Imagine this scenario: You’re an anesthesiologist giving anesthesia care in the operating room to your second patient of the day. The Post Anesthesia Care Unit (PACU) nurse calls you regarding your first patient who is in the PACU following appendectomy. The nurse says, “Your patient Mr. Jones is still nauseated and very sleepy. I’ve medicated him with ondansetron and metoclopramide as ordered, but he’s still nauseated and sleepy.”
What one question should you ask to determine whether this patient has a serious medical problem? What one question must you ask to determine whether urgent intervention is required?
That one question would be: “What are his vital signs?”(This is a bit of a trick question, since you are asking not one question, but four or five. It’s as if you’re down to your last request from the Genie from Aladdin’s lamp, and you’re wishing for more wishes. As Robin Williams’ Genie character said in Disney’s Aladdin, “Three wishes, to be exact. And ixnay on the wishing for more wishes. That’s all. Three. Uno, dos, tres. No substitutions, exchanges or refunds.” )
The traditional four vital signs are the blood pressure, heart rate, respiratory rate, and temperature. For anesthesiologists, surgeons, emergency room physicians, and ICU doctors, the fifth vital sign is the oxygen saturation or O2 sat. Some publications tout the pain score (on a 1-10 scale) as a fifth vital sign. While I subscribe to the pain score’s importance, it’s of less value in most acute care situations than the O2 saturation.
Let’s return to the patient scenario. You ask the nurse, “What are the patient’s vital signs?”
The nurse answers, “His heart rate is 48, his blood pressure is 88/55, his O2 sat is 100, and his respiratory rate is 16.”
You answer, “His heart rate is too low and so is his blood pressure. Let’s give him 0.5 mg atropine IV now.”
Five minutes later the nurse calls back. The heart rate increased to 72 and the blood pressure is 110/77. The patient’s symptoms resolved as the vital signs normalized.
Let’s look at a second scenario. You drop off a 48-year-old hysterectomy patient in the PACU. The patient is awake, and her initial vital signs are BP 120/64, pulse 100, respirations 18, and O2 saturation 99%. You return to the operating room to initiate care for your next patient for a laparoscopy. Thirty minutes later, the PACU nurse calls you to report your first patient has increasing abdominal discomfort. Her repeat vital signs are: BP 110/80, pulse 130, respirations 26, and O2 saturation 99%. You’re concerned an intra-abdominal complication is brewing. Five minutes later, the nurse reports a third set of vitals. The patient’s heart rate continues to rise to 140. Her blood pressure is now 82/40, her respirations are 30, and her skin has become cold and moist to the touch. She’s unable to speak coherently and is losing consciousness. You can not leave the patient you are anesthetizing, but you call a fellow anesthesiologist to evaluate the patient in person, and prepare her for emergent re-operation.
The patient’s initial vital signs were stable, but the downward trend of her vital signs were a harbinger of the serious complication. Eventually the symptoms of abdominal pain and decreasing consciousness appeared, and confirmed the diagnosis of intra-abdominal hemorrhage and impending shock. The increased heart rate, decreased blood pressure, and increased respiratory rate were red flags early on.
Abnormal vital signs can indicate that a patient is acutely ill. Equally important to the value of each vital sign is the temporal trend in the vital signs. A vital sign trend increasing or decreasing from the normal range can validate that the patient is becoming acutely ill.
You may be thinking, why is Dr. Novak telling me vital signs are important? Everybody know vital signs are, well … vital.
My message to you is to seek out the vital signs, all of them, as essential clues in all patients.
As anesthesiologists, we spend our entire intraoperative clinical career staring at a patient’s vital signs on a video screen. When the blood pressure goes up, we act. When the blood pressure goes down, we act. When the heart rate goes up, we act, and when the heart rate goes down, we act. When oxygen saturation trends downward, we act. Because most intraoperative patients are unconscious, the patient’s verbal history—the traditional clues regarding acute illness—are unavailable. We can not ask our patient questions to determine whether vital sign changes are associated with symptoms of chest pain, shortness of breath, or neurologic deficits. We’re accustomed to treating patients by normalizing their vital signs.
Other healthcare providers lack this perspective. Nurses and non-acute-care physicians such as family practitioners and internists can fill a patient’s history chock full of other details so thick that the vital signs are buried. The five or six vital sign numbers are often obscured in pages of text. Most physician and nursing notes in an electronic medical record (EMR) are lengthy, and are many are copied and pasted from previous encounters. Each patient interview is a quiz bowl of medical history answers. The five or six vital sign numbers are a needle in the haystack of a modern medical history. The EMR in a clinic or a hospital can serve to worsen this plight, as vital signs are recorded by nurses and entered into nursing documents on the computer, and treating physicians may have to dig to find the correct page that lists vital signs. One possible benefit of an EMR is a proposed safety system that requires, for any abnormal vital sign entered into the computer, the nurse to document they have verbally informed a physician of that abnormal value. This system would assure that abnormal values are never ignored, and that an MD will assess whether further diagnostic or therapeutic steps need to be taken.
Ferret out the vital signs. In my career as a clinical anesthesiologist and anesthesia expert witness, I can’t recall one significant complication that wasn’t foretold by an increased or decreased heart rate, blood pressure, respiratory rate, or temperature, a decreased O2 saturation, or an increased pain score.
Keep your eye on the vitals, and keep your patients out of trouble.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.
On October 2, 2014 THE DOCTOR AND MR. DYLAN became the world’s #1 bestselling anesthesia Kindle book on Amazon.com.
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 email@example.com, 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: