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Who is this book for?

This book is written for all those involved in pain management. Although we are not indifferent to the political and economic contradictions between anesthesiologists and nurses, they have nothing to do with the tasks of this book. The central principle of our training is the realization that any physician who is with the patient during anesthesia should have the highest degree of preparedness to act in a critical situation - both individually and as part of a medical team. Much of what we learn about managing a surgical team can be extremely helpful to the anesthetist who nominally leads the anesthesiology team. At the same time, it should be emphasized that the optimal management of a crisis situation requires coordinated action from all members of the brigade. In this book, we use the general concept of an anesthetist, referring to both anesthetists and specially trained nurses.

The book “Critical situations in anesthesiology” is addressed to those who have a certain work experience, and those who are still just learning. It is safe to say that the concepts presented here were not fully taught before and are not easily understood in everyday practice. Beginners will strive to study them as early as possible in order to adopt them in their work, and specialists will need them to constantly review and improve the existing order, just as pilots must continuously strengthen their skills in solving critical problems regardless of their summer experience.

What is this book about

The book Critical Situations in Anesthesiology focuses on topics that are not found in traditional textbooks on medicine or anesthesiology. While other works on anesthesiology focus primarily on the physiology or pathophysiology of the patient or the clinical and technical characteristics of medicines or equipment, this book focuses primarily on the thinking of the anesthetist. Just as pharmacologists are trying to synthesize a “perfect” drug, and engineers are trying to create an “absolutely trouble-free” device, so we strive to help anesthetists optimize their actions, because they are the most important link in a chain of circumstances ensuring patient safety.

This book talks about how to behave in critical situations arising from anesthesia. The first two chapters analyze the decision-making stages of an ideal anesthetist. An ideal anesthetist uses the process of repeated observations over and over again under the adaptive “internal control”, the decisions made on them and the actions taken thereafter. In addition to his own work, the specialist must also organize the actions of the team working with him in the interests of the patient. The material in these chapters is similar to the training components of crew resource management programs, which are currently an integral part of training for airline pilots.

The second section, “A List of Critical Situations in Anesthesiology,” is intended to help the anesthetist in applying another strategy used in aviation. The “List” is a systematic selection of emergency measures taken during crises that occur in clinical practice. Anesthetists, like pilots, must learn to recognize many emergency situations and respond accordingly. The “List” presents situations that may interest anesthetists in a concise, uniform manner, which facilitates the recognition process and the ability to deal with them. It can be used as a guide, allowing you to prepare in advance for recognition and resolution of problems of this kind, or refer to it when analyzing a real case as a reminder of what could be taken into account or done in this case. Finally, the “List” will serve as a tool in training when resorting to verbal or real modeling of situations or role models.

What is not in this book

Although crisis management in anesthesiology is based on basic knowledge and relevant technical skills, “Crisis Situations in Anesthesiology” is based on the fact that the reader is either already familiar with the medical information needed by a practical anesthetist and has mastered certain professional skills, or is in the process of studying this science. This is not a guide to anesthesiology, the pathophysiology of a patient with a surgical profile, or specific preoperative assessment and treatment. These topics are discussed in detail in numerous other textbooks and reference books.

The main thing is not a cookbook on anesthesia. You will not find in it recipes for performing ideal anesthesia. The “List of Critical Situations” is nothing more than a general guide. The section entitled “How to act in each described situation” does not represent a tree of a solution or algorithm. We believe that managing the patient during anesthesia is too complex a task to try to give schematic solutions. Such schemes, in addition, due to their branched structure, are difficult to remember. Thus, our recommendations are a list of what should be checked or what should be done, approximately in the order in which an experienced specialist would act.

We do not claim that the implementation of practical recommendations guarantees a way out of all the listed clinical situations or prevents an undesirable outcome for the patient. The book does not claim to be anything more than a guide to training anesthetists. Trying to make the material comprehensive, we do not affirm at the same time that it is exhaustive. The list of manifestations of each situation contains only the most important, from our point of view, symptoms, and no practical recommendations can take into account the whole variety of combinations that characterize the patient's condition and non-standard circumstances.

We strongly welcome deviations from the practical recommendations set forth in the “List” in all cases where anesthetists have any need to cope with a special situation. We also strongly recommend that anesthetists adapt this “List” to the conditions of their particular practice, based on their own experience, taking into account the differences in medicines and equipment.

Who wrote this book

Perhaps the reader has a question why we undertook to write such an unusual book. We are all full-time teachers of anesthesiology at Stanford University School of Medicine and the Palo Alto Veterans Department Medical Center. David M.Gaba graduated from Stanford and has been in practical anesthesiology for 12 years.
He was always interested in aviation, astronautics and has a license of an amateur pilot. Kevin J. Fish studied in Britain and Canada, has been working in practical anesthesiology for 22 years. Steven C. Howard also graduated from Stanford University and has been in anesthesiology for four years.

In addition to clinical training, we conducted a lot of research on the human factor in anesthesiology, examining the thinking patterns of those people who perform anesthesia (see the list of recommended literature in Chapter 1). When writing a significant part of this work, we used a practical, affordable anesthetic model, invented in our laboratory - integrated modeling of anesthesia conditions (CASE). The source for the creation of “Critical Situations in Anesthesiology” was the special course “Resources for Resolving Critical Situations in Anesthesiology” developed by us for classes with the CASE model. Currently, 120 anesthesiologists, teachers, private practitioners and nurse anesthetists have attended this course. Their comments and criticisms were taken into account in this book.

Given the specific experience of Robert Hoizman in pediatric anesthesiology, and Emily Ratner in obstetric, we asked them to write the appropriate chapters. In the early stages of compiling the “List of Critical Situations in Anesthesiology”, we also turned to the help of MD Frank Sarnquist, a professor of anesthesiology at Stanford University who has 23 years of teaching and private practice.

David M. Gaba

Kevin J. Fish

Steven K. Howard


The book Critical Situations in Anesthesiology would not have been released without the support of the Anesthesia Patient Safety Foundation (APSF). We are grateful to the APSF, which initially funded Integrated Modeling of Anesthesia Conditions and, later, the creation of the course Resources for Resolving Crisis Situations in Anesthesiology (ACRM).

We would like to pay tribute to the contribution of many residents of the anesthesiology faculty of Stanford University, who, as part of their training, compiled the first versions of some of the items in the List. These collective efforts gave us a starting point for the compilation of the “List”, and their contribution greatly facilitated our editorial work.

I would like to express my gratitude to a number of researchers in the field of cognitive sciences and the human factor, whose work is discussed in this book. Although they are mentioned in the text, simple academic citations cannot express the depth of our respect for the work they published and the value of their personal support for our efforts to apply their ideas in the field of anesthesiology. Jens Rasmussen is probably one of the first in his attempts to study the real cognition of the world by individuals and groups working in difficult circumstances. We owe a lot to his descriptions of different levels of mental activity, which are included under dynamically changing circumstances.

James Reason outlined his deep understanding of the root causes that sometimes arise from errors and complications. These data are summarized in his book Human Error (Human error, Cambridge University Press, Cambridge, UK, 1990). Since these topics are very complex and mostly outside the control of a particular anesthetist, our book does not fully disclose these issues, although to some extent they are covered in the sections “Pressure of Circumstances”. In essence, a special book for anesthetists should be devoted to these problems.

David Woods not only helped us understand how anesthesia is similar to other, complex and dynamic areas of human activity and what errors are, but it enriched us with other concepts that subtly influenced the formation of our views.

Of all the dynamic decision-making models presented in the literature, the closest to our formulations is “Gary Klein Recognition-Primed Decision Making”, although we did not know about the existence of this work in the course of our work. The latest book by Klein, Orasanu and Calderwood Decision Making in Action: Models and Methods (Ablex Publishing, Norwood, NJ, 1993) gives a new definition of decision making, emphasizing the naturalness of this process in people in complex, dynamic realities, in conditions of insufficiently clear organization. The RPD option is currently gaining widespread use in aviation, military command and control.

Daniel Gopher explained how important it is for an anesthetist to properly distribute attention and choose the right strategy in order to control his workload.

It is no coincidence that professors Rasmussen, Reason, Woods and Gopher participated in the Conference on Human Anesthesia Errors (February, 1991), organized by two of us (Gaba and Howard) as an expert meeting on the most important human factor issues in our specialty. This conference was an additional incentive to complete the "Critical situations in anesthesiology."

We would like to express our appreciation to the known number of people working on the human factor problem in aviation, whose work directly or indirectly helped shape our approach to crisis management in anesthesiology. This is John Lauber, Ph.D., National Committee for Transport Safety; N. Clayton Foushe, Ph.D., Federal Aviation Administration; Robert Helmreich Ph.D., National Administration of Aeronautics and Space Research (University of Texas Space Crew Project); Judith Orasanu, Ph.D., National Aeronautics and Space Administration, Department of Human Factors in Aeronautics and Space, and Rand McNally, MD, American Airlines.

We are grateful to those numerous students and staff whose work in our laboratory contributed to the appearance of this book, in particular to Dr. Abe DeAnda, ml. Dr. John Williams, Thomas Lee, and George Yang, as well as Clarita Domingo, for their technical assistance in preparing our course and the “List of Critical Situations in Anesthesiology”.

Finally, we would like to emphasize that the opportunity to complete this book is due to the extremely substantial assistance of a close-knit team of researchers and teachers of the Anesthesiology Service of the Medical Center at the Department of Veterans Affairs in Palo Alto, close cooperation between the faculty of Stanford University School of Medicine.

We are indebted to the Department of Veterans Affairs, which created the necessary conditions for writing this book.
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