PEDIATRIC ANESTHESIA: WHO IS ANESTHETIZING YOUR CHILD?

Your 4-year-old son Jake snores and has enlarged tonsils.  Your pediatrician refers you to an ear, nose, and throat (ENT) specialist.  The ENT specialist recommends tonsillectomy, and schedules Jake for tonsillectomy for next Friday morning.  Who will do Jake’s anesthesia, and how will the anesthesia care be done?

Jake may or may not be diagnosed with Obstructive Sleep Apnea (OSA), based on his history of snoring.  Most children who snore and have enlarged tonsils are not subjected to a formal sleep study.  In a formal sleep study, doctors attach monitors such as pulse oximeters and apnea monitors to the child during a night’s sleep, to determine how often the child stops breathing during sleep and how low the oxygen level in his or her arterial blood drops during disordered sleep.  A sleep study is commonly done for adults with suspected OSA, but  not commonly ordered in children.

The decision to excise tonsils in pediatric patients is a clinical decision, based on the judgment of the pediatrician and ENT surgeon.  The surgery can be scheduled at a community hospital, a university hospital, a pediatric hospital, an ambulatory surgery center, or a freestanding ambulatory surgery center.  The nature of the anesthesia personnel can vary significantly depending on which type of facility the surgery is scheduled at.

In a community hospital, the anesthesia staff will be medical doctors (anesthesiologists), and/or nurse anesthetists (CRNA’s).  The anesthesiologists may or may not be pediatric specialists, but all anesthesiologists receive training in anesthetizing children.  Most likely, the ENT surgeon operates with an anesthesia team he or she is comfortable with, and this anesthesia team is comfortable anesthetizing children for a routine, elective surgery like tonsillectomy.  At a community hospital, it is possible but unlikely that the anesthesiologist will have completed extra years of training in pediatric anesthesia called a pediatric anesthesia fellowship.

In a university hospital, the anesthesia staff will include anesthesiologist faculty and also anesthesiologist residents and fellows who are in training.  The anesthesia care is directed or performed by a faculty member.  The actual hands-on anesthesia care, such as the placement of breathing tubes and IV catheters, is usually done by the residents and fellows, who are in the midst of their training.  An advantage of university hospitals is that pediatric anesthesia specialists are plentiful.  A disadvantage is that the anesthesia care is usually done by the trainee anesthesiologists who are supervised by these specialists.  At times, one faculty anesthesiologist may be supervising trainee anesthesiologists in two separate operating rooms for two separate surgeries concurrently.

In a pediatric hospital, the anesthesia care will be done by specialty pediatric anesthesiologists.  However, if the pediatric hospital is a university pediatric hospital, all the analysis in the preceding paragraph pertaining to university hospitals will apply.

An ambulatory surgery center (ASC) is a set of surgical suites that is designed to take care of outpatient surgeries, and designed to send the patient home directly from the ASC after recovery from surgery and anesthesia.  Most tonsillectomies are done as outpatient surgeries, and therefore many tonsillectomy patients are operated on in an ASC.  If the ASC is located inside a hospital, the anesthesia care will follow the analysis of community, university, and pediatric hospitals as discussed in the paragraphs above.  Many ASC’s are freestanding–that is, they are not on site in a hospital.  Many are located miles away from hospitals.  It is commonplace in the United States for tonsillectomies to be safely done in freestanding ASC’s.  The anesthesia care in most freestanding ASC’s will be anesthesiologists and/or nurse anesthetists, and once again the ENT surgeon will select an anesthesia provider he or she feels will provide safe care for his patient.

Some anesthesia teams prefer to meet and interview their patients days before surgery.  For a routine surgery such as tonsillectomy, it is common for the family to not meet the anesthesiologist until the day of surgery shortly before the procedure.  Some anesthesiologists will telephone the parent(s) the night before surgery to interview them and provide a preview of what to expect on the day of surgery.

The actual anesthesia care will typically follow this scenario:  Most practitioners will premedicate the child with oral midazolam (Versed) 20 minutes before the surgery.  This medication will make the child sleepy and relaxed, and calm the patient through the time when they separate from their parent(s).  Most facilities in the United States will not allow parents into the operating room.  Inside the operating room, the anesthesiologist will apply standard monitors of oxygen level, pulse, and blood pressure, and induce anesthesia by having the child breath the anesthesia gas sevoflurane through a mask.  Once the child is asleep, the anesthesiologist will place an IV in the child’s arm and a breathing tube in the child’s airway.  After the surgery is completed, the anesthesiologist will discontinue the anesthetics, awaken the child, and remove the breathing tube.  He or she will accompany the child to the Post Anesthesia Care Unit (PACU) and turn over the care of the child to a nurse there.

Is it safer if your child has a pediatric anesthesiologist, rather than a general practitioner anesthesiologist who takes care of both adults and children?  It depends.  It’s important to ask how often the practitioner anesthetizes children.  Someone who rarely anesthetizes a child under 6 years of age will be less comfortable with such a case, and may be less skillful in dealing with a complication or emergency should one occur.

Is it safer if your child has a fully-trained anesthesiologist rather than an anesthesia trainee/faculty team such as at a university hospital program?  Once again, it depends.  It depends on how much of the care is done by the trainee, and how intensive the faculty supervision is, as compared to an alternative facility where a fully-trained anesthesiologist stays present throughout the entire surgery.

At a community hospital or ASC, it is uncommon to have multiple specialist anesthesiologists on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and others for the general operating rooms.  Instead, general anesthesia practitioners cover many or all specialties.  If an anesthesiologist is not comfortable with an individual case, they can seek out a better trained anesthesiologist to cover the case, if such an anesthesiologist is available.  The trend for having a specialist anesthesiologist for every type of case is a difficult one to staff.  The goal at a community hospital is to assure that the standard of anesthesia care can be met with the physicians who are on staff and available.

In my opinion, neonates and  young infants should be cared for by  anesthesiologists with specialized pediatric training.  Whether specialized training should be mandated for children older than infants is debatable.  Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic in the future.

In the meantime, I recommend you ask your child’s anesthetist:  1) who is doing the actual anesthesia care today, a fully-trained anesthesia doctor, a doctor-in-training, or a nurse anesthetist?  2) how much training does the anesthetist have with children Jake’s age? and 3) how many children of Jake’s age have they anesthetized for a similar surgery in the past 12 months?  If you are uncomfortable with any of the answers, find another place for Jake to have his surgery.

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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3 thoughts on “PEDIATRIC ANESTHESIA: WHO IS ANESTHETIZING YOUR CHILD?

  1. My son is due to have an ENT operation and I found this information to be very helpful, I work in theatres but not with children and in my option I would agree that a specialised child anaesthetist whom has had extra special training should be the one who puts any child to sleep.

    Like

  2. Hello
    RICHARD NOVAK, M.D.

    I have a question my daughter 4 years 11mont need 17 therapeutic pulpotomy (baby root canal)

    they told the treatment is on her office with sedation IV, did you known is correct get IV or GA
    for this case.

    also it is necessary give the oral child midazolom , because my children is very cooperate she don’t have fear.

    I don’t known to make this treatment I am worried about it, And how long take IV almost tell me around 2 or 3 hours I am very confuse FOR What kind the Anesthesia need?

    thank you

    Like

    1. If they want to give your 4-year-old a general anesthetic, you have a right to be concerned. If an oral surgeon is doing both the surgery and the pediatric anesthetic, there are risks. Oral surgeons receive training in anesthesia, but if an anesthetic emergency evolves, they may fail to be able to handle it.

      In a significant case in California, a 6-year-old died after a mishap in general anesthesia by an oral surgeon. See story link at

      http://kron4.com/2016/03/31/east-bay-childs-death-triggers-investigation-into-safety-of-anesthesia-or-sedation-for-young-patients/

      The safest plan for pediatric anesthesia in a dental office is for one person to do the surgery (oral surgeon), and a second to do the anesthesia (an anesthesiologist).

      Like

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