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Kellogg is the senior partner, he has worked for 18 years, his personal time is his
own, and “he doesn’t have to give more than is required.”
I teach this case by asking “what went right and what went wrong?” Ostensibly,
the most important piece of this case was the error itself. The problems began with
the handoff that occurred between anesthesiologists and Dr. Rohit stating that James
had “a difficult airway” when this was not the case. When time came for the reintu-
bation after the case, Dr. Rohit became apprehensive because James had been mis-
labeled, and he was unfamiliar with the thoracic case. He brought in another
anesthesiologist, Dr. Markus, who passed the tube through the esophageal anasto-
mosis rather than into the trachea. This tore Dr. Colon’s anastomosis and led to the
complications that ensued. Despite Dr. Colon’s high suspicion after the failed intu-
bation, he chose to send James to the ICU rather than to reexamine the anastomosis
and possibly order some imaging at that point.
Did Dr. Kellogg, chair of anesthesiology, walk away from the patient? Was he
clinically negligent? Did he violate his psychological contract with the team?
And what of the leadership of Dr. Colon? What was the quality of his strategic
thinking? Were the “what ifs” developed and understood? Did Dr. Colon build com-
mitment to the goals? Was the team engaged? Why or why not? Is it possible for a
surgeon to play both roles i.e., chief technical expert and team leader, planning and
implementing this procedure?
Case 3: Flight 1549—Collaborative Leadership in Action
The first responders expected the worst case scenario. An Airbus A320 with 155
passengers crash landed in the middle of the Hudson River. What happened?
On January 15, 2009, US Airways flight 1549 departed New York City’s La
Guardia Airport at 3:25p.m. Ninety seconds after takeoff, the Airbus 320, headed to
North Carolina, hit a flock of Canadian geese. The captain noticed large birds filling
the entire windscreen. There was the sound and smell of birds smoldering in the
engines. There was a “dramatic loss of thrust” and no sideward motion—conclu-
sion: they lost both engines. What would you do?
In the cockpit, the conversation was as follows:^35
H1 (Captain): birds
H2 (Copilot): uh oh
H1 (Captain): we got one rol-both of em rolling back
H1 (Captain): ignition start. I’m starting APU.
H1 (Captain): my aircraft
H2 (Copilot): your aircraft
H1 (Captain): get the QRH...lost thrust in both engines
H1 (RDO-1): mayday mayday mayday. Uh this is uh Cactus 1549. We’ve lost thrust
in both engines, we’re heading back to La Guardia.
(^35) Contact the author for a copy of the case study; however the best way to teach this case is to show
the video at https://www.youtube.com/watch?v=pWpSAfF6elI
J.A. Chilingerian