Clinical Case for Discussion:  One week before you graduate from anesthesia residency, you lose the peripheral nerve stimulator you use to monitor neuromuscular blockade.  Should you bother to purchase another one?

Discussion: Fast forward to your first day in post-residency private practice.  Your first case is a colectomy on an obese, 5 foot 2 inch, 100-kilogram male with adenocarcinoma of the sigmoid colon.  You bring the patient into the operating room, anesthetize him with propofol, and inject 10 mg of vecuronium into his IV.  You wait 90 seconds before intubating the trachea.  The surgeon enters the room.  After the Timeout, the patient is placed in lithotomy position.  The surgeon performs a rectal exam and sigmoidoscopy under anesthesia.

“We’ve got a problem,” the surgeon announces.  “The tumor has grown since my last exam, and it’s too close to the anus to treat with simple colectomy.  He needs a total proctocolectomy, and I didn’t give him informed consent for that.  We need to wake him up and come back another day.”  He shrugs his shoulders, and walks out of the room.  (Seem like an far-fetched scenario?  It’s not–this exact incident happened to me at Stanford about 8 years ago.)

You are stunned.  “Come back another day?”   The circulating nurse shakes her head.  She and the scrub tech are looking at you–waiting for you to wake up the patient.  It’s only been twelve minutes since you injected the muscle relaxant, and you have no nerve stimulator.  Being a resourceful Stanford graduate, you call another anesthesia attending and ask to borrow her nerve stimulator.  When the nerve stimulator is delivered to you, you discover no twitches at either the patient’s facial nerve or ulnar nerve.

The nurse asks, “Is there a problem?”

You answer, “Not really, but I can’t wake up the patient until the muscle relaxant wears off further.” You decide to wait until one twitch returns before you administer neostigmine/glycopyrrolate reversal.  You sit down, the nurse sits down, and the scrub tech scrubs out.  The operating room seems absurdly quiet for thirty minutes while you wait to reverse the muscle relaxant.  Forty minutes later, you extubate the trachea and take the patient to the Post Anesthesia Care Unit.

After you finish your Stanford residency, you need to be prepared for faster surgeons and shorter operative times.  Overdosing patients with muscle relaxants is a common mistake when newly-trained anesthesiologists leave residency.  The operative time for a laparoscopic appendectomy may be as little as fifteen minutes.  A pediatric tonsillectomy may last only twelve minutes.  An anterior cruciate ligament repair may last only 45 minutes.

In private practice, you will probably use modest doses of vecuronium or rocuronium when paralysis is necessary.  If the surgeon finishes earlier than expected, you always want to be able to reverse muscle relaxation and awaken the patient without delay. Whenever appropriate, you will prefer to use an LMA instead of an endotracheal tube, partly because the LMA insertion does not require a muscle relaxant, and partly because it’s easier for the patient to breath spontaneously with an LMA.

How about the need for a nerve stimulator to monitor neuromuscular blockade?  I polled the thirty-three private anesthesiology attendings at Stanford via email, regarding their practices using nerve stimulators and muscle relaxants.  I learned the following:  Most practitioners do not administer additional muscle relaxant following intubation unless surgical conditions demand it. Most practitioners do not reverse muscle relaxants if no dose was given in the last hour of a case.

Almost every private attending still owns a nerve stimulator.  Half of the attendings use a nerve stimulator routinely whenever they administer muscle relaxants, but half the attendings use the device occasionally or rarely, relying on clinical criteria and judgment alone in regards to the level of neuromuscular blockade. Is this practice wise, or not?

The American Society of Anesthesiologists Standards for Basic Anesthesia Monitoring, posted on, does not list the use of a peripheral nerve stimulator as a standard.

However, in Miller’s Anesthesia, 2008 Edition, Chapter 47 on Neuromuscular Monitoring, author Jørgen Viby-Mogensen makes the following statements:

  • “Many anesthesiologists do not agree with extensive use of nerve stimulators and argue that they manage quite well without these devices. However, the question is not how little an experienced anesthetist can manage with but rather how to ensure that all patients receive optimal treatment.”
  • “It is difficult and often impossible to exclude with certainty clinically significant residual curarization by clinical evaluation of recovery of neuromuscular function.”

The author further states that the following clinical tests of postoperative neuromuscular recovery are NOT reliable:

  • Sustained eye opening
  • Protrusion of the tongue
  • Arm lift to the opposite shoulder
  • Normal tidal volume
  • Normal or nearly normal vital capacity
  • Maximum inspiratory pressure less than 40 to 50 cm H2O

The author states that the following clinical tests of postoperative neuromuscular recovery ARE reliable:

  • Sustained head lift for 5 seconds
  • Sustained leg lift for 5 seconds
  • Sustained handgrip for 5 seconds
  • Maximum inspiratory pressure 40 to 50 cm H2O or greater

The author concludes that  “Adequate recovery of postoperative neuromuscular function cannot be guaranteed without objective neuromuscular monitoring.”

In private practice in Palo Alto, most of us use a MiniStim unit Model MS-1B Miniature Nerve Stimulator (Life-Tech, Houston, Texas), a simple device with one red button for Tetanus, and one green button for Twitch.  The MiniStim assessment of tetanus or twitch response is done by visual and tactile evaluation of muscle movement, with no quantitation of blockade.

Is there any good reason to avoid using a nerve stimulator?  The benefit/risk ratio of using the device approaches infinity.  If you ever lose it, you can purchase another one on the Internet for a mere $155.  I’ve had my current unit for ten years, during which I’ve administered 7000 anesthetics.  The cost of the MiniStim so far works out to be about 2 cents per case.

During residency or during the years afterward, a MiniStim and a stethoscope are arguably the only tools of your own you need to carry into an operating room to conduct a 21st-century general anesthetic.

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. PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press, 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 by clicking on the picture below:




  1. Is there a study that shows periodic or regular TOF monitoring over a long case with multiple re-dosing of intermediate acting relaxants affecting the accuracy of TOF monitor or/and other modalities like double burst stimulation together with clinical assessment at the end of the case in deciding if the patient has adequately recovered for extubation? I understand not using nerve stim to guide re-dosing may cause inability to extubate promptly. Time to exubate is not the issue at point. My query is about the reliability of the NM stim monitor at the end of the case prior to extubation without regular use intraop.
    Related to this, is the question of when airway problems occur after extubation, does the anesthesia provider carry more legal liability because he/she was not using/ recording NM monitor regularly despite adequate clinical and NM monitoring evidence of full NM recovery at the end. This is the fear most practitioners have who are anal about NM monitoring.
    Just as clinical signs are not accurate, NM stim monitors specially non-quantitative devices are not either in predicting with 100% accuracy that patient is fully recovered for extubation. The science is there but application for practical use is not perfect and requiring cumbersome routine use specially in this day and age of high turnover “do as many cases as you can in one day” is just not practical.
    I wonder if the studies that cite airway problems because of residual NM blockers after extubation are mostly in Academic/ training hospitals and if the problem would be just as bad with experienced practitioners in private practice.


    1. Usually, NM monitoring is most important at the time of extubation, to determine if the paralysis has been reversed. Yes I believe there is increased medical-legal liability if you’re not using a NM monitor at that time and then a patient has respiratory failure secondary to residual paralysis post-extubation.

      I use a non-quantitative NM monitor, and I believe it is sufficiently accurate.

      I’ve been very impressed with sugammadex as a reversal agent for paralysis prior to extubation. It should almost eliminate the occurrence of respiratory failure secondary to residual paralysis post-extubation.

      I don’t know of any studies comparing private practice vs academic practice regarding respiratory failure secondary to residual paralysis post-extubation, but I know I had more frequent problems in training than I do now, primarily because I used higher doses of paralytic drugs in training. In training I was afraid the patient would move during surgery, and the surgical team would either be angry or would think I was incompetent. Now I rely on sufficient anesthetic depth rather than paralyzing every patient.


  2. Thank you very much for your response but I don’t think my first question was answered adequately. Let me rephrase another way: If I use my NM monitor (non-quantitative) only at the end of the case right before extubation, and do not regularly use it throughout the case (relying on clinical signs and pharmacological knowledge )- Is there an actual study that proves the accuracy of the NM monitor at the end of case is unreliable? Or is this just an assumption by many clinicians and academicians who are medico-legal adverse specially in the US.
    Many a times, there are airway issues after extubation that may not be caused by problems with residual muscle relaxant use. However, because on review of the anesthetic record, TOF monitoring was not recorded on a regular basis, although it was used and recorded at the end, before extubation, the blame is attributed to inadequate TOF monitoring.
    Is this right?


    1. I am not aware of any study that documents use of the NM only at the end of the case as unreliable.

      Most anesthetic records I read or review do not have TOF data marked throughout the case.

      If you use TOF monitoring at the time of extubation you are on firm ground. Your TOF result may or may not be documented on your anesthetic record. If you testify or state that the non-quantitative TOF was four strong twitches, that would be be safe, and in my opinion is standard of care.


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