A general anesthetic renders the patient asleep and insensitive to pain for surgery. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. Before the anesthetic, oxygen is administered by mask to fill the patient’s lungs with 100% oxygen. Most adult patients are given general anesthesia by intravenous injection, usually of the medication propofol. This injection causes the patient to lose consciousness within 10 – 20 seconds. This is called the induction of anesthesia. The maintenance of anesthesia during surgery is done by mixing an anesthesia gas or gases with the oxygen. Typical inhaled anesthesia gases are nitrous oxide, sevoflurane, or isoflurane. Sometimes a continuous infusion of intravenous anesthetic such as propofol is given as well. The choice and dose of drugs is done by the anesthesia attending, based on the patient’s size, age, the type of surgery, and the anesthesiologist’s experience.
Many patients are given prophylactic anti-nausea medication during the anesthetic. If postoperative pain is anticipated, the anesthesiologist can also administer intravenous narcotics such a morphine, meperidine (Demerol), or fentanyl.
Depending on the patient’s medical condition and type of surgery, the anesthesiologist may protect the patient’s airway during the general anesthetic by placing a breathing tube through the mouth, either an endotracheal tube (ET Tube) into the patient’s windpipe, or a laryngeal mask airway (LMA) just above the voice box.
At the conclusion of surgery, the general anesthetic gases and/or intravenous anesthetic infusion(s) are discontinued. The patient usually regains consciousness within 5 – 15 minutes. The patient is then transferred to the recovery room.
Spinal anesthesia is done by the injection of local anesthetic solution into the low back into the subarachnoid space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word subarachnoid translates to “below the arachnoid”. The arachnoid is one of the layers of the meninges covering the nerves of the spinal column. In the subarachnoid space lies the cerebral spinal fluid (CSF) which surrounds the spinal cord and brain. In a spinal anesthetic, the subarachnoid space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.
Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the subarachnoid space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.
Following the onset of numbness from spinal anesthesia, the patient may either stay awake for surgery, or more often intravenous anesthesia is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement spinal anesthesia.
Epidural anesthesia is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected. Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given. The catheter is removed at the end of surgery, or sometimes days later if continued epidural medications are administered for postoperative pain control.
Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the epidural space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.
Following the onset of numbness from epidural anesthesia, the patient may either stay awake for surgery, or more often intravenous sedation is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement epidural anesthesia.
Regional anesthesia is the injection of local anesthetic (either lidocaine or Marcaine) near a nerve to block that nerve’s function. Examples of regional anesthesia include arm blocks (axillary block, interscalene block, subclavicular block), and leg blocks (femoral block, sciatic block, popliteal block, ankle block). An advantage of regional anesthesia blocks is that the patient may remain awake for the surgery. If desired, the anesthesia provider may administer intravenous sedation or general anesthesia in addition to the regional anesthetic, to allow the patient to sleep during the surgery–the advantage of this combined anesthetic technique is the regional anesthetic blocks all surgical pain and less sleep drugs are required.
Some minor surgical procedures (for example: breast biopsies, eyelid surgery, some hernia surgeries) can be done with the combination of local anesthesia plus intravenous anesthesia sedation. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The anesthesiologist is present for the entire surgery, and administers intravenous sedatives as required for the patient’s comfort and the surgeon’s needs. If the sedation is deep enough, the intravenous sedation will be termed general anesthesia. While the patient is sedated, the surgeon usually injects local anesthetics into the surgical site to block both surgical and post operative pain.
Vigilance by an anesthesiologist during intravenous sedation is also known as Monitored Anesthesia Care, or MAC.
Because the separation of a young child from his or her parents can be one of the most distressing aspects of the perioperative experience, many children benefit significantly from oral preoperative sedation with midazolam. This relatively pleasant-tasting liquid is given by mouth about twenty minutes prior to the start of the anesthetic. Although the midazolam rarely causes children to fall asleep, it does reduce anxiety dramatically, allowing for a much smoother separation from parents. It also tends to cause a wonderful short term amnesia, so that the children often have no recollection of separating from their parents, or even of going to the operating room.
Although the initial anesthetic is usually administered via an intravenous infusion in adult patients, this approach requires starting an IV while the patient is still awake. This technique would be quite unpopular with younger children. Most young children prefer to go to sleep breathing a gas, a technique known as an inhalation induction. This technique is used for almost all routine surgeries, but cannot safely be employed in certain rare situations, such as emergencies.
An inhalation induction consists of the child breathing a relatively pleasant smelling anesthetic vapor – usually sevoflurane – via a facemask for approximately 30 to 60 seconds. The child loses consciousness while breathing the gas, and the IV can then be started painlessly. Generally, the child continues to breath the gas throughout the duration of the surgery, either via the facemask or an endotracheal tube, depending on the duration and type of surgery. It is this breathing of the gas which keeps the child anesthetized. At the end of the surgery, the gas is discontinued, and the child begins to awaken.
Prior to awakening, children may be given either analgesics (pain medicines) or anti-emetics (drugs which reduce the likelihood of nausea and vomiting). The type of surgery will determine which of the many possible medications will be used for these purposes. The purpose of these medications is to make the child’s awakening as calm and pleasant as possible. Equally important in this regard is reuniting the child with his or her parents as quickly as possible.
Despite best attempts, it is important for parents to realize that children, especially those less than five years of age, often are somewhat cranky and irritable following anesthesia and surgery. We do our best to minimize this, but we cannot prevent it in all cases. Similarly, some children will experience postoperative nausea and vomiting despite receiving medications which are intended to prevent it.
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 firstname.lastname@example.org, 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: