EMERGENCY AIRWAY BLEEDING AFTER SLEEP APNEA SURGERY

Clinical Case for Discussion:   You are called at 0200 hours  to anesthetize a 50-year-old man who is bleeding from his palate.  He is 14 hours status-post  a uvulopalatopharyngeoplasty (UPPP) for sleep apnea.  He is 6 feet tall, weighs 200 pounds, and  he is spitting up blood.  What do you do?

Discussion:   You meet the patient in the ICU.  He is sitting up in bed,  spitting out small amounts of blood and swallowing the rest.  He has been bleeding for four hours, and the total volume of blood seen has been less than a cup.   Vital signs are:  pulse 100, blood pressure 160/90, and oxygen saturation 97% on room air.  The airway exam reveals dried blood on the mouth and tongue, moderate edema of the  pharynx, tongue, and mucous membranes, and no bleeding point is seen.  Review of the chart reveals that your partner intubated the trachea with a Miller #2 blade without difficulty that morning for elective surgery. The surgeon wants the patient asleep as soon as possible.  You transport the patient to the operating room, and have him breath 100% oxygen through a mask while you prepare for the anesthetic.

The A-B-C’s of Airway-Breathing-Circulation dictate that the Airway is the most important factor to consider in this case.   You have the principles of the ASA Difficult Airway Algorithm (see http://www.ASAhq.org) committed to memory.  You plan a strategy for the airway management.  Per the Algorithm, you begin by assessing the likelihood of four basic problems:  1) Difficult ventilation, 2) Difficult intubation, 3) Difficulty with patient cooperation, and 4) Difficult tracheostomy.   You assess that you will be able to mask ventilate this patient, but there is some chance that the blood and edema will make intubation difficult.  You also consider that blood and edema could make both mask ventilation and intubation difficult.  Patient cooperation is adequate, and the surgeon states that he would not have difficulty doing a tracheostomy or cricothyroidotomy.

Next you consider the choices of:   a) awake intubation vs. inducing general anesthesia first, b) use of non-invasive techniques as the initial approach to intubation vs. surgical techniques like tracheostomy, and c) preservation of spontaneous ventilation during intubation attempts vs. ablation of spontaneous ventilation.

Your assessment is that awake fiber optic intubation would be difficult secondary to the active airway bleeding.  Blind awake nasal intubation is a possibility, but looking at the patient, you make a different choice.   You are confident that you can induce general anesthesia, use cricoid pressure, paralyze the patient, and intubate the trachea using a Miller #2 blade as your partner did the previous morning.  If you have difficulty seeing the larynx, you will use a Yankauer suction to clear blood, try alternate laryngoscope blades, and support oxygenation by mask ventilation while cricoid pressure is continued. You may utilize other options as necessary, including a bougie or a light wand.  If ventilation becomes difficult, you will insert an LMA.  If ventilation becomes impossible, the surgeon will perform an emergency surgical airway.

You need an assigned individual to assist you during your airway management.  Because there is no other anesthesiologist in the hospital, your otolaryngology colleague is the obvious assistant.   Before you induce anesthesia, you bring the difficult airway cart into the operating room, as well as a tracheostomy tray for the surgeon.

You discuss this plan with the surgeon.  After  preoxygenation, you induce anesthesia with propofol and succinylcholine.  Cricoid pressure is applied.  When you insert the  laryngoscope  into the mouth, all you see is blood, swollen tissues, and no view of the larynx.  Your next action is aggressive suctioning with a Yankauer catheter, and after repositioning the laryngoscope, you are able to see the larynx.  The tracheal tube is placed, the cuff is inflated, and its location confirmed by CO2 and auscultation.  You recheck vital signs, begin  maintenance anesthesia with sevoflurane, and the surgery begins.

I had a case of this type twice in the last 5 months.  Both cases were effective in raising the endogenous catecholamine level of this anesthesiologist.   Both were good exercises in planning airway management.  The most striking characteristic of each case was the amount of blood in the airway when I inserted the laryngoscope.  The Yankauer suction catheter was essential, and I recommend inserting it immediately after inserting the laryngoscope.

The literature documents the prevalence of bleeding after UPPP as 1.4% (Mickelson SA, Is Postoperative Intensive Care Monitoring Necessary After UPPP?, Otol Head Neck Surg 1998 Oct, 119(4) 352-6.)   The bleeding patient post-tonsillectomy is a similar presentation.  Miller (Anesthesia, 2000, p 2188) writes “The incidence of post-tonsillectomy bleeding that requires surgery is 0.3 to 0.6 %. . . The extent of blood loss may not be obvious and is usually underestimated. . . Most problems before induction of anesthesia for bleeding tonsil are caused by unsuspected hypovolemia, full stomach, and airway obstruction. . . At induction of anesthesia, an additional person should be available to provide good suctioning of blood.  A rapid-sequence induction of anesthesia with application of cricoid pressure and slight head-down positioning of the patient will protect the trachea and glottis from aspiration of blood.”

The ASA Difficult Airway Algorithm. . . learn it well, and be prepared to apply it in the middle of the night.  Your heart rate may be faster than the patient’s.

Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date September 9, 2014 by Pegasus Books.

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:

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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.

REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
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.

TwinCities.com PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press mgrossman@pioneerpress.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.

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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.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
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”

By

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 novak.com by clicking on the picture below:

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