Every anesthesia practitioner dreads an airway disaster. Anesthesiologists and nurse anesthetists are airway experts, but anesthesia professionals are often the only person in the operating room capable of keeping a patient alive if the patient’s airway is occluded or lost. Hypoxia from an airway disaster can lead to brain damage within minutes, so there is little time for human error.
A fundamental skill is the ability to assess a patient’s airway prior to anesthesia. One must assess whether the patient will pose: 1) difficult bag-mask ventilation, 2) difficult supraglottic/laryngeal mask airway placement, 3) difficult laryngoscopy, 4) difficult endotracheal intubation, or 5) difficult surgical airway.
Of critical importance is #1) above, that is, recognizing the patient who will present difficult mask ventilation. Conditions that make for difficult bag-mask ventilation are uncommon, and usually can be detected during physical examination. Despite the importance of expertise in endotracheal intubation, I teach residents and trainees that the most important airway skill is bag-mask ventilation. Every year I encounter several patients who present unanticipated difficult intubations. In each of these patients, I’m able to mask ventilate the patient to keep them oxygenated while I try various strategies and techniques to successfully place an endotracheal tube or a laryngeal mask airway.
Most anesthesia airway disasters aren’t merely difficult intubations, but scenarios that are classified as “can’t intubate, can’t ventilate.” In these “can’t intubate, can’t ventilate” situations, the anesthesiology professional has only minutes to restore oxygenation to the patient or else the risk of permanent brain damage is very real.
The American Society of Anesthesiologists Difficult Airway Algorithm is a guide for anesthesia practitioners regarding how proceed in airway management. The algorithm is detailed, complex, comprehensive, and defines the standard of care in any medical-legal battle concerning hypoxic brain damage due difficult airway clinical cases. The algorithm is so detailed, complex, and comprehensive that some would say it’s impossible to remember every step in the acute occurrence of an airway disaster.
A simplified approach has been touted.
Dr. C. Philip Larson, Professor Emeritus, Anesthesia and Neurosurgery, Stanford University, and Professor of Clinical Anesthesiology at UCLA, and previous Chairman of Anesthesiology at Stanford, was one of my teachers and mentors for both endotracheal intubation and fiberoptic intubation. In a Letter to the Editor of the Stanford Gas Pipeline in May, 2013, Dr. Larson wrote, “there is no scientific evidence that anesthesia is safer because of the ASA Difficult Airway Algorithm. While an interesting educational document, I question the daily clinical value of this algorithm, even in its most recent form (Anesthesiology 2013; 118:251-70). The ASA Difficult Airway Algorithm was developed by committee and has all the problems that result when done that way. It is complex, diffuse, multi-dimensional, and all-encompassing such that it is not an instrument that one can easily adopt and practice in the clinical setting.”
Dr. Larson recommends a system of Plans A-D, a system he published in Clinical Anesthesiology, editors Morgan GE, Mikhail MS, Murray MJ, Lange Medical publication, 4th edition, 2006, pp 104-5, and in Current Reviews in Clinical Anesthesiology (2009; 30:61-72), and also in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014). An outline of the system is as follows:
A. Plan A is direct laryngoscopy an intubation using a Miller or MacIntosh blade.
B. If Plan A is unsuccessful, Plan B includes use of video laryngoscopy with a GlideScope or similar device.
C. If Plan B is unsuccessful, Plan C is placement of an LMA with intubation through that LMA using a fiberoptic bronchoscope.
D. “If Plans A-C fail,” Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “one needs Plan D. The first and perhaps the most prudent option is to cancel the proposed operation, terminate the anesthetic, and wake the patient up. The operation would be rescheduled for another day, and at that time an awake fiberoptic intubation technique would be used. Alternatively, if the operation cannot be postponed, then the surgeon should be informed that a surgical airway (i.e.: tracheostomy) must be performed before the planned operation can commence. To date, utilization of Plan D because of failure of Plans A-C has not occurred.”
Dr. Larson wrote that the airway skills in Plan A – C should be practiced regularly on patients with normal airways. I agree with Dr. Larson that in managing difficult airways, a practitioner needs a short list of procedural skills that he or she is expert at rather that a large array of procedures that they rarely use (such as the alternative intubation techniques using light wands or blind nasal techniques, or invasive airway procedures such as retrograde wires passed through the cricothyroid membrane or transtracheal jet ventilation through a catheter). It’s wise for anesthesiologists to regularly hone their techniques of video laryngoscopy (Plan B) and fiberoptic intubation via an LMA (Plan C) on patients with normal airways, to remain expert with these skills.
Regarding Plan B, an important advance is the availability of portable, disposable video laryngoscopes such as the Airtraq, a guided video intubation device. In my career I sometimes work in solo operating room suites distant from hospitals. In these settings, the operating room is usually not be stocked with an expensive video scope such as the GlideScope, the C-MAC, or the McGrath 5. I carry an Airtraq in my briefcase, and if the need for Plan B arises I am prepared to utilize video laryngoscopy at any anesthetizing location. I suggest the practice of carrying an Airtraq to any anesthesiologist who gives general anesthetics in remote locations.
Regarding emergency surgical rescue airway management, Dr. Larson recently published a Letter to the Editor in the American Society of Anesthesiologists Newsletter, February 2014, entitled, Ditch the Needle – Teach the Knife. In this letter, Dr. Larson wrote:
“in life-threatening airway obstruction, … an emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. It should be deleted from the ASA Difficult Airway Algorithm. I have participated in seven cricothyrotomies in emergency airway situations, and all of the patients left the hospital without any
neurological injury or complications from the cricothyrotomy. The risk-benefit ratio is markedly in favor the knife technique…. With a knife, or scissors, one cuts quickly either vertically or horizontally below the thyroid cartilage and there is the cricothyroid membrane or tracheal rings. The knife is inserted into the trachea and turned 90 degrees, and an airway is established. At that point, a small tube of any type can be inserted next to the knife. The knife technique is much safer because there is virtually nothing that one can harm by making an incision within two inches or less in the midline of the neck, and it can be performed in less than 30 seconds. In contrast, the needle is fraught with complications, including identifying the trachea, making certain that the needle is entirely in the trachea and does not move ( to avoid subcutaneous emphysema when an oxygen source is established), establishing a pressurized oxygen delivery system (which will take more than five minutes even in the most experienced circumstances), and avoiding causing a tension pneumothorax… I know of multiple cases of acute airway obstruction where the needle technique was attempted, and in all cases the patients died. I know of no such cases when a cricothyrotomy was used as the primary treatment of acute airway obstruction.”
A final note on the awake intubation of patients with a difficult airway: In hindsight in any difficult airway case, one often wishes they had secured an endotracheal tube prior to the induction of general anesthesia. The difficult problem is deciding prior to a case which patient has such a difficult airway that the induction of general anesthesia should be delayed until after intubation. In anesthesia oral board examinations it may be wise to say you would perform an awake intubation on a difficult airway patient rather than risk the “can’t intubate, can’t ventilate” scenario the examiner is probably poised to skewer you with. In medical malpractice lawsuits, plaintiff expert witnesses in anesthesia airway disaster cases often testify that a brain-dead patient’s life would have been saved if only the anesthesiologist had performed awake intubation rather than inducing general anesthesia first and then losing the airway. The key question is: how does one decide which patient needs an awake intubation? As an anesthesia practitioner, if you performed awake intubations on one out of 50 cases because you were worried about a difficult airway, you would delay operating rooms and surgeons multiple times per year because of your caution. You will not be popular if you do this. In my clinical practice and in the practice of the excellent Stanford anesthesiologists I work with, the prevalence of awake intubation is very low. I estimate most anesthesiologists perform between zero and two awake intubations per year. The most common indications include patients with severe ankylosing spondylitis of the cervical spine, congenital airway anomalies, and severe morbid obesity. Dr. Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “I do anesthesia for most of the patients with complex head and neck tumors, and I find fewer and fewer indications for awake fiberoptic intubation. As long as the lungs can be ventilated by bag-mask or LMA, which is true for almost all sedated patients, Plan C is easier, quicker and safer than awake fiberoptic intubation both for the patient and the anesthesia provider. In experienced hands, Plan C can be completed in less than 5 minutes, and one can become proficient by practicing in normal patients. I have done hundreds of Plan C’s, many under difficult circumstances, without a single failure or complication. Obviously, no technique will encompass every conceivable airway problem, but mastering Plans A-D and awake oral and nasal fiberoptic intubation will meet the needs of anesthesia providers in almost all circumstances.”
May you never experience the emotional trauma of an airway disaster. Become an expert in bag-mask ventilation, always have access to a video laryngoscope or an Airtraq, and consider Dr. Larson’s Plan A-D system, described in detail in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014).
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: