

Over the last few days, stories about “thousands of errors made by surgeons” have received a lot of media and Internet attention. All of this was the result of a paper from Johns Hopkins that says surgeons leave an object in 40 patients per week, perform wrong site surgery on 20 patients per week and perform the wrong operation altogether in 20 patients per week.

The paper reported 9,744 such errors in a review of the National Practitioner Data Bank over the 20 years from 1990 to 2010. I’d love to tell you how they extrapolated from 9,744, which over 20 years averages 9.4 such errors per week, to 80 per week, but the paper is not accessible to those who do not subscribe to the journal Surgery.

I agree with those who say these are “never” events that are totally preventable and should never happen.

But I want to set the record straight.

Listen to me. Surgeons are not the cause of sponges being left in patients. I’ll explain.

A surgeon is about to perform an appendectomy. Before she arrives in the operating room, the circulating nurse and the scrub technician will have assembled all of the equipment needed to do the case. They also will have carefully counted all of the instruments, needles and sponges. [The “sponges” are not like the ones you use to clean your sink. They are 4 X 4 inch gauze pads or larger cloths called lap (short for “laparotomy”) pads.]

The surgeon has nothing to do with the counting either before or at the end of the surgery. As the wound is being closed, the nurse and tech perform another count to verify that all sponges etc. are accounted for. A third count is done after the skin is closed. There are checklists for this.

When I protested on Twitter that surgeons were being blamed for the errors involving objects left in patients, many people responded that if I was in charge, I should verify that the counts were correct. I replied that I could either do the surgery or do the counting, but not both. You see, as the case progresses, I might have asked for more equipment or a suture that was not on hand at the start of the case. The staff must add these things to the total count. If a new package of lap pads was opened, they must be counted before they can be used. Would you want your surgeon to look away from your bleeding wound to count the sponges?

Others brought up the alleged “fact” that the surgeon is the “captain of the ship.” That principle, which was established in Pennsylvania law in 1949, has been abandoned by most states. Here is a quote from a textbook on nursing malpractice:

“The viability of this doctrine is dubious, at best, in today’s health care system. Each perioperative health care provider is considered a professional with responsibility and hence accountability for specified tasks and individual actions.”

Many more such references can be found.

By the way, I wanted to see how the prestigious Johns Hopkins Hospital, which is where the authors of the paper work, is dealing with medical errors. However, when I searched the Leapfrog patient safety website, this is what I found for Johns Hopkins Hospital.


Attempts to solve the problem of retained objects with technology such as barcoding sponges or placing radio frequency tags on them have not caught on. And those measures would not be able to help with instruments or needles.

Yes, no object should ever be left in a patient. But at least get the headlines straight. If nurses and techs do their jobs, surgeons cannot leave things in patients.