Clinical Case for Discussion:  You, your spouse, and your 5-year-old son are vacationing in Montana when your son develops acute abdominal pain and fever.  You take him to the largest medical center around, the community hospital in a town with a population of 20,000.  The surgeon there makes the diagnosis of an acute abdomen, and plans on operating.  You meet the anesthesia provider, and it is an unsupervised certified registered nurse anesthetist (CRNA). What do you do?

Discussion: Circa 1985, one of my anesthesia Stanford mentors told me this:  “If you’re on vacation in some rural place like Montana, and you need emergency surgery, let the anesthetist do the case whatever way he usually does it–if the only way he knows how to do things is open drop ether technique, you need to let him do it the way he knows.  It’s not the time to educate him into trying something new and different.”

Now you are in a rural hospital with a sick kid, and you feel nervous.  You ask the CRNA about his clinical experience, and he tells you he’s been out of training for 10 years, and has anesthetized hundreds of children without a single complication.

Your spouse (a non-medical professional) speaks up first, declaring that you are an anesthesiologist, and that he or she (the spouse) is adamantly opposed to the child having an anesthetic by a unsupervised nurse.  Your spouse asks how far it is to the nearest major medical center that would have pediatric anesthesia care supervised or performed by an MD?  The answer: a two-and-a-half hour drive.  Your child is moaning in the bed in front of you, and you realize that delaying the surgery for hours is a bad idea.

Your spouse tells you he/she wants you to do the anesthetic.  There are several problems with this solution.  Number one:  you do not have a state license in Montana.  Number two:  the hospital has a policy that family members are not allowed into the operating rooms during surgery.  Number three:  you have always been advised by your mentors and peers that physicians who take anesthetize or operate on their own family members have a difficult time being either objective or professional if some unfortunate complication arise.

You pull the surgeon aside and ask his views on the CRNA and the pediatric anesthetic assignment.  The surgeon reports that he has been working with this CRNA for 12 months, but has yet to see the CRNA anesthetize anyone under the age of 18 for him.  He confirms that on this weekend evening, there are no other anesthesia professionals within sixty miles.

Your son continues to moan.  Your spouse is pacing, and continues to fret about the CRNA not touching the child.  Your head is spinning.  What do you do?

As a father and an anesthesiologist, on 4 occasions I have handed one of my kids over to another anesthesiologist for surgery.  Each time I selected the anesthesiologist myself, I knew the anesthesiologist well, and trusted their skills under any circumstances.  Each surgery went well, but I can attest that every parent is on edge until they see their child awake and well after the conclusion of the surgery.  You, as a parent, will feel intensely protective of your child.

You realize that surgical emergencies likely occur somewhere in Montana every day, and that unsupervised nurse anesthetists are conducting many of these anesthetics.  You haven’t heard or read of an epidemic of anesthetic disasters in “opt out” states, where governors have decided that CRNA’s can conduct anesthesia without MD supervision.

You reason that your son is probably on safe ground, but . . . if something went wrong, you’d feel guilty for not being more involved. You know you’d feel uncomfortable sitting in the waiting room while the surgeon and CRNA do their best work in the OR.  Can  you convince the surgeon and CRNA that you want to be in the OR with them as an observer, although this is against hospital policy?  Can you convince them to telephone the Chief of Staff to make an exception in this one case?

What if the story played out as follows:  You call the Chief of Staff, you present your request is a cordial fashion, she empathizes, and allows you to observe in the OR.

You watch the anesthetic induction proceed uneventfully.  After intubation, the anesthetist inserts an oral gastric tube to suction out the stomach.  The surgery begins, and the diagnosis is a perforated appendix.  The surgeon performs the required surgery.  On anesthetic emergence, the CRNA untapes the endotracheal tube before your son’s eyes open, and begins letting air out of the cuff with a syringe.  Your heart rate quickens, and you blurt out, “Can you wait until he’s more awake before extubating him?”  The anesthetist answers, “I like to extubate deep, so there is less bucking.  I suctioned the oral gastric tube, so I know his stomach is empty now.”  While the two of you are debating, your son wretches forcefully and vomits a large volume of bilious fluid.  The good news is that the endotracheal tube was still in place, with the cuff inflated.  The good news is that none of the vomitus was aspirated.  Flustered, the anesthetist suctions out the mouth, and waits until the patient is wide awake before extubating him.  Minutes later, your son is awake and safe, but your hands are still shaking.

Fiction?  Sure, but the issue and question is whether or not unsupervised CRNA anesthesia is a good idea.  If your son had aspirated due to poor anesthetic judgment, would that event have shown up as a vital statistic anywhere?  I doubt it.

J H Silber’s landmark study from the University of Pennsylvania (Anesthesiologist direction and patient outcomes, Anesthesiology. 2000 Jul;93(1):152-63) documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists.  This study was widely discussed.  The CRNA community dismissed the conclusions, citing that it was a retrospective study.   In a letter to the editor published in Anesthesiology, Dr. Bruce Kleinman wrote regarding the Silber data, “this study could not and does not address the key issue: can CRNAs practice independently? In fact, the negative outcomes in this retrospective study may be related to the medical direction of nonanesthesiologists and may not be related in any way to the practice of CRNAs per se.” (Anesthesiology: April 2001 – Volume 94 – Issue 4 – p 713)

Governor Schwarzenegger stunned California anesthesiologists in July 2009 by signing a document opting California out of the requirement for CRNA’s to be supervised by an MD.  An important conflict is the fact that California law rules that an MD must supervise the medical practice of CRNA’s.  The outcome for California is still undetermined, but the threat of CRNA’s replacing larger subsets of anesthesiologist’s work in future years is a crucial and daunting issue that all of us will follow with interest and intensity. Your delegates and lobbyists in the California Society of Anesthesiologists and the American Society of Anesthesiologists are working on the issue of unsupervised CRNA anesthesia care.  It’s a battle that needs to be fought, for the patients and their families, as much as for the careers of present and future anesthesiologists.

Back to the Clinical Case–if you are vacationing in Yellowstone or Glacier National Parks next summer, hopefully your family will stay out of the operating room and you never have the ponder any of these  problems.

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:


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.


5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
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.



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:


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
Deann Brady (Sunnyvale, CA USA) – See all my reviews
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”


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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