Clinical Case for Discussion: An anesthesia colleague of yours dilutes a 50-microgram ampoule of sufentanil with 9 cc of normal saline, so the final syringe concentration is 5 micrograms per cc.  He then injects 10 micrograms of sufentanil from this syringe into the clean IV line of three different patients during his OR day.  Is this practice OK?  What do you do?

Discussion:  Your colleague claims this practice is without risk because he injects into an IV port that is six feet proximal to the IV catheter.  He’s done this for twenty years, since his residency training.  He’s “never had a complication” and sees no reason to change.

He needs to change, and here’s the most recent evidence why:  In January 2008, investigators from the Center for Disease Control (CDC) responded to a request from the Southern Nevada Health District to help investigate three persons with acute hepatitis C virus (HCV) infection (MMWR Morb Mortal Wkly Rep. 2008 May 16;57(19):513-7).  All three persons had undergone procedures at a Las Vegas endoscopy clinic. CDC went on to identify a total of six cases of HCV infection among patients who had undergone procedures at the clinic in the 35–90 days prior to onset of symptoms. These patients had no other risks for HCV infection.

On investigation of the clinic, CDC observed practices that had the potential to transmit HCV.  The May 2008 issue of Anesthesiology News reported that “certified registered nurse anesthetists (CRNAs) at the center had been improperly administering anesthesia to patients undergoing routine endoscopic procedures.”  The California Department of Public Health mailed a letter to all California physicians, dated March 27, 2008.  Per this letter, the infected Nevada patients were most likely exposed in the following manner:  “1) A clean syringe and needle were used to draw a sedative medication from a new single-use vial. 2) The sedative was administered to a hepatitis C infected patient, and backflow of blood from the patient into the syringe presumably contaminated the syringe with hepatitis C virus.  3) The needle was replaced on the syringe with a new, sterile needle, but the syringe was reused to draw additional sedative from the same vial for the same patient, presumably contaminating the vial with blood containing hepatitis C virus.  4) A clean needle and syringe were used for subsequent patients, but the contaminated vial was reused, exposing subsequent patients to hepatitis C virus.”

Because these practices had prevailed at this clinic for years, nearly 40,000 Nevada patients had to be notified by letter that they should visit their primary care provider to be tested for hepatitis C, hepatitis B, and HIV.

The same March 27, 2008 letter from the California Department of Health included a list of Safe Injection Practices, drawn from the CDC website (Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, Standard Precautions (www.cdc.gov/ncidod/dhqp/gl_isolation.html).  These Safe Injection recommendations include the following: “1) Use aseptic technique to avoid contamination of sterile injection equipment.  2) Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed.  3) Use fluid infusion and administration sets for one patient only and dispose appropriately after use.  4) Use single-dose vials for parenteral medications whenever possible.  5) Do not administer medications from single-dose vials or ampoules to multiple patients or combine leftover contents for later use.  6) If multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile.”

Viral infections have been reported secondary to unsafe anesthesia practitioners.  A cluster of four patients with hepatitis C virus (HCV) infection was identified in a single surgery clinic (Germain JM et al, Patient-to-patient transmission of hepatitis C virus through the use of multi-dose vials during general anesthesia. Infect Control Hosp Epidemiol. 2005 Sep;26(9):789-92). Molecular characterization revealed close homology between viruses, and this cluster was deemed to be due to intra-operative unsafe injection practices by anesthesia personnel using multi-dose vials.

From this point forward, your friend’s method of administering sufentanil must be stopped. You show him the above references, and urge him to change his practice for the safety of his patients.  Other verboten procedures include:  1) Using an infusion pump to administer portions of a 60 cc syringe of propofol or remifentanyl to more than one patient, even though you change the tubing;  2) Drawing 250 micrograms of fentanyl into one syringe, and then giving 100 micrograms to one patient, and 150 micrograms to the next patient from the same syringe;  3) Using a single 20 cc vial of labetalol to give repeated and multiple doses to more than one patient, if either the needle or the syringe used to draw any dose from that vial was reused.

We’ve urged our freestanding surgery centers to cease stocking large ampoules of drugs such as 5 cc Decadron, 5 or 10 mg midazolam, 5 cc Robinul, or 20 cc labetalol.  Reuse of larger ampoules gives practitioners the opportunity to spread viral infection to more than one patient if aseptic technique is ignored.  The larger vials may save the institutions money, but the saving of pennies is trivial compared to isolating each patient from the patient(s) that preceded them.

May all your present and future intravenous injection techniques comply with CDC guidelines!

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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