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!


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 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.

Leave a Reply