361Ideally the case would be taken over by a specialist thoracic anesthetist. We are
told then that he has told the next anesthetist, Dr. Alexis, “all about James’ history
and signed out on all the things he needs to know.” However Dr. Alexis stays for
only 1 hour and then hands over to another anesthetist, Dr. Rohit. The surgeon has
never worked with Dr. Rohit before. It is not clear if Dr. Kellogg knew that Dr.
Alexis was available for only 1 hour, or that there would be yet another handover.
Dr. Rohit arrives at 4:00 p.m., and by 5:30 it seems clear that he is a less experi-
enced anesthetist. He is anxious about “a difficult airway” and because he has been
given inaccurate and inadequate information. He calls for another anesthetist to help
him. At this time it is late and it may be that Dr. Rohit is a trainee. Certainly manag-
ers should be aware that there are difficulties with handovers, with continuity of
care, and with poor and inaccurate information, that much care is given by a less
qualified workforce, and that is when problems arise.
Following the surgery, there is a rupture of the anastomosis requiring a return to
the operating room. It is clear that the clinical outcome is very poor and so in order
to save the patient’s life, heroic surgery is undertaken, with many further operations,
intensive care, and complications with attendant poor quality of life. Despite this,
and the direct plea from the patient that Dr. Kellogg stay to see him through, Dr.
Kellogg again leaves the operation as soon as his session is completed, handing over
on this occasion to another thoracic anesthetist. Once again he has fulfilled his con-
tracted duties and made arrangements for handover but shown no commitment to
the surgical team in a time of great difficulty or any empathy for the patient’s emo-
tional or medical needs.
It is not possible to be sure that the misplacement of the endotracheal tube into
the esophagus caused the anastomosis to rupture. There is always a risk of this com-
plication occurring, and James had been warned that the risk was somewhere around
25–30%. However, it is certainly possible that the tube had disrupted the anastomo-
sis, and if the case were to proceed to litigation, this would be evident to expert
advisors. Dr. Colon certainly would be concerned about this and would be likely to
favor that explanation over the alternative that it was a direct result of his surgical
skills. More important, however, it seems very probable that his working relation-
ship with Dr. Kellogg, one of the few thoracic anesthetists in the department, would
be badly, if not permanently, damaged. Dr. Colon is likely to believe that Dr. Kellogg
left the team for a trivial social engagement and has contributed to the adverse out-
come. As the first case has gone badly, it may be a long time before Dr. Colon has a
chance to undertake another.
Both clinicians and managers will be disturbed by Dr. Kellogg’s actions and will
question his behavior. Did he act unprofessionally? Was he clinically negligent?
Should a manager take action in terms of his work commitment or his contract? We
make an assumption that he is more financially motivated than focused on the needs
of the patients; he doesn’t like the extra, stressful work involved in looking after
complex, major surgery cases because the insurance doesn’t recognize the addi-
tional workload. We are told he “made a special effort and was there early,” so the
operation could start on time at 07:30; we assume that he does not usually come in
early, and we might infer that he does not like to stay late. A colleague states that Dr.
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