Your 85-year-old grandmother had two gallstone attacks in the past 6 months. Is she too old for surgery? Is it safe for her to have her gallbladder removed?
It depends. A general surgeon would serve as the consultant as to the natural history of the gallbladder disease. He may opine that future gallstone attacks are likely, and that the severe pain and fever of acute cholelithiasis is possible.
If your grandmother was 50 years old, you’d expect the surgical team to operate on her. For an 85-year-old patient, the surgical prognosis depends on her medical condition. She needs preoperative assessment from a specialist, and that specialist would be an anesthesiologist.
At Stanford University the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word perioperative refers to medical practice before, during, and after surgical operations. Preoperative assessment refers to the medical work-up before a surgical procedure—the work-up which establishes that all necessary diagnostic and therapeutic measures have been taken prior to proceeding to the operating room.
Age alone should not be a deterrent to surgery. Increased life expectancy, safer anesthesia, and less invasive surgical techniques such as laparoscopy have made it possible for a greater number of geriatric patients to undergo surgical intervention. The decision to operate should not be based on age alone, but should be based on an assessment of the risk-to-benefit ratio of each individual case. Surgical risk and outcome in patients 65 years old and older depend primarily on four factors: (1) age, (2) whether the surgery is elective or urgent, (3) the type of procedure, and (4) the patient’s physiologic status and coexisting disease. (reference: Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7th Edition, 2009).
Let’s look at each of these four factors:
1) Age. Data support that increasing age increases risk. Complication rates and mortality rates are higher for patients in their 80’s than for patients in their 60’s.
2) Emergency surgery. Patients presenting for emergency surgery are often sicker than patients for elective surgery, and have increased risk. There may be insufficient time for a full preoperative medical workup or tune-up prior to anesthesia.
3) Type of procedure. A trivial procedure such as finger or toe surgery carries significantly less risk than open heart surgery or intra-abdominal surgery.
4) Coexisting disease. The American Society of Anesthesiologists has a classification system for patients which categorizes how healthy or sick a patient is (see the American Society of Anesthesiologists Physical Status Class categories below). A patient with severe heart or lung disease is at higher risk than a rigorous patient who hikes, bikes or swims daily without heart or lung pathology.
Let’s examine these four factors in your 85-year-old grandmother. Regarding factor (1), she is old, and therefore she carries increased risk solely because of her advanced age. Regarding factor (2), her surgery is non-emergent, and this is in her favor. Regarding factor (3), her procedure requires intra-abdominal surgery, which is more invasive and carries more cardiac and respiratory risk than a trivial hand or foot or cataract surgery. She’ll have to cope with post-operative abdominal pain and pain on deep breathing, each of which can affect her lung function after anesthesia. Factor (4), her pre-existing medical history and physical condition, is the key element in her pre-operative consult.
The American Society of Anesthesiologists Physical Status Class categorizes patients as follows:
Class I – A normal healthy patient. Almost no one over the age of 65 is an ASA I.
Class II – A patient with mild systemic disease.
Class II – A patient with severe systemic disease.
Class IV – A patient with severe systemic disease that is a constant threat to life.
Let’s say your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity. She is reasonably active without limiting heart or lung disease symptoms, and she can climb two flights of stairs without shortness of breath.
She is an ASA Class II.
What if your grandmother had a past heart attack which left her short of breath walking up two flights of stairs, or she has kidney failure and is on dialysis, or she has severe emphysema that leaves her short of breath walking up two flights of stairs? These problems make her an ASA Class III, and she is at higher risk than a Class II patient.
If your 85-year-old grandmother is short of breath at rest or has angina at rest, due to either heart failure or chronic lung disease, she is an ASA Class IV patient, and she is at very high risk for surgery and anesthesia.
Laypersons can access an online surgical risk calculator, sponsored by the American College of Surgeons, at www.riskcalculator.facs.org, and enter the specific data for any surgical patient, to estimate surgical risk.
If your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity as described above, then her operative risk is moderate and most anesthesiologists will be comfortable giving her a general anesthetic. The American College of Surgeons risk calculator estimates her risk of death, pneumonia, cardiac complications, surgical site infection, or blood clots as < 1%. Her risk of serious complication is estimated at 2%.
How will the anesthesiologist proceed?
For an 85-year-old patient, most anesthesiologists will require a written consultation note from an internal medicine primary care doctor or a cardiologist prior to proceeding with anesthesia. The anesthesiologist will then confirm that all necessary diagnostic and therapeutic measures have been done prior to surgery. Routine lab testing is not be ordered because of age alone, but rather pertinent lab tests are done as indicated for the particular medical problems of each patient.
The anesthesiologist then explains the risks of anesthesia and obtains informed consent prior to the surgery. He or she will explain that an 85-year-old patient with treated hypertension, asthma, hyperlipidemia, and obesity has a higher chance of heart, lung, or brain complications than a young, healthy patient. Your grandmother will have to accept the risks as described by the anesthesiologist.
What do anesthesiologists do differently for geriatric anesthetics, in contrast to anesthesia practice on young patients?
(1) Anesthesiologists use smaller doses of drugs on elderly patients than they do on younger patients. Geriatric patients are more sensitive to anesthetic drugs, and the effect of the drugs will be more prolonged.
(2) Geriatric patients have progressive loss of functional reserve in their heart, lungs, kidney, and liver systems. The extent of these changes varies from patient to patient, and each patient’s response to surgery and anesthesia is monitored carefully. (Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7th Edition, 2009). The anesthesiologist’s routine monitors will include pulse oximetry, electrocardiogram, automated blood pressure readings, temperature monitoring, and monitoring of all inspired gases and anesthetic concentrations. Because most anesthetic drugs cause decreases in blood pressure, anesthesiologists slowly titrate additional anesthetic doses as needed, and remain vigilant for blood pressure drops that are excessive or unsafe.
What about mental decline following geriatric surgery?
Postoperative short-term decrease in intellect (decrease in cognitive test performance) during the first days after surgery is well documented, and typically involves decreases in attention, memory, and fine motor coordination. Early cognitive decline after surgery is largely reversible by 3 months. The reported incidence of cognitive dysfunction after major noncardiac surgery in patients older than 65 years is 26% at 1 week and 10% at 3 months. (reference: Johnson T, Monk T, Rasmussen LS, et al: Postoperative cognitive dysfunction in middle-aged patients. Anesthesiology 2002; 96:1351-1357).
In conclusion, the decision to proceed with your grandmother’s surgery and anesthesia requires an informed assessment of the benefit of the surgery versus the risks involved. Well-trained anesthesiologists anesthetize 85-year-old patients every day, with successful outcomes. My advice is to choose a medical center with fine physician anesthesia providers, and heed their consultation regarding whether your grandmother poses any unacceptable risk for surgery and anesthesia.
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: