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.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: