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.
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 email@example.com, 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: