Nov sig CMYK 2A forgotten step in an emergency could make the difference between survival and death. Goldhaber-Fiebert and Howard(Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events?) explain why cognitive aids are an essential component of effective crisis management, and outline the steps necessary to incorporate cognitive aids into clinical practice based on their experience at Stanford.  Stuart Marshall (The Use of Cognitive Aids During Emergencies in Anesthesia: A Review of the Literature) found that while most cognitive aids for anesthetic emergencies improved technical performance, some impaired diagnosis and treatment. Tobin and colleagues (A Checklist for Trauma and Emergency Anesthesia) reviewed the essential elements of a trauma anesthesia checklist. In accompanying editorials, Gaba (Perioperative Cognitive Aids in Anesthesia: What, Who, How, and Why Bother?) points out that we already know enough about the utility of cognitive aids (a term he coined) to warrant widespread adoption, while Augoustides and colleagues (Much Ado About Checklists: Who Says I Need Them and Who Moved My Cheese?) speculate that our current “dose” of cognitive aids is below the “therapeutic window,” and well below the dose that would constitute “checklist toxicity.”

Rinehart and colleagues (Closed-Loop Fluid Resuscitation: Robustness Against Weight and Cardiac Contractility Variations) describe the stability and robustness of a closed-loop “Learning Intravenous Resuscitator” to restore and maintain intravascular fluid status in simulation and in a porcine model of hemorrhage (Closed-Loop Fluid Administration Compared to Anesthesiologist Management for Hemodynamic Optimization and Resuscitation During Surgery: An In Vivo Study). In the in vivo test, the closed-loop system performed better than anesthesiologists. As Miller and Gan note in an accompanying editorial (Closed- Loop Systems in Anesthesia: Reality or Fantasy?), closed loop systems are not intended to replace anesthesiologists, just as airplane autopilots are not intended to replace pilots. The goal is to increase safety by reducing variability while enabling the anesthesiologist to focus on the most critical tasks.

Dr. Haridas and Bause (Correspondence by Charles T. Jackson Containing the Earliest Known Illustrations of a Morton Ether Inhaler) describe the earliest known drawings of the Morton ether inhaler, found by Dr. Haridas in a letter from Charles T. Jackson, MD. The letter, dated December 1, 1846 (one and a half months after Morton’s public demonstration of ether anesthesia) is primarily a rant by Jackson that Morton stole his invention.

On The Cover

Youthful inductees into the field of anesthesiology may not appreciate the great evolution in perioperative patient safety that has occurred over decades. The beauty of our field is that we have made the provision of an anesthetic a very safe endeavor. The ironic danger of our field is that we have made the provision of anesthesia a very safe endeavor. We may veil the risk of surgery and anesthesia with the very margin of error we have created with extensive knowledge, preparation and technology. Now it is times of crisis that test our capacity to retain order amidst a clinical environment cascading into an entropic mire. Salvador Dali obsessed over the idea of permanence in his classic painting The Persistence of Memory and in his lesser known The Disintegration of the Persistence of Memory. We have been spoiled by the predictable and geometric state of our craft. When our intellectual architecture devolves into something organic and distorted by catastrophe, perhaps cognitive aids hold a path to resolution.