SEVEN DEADLY DRUGS IN AN ANESTHESIOLOGIST’S DRAWER

As anesthesiologists we are the only physicians who routinely prescribe and administer injectable medications ourselves. Most physicians write orders for medications. Registered nurses then administer the medications on hospital wards, in intensive care units, in emergency rooms, and in clinics. As anesthesiologists we have our own drug cart, stocked with dozens of medications, including hypnotics, paralyzing drugs, cardiovascular drugs, antibiotics, anti-nausea drugs, anti-inflammatory drugs, and resuscitation drugs. Typically, we make a decision to inject a drug, then open the ampoule, draw the contents of the ampoule into a syringe, and inject it into the patient … without the approval, input, or monitoring of any other healthcare provider.

Do medication errors occur? Yes they do, because anesthesiologists are human, and to err is human. In a survey conducted in Japan between 1999 and 2002 in more than 4,291,925 cases, the incidence of critical incidents due to drug administration error was 18.27/100,000 anesthetics. Cardiac arrest occurred in 2.21 patients per 100,000 anesthetics. Causes of death were overdose or selection error involving non-anesthetic drugs, 47.4%; overdose of anesthetics, 26.3%; inadvertent high spinal anesthesia, 15.8%; and local anesthetic intoxication, 5.3%. Ampoule or syringe swap did not lead to any fatalities. (Irita K, et al. Critical incidents due to drug administration error in the operating room: an analysis of 4,291,925 anesthetics over a 4 year period. Masui 2004; 53(5):577–84. )

In a South African study of 30,412 anaesthetics, anaesthetists reported a combined incidence of one error or near-miss per 274 cases. Of all errors, 36.9% were due to drug ampoule misidentification; of these, the majority (64.4%) were due to similar looking ampoules. Another 21.3% were due to syringe identification errors. No major complication attributable to a drug administration error was reported. (Llewellyn RL, et al. Drug administration errors: a prospective survey from three South African teaching hospitals. Anaesth Intensive Care 2009 ; 37(1):93–8. )

What can be done to eliminate or minimize medication errors? A Japanese study examined the value of color-coding syringes, as follows: blue syringes contained local anesthetics; yellow syringes, sympathomimetic drugs; and white-syringes with a red label fixed opposite the scale, muscle relaxants. Although five syringe swaps were recorded from February 2003 to January 2004 in 5901 procedures prior to the change, they encountered no syringe swaps from February 2004 to January 2005 in 6078 procedures performed after switching to color-coded syringes (P <0.05). (Hirabayashi Y, et al. The effect of colored syringes and a colored sheet on the incidence of syringe swaps during anesthetic management. Masui 2005; 54(9):1060–2.)

Published evidence-based practices to reduce the risk of medication error include the following recommendations:

  1. The label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected;
  2. The legibility and contents of labels on ampoules and syringes should be optimized according to agreed standards; syringes should always be labeled; formal organization of drug drawers and workspaces should be used;
  3. Labels should be checked with a second person or a device before a drug is drawn up or administered. (Note: this is impractical in the anesthesia world.)
  4. Dosage errors are particularly common in pediatric patients. Technological innovations, including the use of bar codes and various cognitive aids, may facilitate compliance with these recommendations. (Merry AF, Anderson BJ. Medication errors–new approaches to prevention. Paediatr Anaesth 2011; 21(7):743–53.)

Bar-code medication administration (BCMA) systems exist for anesthesiologists to identify the ampoule of each drug at the time of administration. I’m not seeing these devices in widespread use in the United States yet. A pilot study in Great Britain perceived that bar-code readers contributed to the prevention of drug errors. The study concluded that the  technological aspects of its integration into the operating theatre environment, and learning, will require further attention. (Evley R. Confirming the drugs administered during anaesthesia: a feasibility study in the pilot National Health Service sites, UK. Br J Anaesth 2010; 105(3):289–96.)

In addition to the data from the aforementioned publications on the incidences of medication errors, how many medication errors go unpublished and unreported? Many anesthesiologists I know have shared their tales of medication errors, all of which are unpublished and unreported in the medical literature. Some swaps and errors will be inconsequential. Some swaps and errors will prolong an anesthetic, such as when a muscle relaxant paralyzes a patient at an unintended time or dose. Some swaps and errors contain the potential for dire complications.

The ancient Christian world identified Seven Deadly Sins. They were wrath, greed, sloth, pride, lust, envy, and gluttony. There exist at least seven medications that an anesthesiologist must strive to never inject intravenously in error. I call these the Seven Deadly Drugs.  All are present in the anesthesiologists’ drug drawer or at the operating room pharmacy. They are as follows:

  1. Epinephrine (1mg/1ml ampoule). Epinephrine is an important drug during ACLS to treat asystole and refractory ventricular fibrillation, to treat anaphylaxis, or to be used as an infusion to treat decreased cardiac output. This ampoule is routinely stocked in most drug drawers. If one injects it in error into a healthy patient, major hypertension and tachycardia will ensue.  Think blood pressures in the 250/150 range, and heart rates approaching 200 beats per minute. This can be lethal in elderly patients, or in patients with diminished cardiac reserve.
  2. Phenylephrine (10 mg/1 ml ampoule). Phenylephrine, when injected in 100-microgram doses or used as a dilute infusion, is an important drug to treat hypotension. This ampoule is routinely stocked in most drug drawers. If one injects it in error into a healthy patient, major hypertension will ensue, as well as reflex bradycardia.  Think blood pressures in the 250/150 range, and heart rates dropping below 50 beats per minute. This can be lethal in elderly patients, or patients with diminished cardiac reserve.
  3. Nitroprusside (50 mg/2ml) Nitroprusside, when diluted into an infusion, is an important drug to treat hypertension. If this ampoule is injected undiluted, the patient will experience rapid arterial vasodilation and severe hypotension.
  4. Insulin (100 Units/1ml, 10 ml vial). Insulin is an important medication to treat hyperglycemia. Typical doses range from 5–30 Units, which is a mere 1/20th to 3/10th of one milliliter. An erroneous injection of an insulin overdose to an anesthetized patient can result in severe hypoglycemia and brain death.
  5. Potassium Chloride (20 Meq/10 ml). Potassium chloride is an important treatment for hypokalemic patients. If it is administered erroneously as a bolus, potassium chloride can cause severe ventricular arrhythmias and death.
  6. Heparin (1000 U/ml). Heparin is an important anticoagulant, used routinely in open heart surgery and vascular surgery. If it is administered in error, it can cause unexpected bleeding during surgery.
  7. Isoproterenol (1 mg/5 ml) Isoproterenol can be used as a dilute infusion to increase heart rate in critically ill patients.  One of the hospitals I work at includes an ampoule of isoproterenol in the routine drug drawer, next to ampoules of common medications such as ketorolac (Toradol), hydrocortisone, and promethazine (Phenergan). If one injects a bolus of isoproterenol in error into a healthy patient, major tachycardia and hypertension will ensue. This can be lethal in elderly patients, or patients with diminished cardiac reserve.

What can anesthesiologists do to eliminate the risks of erroneously bolus injecting the Seven Deadly Drugs? This author recommends elimination of major vasopressor drugs such as epinephrine, phenylephrine, and isoproterenol and major vasodilators such as nitroprusside from routine drug drawers. This author recommends elimination of the potent anticoagulant heparin from routine drug drawers. Insulin is routinely sequestered in an operating room refrigerator, and most hospitals have protocols that insulin doses be double-checked by two medical professionals prior to injection. Potassium chloride is routinely sequestered the operating room pharmacy as well, distanced from the anesthesiologist’s routine drug drawer.

Above all, anesthesia practitioners need to be vigilant of the risk of picking up the wrong drug ampoule in error. Read the labels of your ampoules carefully, and take care not to inject any of the Deadly Seven Drugs.

Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:

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Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.

REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.

TwinCities.com PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press mgrossman@pioneerpress.com, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)

Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.

Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.

Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.

The Physician’s Late-Night Reading List

Two Pritzker alums pen captivating tales

By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine

For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.

Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.

Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”

One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.

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The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80

“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.

From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”

After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.

“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”

Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:

BOOK REVIEW “THE DOCTOR AND MR. DYLAN”

This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.

Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.

Rick, I can’t wait for your next book. Bravo!

Hibbingite writes twisted medical tale

HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.

Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.

“The dialogue is sometimes funny, and there are lots of plot twists,” he said.

Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.

“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”

Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”

By

allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

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2 thoughts on “SEVEN DEADLY DRUGS IN AN ANESTHESIOLOGIST’S DRAWER

  1. Thanks for the great post doc! I’m a nurse in the PACU. I’m a firm believer of proper syringe labeling.

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