Martin Jöhr has written an excellent book chronicling the formative cases he has encountered in his career. The initial working title of the book was When Things Go Wrong in Pediatric Anesthesia, and as such, the book alludes to identify common pitfalls and the quest to try and avoid them. Dr Jöhr draws on 40 years of clinical experience and his time as the lead for pediatric anesthesia at a major teaching hospital in Switzerland. The book is well organized into related chapters, with each chapter written as a case discussion and culminating in summary and recommendation sections. Most cases are illustrated with a diagram, table, picture, or graphic that breaks up the text and adds a pictorial aid to the message. The book is divided into chapters related to anesthesia practice: Concepts and Strategy, Airway-Related Problems, Vascular Access, Regional Anesthesia, Medication-Related Problems, Preexisting Conditions, and Miscellaneous. The material is current, and well-referenced discussions support the points that the author is trying to make. Although there are some idiosyncrasies to his clinical advice, which relate to his personal and cultural experiences, most, if not all, of the cases and discussions fit into concepts, checklists, algorithms, and guidelines that are practiced the world over. From the first case report onward, one quickly develops a rapport with the author’s experience and the messages he is trying to convey. As pediatric anesthesiologists, we found it easy to relate to most of the cases described with a sense of familiarity. The book is thought provoking, and reminded us of similar cases that we faced even as novices in the specialty. Dr Jöhr writes with clear wisdom that has been accumulated through many years of experience and sheer volume of exposure. As such, Dr Jöhr has clear expertise and is able to communicate his ideas with a deep understanding of pediatric pathophysiology and anatomy, which he has nurtured in the many years working with his neonatal and pediatric colleagues. A novice anesthesiologist would benefit from reading this book to become aware of the potential pitfalls that may be encountered in pediatric practice. Equally, more experienced anesthesiologists will also relate, by familiarity, to many of the scenarios. Throughout this book, one can imagine being in the very situation described, and picture how one could also easily make such a judgment or misjudgment. We felt our hearts sink as some of the cases with severe outcomes unfolded. This is particularly true for the cases titled “Cannot Intubate, Cannot Ventilate” and “Medication Error.” A lot of the advice in the book should be taken as “golden,” with the emphasis placed on the need for meticulous preparation of cases, including having a thorough knowledge of the patient history, a well-organized anesthetic plan, and a strategy for any emergent problems. The honesty in this book is striking. Clearly, Dr Jöhr wears his heart on his sleeve, and should be commended for his courage in regaling these emotive accounts, which often show the human factors involved in error. Many current issues are touched on, including our evolving safety culture and the use of checklists, which Dr Jöhr had developed and used long before widespread adoption of the World Health Organization resource. There are few negative criticisms of this book. The introductory chapter itself concedes that some of events “occurred many decades ago, and only fragments of the story could be remembered.” The book, perhaps, is a little expensive for both the paperback and digital editions; however, on balance, this seems like a valuable investment for such a resource. Overall, this is an excellent book that serves as a learning aid through a series of real-life cases. It is interesting, enjoyable, and relevant to all those who anesthetize children. It is a worthwhile investment as both a resource for knowledge and, perhaps more important, a blueprint on how pediatric anesthesiologists can reflect on experiences as learning opportunities. Michelle C. White, MBChBDepartment of Paediatric AnaesthesiaGreat Ormond Street HospitalLondon, United Kingdom[email protected] Rajan Saini, MBBSDepartment of Paediatric AnaesthesiaGreat Ormond Street HospitalLondon, United Kingdom