Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.

An anesthesia emergency occurs without warning. Your patient’s vital signs are dropping. As the anesthesiologist, it’s your job to make the correct diagnosis and act promptly to save your patient. You need the ultimate anesthesia emergency guidebook.

That ultimate guidebook is the Stanford Emergency Manual of Cognitive Aids for Perioperative Critical EventsS, written by the Stanford Anesthesia Cognitive Aid Group.

Consider the following situations:

  1. You’re an anesthesia professional, and your patient has a sudden unexpected complication (think unstable cardiac rhythm, unanticipated difficult airway, anaphylaxis, hypotension, hypoxemia, malignant hyperthermia, local anesthetic toxicity, or transfusion reaction) in the operating room or Post Anesthesia Care Unit. You react quickly to support Airway –Breathing- Circulation and apply all your knowledge of the appropriate diagnostic and therapeutic action steps. Will you perform perfectly? Will you remember every detail without fail?
  2. It’s the day before your American Board of Anesthesiology oral board exam, you’re completing your final review, and you’re looking for comprehensive listings of how to manage the array of medical emergencies the Board Examiners may present to you.
  3. You’re a Medical Director or medical educator, and you’re scheduled to deliver a lecture on the management of two or three common operating room emergencies. You’re searching for a concise and accurate listing of the management such emergencies.
  4. You’re an expert witness or a member of your hospital’s Quality Improvement committee, charged with reviewing the unfortunate outcome of an operating room medical complication. You’re searching for an algorithm listing the standard of care in managing that specific emergency.

What do you do in situations 1 – 4 above?

I recommend you consult a new publication, the Emergency Manual of Cognitive Aids for Perioperative Critical Events.

Anesthesia practice is described as 99% boredom and 1% panic. In those emergency moments which coincide with the 1% panic, anesthesiologists must respond with exacting skill. My colleagues at Stanford University have developed the Emergency Manual of Cognitive Aids for Perioperative Critical Events, a useful adjunct in managing critical events during the perioperative period. This Manual is described in detail on the website, and the Manual is available for free download at this location.

I had no role in authoring the Manual—my message here is to inform you that an important new medical reference guide exists, and to convince you to acquire it and use it. I can attest that the Manual is comprehensive, accurate, and valuable for education, preparation, and as a source of real-time checklists during perioperative emergencies that leave little room for error and little time to consult reference textbooks.

This emergency Manual evolved from decades of prior work on both Crisis Resource Management (CRM) concepts and cognitive aids for critical incidents. Dr. David Gaba, Dr. Steven Howard, and Dr. Kevin Fish of Stanford authored a 1994 book entitled Crisis Management in Anesthesiology, and their work and publications involving teaching via an anesthesia simulator led to the development of cognitive aids for operating rooms in the Palo Alto VA Hospital and also a national VA project.

Drs. Kyle Harrison, Sara Goldhaber-Fiebert, Geoff Lighthall, Ruth Fanning, Steven Howard, and David Gaba observed during simulator sessions that practitioners often missed key actions under stress. They developed several versions of pocket cards for perioperative critical events. In 2004 Dr. Larry Chu, also at Stanford, conceived of adapting crisis management cognitive aids into a new book. This became The Manual of Clinical Anesthesiology, published in 2011.

To create the current Emergency Manual of Cognitive Aids for Perioperative Critical Events, the Stanford Anesthesia Cognitive Aid Group was formed. Dr. Larry Chu, director of the Stanford Anesthesia Informatics Management (AIM) lab, provided the graphics and layout. Drs. Sara Goldhaber-Fiebert, Kyle Harrison, Steven Howard, and David Gaba worked together to provide the content, including the exact phrasing, ordering, and emphasis, as well as simulation testing to revise both content and design elements. The Stanford Anesthesia Cognitive Aid Group observed how teams of anesthesiologists used cognitive aids during hundreds of simulated crises. These simulator sessions were crucial for pilot testing of the algorithms in the emergency Manual. Stated goals of the Manual are to support education and patient safety efforts in pre-event review, post-event team debriefing, and during actual critical event management.

The content of the Manual is exhaustive, covering treatment for Advanced Cardiac Life Support (ACLS) arrhythmias as well 18 non-ACLS critical events including unanticipated difficult airway, anaphylaxis, hypotension, hypoxemia, malignant hyperthermia, local anesthetic toxicity, and transfusion reaction.

Each page of the Manual presents an algorithm printed in a prominent font containing, for example, SIGNS, TREATMENT, DIFFERENTIAL DIAGNOSES, and POST EVENT checklists. In an era when pre-operative surgical Time Outs are mandated and the best-selling book The Checklist Manifesto by Dr. Atul Gawande touts the value of checklists in medical care, the Emergency Manual of Cognitive Aids for Perioperative Critical Events is a valued addition to quality care for your surgical patients.

On their website, the authors cite the following Reasons for Implementing an Emergency Manual:

  1. In simulation studies, integrating emergency manuals results in better management during operating room critical events. NOTE: Familiarization and training in why and how to use EMs appears to be key for success.
  2. Pilots and nuclear power plant operators use similar cognitive aids for emergencies and rare events, with training on why & how to use them.
  3. During a critical event, relevant detailed literature is rarely accessible.
  4. Memory worsens with stress & distractions interrupt planned actions.

Expertise requires significant repetitive practice, so none of us are experts in every emergency.

A hard copy of the Emergency Manual of Cognitive Aids for Perioperative Critical Events hangs in the central operating room hallway at the surgery center in Palo Alto where I am the Medical Director. A copy of the Manual hangs in every operating room at Stanford Hospital.

I carried a copy of The Washington Manual of Medical Therapeutics in the pocket of my white coat for three years while I was an internal medicine resident at Stanford. My Washington Manual became dog-eared, underlined, and worn because I knew it was an invaluable resource. The Stanford Manual now occupies this role for the management of perioperative emergencies.

I recommend the Emergency Manual of Cognitive Aids for Perioperative Critical Events at the highest level of enthusiasm. It will help guarantee excellence of care for your patients. It’s free, and the benefit/risk ratio of consulting this Manual approaches infinity.

Download it now at

Appropriate citation of this Emergency Manual:

Stanford Anesthesia Cognitive Aid Group*. Emergency Manual: Cognitive aids for perioperative critical events. See for latest version. Creative Commons BY-NC-ND. 2014 (Version 2) ( 
*Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK.