Clinical Case of the Month:   A 56-year-old internist colleague of yours is scheduled for cholecystectomy.  He has stable hypertension, asthma, and hyperlipidemia.  During your pre-op evaluation, he asks if you will be listening to his breathing and heartbeat continuously during the anesthetic.  What do you say? How do you defend your answer?

Discussion:  What’s more symbolic of the medical profession than a white coat and a stethoscope?  As anesthesiologists strive to become recognized as perioperative physicians in a changing medical world, some of us actually carry stethoscopes around our necks, like those actors on Grey’s Anatomy.

On the first day of my Stanford Anesthesia residency in July 1984, each incoming resident had foam injected in their ears for molds to supply us with custom-made individually-fitted earpieces for our mono-aural stethoscopes.  In 1984, continuous stethoscope monitoring via a precordial or an esophageal stethoscope was a standard of care practiced by residents and attendings alike.  In July 1984, the Santa Clara Valley Medical Center operating rooms had exactly two (2) pulse oximeters.  Anesthesiologists would negotiate with each other daily to determine who had the sickest patients, and therefore most needed to use one of the oximeters that day.  The Stanford University operating rooms had exactly one (1) end-tidal-CO2 monitor, used exclusively by ENT anesthesiologist Dr. Chuck Whitcher.

Pulse oximetry and capnography became widespread in the late 1980’s,  anesthesia safety statistics improved, and unexpected cardiac arrests due to undiagnosed esophageal intubations became rare. The 1999 National Academy of Sciences publication To Err is Human: Building a Safer Health System reported, “Anesthesia is an area in which very impressive improvements in safety have been made.  . . . today, anesthesia mortality rates are about one death per 200,000 to 300,000 anesthetics administered, compared with two deaths per 10,000 anesthetics in the early 1980’s.”

Once OR’s were equipped with oximeters and capnography, most anesthesiologists abandoned routine use of mono-aural stethoscopes.

A prospective single-blind study of 520 consecutive patients in 1995 (Prielipp RC, Use of esophageal or precordial stethoscopes by anesthesia providers: are we listening to our patients? J Clin Anesth. 1995 Aug;7(5):367-72.) found 68% of patients had an esophageal stethoscope placed, 16% had a precordial stethoscope, and 165 of the 520 patients had no stethoscope.  This study documented that many stethoscopes that were placed were not used — overall, providers listened continuously via an anesthetic stethoscope in only 28% of the anesthetics.

In 2001, a study from London utilized questionnaires to document that 35.2% of anaesthetists never used an oesophageal or precordial stethoscope, and the majority of the remaining 64.8% used the devices in less than one-third of their practice. (Watson A, Survey of the use of oesophageal and precordial stethoscopes in current paediatric anaesthetic practice. Paediatric Anaesth. 2001 Jul;11(4):437-42.)

Regarding auscultation, the 2005 American Society of Anesthesiologists Standards for Basic Anesthesia Monitoring says: 1) “every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated.  Qualitative clinical signs such as chest excursion, observation of the reservoir bag and auscultation of breath sounds are useful.”   2) “every patient receiving general anesthesia shall have, in addition to (ECG and blood pressure monitors) circulatory function continually evaluated by at least one of the following:  palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intra-arterial pressure, ultrasound peripheral pulse monitoring, or pulse plethysmography or oximetry.”   3) “when an endotracheal tube or LMA is inserted, its correct positioning must be verified by clinical assessment and by the identification of carbon dioxide in the expired gas.”

Are anesthesiologists in private practice in Palo Alto using esophageal or precordial stethoscopes in 2007?  An e-mail survey of the twenty-five private practice attendings on the Stanford anesthesia Adjunct Clinical Faculty revealed:  1) continuous stethoscope monitoring for adult anesthetics is almost extinct, 2) use of precordial stethoscope monitoring during inhalational induction in pediatric anesthesia is standard for most practitioners, 3) in pre-op, stethoscopes are used during cardiac and pulmonary assessment only as indicated by the patient’s history and the planned surgical procedure, and 4) most practitioners, but not all, use a stethoscope to document bilateral breath sounds after every endotracheal intubation.

Dr. Terri Homer is a former cardiac anesthesiologist who has transitioned into a busy private practice of intravenous sedation general anesthetics in dental offices, where no ETCO2 monitoring is available. Terri discussed the gulf in precordial stethoscope use between herself and the current Stanford residents in her e-mail reply.  Terri wrote, “I use a precordial stethoscope on all of my I.V. sedation cases in dental and oral surgery offices for both my pediatric and adult patients. In my opinion, there is no better monitor to assess the quality of the airway under sedation. On my GA cases in the O.R., I use a precordial on every pediatric case on induction and during maintenance. On my adult GA cases I use an esophageal stethoscope on all prone cases but not anymore on other intubated adult patients. I do not check for bilateral breath sounds on my LMA cases but I definitely still do on intubated patients of any age. When I work with a resident on my Adjunct Clinical Faculty days I am astonished that more than 95% of them have never even seen a precordial stethoscope. That’s when I start feeling like a dinosaur. When I explain the value of this monitor, I don’t think they are at all convinced.”

How should we answer our patient in the Clinical Case of the Month question above?  You tell your colleague the truth:  In light of his history of stable asthma, you will listen to his lungs in the pre-operative room and immediately after endotracheal intubation.  You do not plan to  continuously listen to his breath sounds during the cholecystectomy, but you tell him that if any change or adverse trend occurs in the vital signs, oxygenation, ETCO2 tracing, or airway pressures, you’ll have a stethoscope on his chest in a heartbeat.

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:




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