How This Work Came to Be
This Emergency Manual has a long history, evolving from decades of prior work on both Crisis Resource Management (CRM) concepts and cognitive aids for critical incidents. The 1994 book entitled Crisis Management in Anesthesiology by Dr. David Gaba, Dr. Steven Howard, and Dr. Kevin Fish provided the initial foundations for this project. This simulation group was involved in developing cognitive aids for operating rooms in the Palo Alto VA and then a national VA project, each with bulleted points for many critical events.
Observing that practitioners often miss key actions under stress, Drs. Harrison and Goldhaber-Fiebert along with Dr. Geoff Lighthall, Dr. Ruth Fanning, Dr. Howard, and Dr. Gaba developed several iterations of pocket cards for perioperative critical events, including some with rhythm strips, icons, and color design. In 2004, Dr. Larry Chu conceived of adapting crisis management cognitive aids to a more visually striking format for a new book he envisioned for today’s highly-visual millennial learners. This became The Manual of Clinical Anesthesiology, published in 2011.
To create the current Emergency Manual, the Stanford Anesthesia Cognitive Aid Program was formed. All team members have had integral roles. Dr. Larry Chu, who directs the Stanford AIM (Anesthesia Informatics Management) lab, provided the new graphics and layout, applying his design skills and an understanding of user interface to make the content more easily usable. Drs. Sara Goldhaber-Fiebert, Kyle Harrison, Steven Howard, and David Gaba worked jointly to provide the content, including exact phrasing, ordering, and emphasis, as well as iterative simulation testing to revise both content and design elements.
Observing how cognitive aids are used by teams during hundreds of simulated crises has been crucial for pilot testing throughout. We hope that this Emergency Manual will support both education and patient safety efforts. Effective use has included pre-event review, post-event team debriefing, and ‘during’ crisis management – the latter, particularly after adequate help, has arrived or when the patient is sufficiently stable for a clinician to pause from acute care actions, and helped by a separate ‘reader’ role. We encourage the appropriate use of this Manual and welcome feedback from all practitioners.
For their extensive feedback and team implementation efforts, we deeply appreciate the faculty, residents, staff, and interprofessional leadership at Stanford Hospital and VA Palo Alto.
The material in this Manual is not intended to be a substitute for sound medical knowledge and training. Clinicians using this Manual should use their clinical judgment and decision making for patient management. Since treatment for the medical conditions described in this Manual can have variable presentations, departure from the information presented here is encouraged as appropriate.
Appropriate Citation for Emergency Manual
Stanford Anesthesia Cognitive Aid Program. Emergency Manual: Cognitive aids for perioperative critical events. Version 3.1, 2016. See for the latest version.
*Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK.
Much of the work in this Anesthesia Emergency Manual was adapted from cognitive aids originally published in Appendix of Crisis Management Algorithms in Anesthesia in the Manual of Clinical Anesthesiology, edited by Larry Chu and Andrea Fuller, published by Lippincott Williams & Wilkins, 2011. The authors were*: Harrison TK, (21) Goldhaber-Fiebert SN (21), and Chu L (21), as well as on specific cognitive aids, contributions by: Lighthall G, (2), Howard S (1), and Mudumbai S (1)*First three authors listed in random order; # of cognitive aids contributed to in original publication listed parenthetically.
An emergency manual is a resource that contains sets of cognitive aids or checklists relevant for a specific clinical context. The term ‘emergency manual’ is purposefully used as a clear reference to a familiar and accessible emergency resource at the point of care. This term is parallel to the emergency section of ‘Flight Manuals’ for pilots and aviation crews. Operating rooms and other acute care settings now have many ‘checklists,’ including the helpful and widespread WHO surgical safety checklist. The term ‘cognitive aid’ is the longstanding academic term encompassing all resources that help people to remember or apply relevant knowledge appropriately. However, this term is often not yet well understood by many practicing clinicians. Naming this context-relevant book ‘emergency manual’ quickly developed broad cultural acceptance among interdisciplinary clinical team members. Nurses are using empowering questions, such as “Should I get you the Emergency Manual?” and team leaders are assigning a ‘reader’ role for complicated events such as Pulseless Electrical Activity (PEA) cardiac arrest.
Relevance for Every Healthcare Specialty
The downloadable pdf of this Emergency Manual is most relevant for the operating room, other anesthetizing locations, and perioperative acute care contexts (e.g. Recovery Room, ICU). However, the concept of emergency manuals and downloadable resources with implementation tips, Crisis Resource Management handouts, and other downloadable resources on this website may be broadly useful for champions of effective teamwork and emergency manual use in many healthcare specialties.