Clinical Case for Discussion:  A needle-phobic 16-year-old male is scheduled for a shoulder arthroscopy at a freestanding surgery center.  He is tearful and refuses any needles while he is awake.  He is 5 feet 3 inches tall, weighs 220 pounds, and has a Body Mass Index of 39.

What would you do?

Discussion:  You bring the patient into the operating room and apply the standard monitors.  You begin an inhalation induction with 70% inspired nitrous oxide and sevoflurane.  You increase the concentration of sevoflurane gradually after each breath.  After 2 minutes, at 4% inspired sevoflurane, the patient begins to cough, buck, and have stridor, and the oxygen saturation plummets below 60%.  You see no site to place an I.V., and the nurse and surgeon are no help.  You are not able to improve the airway with jaw thrust, mask ventilation, continuous positive airway pressure, or an oral airway.  You place an laryngeal mask airway (LMA), but the patient continues to have stridor and a weak cough.  No ventilation is possible.  You give intramuscular succinylcholine at 4 mg/kg, but while you are waiting for the drug to take effect,  the patient’s ECG changes to ventricular fibrillation.  You scream for the defibrillator, and do direct laryngoscopy to attempt placement of an endotracheal tube in the now-flaccid patient.  Your heart rate is 180 beats–per-minute, and you are praying for the patient’s heartbeat to return.  You can’t believe that this boy walked into the surgery center as healthy as can be, and that within minutes you have brought on the circumstances of cardiac and respiratory arrest.

In a parallel universe, you anticipate all the above issues, and prepare yourself.  You are aware that his BMI = 39 places him at increased risk for an inhalational induction.  You explain to the patient and his parents that there are risks for an overweight patient being anesthetized without an I.V., and lobby hard for him to permit you to attempt an awake I.V. placement.  You offer him oral midazolam as an anti-anxiety premedication, and topical EMLA to numb the I.V. site.  Alas, he is crying and still refuses any needle. You place an automated blood pressure cuff on his upper arm, and note that veins are visible on his hand when you inflate the cuff in Stat mode on that extremity.  His airway appears normal.  You describe to the parents that there is a risk that their son might have dangerous low oxygen levels during the mask induction of anesthesia.  They agree to accept this risk, and you document the same in the medical records.  You make a plan to proceed with inhalation induction, using the automated cuff to maximize the size of the veins on his hand.

(Note:  If you do not have confidence in proceeding, you may delay the patient until another anesthesiologist is present to assist you, or cancel the case.  Also note that if the anesthetic is done in a hospital rather than a freestanding surgery center, the identical clinical issues will be present, and the anesthetic plan will be similar except for the presence of additional backup anesthesia personnel.)

You enter the operating room and apply the standard monitors.  You place a mask strap behind the patient’s head to help hold the anesthesia mask over his airway, and have him breathe 100% oxygen with high flows of 10 liters/minute for two full minutes prior to beginning induction.  Next you add 8% sevoflurane to the gas mixture, and ask the patient to take deep vital capacity breaths your anesthetic circle system.  This technique is known as Vital Capacity Rapid Inhalation Induction.  (Yurino M, A comparison of vital capacity breath and tidal breathing techniques for induction of anaesthesia with high sevoflurane concentrations in nitrous oxide and oxygen, Anaesthesia.1995 Apr;50(4):308-11).  For safety reasons, I prefer sevoflurane induction with 100% oxygen instead of using nitrous oxide, which limits the delivered oxygen concentration.

As soon as the patient is anesthetized deeply enough, (seeing the eyes conjugate in the midline is a useful monitoring sign), you activate the blood pressure cuff on his upper arm in the Stat mode, and you move to his lower arm to start the I.V.  You leave the patient breathing on his own with the straps holding the mask over his face, and use both of your hands to place a 20-gauge I.V. catheter.  Once the intravenous catheter is placed, you continue the anesthetic using intravenous and inhalation drugs, with either an LMA or endotracheal tube for airway management.

Ambulatory anesthesia in freestanding facilities is a gravy train of healthy patients and straightforward cases, right?  Not all the time.

In the hospital, when you anesthetize elderly, sick patients for complex surgeries, you have a multitude of advanced technologies at your disposal.  You have invasive monitoring, transesophageal echocardiogram machines, laboratories, blood banks, and intensive care unit backup, as well as dozens of other anesthesia providers available within seconds to assist you if you get into trouble.  In addition, it’s understood by the patient and family that there are significant risks if the patient is old, sick, or if the surgery is complex.

In anesthetics for healthy outpatient surgery, the patient and the family expect the rate of adverse outcomes to be … zero.  Despite your informed consent that rare problems could occur, there will be anguish and anger if problems indeed do occur.

Treat needle-phobia with respect.  It can be a life-threatening problem in the hands of an inexperienced anesthesia provider.

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.


5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
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. PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press, 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:


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
Deann Brady (Sunnyvale, CA USA) – See all my reviews
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”


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 by clicking on the picture below:



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