The first public demonstration of inhaled ether as a surgical anesthetic on October 16th, 1846 at the Massachusetts General Hospital in Boston
The first public demonstration of inhaled ether as a surgical anesthetic on October 16th, 1846 at the Massachusetts General Hospital in Boston

The profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.

The Anesthesia Consultant is a portal into the captivating and compelling world of the operating room.  The Anesthesia Consultant is designed to inform and entertain both laypeople and medical specialists, and provides answers not found in traditional textbooks.

The Top Posts and Active Posts are listed in the sidebar on the left. Type your keyword into the SEARCH box to research a specific topic.

Presented by Richard Novak, MD, a Stanford-trained anesthesiologist and internal medicine specialist in active clinical practice at Stanford University Hospital in Palo Alto, California.

A note from Dr. Novak:

I want to thank my readers, as reached the landmark of  1,000,000 all-time views as of March, 2017. Current traffic is approximately 11,000 views per week, on a pace to reach over 500,000 readers per year. The Anesthesia Consultant reaches readers in over 100 countries around the world.

The success of would not be possible without my readers, and I thank you all. I’ll keep writing, and I invite you to keep reading.

Thanks a million!


Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.


In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.


The opening pages to THE DOCTOR AND MR. DYLAN follow:


            first-degree murder n. an unlawful killing which is deliberate and premeditated (planned, after lying in wait, by poison or as part of a scheme)

My name is Dr. Nico Antone. I’m an anesthesiologist, and my job is to keep people alive. Nothing could inspire me to harm a patient. Alexandra Antone was my wife. Alexandra and I hadn’t lived together for nearly a year. I dreaded every encounter with the woman. I wished she would board a boat, sail off into the sunset, and never return. She needed an urgent appendectomy on a snowy winter morning in a small Minnesota town. Anesthetist options were limited.

Life is a series of choices. I chose to be my wife’s doctor. It was an opportunity to silence her, and I took it.

Before her surgery, Alexandra reclined awake on the operating room table. Her eyes were closed, and she was unaware I’d entered the room. She was dressed in a faded paisley surgical gown, and she looked like a spook—her hair flying out from a bouffant cap, her eye makeup smeared, and the creases on her forehead looking deeper than I’d ever seen them. I stood above her and felt an absurd distance from the whole situation.

Alexandra opened her eyes and moaned, “Oh, God. Can you people just get this surgery over with? I feel like crap. When is Nico going to get here?”

“I’m three feet away from you,” I said.

Alexandra’s face lit up at the sound of my voice. She craned her neck to look at me and said, “You’re here. For a change I’m glad to see you.”

I ground my teeth. My wife’s condescending tone never ceased to irritate me. I turned away from her and said, “Give me a few minutes to review your medical records.” She’d arrived at the Emergency Room with abdominal pain at 1 a.m., and an ultrasound confirmed that her appendix was inflamed. Other than an elevated white blood cell count, all her laboratory results were normal. She already had an intravenous line in place, and she’d received a dose of morphine in the Emergency Room.

“Are you in pain?” I said.

Her eyes were dull, narcotized—pinpoint pupils under drooping lids. “I like the morphine,” she said. “Give me more.”

Another command. For two decades she’d worked hard to control every aspect of my life. I ignored her request and said, “I need to go over a few things with you first. In a few minutes, I’ll give you the anesthetic through your IV. You won’t have any pain or awareness, and I’ll be here with you the whole time you’re asleep.”

“Perfect,” she oozed.

“When you wake up afterward, you’ll feel drowsy and reasonably comfortable. As the general anesthetic fades and you awaken more, you may feel pain at the surgical site. You can request more morphine, and the nurse in the recovery room will give it to you.”

“Yes. More morphine would be nice.”

“During the surgery you’ll have a breathing tube in your throat. I’ll take it out before you wake up, and you’ll likely have a sore throat after the surgery. About one patient out of ten is nauseated after anesthesia. These are the common risks. The chance of anything more serious going wrong with your heart, lungs or brain isn’t zero, but it’s very, very close to zero. Do you have any questions?”

“No,” she sighed. “I’m sure you are very good at doing this. You’ve always been good at making me fall asleep.”

I rolled my eyes at her feeble joke. I stood at the anesthesia workstation and reviewed my checklist. The anesthesia machine, monitors, airway equipment, and necessary drugs were set up and ready to go. I filled a 20 cc syringe with the sedative propofol and a second syringe with 40 mg of the paralyzing drug rocuronium.

“I’m going to let you breathe some oxygen now,” I said as I lowered the anesthesia mask over Alexandra’s face.

She said, “Remember, no matter how much you might hate me, Nico, I’m still the mother of your child.”

Enough talk. I wanted her gone. I took a deep breath, exhaled slowly, and injected the anesthetic into her intravenous line. The milky whiteness of the propofol disappeared into the vein of her arm, and Alexandra Antone went to sleep for the last time.


Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:





The, copyright 2010, Palo Alto, California

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  1. Dear Richard,
    I am a practicing anesthesiologist and the medical director of an ASC. What is your view about MultiModal Analgesia? If you use such modalities, what do you like to use and what is your basis for it?

    PS, I really like your blog and find it useful.

    Bob Bullock


    1. Bob,
      A detailed answer to your question would warrant a full blog entry, but in a nutshell my application of multimodal analgesia is as follows: 1) I attempt to minimize IV narcotics as much as possible, 2) I encourage the injection of local anesthesia by surgeon into the field as appropriate, 3) the use of regional nerve block if appropriate (I see this overused by some anesthesia providers who do a nerve block on almost every orthopedic patient, because they either hold the opinion that it is “fun to do,” or because each nerve block earns an extra bill in a fee-for-service practice. See my column on Keeping Anesthesia Simple: The KISS Principle for more on this topic), 4) IV ketorolac if there is no post-op bleeding risk, and 5) I do not currently use gabapentin or IV acetaminophen routinely. If I want to use acetaminophen, I use the cheaper oral medications such as Norco or Percocet in the PACU rather than oxycodone and IV acetaminophen.
      What are your views on multimodal analgesia?


      1. Hi Dr.Richard
        Im Dr.Gautham from India. Just completed my resident ship and practising anaesthesia for more for orthopaedics . Im a free lancing anaesthesiologist.
        Regarding multimodal analgesia my view
        1) Depending upon the plan of anaesthesia for the patient
        a. If it is general anaesthesia paracaetamol iv 8th hourly and tramadol 8th hourly on alternative hours in such a way that the VAS score will be maintained 3 or less
        b. I have seen pregabalin has reduced the analgesic requirements and early patient mobility and satisfaction, surgeons feel that patients feel comfortable .I would star pregabalin form postsurgery day 2 and continue for a month
        c. If its done under regional i would closely watch for the break through pain and administer the same analgesics

        i have one query most of the doctors prefer fortwin and phenerghan for night sedation in the first post operative day is it necessary if the pain is adeqautely controlled??!!!


      2. Doctor Gautham,
        Thanks for your email. Of course I’m not certain which multimodal options you have to choose from at your hospital, but it sounds like your regimen is working well for you. In the US we would not use fortwin (Talwin) and phenergan for first night sedation. More likely choices would be an IV patient controlled analgesia using fentanyl or hydromorphone, or simply oral Ambien. Our countries share many of the same medical and anesthesia challenges, but our solutions may differ depending on what the pharmacy has, what the costs are, and personal preferences. Thanks,


      3. As a retired anesthesiologist, I had a general anesthetic, plus surgeon injection of LA in both knees for bil tka. Having the Conformis 3D generated prosthetics made a big difference. Perfect fit, minimal pain, maximal flexion (90°) first postop day. Blocks are overdone. I didn’t want any chance of muscle weakness.


  2. Enjoyed your Iron Range book and my home town area. You even used my maiden name for one of the characters.

    My question is I have an adopted da with horrible genetics. She had childhood RSD which is now fulblowen CRPS. They want to remove the Medtronic stimulator which has been constant trouble and replace it with St. Jude’s. They expect good results. The issue in the way is her respiratory issues. Severe since childhood. She is now looking like she has COPD. Chronic bronchitis. Pulmonary will not clear for surgery due to lack of lung capacity Surgery will be in Fort Worth, Tx. Can the do an inpatient procedure and intebate her safely? She is 26.


  3. Good day, my name is Esther and a first year pg student studying anesthesiology and intensive care medicine. I really love anesthesiology and I need all the help I can get for all anesthesiologist worldwide. Hope to read from any soon. Thanks


  4. hey Rick Novak i’m under graduate student who want to study anesthesiology.And I heard that anesthesiology have many risks.
    And My question is that How can I avoid risks while I’m working and what are the requirements to became successful Anesthesiologist.


    1. Denis,

      Anesthesia does have risks. I’d refer you to multiple pages at that refer to anesthesiologist training, anesthesia safety, on becoming an anesthesiologist. Read through the titles of the blog posts. You’ll find your answers.

      Rick Novak, MD


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