“Keep It Simple, Stupid…”
Clinical Cases: You’re scheduled to anesthetize a 70-year-old man for a carotid endarterectomy, a 50-year-old man for an arthroscopic rotator cuff repair, and a 30-year-old woman for an Achilles tendon repair. What anesthetics would you plan?
Discussion: In 1960, U.S. Navy aircraft engineer Kelly Johnson coined the KISS Principle, an acronym for “Keep It Simple, Stupid.” The KISS principle supports that most systems work best if they are kept simple rather than made complex. Simplicity should be a key goal in design, and unnecessary complexity should be avoided. The KISS Principle likely found its origins in similar concepts such as Occam’s razor, Leonardo da Vinci‘s “Simplicity is the ultimate sophistication,” and architect Mies Van Der Rohe‘s “Less is more.”
Let’s look at the three cases listed above. For the carotid surgery, you choose an anesthetic regimen based on dual infusions of propofol and remifentanil, aiming for a rapid wake-up at the conclusion of surgery. For the arthroscopic rotator cuff repair, you fire up the ultrasound machine and insert an interscalene catheter preoperatively. After you’ve inserted the catheter, you induce general anesthesia with propofol and maintain general anesthesia with sevoflurane. For the Achilles repair, you perform a popliteal block preoperatively. After you’ve performed the block, you induce general anesthesia with propofol, insert an endotracheal tube, turn the patient prone, and maintain general anesthesia with sevoflurane and nitrous oxide.
All three cases proceed without complication.
Ten miles away, an anesthesiologist in private practice is scheduled to do the same three cases. For each of the three cases she chooses the same anesthetic regimen: Induction with propofol, insertion of an airway tube (an endotracheal tube for the carotid patient, and a laryngeal mask airway for the shoulder patient and the ACL patient, and an endotracheal tube for the prone Achilles repair), followed by sevoflurane and nitrous oxide for maintenance anesthesia and a narcotic such as fentanyl titrated in as needed for postoperative analgesia. The carotid patient is monitored with an arterial line, and vasoactive drugs are used as necessary to control hemodynamics.
“Wait a minute!” you say. “Elegant anesthesia requires advanced techniques for different surgeries. Why would a private practitioner do all three cases with nearly identical choices of drug regimen? Why would a private practitioner fail to tailor their anesthetic plan to the surgical specialty? Total intravenous anesthesia and ultrasound-guided regional anesthesia are important arrows in the quiver of a 21st-century anesthesiologist, aren’t they?”
In my first week in private practice, just months after graduating from the Stanford anesthesia residency program, the anesthesia chairman at my new hospital emphasized relying on the KISS Principle in anesthesia practice. He stressed that the objective of clinical anesthesia wasn’t to make cases interesting and challenging, but to have predictable and complication-free outcomes. Exposing a patient to extra equipment (two syringe pumps), or two anesthetics (regional plus general) instead of general anesthesia alone, adds layers of complexity, and defies the KISS principle.
There are no data indicating that using two syringe pumps and total intravenous anesthesia will produce a better outcome than turning on a sevoflurane vaporizer. There are no data demonstrating that combining a regional anesthetic with a general anesthetic for shoulder arthroscopy or Achilles tendon surgery will improve long-term outcome.
The KISS principle opines that most systems work best if they are kept simple rather than made complex, and doing two anesthetics instead of one adds complexity. I’ve learned that an anesthesiologist should choose the simplest technique that works for all three parties: the surgeon, the patient, and the anesthesiologist. The hierarchy from most simple to complex might look something like this: (1) local anesthesia alone, (2) local plus conscious sedation, (3) a regional block plus conscious sedation, (4) general anesthesia by mask, (5) general anesthesia with a laryngeal mask airway, (6) general anesthesia with an endotracheal tube, or (7) general anesthesia plus regional anesthesia combined. The combination of drugs used should be as minimal and simple as possible.
If all three parties (the surgeon, the patient, and the anesthesiologist) are okay with the patient being awake for a particular surgery, then the simplest of the first three options can be selected. If any one or all of the three parties wants the patient unconscious, then the simplest option of (4) – (7) can be selected.
I’m not an opponent of regional anesthesia. Ultrasound-guided regional anesthesia is a significant advance in our specialty for appropriate cases, and substituting regional anesthesia for a general anesthetic is a reasonable alternative. Compared with general anesthesia, peripheral nerve blocks for rotator cuff surgery have been associated with shorter discharge times, reduced need for narcotics, enhanced patient satisfaction, and fewer side effects (Hadzic A, Williams BA, Karaca PE, et al.: For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery after general anesthesia. Anesthesiology 2005; 102:1001-1007). On the other hand, meta-analysis has demonstrated no long-term difference in outcome between regional and general anesthesia for ambulatory surgery. (Liu SS, Strodtbeck WM, Richman JM, Wu CL: A comparison of regional versus general anesthesia for ambulatory anesthesia: A meta-analysis of randomized controlled trials. Anesth Analg 2005; 101:1634-1642). Why perform combined regional anesthesia plus general anesthesia for minor surgeries? Are we doing regional blocks just to showcase our new ultrasound skills? If there is an ultrasound machine in the hallway and an ambulatory orthopedic patient on the schedule, these two facts alone are not an indication for a regional block. Patients receive an extra bill for the placement of an ultrasound-guided block, and economics alone should never be a motivation to place a nerve block.
In a painful major orthopedic surgery such as a total knee replacement or a total hip replacement, a regional block can improve patient comfort and outcome. This month’s issue of Anesthesiology a retrospective review of nearly 400,000 patients who had total knee or total hip replacement. Compared with general anesthesia, neuroaxial anesthesia is associated with an 80% lower 30-day mortality and a 30 – 80% lower risk of major complications (Memtsoudis et al., Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients, Anesthesiology. 118(5):1046-1058, May 2013).
Many outpatient orthopedic surgeries performed under straight general anesthesia require only modest oral analgesics afterward. I had general anesthesia for a shoulder arthroscopy and subacromial decompression last month, and required no narcotic analgesics post-op. If I’d had an interscalene block, the anesthesiologist could have attributed my comfort level to the placement of the block. No block was necessary.
Achilles repairs don’t require a combined regional–general anesthetic. Achilles repairs simply don’t hurt very much. One surgeon in our practice does his Achilles repairs under local anesthesia with the patient awake, and the cases go very smoothly. Other surgeons in our practice insist that a popliteal block be placed prior to general anesthesia for Achilles repairs, a dubious decision because (a) it defies the KISS Principle, and (b) the surgeon has no expertise in dictating anesthetic practice.
Every peripheral nerve block carries a small risk. Although serious complications are unusual, risks include falling; bleeding; local tissue injury, pneumothorax; nerve injury resulting in persistent pain, numbness, weakness or paralysis of the affected limb; or local anesthetic toxicity. Systemic local anesthetic toxicity occurs in 7.5–20 per 10,000 peripheral nerve blocks (Corman SL et al., Use of Lipid Emulsion to Reverse Local Anesthetic-Induced Toxicity, Ann Pharmacother 2007; 41(11):1873-1877).
Use the simplest anesthetic that works. Assess whether combined regional–general anesthetics are necessary or wise. I realize that complex anesthetic regimens are routine aspects of a solid training program, because residents need to leave their training program with a mastery of multiple skills. But once you’re in private practice, my advice is to take heed of the KISS Principle.
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: