In 2007, Hollywood released the movie Awake, in which the protagonist, played by Hayden Christensen (Anakin Skywalker from Star Wars) is awake during the general anesthetic for his heart surgery, and overhears the surgeon’s plan to murder him.  Producer Joana Vicente told Variety that Awake “will do to surgery what Jaws did to swimming in the ocean.” The movie trailer airs a statement that states, “Every year 21 million people are put under anesthesia. One out of 700 remain awake.”

            Awake was not much of a commercial success, with a total box office of only $32 million, but the film did publicize the issue of intraoperative awareness under general anesthesia, a topic worth reviewing.

If you undergo general anesthesia, do you have a 1 in 700 chance of being awake?  If you are a healthy patient undergoing routine surgery, the answer is no.  If you are sick and you are having a high-risk procedure, the answer is yes.

A key publication on this topic was the Sebel study. (The incidence of awareness during anesthesia: a multicenter United States study, Sebel, PS et al, Anest. Anal.  2004 Sep;99(3):833-9, Department of Anesthesiology, Emory University School of Medicine.)

The Sebel study was a prospective, nonrandomized study, conducted on 20,000 patients at seven academic medical centers in the United States. Patients were scheduled for surgery under general anesthesia, and then interviewed in the postoperative recovery room and at least one week after anesthesia.

A total of 25 awareness cases were identified, a 0.13% incidence, which approximates the 1 in 700 incidence quoted in the Awake movie trailer. Awareness was associated with increased American Society of Anesthesiologists (ASA) physical status, i.e. sicker patients.  Assuming that approximately 20 million anesthetics are administered in the United States annually, the authors postulated that approximately 26,000 cases of intraoperative awareness occur each year.

Healthy patients are at minimal risk for intraoperative awareness. Patients at higher risk for intraoperative awareness include:

1. Patients with a history of substance abuse or chronic pain.

2. American Society of Anesthesiologists (ASA) Class 4 patients (patients with a severe systemic disease that is a constant threat to their life) and others with limited cardiovascular reserve.

3. Patients with previous history of intraoperative awareness.

4. The use of neuromuscular paralyzing drugs during the anesthetic.

5. Certain surgical procedures are higher risk for intraoperative awareness.  These procedures include cardiac surgery, Cesarean sections under general anesthesia, trauma or emergency cases.

The causes of intraoperative awareness include:

1. Intentionally light anesthesia administered to patients who are hypotensive or hypovolemic, or those with limited cardiovascuar reserve.

2. Intentionally light anesthesia administered to obstetric patients, in the attempt to avoid neonatal respiratory depression.

3. Efforts to expedite operating room turnover and minimize recovery room times.

4. Some patients have higher anesthetic requirements, due to chronic alcohol or drugs.

5. Equipment and provider errors:

Empty vaporizers with no potent anesthetic liquid inside

Syringe pump malfunction

Syringe swap, or mislabeling of a syringe

6. Difficult intubation, in which the anesthesia provider forgets to give supplementary IV doses of hypnotics.

7. Choice of anesthetic.  In multiple trials, the use of neuromuscular blockers is associated with awareness.

8. Some studies show a higher incidence of awareness with total intravenous anesthesia or nitrous-narcotic techniques.

What are the legal implications of intraoperative awareness?

One study (Domino, et al, Awareness during anesthesia: A closed claims analysis.  Anesthesiology 1999; 90: 1053-1061) reported that cases of awareness represented 1.9% of malpractice claims against anesthesiologists.

Deficiencies in labeling syringes and vigilance were common causes for awake paralysis. The patients’ vital signs were not classic clues:  hypertension was present in only 15% of recall cases, and tachycardia was present in only 7%.

What are the consequences of intraoperative awareness?

Reference:  (Samuelsson P et al: Late psychological symptoms after awareness among consecutively included surgical patients.  Anesthesiology 2007;106;26-32.)

The following consequences have been reported:

1. Recollections of auditory perceptions and a sensation of paralysis.  Anxiety, helplessness, and panic.  Pain is described less frequently.

2. Up to 70% of patients develop Post-Traumatic Stress Disorder (PTSD), i.e. late psychological symptoms of anxiety, panic attacks, chronic fear, nightmares, flashbacks, insomnia, depression, or preoccupation with death.

What about BIS Monitoring?

Bispectral Index monitoring, or BIS monitoring, uses a computerized algorithm to convert a single channel of frontal EEG into an index score of hypnotic level, ranging from 100 (awake) to 0 (isoelectric EEG).

The BIS monitor was FDA-approved in 1996.  A BIS level of 40 – 60 reflects a low probability of consciousness during general anesthesia.  BIS measures the hypnotic components of anesthesia (e.g. effects of propofol and volatile agents), and is relatively insensitive to analgesic components (e.g. narcotics) of the anesthetic.  The BIS monitor is neither 100% sensitive nor 100% specific.

The B-Aware Trial (Myles RS et al: Bispectral index  monitoring to prevent awareness during anaethesia: the B-Aware randomized controlled trial.  Lancet 2004;363:1757-63) was a randomized, double-blind, multi-center controlled trial using BIS in 2500 patients at high risk for awareness (cardiac surgery, C-sections, impaired cardiovascular status, trauma, chronic narcotic users, heavy alcohol users).   Explicit recall occurred in 0.17% (2 patients) when BIS used, vs. 0.91% (11 patients) when no BIS was used. This was a significant finding with p

A significant paper published in the world’s leading anesthesia journal, (O’Connor,et al: BIS monitoring to prevent awareness during general anesthesia. Anesthesiology 2001;94:520-2.) concluded that the predictive positive and negative values of BIS monitoring were low due to the infrequent occurrence of intraoperative awareness.  In addition, the cost of BIS monitoring all patients undergoing general anesthesia is high. Because there have been reported cases of awareness despite BIS monitoring, the authors concluded that the effectiveness of the monitor is less than 100%. The authors concluded that the contention that BIS Index monitoring reduces the risk of awareness is unproven, and the cost of using it for this indication is currently unknown.

In 2005, the American Society of Anesthesiologists published its Practice Advisory for Intraoperative Awareness.  The anesthesia practitioner is advised to do the following:

1. Review patient medical records for potential risk factors. (Substance use or abuse, previous history of intraoperative awareness, history of difficult intubation, chronic pain patients using high doses of opioids, ASA physical status IV or V, limited hemodynamic reserve).

2. Determine other potential risk factors. (Cardiac surgery, C-section, trauma surgery, emergency surgery, reduced anesthetic doses in the presence of paralysis, planned use of muscle relaxants during the maintenance phase of general anesthesia, planned use of nitrous oxide-opioid anesthesia).

3. Patients considered to be at increased risk of intraoperative awareness should be informed of the possibility when circumstances permit.

4. Preinduction checklist protocol for anesthesia machines and equipment to assure that the desired anesthetic drugs and doses will be delivered.  Verify IV access, infusion pumps, and their connections.

5. The decision to administer a benzodiazepine prophylactically should be made on a case-by-case basis for selected patients.

6. Intraoperative monitoring of depth of anesthesia, for the purpose of minimizing the occurrence of awareness, should rely on multiple modalities, including clinical techniques (e.g., ECG, blood pressure, HR, end-tidal anesthetic gas analyzer, and capnography)…. Brain function monitoring is not routinely indicated for patients undergoing general anesthesia, either to reduce the frequency of intraoperative awareness or to monitor depth of anesthesia…. The decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner of selected patients (e.g. light anesthesia).

Published suggestions for the prevention of awareness include (Ghoneim MM:  Awareness during anesthesia.  Anesthesiology 2000;92:597-602.):

1. Premedication with an amnestic agent.

2. Giving adequate doses of induction agents.

3. Avoiding muscle paralysis unless totally necessary.

4. Supplementing nitrous/narcotic anesthesia with 0.6% MAC of a volatile agent.

5. Administering 0.8 – 1.0 MAC when volatile agent is used alone.

6. Confirming delivery of anesthetic agents to the patient

In 2006, the California Society of Anesthesiologists released the following Statement on Intraoperative Awareness:

“ . . . Anesthesiologists are trained to minimize the occurrence of awareness under general anesthesia.  It is recognized that on rare occasions, usually associated with a patient’s critical condition, this may be unavoidable.  Furthermore, it is commonplace in contemporary anesthetic practice to employ a variety of techniques using regional nerve blocks and varying degrees of sedation.  Patients often do not make an distinction between these techniques and general anesthesia, yet awareness is often expected and anticipated with the former.  This may have led to a misunderstanding of ‘awareness’ during surgery by many patients.”

In 2011, the New England Journal of Medicine, arguably the most prestigious medical journal in the world, published a study looking at using the BIS monitor for the prevention of intraoperative awareness. (Avidan MS, et al., N Engl J Med. 2011 Aug 18;365(7):591-600. doi: 10.1056/NEJMoa1100403. Prevention of intraoperative awareness in a high-risk surgical population). The researchers tested the hypothesis that a protocol incorporating the electroencephalogram-derived bispectral index (BIS) was superior to a protocol incorporating standard monitoring of end-tidal anesthetic-agent concentration (ETAC) for the prevention of awareness.

They randomly assigned 6041 patients at high risk for awareness to either BIS-guided anesthesia or ETAC-guided anesthesia. Results showed that a total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, had definite intraoperative awareness.  The superiority of the BIS protocol was not established.  Contrary to expectations, fewer patients in the ETAC group than in the BIS group experienced awareness.

To conclude, intraoperative awareness is a real but rare occurrence, with certain patient populations at higher risk. The BIS monitor is no panacea. Specific pharmacologic strategies can minimize the incidence of awareness. If you are a healthy patient undergoing a routine procedure, intraoperative awareness should be very rare.

The best defense against intraoperative awareness will always be the presence of a well-trained and vigilant anesthesiologist.

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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