n a crystal clear night in 1912, the Titanic struck a massive iceberg and sank with the loss of 1,500 lives. For almost a century, this story has remained alive. There continues to be discussion about the causes of the disaster, such as the number of lifeboats, the strength of the steel and the behavior of the crew.

The question that is seldom addressed is why the highly skilled crew on the most sophisticated commercial vessel of its time drove their ship into an iceberg. Conventional wisdom is that the crew spotted the obstruction too late to take effective corrective action. Was that really the case? Was this catastrophe inevitable? Why did the officer of the watch fail to take timely corrective action?

This disaster was thoroughly investigated by the American and British governments, but some of the factual information seems to have been ignored. Unfortunately the key person, the officer of the watch, failed to survive.

I submit that there were a series of errors that led to this disaster. Those of you who regularly attend conferences that discuss complications will quickly recognize the pattern.

The first error was ignoring the prevailing conditions. The Titanic did not take ice warnings from nearby ships seriously. To one such warning, just before the Titanic struck the berg, the Titanic’s wireless operator responded, “Shut up. I am busy.” The officer of the watch and the captain failed to appreciate the significance of the danger that lay in their path and did not reduce speed.

The second was inadequate preparation. The lookouts were not equipped with binoculars.

The third was inadequate communication. The Titanic had telephone circuits from the lookouts to the bridge, but the officer of the watch conned the ship from the bridge deck. The bridge deck was separated from the bridge by a closed door. The only direct communication that the officer of the watch had with the lookout was the warning bell. The Titanic’s bridge and its communication was an anachronism caught in a maelstrom of technological development.

The fourth error was erroneous prioritization. Part of the investigation included testimony of an able seaman, Joseph Scarrott. His testimony indicated that the lookout saw the iceberg and sounded the alarm five to eight minutes before the contact, plenty of time to alter course. Why would the officer of the watch wait that long before altering course?

Before the advent of electronic navigation, conventional magnetic compasses were extremely important. The standard compass was the most accurate compass onboard. It was meant to be the standard that all other compasses were to be compared to throughout the voyage. As such, the standard compass was isolated as much as possible from magnetic influences. The Titanic’s standard compass was located 230 feet aft of the bridge on a wooden platform raised 15 feet above the deck and illuminated by an oil lamp to eliminate inaccuracies. Every 30 minutes, a junior officer climbed onto the compass platform to steady the ship on the proper course using the standard compass by communicating with a one-way bell system. This was happening when the lookout spotted the iceberg. The officer reading the compass was adjusting the oil lamp and, therefore, slow in reporting the steering corrections to the officer of the watch. The officer of the watch heard the alarm bell but likely delayed his steering response to the presence of the iceberg to allow the officer reading the compass to send his corrections. Danger lay three miles ahead, but the officer of the watch continued to carry out his written instructions to make the every-30-minute steering correction.

The fifth error was that the corrective action was wrong. He ordered a change in course — obviously correct. But he also ordered the engines to be put into reverse. The turning effect of a ship’s rudder is caused by the flow of water across the rudder surface — the faster the flow, the greater the force. His action to reverse the engines decreased the effectiveness of the rudders and actually delayed Titanic from steering away from the berg.

What is the relevance to anesthesiology? The relevance is that there are hazards and obstacles in our path to the future. The health of the specialty and the care we deliver will be determined by how effectively we see obstacles and change course.

Let us review the Titanic’s errors:

1. failure to be prudent during uncertain times

2. inadequate efforts to look ahead

3. poor internal communication

4. misplaced priorities

5. hasty action with adverse consequences.

How does anesthesiology measure up to the traps that caused the Titanic to strike the iceberg? Please note that the question did not speak to ASA but to the specialty as a whole because, without pushing this analogy too far, we are all in the same boat.

Many of us know that we are in uncertain times. I hope that we remain prudent and vigilant.
The Foundation for Anesthesia Education and Research started our process of looking into the future. Eugene P. Sinclair, M.D., has set in place the tools for our lookouts. ASA is making a genuine effort to ascertain what lies ahead.

However, we have failed in some instances to clearly communicate. The problems encountered with the residency curriculum changes clearly show that we need to do a better job talking to one another.

It is important that our priorities improve patient care in the long run. The House of Delegates will be asked to complete a priority assessment to help the leadership steer the right course.
And finally, we must be savvy in our actions and ensure that they are driven by facts and not emotion.

As we have talked more about the future, many anesthesiologists have asked me what they or their groups ought to be doing to prepare for the future. I do not claim to be a prophet but I have given this matter some thought. My advice is to do everything possible to be a good physician and anesthesiologist and become invaluable to your patients and institutions.

I bet that each of you could come up with what that is, and it’s probably the same as my list. This is my list:

• Preanesthetic evaluation that minimizes cost and delays and maximizes anesthetic safety

• Efficient operating room care that maximizes institutional efficiency

• Electronic medical record

• Provision of sedation and anesthesia services throughout the institution

• Postanesthesia care both in PACU and elsewhere

• Critical care

• Acute pain

• Chronic pain

• Operating room management

• Protocol development and implementation such as beta blockade and glucose control

• Institutional management.

Anesthesiologists who do all these things well and remain flexible to accept new challenges will be invaluable and in the best position to face the future.

Hurricane Katrina was another lesson in preparation, flexibility and doing the right things for the right reasons. Let us make sure that we collectively and individually remember these lessons.

Orin F. Guidry, M.D., is a staff anesthesiologist at the Ochsner Clinic Foundation, New Orleans, Louisiana.