Clinical Case for Discussion:  You are an attending anesthesiologist in private practice, in your first year out of residency.  Your schedule for the next morning includes a 60-year-old, 350-pound male with ankylosing spondylitis and congestive cardiomyopathy for cholecystectomy.  You turn off the lights the night before at 10 p.m., and cannot fall asleep, as you are worried about the case.  What do you do?

Discussion:  During my first year in private practice, one of my senior anesthesia colleagues, ripe with gray hair and receding hairline, stood outside of his operating room at 7 a.m.  I bid him good morning and he said, “It is a good morning, despite the usual anxieties that come with what I’m about to do.”  I asked him to explain, and he said, “Every day I come to work knowing that something could go wrong, and my patient could be harmed, and it could change my life forever.  That gives me anxiety, which I have to cope with every day.”

Anesthesia textbooks are thick with information on how to assess patients preoperatively, how to perform anesthetics, and how to manage postoperative medical problems.  You won’t find much guidance on how to handle your own anxieties as an anesthesia provider.

What are chances that you will have a perioperative death during your career in anesthesia?  In a recent published survey, 84% of anesthesiologist respondents had an unexpected perioperative death or serious injury of a perioperative patient during their career (Gazoni FM, et al, The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey, Anesthesia and Analgesia, Jul 7, 2011). A majority of these respondents indicated that they experienced guilt, depression, anxiety, sleeplessness, fear of litigation, fear of judgment by colleagues, anger, and reliving of the event. Five percent experienced use of drugs or alcohol and 12% considered a career change after the event.

During my 25-year career as an attending anesthesiologist in private practice, I’ve had two unanticipated patient deaths.  Both were awful events for me, and had me reeling for some time.  The first was a male in his 70’s for an open abdominal aortic aneurysm repair.  The case occurred at a local community hospital, six months after completing my Stanford training.  As the vascular surgeon closed the abdominal incision, the patient went into pulmonary edema, dropped his cardiac output and arrested.  The resulting unsuccessful CPR, followed by the conversations with the surgeon and the patient’s family, were gut-wrenching experiences.  Because I was new at the hospital, I’m sure there were individuals who doubted my abilities and competence.  The post-mortem diagnosis was myocardial infarction.  The case went through peer review, my management was not challenged, and no one blamed the anesthesiologist.  But I remember that one day after this patient died, my first patient was a sickly 90-year-old.  If my hands weren’t shaking that morning, my confidence was.

The second death was an elderly insulin-dependent diabetic end-stage-renal-disease patient who was having an upper extremity arterial-venous fistula revision for dialysis access.  At the conclusion of the case, I administered protamine to reverse the heparin, and the patient’s oximeter stopped beeping.  Her automated blood pressure cuff readings became unobtainable.  It took me several moments to figure out that she had no discernable pulse either.  Her only working monitor was the sinus rhythm on the ECG, and that soon deteriorated into ventricular fibrillation.  We could not resuscitate her. The post-mortem assessment was anaphylaxis to protamine.  This case occurred in the third year of my private practice career, and again it shook my confidence for a while.

Anesthesia practice can be lonely.  During university training, each anesthesia resident has an attending to back them up and emotionally hold their hand through both easy and difficult cases.  When you finish training and enter the next phase of your career, you have to work alone.  In the middle of the night, you may be presented with an extraordinarily sick patient and you may be the only anesthesiologist for miles around.  In some practices you will work in freestanding facilities, and again you will be the only anesthesiologist for miles around.

What about the Clinical Case above, where you are the first-year attending anesthesiologist who can’t sleep because you’re worried about the difficult airway, the morbid obesity, and the congestive cardiomyopathy in your patient for the next day?  What are solutions to the anxieties an anesthesiologist experiences?  I’m no psychiatrist, but here’s my advice after having toiled in the anesthesia arena for 25 years:

1) You’re often going to feel anxious, and that’s normal.  Expect it.

2) Learn as much as you can during your residency, so you emerge from your training with confidence.  Not cockiness–“Man’s got to know his limitations,” as Dirty Harry famously said in Magnum Force–but you need to be confident.

3) If you’re truly worried or in over your head, remember how reassuring it was in residency to have an ally. Call another attending the night before for their opinion on a difficult case for the next day. Call for help before you start a challenging case regarding a difficult intubation or a complex anesthetic induction.

4) Cultivate a strong emotional support team of people, inside and outside of the hospital.  You’ll need them.

4) If you run into ongoing insomnia, depression, or fear, seek professional help.  It’s well known that anesthesiologists are vulnerable to chemical dependence.  Treating your own insomnia or anxiety with fentanyl or Versed or propofol will be a dead end.

The same anesthesia attending I referred to in the first paragraph once told me, “There are three ways an anesthesiologist can end his career.  He can: 1) die in mid-career, 2) quit because he can’t handle the stresses of the job any more, or 3) walk away and retire on their own terms when they choose to.”

Let’s hope each of us gets to choice number 3!

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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