Introduction

Between my first and second years of medical school, I had three months off to do whatever I wanted. Some students completed clinical externships, some backpacked in Europe, and I chose to study blood clotting in pediatric cardiac surgery patients. In addition to my laboratory research, I rounded with the critical care team in the pediatric intensive care unit (PICU). It was there I met someone I will never forget.

A five-year-old boy named John had been admitted the previous night after nearly drowning in a bathtub. When I first saw him, he was lying on his back with his eyes closed. His hospital gown had elephants on it. I felt like I was peeking into the bedroom of a sleeping child. By the bedside, his mother held his hand and sobbed silently.

As I looked around the PICU, I noticed other rooms similar to John’s: 24 glass boxes neatly arranged in a U-shape around a common computer workspace. Doctors were recording and interpreting patient data, looking for patterns of improvement or deterioration. The various monitor tones, ventilator breaths, computer keystrokes, and quiet conversations merged into an emotionless symphony.

When it was time for rounds, I was surprised by the topics of discussion. Our team focused on hypothetical catastrophes instead of what was actually happening to their patients. I noticed ICU physicians—who are supposed to be the best-trained doctors in the hospital—seemed obsessed with what they didn’t know. They talked about arterial blood gases and acute respiratory distress syndrome as they played with the ventilator like a new video game. I spent my nights in the library learning how to interpret the endless data, wondering why we were collecting all these seemingly useless numbers.

Over the course of three days, John’s lungs improved, and his breathing tube was removed. Still, the ICU physicians obsessed over dangerous, uncommon events that never happened. Couldn’t they see John was improving? Their vigilance seemed out of proportion to the situation.

On my fifth day at the hospital, our team gathered in front of John’s room for our morning rounds. Just as I did on my first day, I peeked into his room. But this time, he woke up, rose to his feet, and walked energetically back and forth in his crib! When he came to the side of the crib facing the doorway, he looked at me with the silly, innocent smile of a happy, well-adjusted five-year old.

Suddenly, in the midst of the countless vital signs and machinery that often makes hospitals seem so grim, my eyebrows unfurled, my shoulders relaxed, and my pursed lips transformed so much that the corners of my eyes wrinkled. On two sides of the glass, John and I began to laugh together. It was a joyous moment, and years later in residency, I finally understood why the ICU physicians’ management of uncertainty was the key to making it a reality.

§ Anesthesiology, Synergy, and Black Swans §

During my third year of medical school, I decided to become an anesthesiologist. Anesthesiologists and intensivists have more than a few things in common: both manage vital functions when patients cannot do so themselves, both interpret complex physiologic changes in real time, and both prevent catastrophic events in uncertain situations. In fact, the ICU was invented by an anesthesiologist in 1952 when Danish anesthesiologist Dr. Bjørn Ibsen applied operating room ventilation strategies to a ward of paralyzed polio patients in Copenhagen, Denmark.1

Several features make anesthesiology unique from other medical specialties. Our patient is always minutes away from death, and we must tolerate long periods of uncertainty interrupted by short bursts of unexpected intensity. We don’t have time to consult anyone when complications occur. Working at a high speed with limited information, anesthesiologists learned how to think statistically about life-threatening conditions, such as bradycardia (low heart rate), hypoxia (not enough oxygen in the blood), and hypotension (low blood pressure). Over the years, we’ve become experts in the recognition, management, and prevention of emergencies occurring in high-uncertainty situations.

To save the lives of our patients, we’ve traded a simple cause-and-effect view of reality for a systems-based approach. Because we manage every organ system in the body—in real time, as they adapt to their internal changes and the changing surgical environment—we view the operating room in terms of synergy.

Synergy is the random, unintentional, and oftentimes invisible interactions between components of a system. As the number of components increases, synergistic interactions also increase. If the number of random interactions is high enough, they organize into events. A few events will cause desirable changes, most will cause no changes, and some will cause undesirable changes. Eventually, if enough synergy is present, a catastrophic event will destroy the system. In anesthesiology, the system is our patient, and the events are hypoxia, hypotension, and bradycardia. Outside of the operating room, these events are called Black Swans.

Black Swans are unpredictable, cataclysmic events retrospectively “obvious” due to psychological biases.2 They are named after the ancient metaphor rara avis, which means “rare bird” in Latin. The metaphor was originally used as a compliment, meaning “one of a kind.” In Ancient Greece, the expression evolved into Black Swan because, at that time, all known swans were white. Black Swan meant “someone so exceptional they have never been seen before.”3

The modern expression—popularized by Nassim Taleb in 2007—means “a cataclysmic, unexpected, unpredictable event beyond the scope of human knowledge when it occurred.” Black Swans are unexpected and unpredictable because they form from a random combination of synergistic interactions. Historical examples include the US stock market crash of 1929, World War II, and the sinking of the Titanic. Modern examples include the 9/11 New York City terrorist attack, the Sandy Hook Elementary School shooting, and COVID-19.

Over the last 70 years, the world’s political and economic systems have become increasingly synergistic. In their complexity, these systems generate unprecedented wealth and innovation. However, that same complexity also makes them vulnerable to Black Swans. As we move forward, Black Swans will become more intense and occur more often because complexity and connectivity create more synergy, and more synergy creates Black Swans. Our world is a car accelerating toward the edge of a cliff.

So what does all this talk about synergy and Black Swans have to do with anesthesiology? Well, anesthesiologists already have a solution.

§ What to Expect in This Book §

This book describes how anesthesiologists perceive the world, how they measure synergy to manage Black Swans, and how they ultimately prevent patient death. Our success speaks for itself. Anesthesia-related deaths in the United States—primarily from Black Swan events—have decreased from 640 per million anesthetics between 1948 and 1952 to 8.2 per million anesthetics between 1999 and 2005. A more recent study from 2018 showed an additional drop to 5.1 deaths per million anesthetics. This represents a 99.7% absolute reduction over 70 years.4

For perspective that means, on average, one patient dies because of anesthesia every 196,078 cases. Today, if I did three cases per day every day without taking any days off (1,095 cases/year), I would encounter a single death in 179 years. In the 1940s, I would encounter a death every 1.5 years. What’s more, patients became exponentially more complex over the last 70 years: as physicians learned to treat disease, patients often developed additional more advanced diseases later in life that required more complicated treatment. Despite this positive feedback loop between patient treatment and increasing complexity, anesthesia has become exponentially safer.

The book is divided into four parts:

• Part I reveals how anesthesiologists recognize uncertainty: our philosophy of perception, our thinking patterns, and how we stay calm in dangerous situations. You will see what actually happens in the operating room, receive a firsthand account of my medical school training, and discover how cognitive psychology saves lives during emergencies.
• Part II depicts how anesthesiologists manage Black Swans: our early recognition of problems, how we extend the time horizon of catastrophic events, and how we protect essential systems of the body. You will see the seconds between life and death, learn about the history of anesthesiology, and gain a different perspective of cardiopulmonary resuscitation (CPR).
• Part III focuses on navigating complex systems: how time affects decision making, why mistakes compound over time, and how every intervention has the potential to cause more harm than good. I will share my...