Clinical Case of the Month: A 76-year-old, 65 kg, 4-foot 11-inch tall friend of your family has elective CABG surgery at an outside hospital. Twenty-four hours after the surgery, she is still asleep and on the ventilator. You inspect the anesthetic record, and discover that the anesthesiologist used 20000 micrograms of fentanyl and 10 mg of midazolam for a four-hour anesthetic. The patient received no additional sedation in the ICU. What do you do?
Discussion: I’m not going to tell you to argue with the ICU staff until they give the patient Narcan to wake her up. Instead, you find the attending anesthesiologist, and discuss the case with him. When you ask why the enormous dose of narcotic was used, the anesthesiologist looks you in the eye and says, “That’s the way I’ve been doing it for 20 years.”
How is this possible? Imagine you are a 55-year-old mid-career anesthesiologist, and you have just completed a nine-hour day of giving anesthetics. After eating dinner at home, which of the following would you choose to do?
a) Play with your children,
b) Watch American Idol on television,
c) Go to a movie with your wife,
d) Take a nap, or
e) Read some anesthesia journals.
Let me guess how you responded. How about, “Anything except e).” Once you have finished your training and you have finished obtaining board certification in anesthesiology, other aspects of life call out for your time. We are all masters of delayed gratification — anesthesiologists wait until age 30 or more before beginning their first “real job.” You have friends who pursued M.B.A. degrees who are in mid-career by age 30, and have purchased homes and started families. At the same age, many medical graduates are still dealing with fellowship training and hefty student loans.
When you finally get off the hamster wheel and are fully trained, many of you will feel like catching up for lost time. This may mean working long hours to earn a down payment on a house, beginning a family and raising young children, or just traveling, relaxing, and playing in your post-residency euphoria.
After a decade or two, a problem arises. Medicine changes, your specialty changes, and you get can get left behind. The temptation is to do everything “The way Dr. So and So taught me at Stanford back in 2005.” In the year 2025, this may be an obsolete way to practice. Your state licensure and medical staff privileges require you to attend 100 hours of Type I Continuing Medical Education every two years. The sad reality is that one can satisfy this requirement and learn practically nothing that is relevant. When it comes time to select a CME conference, the location and time of the meeting is often more important to you and your family than what the lectures are about. Many CME conferences are thinly veiled vacation packages, and the lectures you attend may or may not give you any information you can use the week you return to work.
The good news is that the American Board of Anesthesiology (ABA) mandates a Maintenance of Certification in Anesthesiology (MOCA) program for all diplomates whose initial board certification was in the year 2000 or after. The MOCA program involves a written Cognitive Examination which must be passed every 10 years to maintain board certification. Per the ABA’s website (home.theaba.org) the examination is “very clinically oriented, with an emphasis on customary practice.”
Should you wait until the year before each MOCA recertification exam, and study for weeks? Should you read anesthesia journals, read the new editions of anesthesia textbooks, or go to the ASA national meeting each October and attend a full slate of refresher courses?
I recommend all of the above, but there is a key ingredient to staying current: You need to stay hungry for knowledge that concerns anesthesia. You need to be a self-starter. Every time you are consulted on a patient who has a diagnosis or a medication you are not familiar with, look it up. Teach yourself. Use the information sources available to you every day: Medline, the medical library at the medical center you work at, and select institutional sites on the Internet. For those of you in the Stanford neighborhood, Monday morning Grand Rounds meetings are an invaluable source of lectures from academic experts, and give private practitioners a venue to maintain relationships with their former professors.
My second recommendation involves your colleagues. Stanford is an active, vital medical center where at any time you may ask an expert colleague a question, or be asked a question from a resident junior to you. Either situation reinforces learning. Twenty years from now, you may find yourself in a smaller community hospital or even a surgery center, where the staff doctors all look at each other and say, “You are the best anesthesiologist I know!” and the colleague answers, “And you are the best surgeon I know!” You may find yourself a big fish in a small pond, where nobody is “the best” at anything except complimenting each other. Don’t isolate yourself. Foster ongoing relationships to colleagues who are on the cutting edge of your specialty, so that you can contact them when you have questions about evolving standards of care. Continue to teach in some way — nothing forces you to stay well informed quite like trying to explain your actions to a bright trainee who challenges you.
To wrap up, let’s return to our Clinical Case of the Month above. In the 1980’s, the standard anesthetic for cardiac surgery was a large dose of fentanyl equal to 100 mcg/kg, so a 65 kg patient would have received 6500 mcg of fentanyl for anesthesia, never 20000 mcg. And the doctor who administered the 20000 micrograms of fentanyl because he’s “been doing it that way for twenty years”?
Doctors like that are out there. You don’t want to be one of them, twenty years 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.
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 email@example.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:
BOOK REVIEW “THE DOCTOR AND MR. DYLAN”
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.
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: