The CSA Committee on the History of Anesthesia congratulates the winner of the 2021 CSA History of Anesthesia Essay Contest: Albert B. Lin, MD, author of “Rethinking ‘Normal Accidents’ in Anesthesia: How Dr. David Gaba Translated Crisis Management Principles from Aviation to Anesthesiology.”
Dr. Lin, a CA-2 resident at Stanford, is a proud Bay Area native who was born and raised in San Jose. In his free time, he enjoys cooking pan-Asian cuisine and mountain biking in the majestic Santa Cruz mountains.
In this second year of our contest, we received several remarkable entries from across the state. Our panel of judges evaluated these essays in a blinded manner and determined Dr. Lin’s piece to be the best all-around entry. As an award, Dr. Lin will receive a CSA Foundation for Education prize of $1000 and a copy of the first edition of Dr. Gaba’s landmark textbook Crisis Management in Anesthesiology. Dr. Lin has also been invited to present his piece at the 2021 CSA Annual Meeting, which will occur virtually in April.
Rethinking “Normal Accidents” in Anesthesia: How Dr. David Gaba Translated Crisis Management Principles from Aviation to Anesthesiology
“Hey, doc, uh, am I supposed to feel this hot?” I jumped up, nervously reassured my patient, and scanned the vitals monitor for any abnormalities. My patient stared ahead stoically, glassy-eyed, trying hard to conceal his fear. His heart rate and blood pressure appeared normal, although he was more tachycardic than I remembered.
“I’m really sweating here, doc,” he said, panic rising in his voice. “Aren’t you going to do something?” Trying to suppress my own rising panic, I frantically scanned the anesthesia machine for clues, noticing this time that the end-tidal CO2 had steadily crept up to 55 mmHg. I called for additional help, instructed the circulating nurse to retrieve dantrolene, and informed the surgeon of the situation, all while trying to speak directly into the microphone clipped onto my scrubs.
The mannequin in front of me blinked twice, then exclaimed, “That’s a wrap! You’re done.” The room lights came on, and I let out a sigh of relief. My “patient”—a programmable polymer mannequin powered by a simulation computer—turned out to be voiced by David Gaba, MD, who had invented the first prototype of this mannequin in 1986.1 Thanks to Dr. Gaba’s pioneering work in simulation-based learning and operating-room (OR) crisis management, anesthesia simulation training is now widely offered—and considered essential—in residency programs across the country.
In the lobby of Stanford’s Center for Immersive Simulation-Based Learning, a glass cabinet near the main entrance prominently displays Dr. Gaba’s first simulation mannequin prototype, which he created with research fellow Mary Maxwell, MD, and medical student Abe DeAnda, Jr.1 Dr. Gaba traces much of his passion for simulation and quality improvement back to his childhood in Kansas City, MO, and his early fascination with NASA’s Apollo program.2 At the time, NASA often used simulation to train its astronauts for spacewalks and accident prevention drills.
“I was one of those kids who audiotaped the TV broadcasts of all the Apollo missions,” Dr. Gaba said.2 “And Alan Shepherd’s historic flight was launched on my seventh birthday.”
Dr. Gaba went on to study biomedical engineering and artificial intelligence at Northwestern University before attending medical school at Yale in 1976. His MD thesis at Yale investigated the adverse effects of defibrillation, an inquiry he continued in animal models after joining Stanford’s anesthesiology faculty in 1984. That same year, Dr. Gaba read Charles Perrow’s Normal Accidents: Living with High-Risk Technologies, a book that would set the course of his professional life.2
Perrow was a Yale sociologist who sat on the Kemeny Commission that investigated the Three Mile Island Accident of 1979. In his book, Perrow analyzed a series of high-profile catastrophes using root cause analysis of system errors. As Dr. Gaba read Perrow’s theory of how accidents emerged from the accumulated mistakes of everyday operations, he immediately thought, “this is just like anesthesia.”1 His team initially considered using an animal model to study decision-making in the OR, with a plan to “bring people here, make bad things happen [to the dog], and to see how the anesthesiologists respond.”1 The impracticality and ethical concerns with using animals, however, quickly ruled out this option.
Drawing upon his lifelong love for aviation and space, Dr. Gaba turned his focus to creating a simulator. He and Dr. DeAnda, Jr. cobbled together their first prototype using programmed vital signs and a reservoir bag attached to a plastic trachea. After securing a $35,000 research grant from the Anesthesia Patient Safety Foundation, the pair introduced their first functioning simulator, the CASE 1.2, in 1988.1
Between 1990 and 1992, Dr. Gaba produced his second-generation simulator (CASE 2.0) with John Williams, another medical student who happened to be a talented electrical engineer. Together, they created a robust cardiovascular modeling algorithm that could generate real-time pressure waveforms that correlated to ECG samples from a stored library.1 Iterations of this algorithm are still used today at Stanford’s simulation center.
During this time, Dr. Gaba also became interested in the principles of Cockpit Resource Management (CRM), which focused on high-pressure decision-making in commercial aviation.1 In 1987, the PBS science documentary series NOVA aired an episode titled “Why Planes Crash,” which investigated three recent airline crashes. Citing pilot error as the primary cause of plane crashes in 60 to 80 percent of cases, the show explored CRM as a promising solution. It also featured a NASA psychologist from the Ames Research Center, which happened to be down the street from Stanford in Mountain View, CA.
After watching the special, Dr. Gaba visited NASA Ames to discuss decision-making and teamwork psychology with leading experts in the field. These discussions led to the development of an analogue course for anesthesiologists called Anesthesia Crisis Resource Management (ACRM), which was introduced in 1990 to very positive reception. The accompanying textbook, Crisis Management in Anesthesiology, is considered to be a landmark text on patient safety. Dr. Gaba also led efforts to establish simulation centers at the Palo Alto Veterans Affairs Hospital and at Stanford University in 1995 and 2010, respectively.3 Today, both institutions host cutting-edge simulation courses for guests from around the world.
As an anesthesia resident learning modern medicine, I stand on the shoulders of giants who came before me. Dr. Gaba is no exception. He was the first to introduce a comprehensive simulator system into medical training, and in doing so, drastically improved patient safety outcomes. He also introduced the terms “crisis resource management” and “team resource management” into common anesthesiology parlance, greatly advancing how anesthesiologists think about error prevention in the OR. Patients and anesthesiologists everywhere have benefitted tremendously from Dr. Gaba’s legacy of simulation-based learning.
1. Gaba DG. Pioneers and Profiles A Personal Memoir by David Gaba. In: Levine AI, eds. The Comprehensive Textbook of Healthcare Simulation. New York: Springer Science + Business Media; 2013:18–21.
2. Chutkow P. A Safer OR. Yale Medicine. 2003;Summer:34-38.
3. Cooper JB, Issenberg BS, DeVita MA, Glavin R. Tribute to David Gaba on the occasion of his retiring as editor-in-chief of simulation in healthcare: Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2016;11(5):301-303.