13-year-old Jahi McMath of Oakland, California suffered sudden bleeding from her nose and mouth and cardiac arrest following a December 9th 2013 tonsillectomy, a surgery intended to help treat her obstructive sleep apnea. After the bleeding she lapsed into a coma. Three days later she was declared brain-dead.
How could this happen?
Behind circumcision and ear tubes, tonsillectomy is the third most common surgical procedure performed on children in the United States. 530,000 tonsillectomies are performed children under the age of 15 each year. Tonsillectomy is not a minor procedure. It involves airway surgery, often in a small child, and often in a child with obstructive sleep apnea. The surgery involves a risk of bleeding into the airway. The published mortality associated with tonsillectomy ranges from 1:12,000 to 1:40,000. (American Academy of Otolaryngology-Head and Neck Surgery Guidelines for Tonsillectomy in Children and Adolescents, Am Family Physician. 2011 Sep 1;84(5):566-573).
Between 1915 and the 1960’s, tonsillectomy was the most common surgery in the United States, done largely to treat chronic throat infections. After the 1970’s, the incidence of tonsillectomies dropped, as pediatricians realized the procedure had limited success in treating chronic throat infections. The number of tonsillectomies has increased again in the last thirty years, as a treatment for obstructive sleep apnea (OSA). Currently 90 percent of tonsillectomies are performed to treat OSA. Only 1 – 4 % of children have OSA, but many of these children exhibit behavioral problems such as growth retardation, poor school performance, or daytime fatigue. The American Academy of Otolaryngology concluded that “a growing body of evidence indicates that tonsillectomy is an effective treatment for sleep apnea.” (AAO–HNS Guidelines for Tonsillectomy in Children and Adolescents, Am Family Physician. 2011 Sep 1;84(5):566-573).
Tonsillar and adenoid hypertrophy are the most common causes of sleep-disordered breathing in children. Obstructive sleep apnea is defined as a “disorder of breathing during sleep characterized by prolonged upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep.” (Miller’s Anesthesia, 7th edition, 2009, Chapter 82).
In OSA patients, enlarged tonsils can exacerbate loud snoring, decrease oxygen levels, and cause obstruction to breathing. Removal of the tonsils can improve the diameter of the breathing passageway. Specific diagnosis of OSA can be made with an overnight sleep study (polysomnography), but applying this test to large populations of children is a significant expense. Currently only about 10 percent of otolaryngologists request a sleep study in children with sleep-disordered breathing prior to surgery (Laryngoscope 2006;116(6):956-958). In our surgical practice in Northern California, most pediatricians and otolaryngologists forego the preoperative overnight sleep study if the patient has symptoms of obstructed sleep, confirmed by a physical exam that reveals markedly enlarged tonsils.
Every tonsillectomy requires general anesthesia, and anesthesiologists become experts in the care of tonsillectomy patients. Prior to surgery the anesthesiologist will review the chart, interview the parent(s), and examine the child’s airway. Most children under the age of 10 will be anesthetized by breathing sevoflurane via an anesthesia mask, which is held by the anesthesiologist. Following the child’s loss of consciousness, the anesthesiologist will place an intravenous (IV) catheter in the child’s arm. The anesthesiologist then inserts a breathing tube into the child’s windpipe, and turns the operating table 90 degrees away so the surgeon has access to operate on the throat. The surgeon will move the breathing tube to the left and right sides of the mouth while he or she removes the right and left tonsils. (note: children older than the age of 10 will usually accept an awake placement of an IV by the anesthesiologist, and anesthetic induction is accomplished by the IV injection of sleep drugs including midazolam and propofol, rather than by breathing sevoflurane via an anesthesia mask).
The child remains asleep until the tonsils are removed, and all bleeding from the surgical site is controlled. The anesthesiologist then discontinues general anesthetic drugs and removes the breathing tube when the child awakens. Care is taken to assure that the airway is open and that breathing is adequate. Oxygen is administered until the child is alert. Tonsillectomy is painful, and intravenous opioid drugs such as fentanyl or morphine are commonly administered to relieve pain. The opioids depress respiration, and monitoring of oxygen levels and breathing is routinely done until the child leaves the surgical facility.
Most tonsillectomy patients have surgery as an outpatient and are discharged home within hours after surgery. Prior to the 1960’s patients were hospitalized overnight routinely post-tonsillectomy. In 1968 a case series of 40,000 outpatient tonsillectomies with no deaths was reported, and performance of tonsillectomy on an outpatient basis became routine after that time. (Miller’s Anesthesia, 7th edition, 2009, Chapter 33).
Published risk factors for postoperative complications after tonsillectomy include: (1) age younger than 3 years; (2) evidence of OSA; (3) other systemic disorders of the heart and lungs); (4) presence of airway abnormalities; (5) bleeding abnormities; and (6) living a long distance from an adequate health care facility, adverse weather conditions, or home conditions not consistent with close observation, cooperativeness, and ability to return quickly to the hospital. (Miller’s Anesthesia, 7th edition, 2009, Chapter 82).
The incidence of post-tonsillectomy bleeding increases with age. In a national audit of more than 33,000 tonsillectomies, hemorrhage rates were 1.9% in children younger than 5 years old, 3% in children 5 to 15 years old, and 4.9% in individuals older than 16. The return to the operating room rate was 0.8% in children younger than 5 years old, 0.8% in children 5 to 15 years old, and 1.2% in individuals older than 16. (Miller’s Anesthesia, 7th edition, 2009, Chapter 75).
Primary bleeds usually occur within 6 hours of surgery. Hemorrhage is usually from a venous or capillary bleed, rather than from an artery. Complications occur because of hypovolemia (massive blood loss), the risk of blood aspiration into the lungs, or difficulty with replacing the breathing tube should emergency resuscitation be necessary. Early blood loss can be difficult to diagnose, as the blood is swallowed and not seen. Signs suggesting hemorrhage are an unexplained increasing heart rate, excessive swallowing, pale skin color, restlessness, sweating, and swelling of the airway causing obstruction. Low blood pressure is a late feature. (Miller’s Anesthesia, 7th edition, 2009, Chapter 75).
What happened to 13-year-old Jahi McMath in Oakland following her tonsillectomy? We have no access to her medical records, and all we know is what was reported to the press. The following text was published in the 12/21/2013 Huffington Post:
After her daughter underwent a supposedly routine tonsillectomy and was moved to a recovery room, Nailah Winkfield began to fear something was going horribly wrong.
Jahi was sitting up in bed, her hospital gown bloody, and holding a pink cup full of blood.
“Is this normal?” Winkfield repeatedly asked nurses.
With her family and hospital staff trying to help and comfort her, Jahi kept bleeding profusely for the next few hours then went into cardiac arrest, her mother said.
Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.
“Ms. McMath is dead and cannot be brought back to life,” the hospital said in the memo, adding: “Children’s is under no legal obligation to provide medical or other intervention for a deceased person.”
In an interview at Children’s Hospital Oakland on Thursday night, Winkfield described the nightmarish turn of events after her daughter underwent tonsil removal surgery to help with her sleep apnea.
She said that even before the surgery, her daughter had expressed fears that she wouldn’t wake up after the operation. To everyone’s relief, she appeared alert, was talking and even ate a Popsicle afterward.
But about a half-hour later, shortly after the girl was taken to the intensive care unit, she began bleeding from her mouth and nose despite efforts by hospital staff and her family.
While the bleeding continued, Jahi wrote her mother notes. In one, the girl asked to have her nose wiped because she felt it running. Her mother said she didn’t want to scare her daughter by saying it was blood.
Family members said there were containers of Jahi’s blood in the room, and hospital staff members were providing transfusions to counteract the blood loss.
“I don’t know what a tonsillectomy is supposed to look like after you have it, but that blood was un-normal for anything,” Winkfield said.
The family said hospital officials told them in a meeting Thursday that they want to take the girl off life support quickly.
“I just looked at the doctor to his face and I told him you better not touch her,” Winkfield recalled.
Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.
Despite the precaution of hospitalizing Jahi McMath post-tonsillectomy, when her bleeding developed it seems the management of her Airway-Breathing-Circulation did not go well. I’ve attended to bleeding post-tonsillectomy patients, and it can be a harrowing experience. It can be an extreme challenge to see through the blood, past the swollen throat tissues post-surgery, and locate the opening to the windpipe so that one can insert the breathing tube needed to supply oxygen to the lungs. Assistance from a second anesthesiologist is often needed. The surgeon will be unable to treat or control severe bleeding until an airway tube is in place. Difficult intubation and airway management can lead to decreased oxygen levels and ventilation, jeopardizing oxygen delivery to the brain and heart. If severe bleeding is unchecked and transfusion of blood cannot be applied swiftly, the resulting low blood pressure and shock can contribute to the lack of oxygen to a patient’s brain.
A bleeding tonsillectomy patient can be an anesthesiologist’s nightmare.
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: