AMBULATORY SURGERY AND THE ANESTHESIOLOGIST: HOW TO BE EFFICIENT IN THE OPERATING ROOM

You are an attending anesthesiologist, and you are scheduled to do 8 breast biopsy cases beginning at 0730 and ending at 1730 hours.  How will you manage your day?

Discussion:   doeverythingrealfastanddonttakebreakstheend.  So it can be in the “real world” of anesthesia.  At the American Society of Anesthesiologists National Meeting each October, you will not hear a Refresher Course on how to manage a day of 8 cases in 10 hours.  The slow pace of surgeons-in-training makes it unlikely most university faculty anesthesiologists have ever experienced such a day, so it’s unlikely they would lecture on the topic.

Safe anesthesia care is the most important goal of any day in the operating room.  But to be outstanding in practice, you will have to be efficient as well as safe.  Operating room time is expensive, and in addition,  surgeons will judge you on how rapidly you work.  To a surgeon, the time between when they put the dressing on one patient until they make the incision on the next patient is “down time.”  They want this minimized.   Surgeons as well as patients are your customers in private practice.  If you do not believe this, try ticking off your surgeons on a regular basis, and see how long you have a position in any private group.

If the surgeon does each breast biopsy in 30 minutes, and there are 8 cases, that adds up to 4 hours of operating time.  The other 6 hours are  for the anesthesiologist and the nurse to wake the patient up,   get the room turned over, and get  the next patient to sleep and prepped.

Some surgeons prefer to do  breast biopsies under general anesthesia, and some request deep sedation plus local anesthesia.   For general anesthesia, you choose propofol for induction, with sevoflurane, nitrous oxide, and/or propofol for maintenance.    A laryngeal mask airway is used for most patients.  For cases done under local plus deep sedation, you may choose a small dose of narcotic, followed by a propofol infusion starting at 100 mcg/kg/minute.   Oxygen is delivered by face mask.

I will offer  a few  labor and time saving suggestions for a rapid pace of practice:

1)  When the patient moves onto the operating room table, attach and activate the automated blood pressure cuff first.  While it is inflating, place the oximeter and the ECG leads.  When the blood pressure cuff has finished its initial reading,  you ask the patient to use  that hand to hold the oxygen mask over her  face.  This frees both of your hands to begin the induction once the oxygen saturation reaches 100%.

2)  As soon as the patient is asleep, finish the paperwork or the computerized medical records.  The paperwork on a day like this one is a burden.  Your paperwork errands include the history and physical, the recovery room orders, the anesthesia record, your billing form,  and the narcotic form – and all these will be repeated 8 times on this work day.  My advice  is to simplify the paperwork or computerized forms at your facility, so that all the pertinent medical-legal information is present, but the forms can still be filled out in minutes.

3)  When the paperwork is finished, get your syringes and equipment ready for the next case.

4)  When the surgery ends, you wake the patient, and transport her to the recovery room.  After a sign-out to the nurse there, you return to the pre-operative room to meet the next patient.  Patients are often very nervous before breast biopsy, both because of the surgery, and  because of the worries of the outcome of the biopsy.  You  attempt to ease her  anxiety as much as possible, at first with your verbal skills.   After discussion  of the procedure and risks, you place the IV,  further relieve anxiety with a dose of midazolam, and transport her to the operating room.  At some private hospitals, the   IV may be placed by a nurse while you are in the operating room, saving turnover time.  At most private hospitals or surgery centers, someone other than the anesthesiologist will transport the patient into the operating room.  This is your best chance for a short break between cases, without slowing the system down by your absence.

In a fee-for-service practice, both you and the surgeon have the same incentives:  to do as many cases as safely possible, and finish the day promptly.   There is an incentive to do an extra case, because every extra case is extra income.  The patients definitely benefit in this system, because in addition to the opportunity to practice their healing art, their doctors are receive extra renumeration for extra work.

Anesthesia professionals who are salaried employees do not have this incentive.  They earn as much if they do 4 cases or if they do 8 cases, as long as they serve out their 8-hour shift.  For this reason, salaried anesthesia professionals may work at a slower pace.  In an era where every labor union has mandatory lunch breaks and coffee breaks, the idea of  working for 10 straight hours on 8 patients may seem unreasonable, but it does happen in community anesthesia practice.  Thousands of  anesthesiologists you walked at the American Society of Anesthesiologists National Meeting could give you a lecture on it.  Every one will have their own advice on how best to handle a day like this one.

I’d wager that every anesthesiologist who is in a private practice would envy the opportunity to do 8 surgeries in 10 hours.

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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