Clinical Case: You are working at a freestanding surgery center. A healthy 58-year- old man has a mask anesthetic for a shoulder manipulation. During the procedure he coughs and bucks, and his oxygen saturation drops to 80%. With mask continuous positive airway pressure (CPAP) the airway improves, and the oxygen saturation returns to 100%. In the recovery room he looks well and feels great, but his oxygen saturation on room air is 90%. What do you do?
Discussion: One key difference between academic and private practice is the number of operating rooms in freestanding facilities, located miles from the nearest hospital. There are marketplace incentives that induce surgeons to take their surgeries to facilities that they own themselves, or to remodel part of their office space into approved operating facilities. This makes for additional challenges for perioperative physicians.
In this case, the preoperative oxygen saturation was 99% on room air. The anesthetic included 200 mg of propofol, 1-2% sevoflurane, and 50% nitrous oxide. The surgeon injected 20 cc of .5% bupivicaine into the shoulder joint. In the recovery room, the initial oxygen saturation was 95% on 4 liters/minute of nasal oxygen. As the patient became more awake, he received a total of 8 mg of morphine I.V. over 30 minutes for shoulder pain. An hour later, at 1600 hours, you are called to see him because his oxygen saturation on room air does not meet discharge criteria. You find the patient in the recovery room looking well, with no complaints of dyspnea or chest pain. His heart rate is 95, blood pressure is 120/80, respiratory rate is 20, temperature is normal, and his oxygen saturation is 88-92% on room air. His physical exam is negative except for bilateral inspiratory rales at the lung bases.
What is the diagnosis? You did not see any sign of aspiration in the operating room, although that is a possibility. When the coughing and bucking occurred, he had an episode of laryngospasm, which you treated with mask CPAP. It is possible he had a mild case of negative pressure pulmonary edema. Atelectasis is also a possibility. You order incentive spirometry, but it does not increase his oxygen saturation. An ECG is normal. You continue to treat the patient with 4 liters/minute nasal oxygen while you make a plan.
The patient and his wife are pleading with you because they want to go home. They promise to telephone you if he gets short of breath during the night. However, there is a new abnormal vital sign and a new finding of rales. You are not able to do a chest radiograph at the surgery center. Your facility is about to close for the night. The surgeon wonders if the patient’s wife can drive the patient to the emergency room in the family car.
You are concerned that the standard of care for a reasonably trained anesthesiologist would not include sending this patient home. Nor would it include letting a patient drive to the hospital in the family car, without oxygen. You telephone the patient’s family physician, and he agrees to manage the patient after transfer to the hospital. You discuss that the differential diagnosis includes aspiration versus negative pressure pulmonary edema. He will order a chest radiograph, and consider a dose of furosemide. You spend an extended period of time explaining to the family the necessity of transfer, and then call for an ambulance to pick up the patient. Your assessment is that he is stable enough that you do not need to accompany him to the hospital.
In follow up the next day, you find that the X-ray showed minimal infiltrates at the lung bases. The patient improved without diuretic therapy, and was discharged home at noon. His oxygen saturation was 97% room air, and he was taking Vicodin for shoulder pain.
At Stanford Hospital, the Ambulatory Surgery Center is in the middle of the hospital, and it is not difficult to get a chest X-ray, a blood gas, admit a patient to the hospital, or even transfer a patient to the ICU. In freestanding centers, these things can be a big production. Physicians performing or supervising a scheduled medical procedure outside of a hospital, resulting in the patient’s transfer to a hospital for medical treatment exceeding 24 hours, are required to fill out a Patient Transfer Reporting Form and send it to the Medical Board of California within 15 days. The Medical Board monitors freestanding facilities for patterns of frequent transfers and complications.
This patient did well and was discharged in less than 24 hours. Because it was possible for worsening hypoxia or pneumonitis to develop in the first 24 hours after surgery, you were conservative and wise to transfer the patient. The trend toward freestanding facilities is not going away. This case illustrates only some of the issues of doing quality medical care in these settings.
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.
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