Clinical Case of the Month: You are in an operating room in a freestanding plastic surgery center giving general anesthesia to Patient A, and you are called by the PACU nurse because Patient B in the PACU is having stridor. The PACU Patient B is a healthy 39-year-old female, one hour status-post liposuction, and her anesthesiologist has signed out to you. Patient B is now cyanotic. You are the only anesthesiologist for miles, and both Patient A and B need you. What do you do?
Discussion: You perch the circulating R.N. from your O.R. in front of the monitors, tell her to let you know if anything changes, and you leave the O.R. to attend to the patient in the PACU. Is there any alternative? Are you going to stand there with stable Patient A while Patient B dies of airway obstruction thirty feet away from you?
When you arrive in the PACU, you see a young woman sitting up in bed making loud crowing sounds with every inspiration. Her oxygen saturation is 89% on 4 liters of nasal oxygen, and her heart rate is 110. Her husband is standing at the bedside, and his eyes are bugging out of his head watching his wife gasp for air. The PACU nurse is standing on the other side of the patient, and her eyes are bugging out almost as far as the husband’s.
You ask the nurse to open an Ambu bag and connect it to the oxygen source. You ask the husband to leave the room while you evaluate and treat his wife. A second nurse escorts him out. You listen to the patient’s lungs, and her breath sounds are normal except for upper airway stridor. The exam of her mouth and neck is normal. You take additional history, and learn that she had a three hour intubation for a prone liposuction, and was extubated without complication. She received 20 mg of meperidine 45 minutes earlier, and no other medication was given in PACU. The stidor started two minutes earlier, when her oxygen saturation decreased from 100% to the high 80’s.
Your diagnosis is laryngospasm of unclear etiology. You apply an anesthesia mask over her face, deliver 100% oxygen via the Ambu bag, and attempt to apply continuous positive airway pressure (CPAP) to break her laryngospasm. You ask her to cough hard to clear secretions that may be lodged on her vocal cords. Within a minute the stridor passes, and her oxygen saturation returns to 100%. Her other vital signs are normal, and her skin is free of urticaria. You review her anesthesia record, and it is unremarkable. The patient feels significantly better, and you return to the OR to check on your patient who is still under general anesthesia. The OR circulating nurse reassures you that Patient A is fine, and nothing changed during your absence.
Two minutes later, the PACU nurse calls in a panic again, because Patient B is having stridor again. You run to the PACU, and repeat the assessment and therapeutic moves you made in the paragraphs above. Your diagnosis is post-intubation laryngospasm. You can not rule out post-intubation vocal cord paralysis. You treat with 8 mg of IV dexamethasone. There is no vaporized racemic epinephrine in the facility. The patient is moving air well, but intermittently crowing with stridor. You call 911 for an ambulance, and call the ER attending at the nearest hospital to tell him you are coming over. You place a third call to the Respiratory Therapy service at the hospital, and tell them to meet you at the ER with a racemic epinephrine treatment for the patient.
Patient A’s surgery ends in the next 10 minutes, as the ambulance crew arrives and prepares Patient B for transport. You extubate Patient A and deliver her in stable condition to the PACU just in time to join the Emergency Medical Techs as they load Patient B into the ambulance. You load your pockets with vials of propofol and succinylcholine, a laryngoscope, and two syringes, and follow her into the ambulance. The siren blares, and the ambulance drives Code 3 to the ER. The patient’s intermittent stidor continues, with oxygen saturation in the low 90’s on a 100% non-rebreather mask.
In the first twenty minutes in the ER, the Respiratory Therapist arrives and gives a nebulized racemic epinephrine treatment to Patient B. Within the next twenty minutes her symptoms resolve. Her husband arrives, and he looks a lot happier than the first time you saw him, too.
You make a phone call. Minutes later, one of the nurses from the freestanding plastic surgery center drives up in their car to give you a ride back to where your automobile is parked back at the surgery center.
Sound impossible? Guess again. This entire scenario occurred three months ago, a mile or two from Stanford hospital.
The diagnosis of post-extubation stridor is more common in newborn infants after prolonged or multiple intubations, but it occurs in adults as well. In one series of 112 extubations of adults in an ICU in France, the prevalence of post-extubation stridor was 12% (Jaber S, Intensive Care Med. 2003 Jan;29(1):69-74). Occurrence after extubation post-surgery is less common. When laryngospasm occurs in the OR immediately post-intubation, we are all taught to treat the patient with 100% oxygen and CPAP by face mask. The laryngospasm usually clears as the patient awakens from anesthesia and mounts a strong cough to clear secretions from the larynx.
When stridor occurs in the PACU of a hospital, the established medical therapy is nebulized racemic epinephrine (Vaponefrin), .5 ml of a 2.25%solution q 3-4 hours given by Respiratory Therapy, and a dose of dexamethasone 4 – 8 mg IV (Miller, Anesthesia, 2005, pp 2817, 2538). Nebulized epinephrine acts as both an alpha and beta adrenergic agonist, and has both vasoconstrictor and bronchodilator properties.
The lack of Respiratory Therapy in freestanding surgery centers is another of the issues that differentiates them from in-hospital ambulatory surgery centers. The plastic surgery center that suffered through this episode has now purchased the equipment to deliver nebulized epinephrine post-op. It may be years, or decades, before they get an opportunity to use it. A more important lesson is that the perioperative care of surgical patients is multi-faceted, and no one is better prepared to diagnose or treat problems than an anesthesiologist. If you practice anesthesia in freestanding surgery centers long enough, you too will experience a ride in an ambulance to the ER. Hopefully your story will have a happy ending, as our Clinical Case of the Month did.
Our patient was discharged home from the ER after a stable four hour observation period, and she had no further problems at home.
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 firstname.lastname@example.org, 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: