Clinical Case for Discussion:  A 5-year-old male is scheduled for tonsillectomy.  The child is fearful in the preoperative suite, and is crying, agitated, and clinging to his mother.  The patient refuses to swallow oral midazolam. During the preoperative interview, the mother reveals the patient’s interest in the cartoon show SpongeBob SquarePants.  What do you do?

Discussion:  You pull your smart phone out of your pocket, cue up YouTube, enter “sponge bob” into the search window, and select a SpongeBob SquarePants video.  Once the video is playing on the screen, you hand the phone to the child.  The boy immediately becomes calmer, and grows absorbed and distracted with watching the video.  You are able to wheel the patient’s gurney away from the mother and take the patient into the operating room.  The patient holds onto the phone and watches the video while the staff positions him on the operating room table, and a smooth and uneventful sevoflurane mask induction is carried out.

Anxiety at induction of anesthesia was studied in 1250 children aged 3-12 (Davidson AJ, Shrivastava PP, et al: Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study,  Paediatr Anaesth 16(9):919-27.2006).  The incidence of high anxiety at induction was 50.2%. Younger age, behavioral problems with previous healthcare attendances, a longer duration of procedure, having more than five previous hospital admissions and anxious parents were all associated with high anxiety in the patients.

Cancellation of planned surgery because of child refusal is not uncommon. Nine percent of anesthesiologists responding to a survey cancelled one or more cases for child refusal in the past year, and 45% cancelled one or more cases for child refusal during their career (Lewis I, et al: Children who refuse anesthesia or sedation: a survey of anesthesiologists.  Paediatr Anaesth 17(12),1134-42.2007)

Oral midazolam premedication is the most common method for relieving anxiety in pediatric patients prior to inhalation induction.  The majority of patients are calm and sedated after oral midazolam, and separate from their parents without excessive crying.   Oral midazolam may have a delayed onset or be spit up, and child cooperation is the main variable.  Intramuscular medications are effective but cause pain, and are usually reserved for children who refuse oral premedication or those in whom lighter premedication regimens have failed in the past.  Intravenous medications are effective but require an IV be inserted in an awake child. Mask induction can be achieved without premedication.  The anesthesiologist can hold the mask over the face of a screaming child, and inhalation induction can be achieved in less than one minute, but the child may have unpleasant or fearful memories of the event.

Non-pharmacologic methods to reduce preoperative pediatric anxiety have been studied. Parents commonly request to be present during induction of anesthesia.  Many anesthetizing locations in the United States, including all facilities where the author practices, no longer permit or encourage parental presence at induction of anesthesia (PPIA).  Adding PPIA to oral midazolam premedication to treat preoperative anxiety in children has been studied versus a control group using midazolam premedication alone, and anxiety levels at the introduction of the anesthesia mask did not differ significantly between the two groups with or without PPIA.  Parents who accompanied their children to the operating room, however, were less anxious and more satisfied (Kain ZN, et al: Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study, Anesthesiology 92(4).939-46.2000).

Use of a hand-held video game for pediatric preoperative anxiolysis has been described (Patel, et al: Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatr Anaesth 16(10).1019-27.2006).  In a randomized, prospective study of 112 children (4-12 years of age) undergoing outpatient surgery, anxiety was assessed after admission and again at mask induction of anesthesia. Patients were randomly assigned to three groups: parent presence at induction (group P), parent presence at induction + a hand-held video game (group VG), and parent presence at induction +  oral midazolam (group M). There was a statistically significant increase in anxiety (P<0.01) in groups P and M compared with baseline, but not in the video game group. A hand-held video game was concluded to be a low cost, easy to implement, portable, and effective method to reduce anxiety in children in the preoperative area and during induction of anesthesia.

The use of YouTube prior to pediatric anesthesia induction has been previously described, using a video screen attached to the anesthesia machine in the operating room (Gomes SH: YouTube in pediatric anesthesia induction. Paediatr Anaesth 18(8).801-2.2008).  The disadvantage of this method is that the YouTube video cannot be screened until the patient has already entered the foreign and sometimes-fearful environment of the operating room.  If parents are not be allowed into the operating room, the child must separate from his parent(s) prior to viewing any cartoon video.

In the 21st Century, the availability and portability of smart phones or iPads make for a superior method of inducing relaxation prior to pediatric surgery. YouTube includes a library of thousands of video clips including videos of nearly every cartoon known to children, all accessible via a 3G or wireless Internet network.  Children love cartoons, and watching a cartoon is a favorite activity of presumably every pediatric patient.  Merging the smart phone from the physician’s pocket with the children’s love of cartoons creates a wonderful opportunity for a new non-pharmaceutical premedication–video relaxation.  In addition to video entertainment, a smart phone provides access to thousands of game applications.  Playing a video game of the child’s choice prior to pediatric induction can help relax both child and the parent in the minutes prior to surgery.

If you haven’t tried it previously, pull out your smart phone and hand it to the next 5-year-old you’re scheduled to anesthetize.  The patient, his parents, and the anesthesiologist will all be smiling within minutes!

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. I got permission to let parents be present in the OR for non-emergency inductions in 1986. It just seemed logical. Parents were allowed to stay with their kids in the ER, dads were present during c-sections.

    If you were a child, going into a room with masked strangers would be disquieting. Going in for a repeat procedure would be very frightening. It just made sense to alleviate children’s anxiety. Oral midazolam was not yet on the market; rectal nembutal was effective for smoothing inductions, but it was kind of silly to add 15 minutes pre-surgery and an extra hour of PACU time for 5 minute M&T’s and 15 minute T&A’s.

    The old fashioned brutane was quick, yes, but also objectionably barbaric. Stuffed animals, especially talking ones, were often, but not always effective, particularly for kids who had had prior surgeries.

    It was a small hospital in a progressive, educated-populace community (Ashland Oregon).
    There was some reticence on the part of the nursing staff at the outset, but after awhile, everyone thought it was great.

    I even got to the point of letting moms hold the mask, while I watched the patient and monitors and adjusted gas flows.

    It required being in a special place, with thoughtful people who were open-minded about developing new and better procedures to address old problems.

    So when I suggested, “I’d like to let moms come into the OR (again we already had families in for c-sections),” the docs and nurses gave me sensible objections, I gave sensible responses to alleviate their concerns, so they agreed to a trial run, and it worked out fine.

    The PACU nurses especially loved the easier job of having conscious children to take care of, and it eliminated the risk of them calling me to PACU to address a compromised airway while I was doing the next case. The ENT for whom I primarily devised the method, because he liked to schedule 3-4 cases en batch, was quite happy to shave an hour off his morning OR time as well.


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