Anesthesia Guidebook

On the corner of Skyland Drive and 23 in a little town called Sylva in Western North Carolina, sit’s PJ’s gas station. One hot summer day back in 2005, I was filling up the tank in a convalescent transport van on my very first day as an EMT-Basic. That’s the most basic, entry-level certification of working as an Emergency Medical Technician or EMT.  My convalescent transport van had a wheelchair ramp and my role as an EMT-B was not to do 911 calls, but to drive this glorified shuttle bus. My role was to transport people to and from their doctor’s appointments. Maybe to help them get home after being discharged from the hospital. If you were too sick for a taxi but not quite sick enough for an ambulance, I was your guy.

The guy training me that day, a senior paramedic, was actually a good friend of mine and happened to also be my boss at a local outdoor education company. Everyone affectionally called him “the Padj,” a shortened third-person version of his last name, Padgett. The Padj ran Landmark Learning, which offers wilderness medicine educational courses for outdoor guides and enthusiasts and eventually became the Southeast training center for NOLS Wilderness Medicine. Pretty much everyone who taught for NOLS Wilderness Medicine had a part time gig working in EMS and so that became my path too and this was my first day on the job.

I felt supremely important because of two things: as part of my standard issue uniform, on my thick polyester blue shirt, I was wearing a chrome name badge that said “J. Lowrance, Since 2005” and I had a big, heavy, professional walkie talkie. We had no more checked out the van and driven a mile down the road from base to fill up with gas at PJs when the tones went off on the walkie talkie, indicating a serious 911 call had just been dispatched. As I was pumping gas and the Padj was relaxing in the passenger seat, the radio crackled with the call: there was an unresponsive patient about a half mile down the road from where we were. We looked at each other and shrugged, knowing that even though we were essentially in a shuttle bus with next to no medical supplies, we wanted to see if we could help. We hurriedly paid for the gas, jumped in the van and ended up beating the ambulance to the house where the 911 call came from.

We were met by a distraught woman in her 60’s who told us she couldn’t wake her husband up. We went in the house through the side door, immediately finding ourselves in her kitchen. The bedroom was just off the kitchen and walking in, I remember the time on the bedside clock – one of those little rectangular digital clocks with red numbers: the time was 10:10 in the morning.

Photo credit: OpenAI (2025). ChatGPT 4o version. [Large language model]. https://chatgpt.com. 

The man was large, heavy and not moving. He looked like he was still asleep except he was a deep shade of purple… not quite blue yet, but definitely not alive-looking. 

The Padj called out to him and checked a pulse. Nothing. My heart, however, was racing. 

As my palms began to sweat, the Padj looked at me serious, which he never did, and said quietly out of respect for the man’s wife, standing in the doorway, “dead on arrival or do you wanna run the code?”

I could hear the sirens of the ambulance approaching the house.

“Let’s do it.” 

We heaved the man onto the floor… he was heavier than I thought he would be. It dawned on me that dead people don’t try to help you like our wilderness medicine students do when they’re trying to act like patients in simulated scenarios. This was not a scenario.

Padj said he’d get the O2 tank in the van and that I should start CPR.

I knelt down, looked left and right for our jump bag, which contained a bag-valve mask or BVM, which we used to breathe for patients in cardiac arrest. We left the jump bag in the kitchen. I was in rescue mode. No time to waste.

I looked at the man, zeroed in on those purple lips and scrubby, lifeless face, pinched his nose and leaned in to do mouth-to-mouth resuscitation. As time slowed down and I leaned in to my new career in EMS, a paramedic shouted from the front door, “STOP,” shaking his head. He had arrived just in time to yell at me and snarled, “JLo, we don’t do that! Somebody get him a BVM.” A bag-valve-mask was thrown at me from the kitchen. I quickly pumped two breaths with the bag into the man and started chest compressions.

We all worked together as hard as we could to save that man’s life but our efforts were in vain. Who knows when he had died before his wife found him that morning. We ran the code, started an IV, intubated him and did CPR the mile and half back up the road to the hospital, where the code was called. I walked out as his wife, crying, walked in to see him.

It was my first day on the job. It would be her first day without him.

Two things happened that day for me: 

I became hooked on resuscitation. 

And I realized that the people and teams doing this kind of work have their own special flare in the midst of the chaos. For the first time, I saw the human factor in emergencies.

Not just my ignorance and naiveté. But how more experienced providers find work arounds. How seasoned clinicians have unspoken rules that govern the work they do. A certain sort of knowing that only comes with experience. I’ll come back to that in a minute.

That first call on my first day in EMS in Western North Carolina seared into some deep squishy corner of my brain a true love of resuscitation. I was hooked. I thought this is definitely the kind of work I want to do, and I want to learn how to do it better and how teams can do this kind of thing better. That drive would become a central theme of my professional career moving forward and is why I’m writing this now.

The other thing it did was create a certain level of cognitive dissonance. It interjected the reality of human factors in resuscitation and emergencies in an incredibly powerful way. 

There was my ignorance coupled with an overwhelming desire to do the right thing. I’m going to breathe for this patient because that’s the right thing to do! And then there’s the disruption to that plan; the alternative approach; the wisdom of a senior clinician. Here I am about to follow the algorithm and get the job done despite my immediate resource limitation… adapt and overcome and all that and then there’s the senior paramedic saying, “What are you doing? We don’t do that!” I was like: but we’re supposed to save lives! In every TV drama I’ve ever seen – which I happen to be literally in the middle of right now on my first day on the job – EMS people are supposed to save lives; and now I’m an EMS people.  WE are supposed to SAVE LIVES!  Not wait for an AMBU bag because I left it in the kitchen. 

This disruption to my preconceived notion of how things were supposed to go was a poignant introduction to the idea that humans will often deviate from expected work patterns to best get the job done.  

What I learned was there is a way more senior people do things that the newbies don’t know about. They have that special kind of knowing that only comes with experience. 

Check this out: the Greeks have several different words for different kinds of knowing. There’s knowing about something, like scientific facts & figures, which is where most new anesthesia trainees are with their knowledge. This is gnosis (‘nō-sis), to know about something in a general way. Similar to this is epistēmē (ep-uh-steam), which is knowing more scientific, academic knowledge. Epistēmē is where we get epistemology (eh-puh-stuh-mo-lo-gy) from, which is the study of how we know things, what we know and the limits of that knowledge. 

There’s the work as imagined, which is informed by protocols and standards and expected norms of behavior or even expectations that society has on healthcare providers: we will save lives even if it means putting our own lives at risk.  And then there’s the work as done, which is often shaped and determined by this special kind of knowledge about how to do things.

What I’m talking about with experienced resuscitationists is ginōskō (gi-know-sko). Ginōskō is an experiential knowledge that only comes through deep experience or relationship with the subject, practice or person. You only get this kind of knowledge through experience.  If you know, you know, you know what I mean?

All right, so there’s your Greek lesson for the day and where my gnosis of the Greek language ends. 

So, what this very first resuscitation taught me is that providers who do this kind of work have a very deep, experiential knowledge that guides their decision-making. This goes beyond the algorithms. Gary Klein talked about this within his recognition-primed decision-making model (Klein, 2017). Daniel Kahneman (2011) spoke of System 1 and System 2, with System 1 being our intuitive decision-making and System II our more deliberate, concentrated thinking. 

These modalities of decision making are important parts of how people operate on a daily basis in jobs that require people to be very knowledgeable about their work.  

There’s the work as imagined and then there’s the work as done.

There’s the protocols, rules & regs, expected behavior and then there’s the work arounds, real adaptations and the way the work actually gets done.

This little moment in my career taught me that resuscitation is a wild place. You have all kinds of experience levels converging on a moment and each of those people has a different mental model of what’s supposed to happen. And that’s just the front line staff that actually get their hands dirty during a resuscitation. We’re not even talking about safety or risk professionals yet who might review cases or senior leaders who don’t actually do the work that they’re charged with overseeing, supporting, reviewing or administrating.

The human factor in emergencies is a bit of a wild card. 

When humans are managing emergencies, there will inherently be variability in performance despite the expectation for consistent execution of normal behavior. 

While reducing variation is a noble goal that organizations and even individuals should work towards, we have to recognize that variable performance is likely normal in volatile, uncertain, complex and ambiguous (VUCA) settings (Edmonson, 2018).

Resuscitation is a classic VUCA setting. While not all resuscitations are volatile, most have uncertain outcomes, are complex and contain ambiguous elements to them requiring judgment, rapid differential diagnosis and decision-making. 

Algorithms, rules & regs and policies guide care, but it’s people who actually do the care. 

There’s the way we think healthcare providers will act – because of the incentives or constraints in place, the rules and regulations and the system we’ve set up. Then there’s the way healthcare providers actually behave. There’s the way we imagine work will be done and then the way work is actually done. And usually the folks on the sharp end find the most effective, expedient, efficient way to do things.

So, what does this mean for you? 

If you’re a provider, keep practicing. Keep finding the best path forward. Don’t stagnate with what you know. There may be better ways to do something. You may need better systems to operate in. You may need more experience to develop judgment and wisdom beyond the rule book, protocols and algorithms. Why was the BVM not brought to the bedroom on this call in the first place? Whose responsibility was it to haul the gear in the house? Did we talk about the plan ahead of time? Were we following a pattern of performance or just winging it and seeing what would happen? Remember, the way you do anything is the way you do everything.

As healthcare providers on the path towards mastering our craft, we have the responsibility to engage in self-reflection about our practice and our habits.  

Elaine Scarry, a professor of English at Harvard, has this quote which I love:

“What occurs in an emergency is either immobilization… incoherent action or… coherent action.  If we act, we act out of the habitual.  If no serviceable habit is available, we will use an unserviceable one and become either immobilized or incoherent” (Scarry, 2011).

What this means to me, especially when coupled with all of the science on deliberate practice and expertise from Anders Ericsson and others, is that we have a responsibility to develop good work habits.  Because when push comes to shove in an emergency, we don’t rise to the occasion, we fall back on our training and our practice… we fall back on our habits.  

Now, if you’re a practice leader, be open to the fact that your team may not follow the rules because the rules may not be in their best interest. It’s not your job to get your team to follow the rules. It’s your job to build an environment that optimizes your team’s ability to do their job – yes, safely; yes, in congruence with standards & regulations. But you may have dumb rules that need to be re-written. You may have policies that don’t align with work as done or as it should be done. You might need to do some really boring background work to clean up your rules and regs, and more importantly, to improve your processes, so that your team can do their jobs better, more efficiently and more effectively and in a way that is in alignment with what the organization expects.

By the way, don’t punish people when you hear they’re not following the rules. Think: why did they do it that way? What kind of work environment are they adapting to? What incentives are they operating with right now? Are there ways we can improve the environment or change the incentives in which these really smart people work?

I was out on a run yesterday listening to Todd Conklin’s Pre-Accident Investigation podcast (Conklin, 2025).  Conklin is a leading thinker in the organizational safety & development space.  He was talking with another safety scientist and said something to the effect that if you’re best people are breaking your most important rule, something in the system is wrong.  It’s not the people’s fault.  They’re just trying to do their job.  As a leader, you need to improve the system.

It’s not about finding bad apples and weeding them out.  It’s about improving the entire system.  Because safety is not about minimizing errors but rather building a capacity for the right kind of work to happen.  Errors will be inevitable in complex environments – VUCA environments (volatile, uncertain, complex and ambiguous).  Things will not always go as planned or imagined.  Safety is about recognizing that the people on our teams don’t show up to work planning to make mistakes and hurt people or get hurt themselves.  Mistakes are not intentional or willful acts.  Safety is about figuring out how we as providers and all yall out there who are leaders can build more resilient systems with a higher probability of the right kind of work happening.     

So I know we’ve wandered a bit today.  There’s something about that very first resuscitation that I was a part of that stuck with me.  

Actually, since we’re on the topic… there was actually a resuscitation, or an accident, before that one on my first day as an EMT that really sparked things for me.  I’ll share this quickly as it does tie in to the whole trajectory that I’ve been on for quite some time now.  

On another hot summer day… this one in southwest Missouri when I was in between my junior and senior year of high school, I was on a flat-nosed school bus leaving a summer church camp when our bus crested the hill of a highway going about 60 miles per hour and we hit a tractor that was pulling a trailer full of hay.  For whatever reason, the bus drive didn’t see this tractor, which was probably going about 25 miles per hour at best, was straddling the shoulder and the right-hand lane. By the time we crested the hill and he could see, it was too late; we slammed into the back of that trailer and it seemed like everything on God’s green earth went airborne and time slowed down.  A could see the little particles of broken glass suspended in the air, the hail bails exploding in the wind, the trailer and tractor being lifted off the hot pavement, and then we all came crashing down as time sped up and the bus screeched to a halt.  I had just finished an Advanced First Aid & CPR class at my high school the previous semester.  Advanced First Aid, mind you.  I had my keychain CPR mask on me… one that was big enough to hold a pair of gloves and a little flimsy CPR mask… and I grabbed a blanket from the bus thinking the farmer on that tractor could be in shock and I jumped out of the bus and ran back to him along with some of the adult youth leaders.  The guy’s head was split open from his forehead down between his eyes to over his cheek.  He ended up living and making a reasonable recovery but standing there in the heat and sun, I was immobilized.  I had no idea what to do other than feebly offer up a blanket even though it must have been over a hundred degrees on the pavement.  I got to watch the firetrucks shut down the highway and the helicopter land, which was pretty cool.  But I couldn’t do much.  So like Elaine Scarry said: I became acutely aware that despite having some first aid training, I was pretty much unequipped with any serviceable habits so I just kinda stood there and waited for EMS to show up.

Fast forward a bunch of years and I was through college with an outdoor recreation degree, teaching wilderness first responder courses and on my first day as an EMT I found myself kneeling over a patient in cardiac arrest.  

These moments highlight steps in my personal journey where I decided to level up.  I knew I didn’t know everything, and I needed to keep training, keep studying.  

They also serve as really interesting reference points on systems thinking and human factors in emergencies.  

Mistakes and errors are going to happen.  Progress is not inevitable or permanent.  How we build systems and maintain systems of care has a profound impact on how people work and how we generate the outcomes that we want.  

I hope this was fun for you and interesting.  I hope this spurs some thinking for you on how you operate as a provider and maybe how your organization thinks and talks about risk, errors and safety.  

Drop me email if you want to talk more.  Leave a review on Apple podcasts if you like this show: that helps other people find and trust Anesthesia Guidebook.

Thanks for the work you do and for checking this show out!  

Conklin, T. (2025, March 15).  PAPod 537 – Unveiling the myths of modern safety: a conversation with Todd and Georgina.

Podcast: Play in new window | Download

. PreAccident Investigation Podcast.  https://podcasts.apple.com/us/podcast/preaccident-investigation-podcast/id962990192?i=1000699305329

Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons.

Kahneman, D. (2011). Thinking, fast and slow. Farrar, Straus, and Giroux. 

Klein, G. A. (2017). Sources of power: How people make decisions. MIT press.

Scarry, E. (2011).  Thinking in an Emergency.  W. W. Norton & Company, Ltd. 

Podcast: Play in new window | Download