Clinical Case of the Month:   You’re setting up to give anesthesia for a laparoscopic cholecystectomy.  How many syringes and labels do you draw up and prepare?  For a D & C?  For an open abdominal aortic aneurysm repair?

Discussion:  Try something new.  When  preparing for a cholecystectomy, open two syringes, both unlabelled, and don’t open any ampules until the patient is in the OR.  More on that later.

Let’s examine two questions:  Why do we label syringes, and why do we load syringes with drugs ahead of time?  The answer to the first question is easy — we label syringes because we want to know what’s inside of them.  The Institute of Medicine’s report from 1999, entitled, To Err is Human:  Building a Safer Health Care System, reported that 98,000 patients died in U.S. hospitals each year due to medical errors.  Administering the wrong drug is a known anesthesia risk which we all try to avoid.

In a study of 55,426 anesthetics in Norway over 36 months, drug error was reported in 63 cases, or 0.11% of cases. (Fasting S, Can J Anaesth.2004 Oct;51(8):853-4.)  Drug errors included 28 syringe swaps, 9 ampule swaps, 8 ‘other wrong drug’ cases, and 18 cases where the wrong dose of the correct drug was given.  In the second 18 months of their study, they switched to color-coded syringe labels, and found their results unchanged except for a decreased number of ampule swaps (P=.04).  They concluded that drug errors were uncommon, that syringe swaps occurred most often between syringes of equal size, and that drug errors were not eliminated by color-coding of labels.

In a study of 896 drug errors reported in Australia, syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labeled but given in error, and 187 (20.8%) due to selection of the wrong ampule or drug labeling errors. (Abeysekera A, Anaesthesia. 2005 Mar;60(3):220-7).  Contributing factors included inattention, haste, drug labeling error, communication failure, and fatigue.  Factors minimizing the events included prior experience and training.

According to the first reference, a drug error was reported about once per 1000 cases in Norway.  I’d ask you to consider how many incidents of drug error occur, versus how many are actually reported.  I submit that the real prevalence probably exceeds the amount of cases that anesthesiologists admit to, and the real prevalence is significantly greater than .11%.  And even though labeling syringes is important and mandated, it fails to decrease medication error to zero.  In the future, we may see computerized visual and auditory bar-code verification of ampules and/or labels just before drug administration.

My second question to you was “why do we load syringes with drugs ahead of time?”  Common sense answers might be, “because it makes our work more efficient,” or “we might need them fast, and we don’t want to draw the drugs up at the last moment.”  Opinions regarding the preparation of pre-drawn emergency syringes differ.  In a study from New Zealand, a quarter of respondent anesthesiologists routinely drew up emergency drugs, and a third either never or very infrequently did so(Ducat CM, Anaesth Intensive Care. 2000 Dec;28(6):692-7).  Among the drugs most commonly drawn up were succinylcholine, atropine, and ephedrine.  Pediatric, obstetric, or vascular cases were cited as factors which prompted anesthesiologists to draw up one or more of these drugs.

Drug wastage is a known to be a significant portion of anesthesia drug budgets.  In one fiscal year, the cost of unadministered drugs at Rhode Island Hospital was $165,667 (Gillerman RG, Anesth Analg. 2000 Oct;91(4):921-4).  Efficiency indexes, defined as the percent of a restocked drug that was actually administered to patients, were as follows:  succinylcholine, 33%, propofol, 49%, rocuronium, 61%, and thiopental, 31%.  In a study at UC San Diego, drug wastage was quantitated in 166 cases during  a two week period (Weinger MB, J Clin Anesth. 2001 Nov;13(7):491-7).  Based on hospital drug acquisition costs, $1802 of drugs were wasted in two weeks.  Six drugs accounted for three quarters of the total wastage:  phenylephrine (20.8%), propofol (14.5%), vecuronium (12.2%), midazolam (11.4%), labetolol (9.1%), and ephedrine (8.6%).

Think about it, my colleagues.  Do you really need to draw up atropine and ephedrine before every case?

I queried Fred Hurt from the Stanford OR Pharmacy, and he gave me the following drug ampule acquisition costs:  atropine $.23, ephedrine $.74, phenylephrine $2.47, vecuronium $2.51, rocuronium $18.89, succinylcholine $1.93, propofol 20ml $4.76, and propofol 50 ml $11.91.

I’ll admit, in the scope of the healthcare budget of the United States, these numbers are miniscule, and you may not give a damn if your unused atropine and ephedrine costs Stanford 97 cents.  But let’s go back to the first paragraph, and a technique to avoid drawing up a lot of drugs and labeling them.  Part of the rationale is to avoid drug wastage, but the greater issue is the KISS principle — Keep It Simple Stupid.  In a 20 year career you’ll do 14,000 cases, and any practice that avoids wasted time and energy on each case is of value.

Try this:  For a cholecystectomy, use an unlabelled 5 ml syringe to draw 2 mg of midazolam from its already labeled ampule, and inject it into the patient’s IV.  Minutes later, use the same syringe to draw 100 micrograms of fentanyl from its already labeled ampule, and inject it into the patient’s IV.  Then use a second syringe, a 20 ml syringe, to draw 200 mg of propofol from its already labeled ampule, and inject it into the patient’s IV.  Finally, use the first syringe to draw 10 ml of Lactated Ringers from the IV bag and inject it into an already labeled ampule of vecuronium, mix it up, and inject 0.1mg/kg of vecuronium into the patient’s IV.

Reusing the same syringe on the same patient for several single-patient use ampules is safe.  The ampules are already labeled — why add another intermediate step and store them in a labeled syringe?  The exception to this practice is for drugs that need to be diluted — this would include phenylephrine (for a case you expect you might need it, such as vascular surgery or geriatric surgery), or narcotics such as morphine and meperidine.  These syringes need to be prepared and labelled.  Syringes should not be carried over from one patient to the next.

Like Burger King used to say, “Have it your way!”  You don’t have to agree with or accept the above suggestions, but I’d be interested in hearing if you’ve changed your mind, 14,000 cases from now.

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. Thank you for the information that you share here. My question about syringe labeling of anesthetic medications lead me to your site. I am trying to identify the correct labels to have available. My label dispenser has 16 slots, what 16 medications would you suggest?


    1. propofol, fentanyl, midazolam, rocuronium, atropine, phenylephrine, ephedrine, neostigmine, glycopyrrolate, labetolol, meperidine, morphine, ondansetron. lidocaine are widely used, to name 14.
      As I’ve written in my article, one can leave many medications in the vial until the time of use, so no labelling is required at time of injection. This applies to one-time injections such as atropine, ondansetron, Narcon, furosemide, or dexamethasone–so less labels are necessary.


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