WHY SHOULD YOU BECOME A DOCTOR?

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The greatest joy in my professional life comes immediately after the conclusion of a pediatric anesthetic. I stay with the child until the anesthetic depth has dissipated, the breathing tube is removed, and the child is awake and safe with the recovery room nurse in the Post Anesthesia Care Unit. At that point I walk out to the waiting room to find the parents so I bring them back to see their child. I invariably have a bounce to my step, and I’m a bit choked up with anticipation. I’ve done this enough times to know what to expect. The mother and father are waiting with wide eyes and worried looks on their faces. I give them a reassuring smile and my first words are, “Everything went perfectly. Your son (or daughter) is safe. Follow me.” The three of us return to the bedside in the recovery room, where the mother and child reunion occurs (cue up the Paul Simon soundtrack). The parents fawn over their child, the child reaches out his or her arms, the relief is palpable, and I’m proud to have contributed to the positive outcome.

Why go to medical school? Bright, hard-working college students have choices to make. Many ambitious young people wonder if they should apply to medical school. It’s difficult to get into med school, the journey is long (four years of medical school followed by three to seven years of residency), and the tuition can be high.

Why go to medical school? The daughter of one of my friends is an undergraduate business school student, and her last summer internship was with Proctor and Gamble working in the sales and marketing force selling Clorox. Selling bleach is a career choice radically different from going to medical school.

Do you want to sell bleach, or do you want to help people? The answer to “Why do you want to go to medical school?” is almost that simple. So many jobs in America are related to selling some product, some service, or some commodity. Becoming a physician is about helping people, and it’s also about making your own life have a greater purpose.

“Why do you want to be a doctor?” is the first question asked at most medical school interviews. Answers vary. Why do young men and women choose to become doctors nowadays? One guiding factor might be economics. The average salary for a physician in the United States is in excess of $250,000. To a 22-year-old, that high salary is alluring. Non-medical students who pursue careers in teaching, engineering, or business will start at lower annual salaries, but the future income of a physician is balanced against the deferred gratification of the years involved in their education. The student must pay for four years of medical school tuition and living expenses, and then work for meager wages for 3-7 years afterwards as a resident. The medical student delays the onset of their “real world” employment until age 30-32. Non-medical students who go to work straight out of college at age 22 may already have families, mortgages, multiple cars, and perhaps a vacation home, while the 32-year-old physician has an 80-hour-a-week job, $250,000 of student loans, and the obligation to take care of sick patients at 3 a.m. It’s not an easy life, it’s not all fun, and most doctors wonder at one time or another whether they made the right choice. Making a lot of money is not the right answer to the question of why you want to go to medical school.

So why do we go to medical school? Young men and women who have a physician parent are in the best position to reply from the heart—they’re aware that their parent works long hours, reads incessantly to stay well informed, and gets out of bed in the middle of the night to handle emergencies. A doctor’s son or daughter has heard all the good and bad stories that describe a physician’s lifestyle. But most college students don’t have a doctor for a parent, and most college students have a little idea what the lifestyle of a physician would feel like. My father was a welder. I had no family experience to guide my career choice. For students like me, without a physician parent, it’s important to work medical volunteer jobs and/or research jobs to test the waters before applying to medical school, to decide whether the life of a doctor would appeal to them.

Why go to medical school? Each new patient I meet treats me with respect—a respect I don’t get if I’m outside of the hospital walking down the street or shopping at a grocery store. Years ago I shared this impression with my wife, and she said, “Of course your patients treat you with respect. You’re about to take their lives into your hands. They’re nervous, they’re scared, and the last thing they want to do is to get you in a bad mood!” This may be true, but the respect your patients give you is bona fide, and it’s a feeling few other jobs can offer.

Why go to medical school? I don’t think you’ll ever get equivalent joy out of selling bleach (or some other commodity) that you’ll gain helping other human beings with their health problems. Medicine is a profession. A career in medicine is an opportunity to entwine your work life with other people’s lives in a meaningful and remarkable way. You might make more money as a CEO or a venture capitalist, but few other jobs bring the potential to change lives for the better to the degree that being a physician does.

When you go to your medical school interview and the professor asks you “Why do you want to be a doctor,” the answer from your heart must be five words long:

“I want to help people.”

Your reward for becoming a doctor will arrive years later, when you feel what I feel when I reunite parents with their child after surgery. You’ll feel the joy and satisfaction of a purposeful life.

 

P.S. In 2012 the journal Anesthesiology published my poem “The Metronome,” which describes a scene from my life as a pediatric anesthesiologist:

 

The Metronome

 

To Jacob’s mother I say,

“The risk of anything serious going wrong…”

She shakes her head, a metronome ticking without sound.

“with Jacob’s heart, lungs, or brain…”

Her lips pucker, proving me wrong.

“isn’t zero, but it’s very, very close to zero…”

Her eyes dart past me, to a future of ice cream and laughter.

“but I’ll be right there with him every second.”

The metronome stops, replaced by a single nod of assent.

She hands her only son to me.

 

An hour later, she stands alone,

Pacing like a Palace guard.

Her pupils wild. Lower lip dancing.

The surgery is over.

Her eyebrows ascend in a hopeful plea.

I touch her hand. Five icicles.

I say, “Everything went perfectly. You can see Jacob now.”

The storm lifts. She is ten years younger.

Her joy contagious as a smile.

The metronome beat true.

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

 

 

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

 

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FENTANYL AND THE OPIOID CRISIS: AN ANESTHESIOLOGIST’S PERSPECTIVE

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The United States is in the midst of an opioid epidemic. The crisis consists of two separate threats. One is the increased presence of powerful illicit street drugs such as fentanyl. The second threat is the increasing use of oral prescription painkillers like Oxycontin, Percocet, and Vicodin. This column addresses fentanyl—its medical aspects and the on-the-street abuses of this powerful narcotic.

 

MEDICAL USE OF FENTANYL

I’ve administered fentanyl to over 20,000 patients in my career, and can vouch for the medical utility and import of this drug. Fentanyl is the most commonly administered narcotic during surgery in the United States. If you’ve had a surgical anesthetic, or even a colonoscopy, you’ve likely received fentanyl with few ill effects. Fentanyl is an essential ingredient in the pharmaceutical armamentarium of acute care medicine in hospitals, surgery centers, intensive care units, and emergency rooms throughout the United States. On the streets, fentanyl is killing people. In our hospitals and surgery centers, fentanyl is a useful adjunct as omnipresent as Tylenol.

Fentanyl was first synthesized by Dr. Paul Janssen of Janssen Pharmaceuticals in the 1960s, and was then introduced into anesthetic practice under the brand name Sublimaze.1 Fentanyl is a rapid-onset narcotic drug usually administered by intravenous injection. Compared to morphine, fentanyl is more lipid (fat) soluble, which means the drug crosses into the central nervous system more quickly and works faster than morphine. The termination of the effect of low doses of fentanyl results from decreased concentration, as the drug redistributes from the bloodstream to other organ tissues. The elimination of higher doses of fentanyl from the body depends on elimination by the liver. Morphine, Demerol, and Dilaudid are other common intravenous medical narcotics, which have slower onset and longer duration of action. When injected into an intravenous line, fentanyl reaches its peak analgesic effect in minutes, significantly faster than morphine. This quicker onset makes fentanyl an easier drug for anesthesiologists to titrate to a desired effect., which makes fentanyl superior when timing for a patient’s awakening from anesthesia. As outpatient and ambulatory surgery blossomed, a short-acting narcotic such as fentanyl, which wore off promptly, became the narcotic of choice. The most daunting feature of fentanyl is its potency. Most drugs used by anesthesiologists are in doses of milligrams (mgs) or grams (gms). Fentanyl is approximately 100 times more potent than morphine, so a typical 5 mg (5 mg = 5000 microgram) dose of morphine is equivalent to a mere 50 microgram dose of fentanyl. A typical intravenous incremental dose of fentanyl to an adult patient is a mere 50-100 micrograms. The drug is marketed as one milliliter = 50 micrograms for this reason, so 1 – 2 milliliters is an appropriate dose. This potency and the need to be packaged in micrograms is unique to fentanyl and its analogues sufentanil and remifentanil, and requires medical personnel to become comfortable with the low ranges of the appropriate microgram doses.2

Medical fentanyl can be administered in several ways:

  • Intravenous fentanyl, as described above, is the most common medical usage of the drug.
  • Rarely, fentanyl is added to the spinal fluid as part of a spinal anesthetic block prior to surgery, or to the epidural space as part of an epidural block prior to surgery or prior to labor for childbirth.
  • Transdermal drug delivery of fentanyl via an adhesive skin patch is also possible, because of the drug’s high solubility in both water and oil, low molecular weight, high potency, and its lack of skin irritation. Fentanyl transdermal patches (Durogesic or Duragesic) are useful in chronic pain management. The patches work by slowly releasing fentanyl through the skin into the bloodstream over 48 to 72 hours, allowing for long-lasting pain management. Dosage is based on the size of the patch.
  • Oral transmucosal fentanyl citrate (OTFC) is a solid dosage form of fentanyl that consists of fentanyl incorporated into a sweetened lozenge on a stick. A commercially available fentanyl product for oral administration, the fentanyl lollipop Actiq, is an application of this technology. The lollipop provides a means by which the drug can dissolve slowly in the mouth. The lollipop is only FDA approved for providing analgesia to patients with chronic pain or cancer pain, and the fentanyl lollipop is not FDA-approved for analgesia after surgery.

Narcotics suppress pain by their action in the brain and spinal cord, but they cause their adverse side effects in multiple organ systems, including the respiratory and cardiovascular systems. The principal danger from narcotics is respiratory depression. The respiratory rate is usually markedly slowed in narcotic overdose, as excessive doses of narcotics make people stop breathing. If there’s an anesthesiologist present to support a person’s breathing, respiratory depression is not a problem. On the streets, with no medical personnel present, respiratory depression from a narcotic overdose can be fatal.

The anesthesia world is well aware of the risks of fentanyl addiction. Narcotic addiction has struck down many anesthesia providers who found themselves vulnerable to sampling the potent euphoria-inducing fentanyl doses they were administering to their patients. Stanford authors described fentanyl addiction in anesthesiologists in 1980.3 More than a dozen of my personal friends and colleagues died anesthetic drug-related addiction deaths in the 1980s and 1990s. For some of these physicians the first sign of their addiction was death by overdose. In others the addiction was uncovered, they were sent to rehabilitation programs, and they are still alive today. Anesthesiologists graduating from narcotic rehab programs are still known to have a risk to relapse. The relapse rate for anesthesiologists after drug abuse treatment is greatest in the first 5 years and decreases as time in recovery increases. The positive news is that 89% of anesthesiologists who complete treatment and commit to aftercare remain abstinent for longer than 2 years. However, death is still the primary presenting sign of relapse in opiate-addicted anesthesiologists.

 

FENTANYL AS A STREET DRUG

The current battle against fentanyl as a street drug has little or nothing to do with American medical practice. Most of the fentanyl found on the streets is not diverted from hospitals, but rather is sourced from China and Mexico. Dealers sought a narcotic product cheaper and even stronger than heroin, and that product is fentanyl. In 2016 there were more than 60,000 fatal overdoses in America. More than half were due to opioids, and the newest and most potent street narcotic was fentanyl. Fentanyl-related overdose deaths increased nearly 600 percent from 2014 to 2016. “If anything can be likened to a weapon of mass destruction in what it can do to a community, it’s fentanyl,” said Michael Ferguson, a special agent in charge of the Drug Enforcement Administration’s New England division. “It’s manufactured death.” Illicit fentanyl is imported directly from China or Mexico, where the drug is manufactured. Dealers then mix the powder into other drugs, making for imprecise potency in sometimes-lethal doses.4 The IV street drug fentanyl is believed to be manufactured in China or Mexico, and is smuggled across the borders. Highly organized drug cartels are spreading the drug throughout the country. Its street nickname is “China White” or “China Girl,” referring at where most of the drug is thought to be coming from. The DEA estimates that drug traffickers can buy a kilogram of fentanyl powder for $3,300 and sell it on the streets for more than 300 times that, generating nearly a million dollars.5

As a street drug, fentanyl can be injected intravenously, taken orally, or snorted nasally. Each of these routes poses a threat:

  • Intravenous fentanyl as a street drug – Prior to fentanyl, heroin was the injectable street drug of choice. Because of the extremely high strength and potency of pure fentanyl powder, it’s difficult to dilute appropriately. The diluted mixture may be far too strong and, may cause respiratory depression and death. Some heroin dealers mix fentanyl powder with heroin to increase potency or compensate for low-quality heroin. Because fentanyl is more potent than heroin, the presence of even small quantities of fentanyl in injected heroin can result in respiratory depression. The fentanyl sold on the streets is likely made in a non-pharmaceutical lab, and is less pure than the medical version anesthesiologists administer. Its effect on the body can be hard to predict. Heroin and fentanyl look identical, and with drugs purchased on the street, addicts don’t know what they’re taking. An intravenous fentanyl overdose can cause a person to cease in breathing within minutes of injection, and result in death. Narcan, or naloxone, is a specific antagonist of narcotic overdose. Administration of Narcan as a fentanyl overdose antidote is a potential acute rescue remedy. 
  • Oral fentanyl as a street drug – Fentanyl is also sold as an oral street drug. Ten people died in just twelve days from fentanyl-laced pills in Sacramento County, California in March of 2016. In San Francisco, fentanyl showed up in pills labeled as Xanax, which turned out to be pure fentanyl. After 26 years in a Orange County crime lab south of Los Angeles, forensic scientist Terry Baisz said, “I was shocked the first time I tested this stuff and it came back as fentanyl. We hadn’t seen it before 2015.” Dealers were describing their pills as Xanax or Oxycodone. The tablets looked nearly identical to products manufactured by commercial pharmaceutical companies, although the pills sold on the streets contained fentanyl.6 The singer Prince’s death in 2016 was due in part to an overdose of fentanyl, likely in a pill form of counterfeit hydrocodone-acetaminophen (Vicodin) tablets.7
  • Intranasal fentanyl as a street drug – If fentanyl is supplied to the addict in powder form, and the powder is confused with cocaine and is snorted intranasallly, the addict may die. A hospital in New Haven, Connecticut treated twelve overdoses, three of them fatal, in just an eight-hour period in June 2016 among addicts who were snorting a white powder they purchased on the city’s streets. 8The powder they believed was cocaine turned out to be fentanyl. The absorption of a nasal dose of fentanyl can lead to immediate respiratory depression and death.

U.S. Surgeon General Jerome Adams, an anesthesiologist, has suggested distributing the narcotic antagonist Narcan freely, so that onlookers can quickly treat fentanyl-overdosed individuals.9 I respect Dr. Adams at the highest level, but I’m skeptical of this approach. An addict injecting fentanyl while he or she is alone is still at high risk of dying, and I’m not aware of any statistics documenting whether addicts reliably have company present while they are injecting themselves. First response Emergency Medical Technicians should carry Narcan. Treatment of patients who are discovered comatose for unknown reasons has long included an empiric injection of Narcan to reverse possible narcotic overdose. The public needs to be aware of the existence of fentanyl powder, its ultra-high potency, and the danger of a fatal overdose immediately after the intravenous injection, oral ingestion, or intranasal inhalation of any street drug. There’s a real threat that any dose of street fentanyl can be lethal.

In our operating rooms, hospitals, surgery centers, and intensive care units, fentanyl is used safely. On the streets, fentanyl poses nothing but problems. Education, prevention, and DEA enforcement will have key roles in addressing the crisis of fentanyl in non-medical settings.

 

References:

  1. Fentanyl, Chemical and Engineering News, https://pubs.acs.org/cen/coverstory/83/8325/8325fentanyl.html
  2. Kazuhiko F, Opioid Analgesics, Miller’s Anesthesia, 8th Edition, Chapter 31, 864-914.
  3. Spiegelman WG, Saunders L, Mazze Ri, Addiction and anesthesiology, Anesthesiology 1984 Apr;60(4):335-41.
  4. Lewis N et al. Fentanyl linked to thousands of urban overdose deaths, Washington Post, August 15, 2017.
  5. https://www.washingtonpost.com/graphics/2017/national/fentanyl-overdoses/?utm_term=.8c722ada39be Nazarenus C. The opioid fentanyl: the new heroin, but deadlier. Medical Marijuana 411, May 11, 2016.
  6. https://medicalmarijuana411.com/opiod-fentanyl-new-heroin-deadlier/Sidner S. The opioid fentanyl: the new heroin, but deadlier. ClickonDetroit.com, May 10, 2016. https://www.clickondetroit.com/health/fentanyl-the-new-heroin-but-deadlier
  7. Kroll D, Prince’s Death From Fentanyl May Have Been Due To Counterfeit Generic Drugs, Pharma and Healthcare, Aug 22, 2016. https://www.forbes.com/sites/davidkroll/2016/08/22/princes-death-from-fentanyl-may-have-been-due-to-counterfeit-generic-drugs/#52096f902b17
  8. Bebinger M, Fentanyl-laced cocaine becoming a deadly problem among drug users, Health News from NPR, March 29, 2018. https://www.npr.org/sections/health-shots/2018/03/29/597717402/fentanyl-laced-cocaine-becoming-a-deadly-problem-among-drug-users
  9. Surgeon General Urges More Americans To Carry Opioid Antidote, NPR Public Health, April 5, 2018. https://www.npr.org/sections/health-shots/2018/04/05/599538089/surgeon-general-urges-more-americans-to-carry-opioid-antidote

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

 

 

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

INTRAVENOUS ACETAMINOPHEN: AN IMPORTANT NON-OPIOID THERAPY, OR AN EXORBITANTLY PRICED VERSION OF AN OVER-THE-COUNTER MEDICATION?

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IV acetaminophen (Ofirmev)

 

tylenol-tylenol-extra-strength-500-mg-150-units

Oral acetaminophen

Healthcare costs continue to skyrocket in the United States. In 2016 Americans spent $435 billion on prescription drugs.1 This month the Trump administration released a 44-page blueprint for executive action on drug pricing entitled “American Patients First.” Their goal is to drive prescription drug costs down by increasing competition. At this time it’s too early to tell how effective these efforts will be.

Anesthesiologists are the only physicians who prescribe and then directly administer medications themselves. CRNAs are the only nursing professionals who prescribe and then directly administer medications themselves. Because anesthesiologists and CRNAs typically don’t pay for the medications, there can be a disconnect regarding costs and value.

If you were in charge of pharmaceutical purchasing at a hospital or an ambulatory surgery center, and you had an identical acetaminophen molecule available for either 5 cents per dose or $42 per dose, which would you choose? The answer is obvious, but as an administrator you are not prescribing the drug.

Acetaminophen (Tylenol) has been available in oral and rectal forms for decades. Intravenous acetaminophen was introduced in Europe in 2002. The United States Food and Drug Administration approved IV acetaminophen (Ofirmev, Cadence Pharmaceuticals) in 2010 for management of mild to moderate pain, moderate to severe pain with adjunctive opioid analgesics, and reduction of fever.

A 2014 study showed that patients who received IV acetaminophen reported superior satisfaction with pain control compared to patients who received placebo.2 In inpatient and postoperative settings, intravenous acetaminophen became a route of choice for rapid analgesia, and appeared to reduce the need for other analgesics such as opioids. Disadvantages of IV acetaminophen included the time and equipment needed for IV drug administration, as well as increased costs.

In a publication from the Canadian Journal of Hospital Pharmacy, Jibril wrote, “The study drug (acetaminophen, either oral or IV) was given when patients first awakened after surgery, and additional doses were given every 6 h until 0900 the next morning. . . . The use of opioids was significantly lower in the group receiving acetaminophen by the IV route than in the group receiving acetaminophen by the oral route (p < 0.05). However, this difference did not translate into a significant difference in rates of postoperative nausea and vomiting or any significant difference in pain scores on a 100-mm visual analogue scale (VAS) at any time. . . . A major finding of this review was the absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . IV acetaminophen may be useful for opioid-sparing in postoperative pain. To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . . In the United States, there has been great debate regarding use of this formulation, which has led many hospitals to adopt policies and procedures that restrict use for a limited period or for patients not able to take medications by mouth. These restrictions are required because of the cost of the product, in addition to other administration-related inconveniences. Canadian hospitals and formulary committees should be aware of the available efficacy and safety data if the formulation is marketed in Canada and its use becomes widespread. Given the high cost and the lack of superiority over oral forms, Canadian hospitals may need to restrict use of the IV formulation, as their US counterparts have already done.”3

In a study of IV acetaminophen use in neurosurgical ICU patients at Virginia Commonwealth University, Gretchen Brophy, PharmD, of the departments of pharmacy and neurosurgery wrote, “We and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better.”4 VCU restricted intravenous acetaminophen use to one dose per patient.

Mallinckrodt purchased Cadence Pharmaceuticals in 2014, and increased the price of Ofirmev from $17.70 to $42.48 per vial. (A full case of Ofirmev includes 24 vials.) Sales increased to $71 million during their fiscal first quarter, double the amount for the same period the previous year. Hospitals noted the rise in expenses and sought alternatives such as oral acetaminophen, and the volume of sales dropped. Robert Press, chief of hospital operations at NYU Langone, which anticipated $1 million in additional costs because of Ofirmev, was quoted to say, “We found out a lot of the use was really not necessary and we found we could give alternative products.”5

Some hospitals removed Ofirmev from their formularies after the price went up. Others simply switched to alternatives such as oral acetaminophen. Others increased their budgets to cover the cost of the drug, but the net effect of Mallinckrodt’s price hike was to reduce the doses of Ofirmev prescribed. Mallinckrodt’s U.S. headquarters are located in Missouri. Senator Claire McCaskill (D-Missouri) wrote a letter to Mallinckrodt CEO Mark Trudeau demanding information about pricing and revenue numbers. In the letter she also suggested that Ofirmev, expensive as it was, might actually be saving hospitals money because of opioid-sparing. Senator McCaskill wrote, “Any obstacle to prescribing non-opioid alternatives, even those used solely in a hospital setting, is cause for concern.” It should be noted that McCaskill received $2,500 in campaign financing from Mallinckrodt during the 2016 election cycle.6

Mallinckrodt released a statement that read, “One recent analysis of health economic data on the use of Ofirmev coupled with a one-level reduction in opioid use was linked to decreasing hospital stays, potential opioid-related complications and related costs for the treatment of acute surgical pain. . . . The study showed a potential of $4.7 million in annual savings for a typical, medium-sized hospital.”6

The clinical benefit of reduced opioid consumption with Ofirmev has not been evaluated nor demonstrated in prospective, randomized controlled trials. In a review in the journal Pharmacotherapeutics, Yeh wrote, “Although use of intravenous acetaminophen has reduced other postoperative resource utilization (e.g., hospital length of stay) in some studies outside the United States in patients undergoing abdominal surgery, a full economic evaluation in the United States has yet to be undertaken.”7

The research study anesthesiologists would like to read is a prospective, randomized, double-blind trial of 1000 mg of preoperative oral acetaminophen, versus 1000 mg of IV acetaminophen administered just prior to the end of surgery. Will this research ever be performed? I hope so, but you can bet Mallinckrodt is never going to fund that study.

I repeat Jibril’s conclusion to sum up the answer to our initial question above:“An absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . Therefore, on the basis of current evidence, if a patient has a functioning gastrointestinal tract and is able to take oral formulations, IV formulations are not indicated.”3

And what is the solution regarding anesthesia providers who frequently choose to prescribe IV acetaminophen despite these recommendations? The hospital I work at, Stanford University Hospital, restricts Ofirmev usage to patients who are NPO (nothing by mouth), and each Ofirmev order has a hard stop after 24 hours, eliminating further usage. The owners of the surgery center I medically direct have an even more decisive solution: Ofirmev is not on the facility formulary at all.

 

References:

  1.  Cortez J. Prescription Drug Spending Hits Record $425 Billion in U.S. Bloomberg, April 13, 2016.                                                https://www.bloomberg.com/news/articles/2016-04-14/prescription-drug-spending-hits-record-425-billion-in-u-s
  2. Apfel CC et al. Patient satisfaction with intravenous acetaminophen: a pooled analysis of five randomized, placebo-controlled studies in the acute postoperative setting. J Healthc Qual. 2014 Jan 16.
  3. Jibril F, et al. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making, Can J Hosp Pharm. 2015 May-Jun; 68(3): 238–247.
  4. Otto MA et al. No pain benefit found for IV acetaminophen vs. oral in the neuro ICU. Clinical Neurology News. January 30, 2015.
  5. Staton T. Price hikes aren’t always sustainable: Just ask Mallinckrodt about Ofirmev. Fierce Pharma. Oct 12, 2015. https://www.fiercepharma.com/pharma/prie-hikes-aren-t-always-sustainable-just-ask-mallinckrodt-about-ofirmev
  6. Staton T. Mallinckrodt’s pain med Ofirmev gets scrutiny in Senate—but this pricing probe has a twist. Fierce Pharma. May 30, 2017. https://www.fiercepharma.com/pharma/mallinckrodt-s-pain-med-ofirmev-gets-scrutiny-senate-but-pricing-probe-has-a-twist
  7. Yeh Y et al. Reviews of Therapeutics: Clinical and Economic Evidence for Intravenous Acetaminophen. Pharmacotherapeutics. 08 May 2012.

 

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41wlRoWITkL

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

LEARJET ANESTHESIA – THE EARLY DAYS OF HEART TRANSPLANTATION

learjet-lear-60

Anesthesia can be a glamorous specialty. During my Stanford training in 1984-1986 I flew on Learjets more times than I can count, during missions to harvest donor hearts from throughout the western United States.

Norman Shumway MD PhD, a Stanford surgical professor and legend, invented the heart transplantation procedure and performed the first heart transplant in the USA on January 6, 1968 in operating room 13 of Stanford University Hospital. Survival rates for heart transplantation patients increased markedly in 1983 with the adoption of cyclosporine as an effective anti-rejection drug. During the 1980’s Stanford was the only prominent heart transplantation program in the western United States, and the quantity of brain dead heart donors was modest. In order to expand their volume of transplants, Stanford created a fixed-wing aircraft harvesting and transportation program to bring donor hearts to Palo Alto from distant locations.

One registered nurse had a fulltime job locating appropriate brain dead heart donors within a 60-90 minute Learjet trip from Stanford. A separate team of physicians and nurses was responsible for assembling a waitlist of prospective heart transplant recipients, and for arranging housing for them within the San Francisco Bay Area.

When Stanford learned of a brain dead donor with a normal heart at a distant location, the following choreography occurred: 1) a matching donor was identified and told to come to Stanford Medical Center immediately; 2) a team of surgeons, anesthesiologists, nurses, and a heart-lung perfusionist was paged to Stanford Medical Center immediately to prepare the recipient patient for his or her transplant surgery; and 3) a transport team of two surgeons (a chief resident in cardiac surgery and a second surgical resident), one anesthesia fellow or resident, one scrub nurse, one circulating nurse, and the nurse in charge of the transport team were all paged to the Stanford Medical Center immediately.

Note that the anesthesia transport team member was only an anesthesia fellow or a resident. The eligible residents were second-year residents (anesthesia residency training was only two years in duration during the 1980’s). As a second-year resident, I was a partially trained anesthesiologist who had done only 800-1000 anesthetics at that time, and was not yet eligible to sit for the American Board of Anesthesia exam.

An ambulance transported our team to the Moffett Field Air Force Base, 10 miles southeast of the Stanford campus, where we boarded a Learjet for the flight to the donor hospital. The donor harvesting catchment area was as far north as Seattle, as far south as Las Vegas, and as far east as Boise. We had no medical tasks to do in flight, and we spent our time looking out the windows and small talking. Upon arrival at the airport in the donor city, an ambulance transported us to the hospital.

At the hospital we proceeded to the intensive care unit where we found the donor’s brain dead body connected to a ventilator and ICU monitors. At this point my work began. Even though the patient was brain dead, it was imperative to maintain his or her vital signs and oxygenation at optimal levels to preserve the cardiac function for the eventual recipient. My first tasks were to insert an arterial line in the radial artery to monitor blood pressure, and to insert a central venous pressure catheter in the internal jugular vein to administer medication infusions as needed to decrease or increase the blood pressure during the upcoming surgery. We would then transport the patient through the hallways of this foreign hospital, accompanied by the surgeons, and directed by staff of that hospital who knew the floor plan. I’d be squeezing an Ambu bag full of oxygen to ventilate the patient, all the while vigilant of the vital signs displayed on a portable monitor during the transport.

We’d arrive in the operating room—a room we’d never seen or worked in before—and prepare the patient for surgery. My job was to connect the patient to the operating room ventilator and the standard cardiac surgery monitors: ECG, oximeter, arterial line, and central venous pressure. The manufacturers of the monitoring equipment varied from hospital to hospital, and it was not unusual for the equipment to be different than machines I’d worked with before. My next task was to prepare vasoactive drips such as nitroprusside and connect them to the central venous pressure IV line. No anesthetic drugs were used, because the donor was brain dead, but surgical stimulus always caused increases in blood pressure and heart rate. It was critical that pumping against a high resistance or pumping at a high rate not tax the donor heart. I also had to fill out a written anesthesia medical record to document what I was doing to the patient.

The scrub tech, nurse, and the two surgeons prepped and draped the patient for surgery, and the initial incision was made over the sternum. A power saw was used to cut the breastbone down the midline to enter the chest. A rib-spreader was used to widen the cavity and improve visualization. The surgeons inspected the heart in terms of its general appearance, size, contractility, and the state of the coronary arteries. Once they’d determined the heart was indeed normal, the transplant nursing coordinator made a phone call to the Stanford operating room in California to inform them it was a green light to anesthetize the heart recipient there.

In our operating room, the two surgeons clamped off the aorta and all other blood vessels leading into and out of the heart, and injected a cardioplegic solution into the coronary arteries via the root of the aorta. This solution preserved the heart function during the upcoming trip when the heart would no longer be beating. The surgeons then cut the heart out of the body, placed it in a sterile bag, and placed the bag into an Igloo chest full of ice. I turned off the ventilator, the surgeons removed their gloves and gowns, and our whole cast scurried out of the operating room with the Igloo and its precious cargo in hand.

It was always a bizarre sight to see that human carcass with an empty thorax lying on an operating room table when we left the operating room. In the later months of my Learjet experiences, a second transplant team was sometimes present to harvest the kidneys or corneas after we departed.

The original ambulance met us at the Emergency Room entrance, and we sped back to the airport Code 3 with alarms blaring. We drove onto the tarmac next to the Learjet and climbed inside. The doors closed, engines flared, and wheels up . . . we were on our way back to Palo Alto.

The flight home was relaxing. We’d spent an intense period of time at the hospital, and we had no work to do except to ride and look out the windows. Beverages and food were always supplied for the trip home. The mood was jubilant—the feeling you get with medical jobs when you realize you’ve accomplished something. We were helping the recipient patient in their journey back to health, and experiencing private jet travel at 35,000 feet at the same time.

On arrival to Moffett Field, an ambulance awaited us on the tarmac. We’d climb in and ride at top speed back to Stanford. We stopped in front of the Emergency Room, and the surgeons and the nurse coordinator ran through the doorway and up the stairs to operating room 13, where the anesthetized recipient patient lay, his or her chest open, ready to receive the new heart at once.

At this point I went home. An anesthesia resident colleague and an anesthesia faculty member were upstairs attending to the recipient. Caring for the recipient patient was their job for today—mine was finished.

How stressful was the entire journey to harvest the new heart? Pretty stressful, to be honest. At that point, I’d done less than two years of anesthesia training, and I was relatively inexperienced. During my training, a faculty member always stood right next to me during every anesthesia induction and a faculty member was immediately available at all times. On the Learjet trips I was without faculty backup for the first time. The setting at the destination hospital was always unfamiliar. The equipment on hand at the destination hospital was often unfamiliar. The cardiac chief resident surgeon was typically an intense 39-year-old who’d been training for decades and who had little interest in waiting any longer than possible while an anesthesia resident-in-training toiled to insert an arterial line and a central venous catheter. Even though the patient was brain dead, there was no tolerance for errors in ventilation or medical management, it was imperative to keep the vital signs stable throughout the donor surgical procedure, and there was time pressure to keep the process moving.

Prior to my anesthesia residency I’d completed three years as an internal medicine resident at Stanford and one year as an attending in the Emergency Room at Stanford. All my experience in internal medicine and emergency medicine was useful on those heart-harvesting trips—but I knew how lucky I was. Internal medicine residents don’t get to ride Learjets, and ER attendings don’t get to ride Learjets either.

An added motivation: We were paid $35/hour for our time, a princely sum in 1986.

Alas, none of this would happen nowadays. Currently there are hundreds of cardiac transplantation programs in the United States, and each program procures their donor hearts from close geographic proximity.

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

ARE SURGERY CENTERS SAFE?

outpatient-surgery-e1451859891882

This column is in response the Kaiser Health News story “How a push to cut costs and boost profits at surgery centers led to a trail of deaths” published on USAToday.com this week. The article set off a firestorm of controversy in the surgery center industry. The article cites anecdotal information and allegations from ongoing litigation cases of patients seemingly harmed by their care at outpatient ambulatory surgery centers.

The quantity of ambulatory surgery centers has greatly increased over the past forty years for three primary reasons: Technologic advances made surgery easier, anesthetic care is safer, and healthcare payment policies encourage ambulatory surgery. I’ve been the Medical Director at a busy freestanding ambulatory surgery center in Northern California for a decade and a half. I’m a Stanford University-trained anesthesiologist and internist, and I’m uniquely qualified to answer the question: Are American surgery centers safe?

Yes, they are safe.

A review of the medical literature on Pubmed shows no peer-reviewed studies or data that surgery centers provide less safe care than hospitals.

Surgery and anesthesia are never 100% safe, no matter where procedures are done. There are always risks. The roles of anesthesiologists and surgeons at surgery centers are to minimize the risks.

There are four key questions regarding safe patient care at surgery centers:

  1. Is the scheduled procedure appropriate for an outpatient surgery center?
  2. Is the patient healthy enough to tolerate the scheduled procedure as an outpatient?
  3. Are the healthcare professionals at that center practicing at the standard of care?
  4. Is the surgery center accredited by an organization such as the Accreditation Association for Ambulatory Health Care (AAAHC)?

 

Question #1.

The most important screening question for a surgery center is, “What is the scheduled procedure?” Knee arthroscopies, tonsillectomies, inguinal hernia repairs, and colonoscopies are standard surgery center procedures. You cannot do large cases such as craniotomies, open heart surgeries, or an aortic vascular surgeries at a surgery center. The necessary backups of an intensive care unit, a blood bank, respiratory therapy, and a clinical laboratory are lacking. The job of a Medical Director is to survey the schedule each week, and decide if any planned cases are outside the usual comfort zone for that center. If there is any question, the Medical Director must gather more information on the procedure and the patient, usually by talking directly to the surgeon, and decide whether or not to give the case a green light. If the verdict is a red light, the surgeon needs to do the case in a hospital.

In recent years, some surgery centers have expanded their scope. Procedures such spine surgeries, total joint replacements, and bariatric surgeries are performed as ambulatory or short stay procedures at some outpatient centers. As the USAToday.com article points out, one motivation is money. A surgery center can extract well-insured cases from hospitals in order to increase profits for the surgery center. Is it better for a patient to have these procedures in a freestanding facility detached from a hospital? There is a paucity of research in peer-reviewed medical literature regarding the performance of these cases outside of hospitals. The USAToday.com article lists multiple spine surgery patients who died after surgery at an ambulatory surgery center. Medicare has only approved payment for spinal surgery at ambulatory centers since 2015. To my knowledge, no one has published the overall statistics regarding complications from spinal surgery in surgery centers and compared this to the complications from similar procedures in hospital settings.

What about the claim from the USAToday.com article that 911 calls from a surgery center are a problem? If a patient unexpectedly becomes acutely ill at a surgery center, calling 911 and transferring the patient to a hospital is routine policy and appropriate medical care.

 

Question #2.

How does a facility decide whether a patient is fit enough to undergo a given surgery at an outpatient center? At a surgery center, it’s the Medical Director’s job to screen every patient prior to scheduling. It’s the Medical Director’s job to prevent patients who are too sick from having a procedure at a surgery center. Different systems exist for preoperative assessment. Large university hospitals staff preoperative anesthesia clinics for their patients, and patients are required to physically visit the clinic to be examined and assessed prior to inpatient surgery. This system is not always practical in outpatient community medicine. Patients are usually assessed by their primary care physicians as indicated before surgery. A typical preoperative screening protocol at a surgery center is as follows: a preoperative assessment professional from the surgery center will telephone each patient several days before surgery, ask a series of pertinent screening medical questions, and fill out a standardized form. Any outlying answers are referred to the Medical Director, who decides if the patient is fit for the surgery. If the patient is too sick, the Medical Director will cancel the case, and tell the surgeon that the surgery needs to be done in a hospital.

 

Question #3.

When a complication occurs, anesthesiologists and surgeons in the operating room have a responsibility to correctly diagnose the problem and apply the correct therapy. The legal term for this is that physicians must adhere to the “standard of care.” The standard of care is defined as “what a reasonably trained physician would do in the same circumstance.” Deviating from the standard care is called negligence, and is part and parcel to medical malpractice lawsuits. If a bad outcome occurs in a surgery center because of negligence, i.e. malpractice, this is not a fault of the surgery center system. This concept is a central flaw in the USAToday.com article. The article cites multiple bad outcomes from surgery center cases, and in many of these cases the central issue seems to be negligent, below the standard of care decisions and actions by the health care professionals involved. Negligence is not specific to surgery centers.

 

Question #4.

Most surgery centers provide care to Medicare patients, and must meet standards approved by the federal government. To obtain Medicare certification, a surgery center must have an inspection conducted by a representative of an organization that the government has authorized to conduct that inspection, such as the Accreditation Association for Ambulatory Health Care (AAAHC). Inspectors will physically visit the surgery center to verify that the center meets established standards. Most surgery centers have passed such an inspection. The surgery center I work at is recertified every three years. If you’re uncertain whether your local surgery center is safe, request documentation that the facility has been certified by an organization such as AAAHC.

Nearly 60% of all surgical procedures in the United States are performed as outpatient surgery. Tens of millions of Americans receive care in ambulatory surgery centers each year. I’ve personally had two arthroscopic surgeries and three colonoscopies, and I chose to have all five procedures at a freestanding outpatient surgery center. The USAToday.com article cited anecdotal adverse outcomes from patients who were cared for at outpatient ambulatory surgery centers. Adverse outcomes will occur, but the frequency of these events (adverse events vs. total number of cases) is extraordinarily small. America’s surgery centers are by and large very safe. I reaffirm that no peer-reviewed data documents that ambulatory surgery centers are unsafe.

The key issues regarding surgery center safety will always be the four questions posed above. Is a given procedure safe and appropriate for an outpatient surgery center? Is a given patient fit enough to have their particular procedure in an outpatient surgery center? Are the healthcare professionals at that center practicing at the standard of care? And is the surgery center accredited by an organization such as the AAAHC?

In the overwhelming majority of America’s surgery centers, the answers to these three questions will be “Yes, yes, yes, and yes.”

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

HANGOVER AFTER GENERAL ANESTHESIA

 

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Prior to surgery your patient tells you, “I’m always hungover after general anesthesia. I sleep for hours and I’m nauseated. All my life I’ve been very sensitive to medications. I never drink alcohol, and even a ½ dose of Nyquil or cold medicine knocks me out all night.”

What do you do with this information?

I’ve been a fulltime anesthesiologist for 34 years, and I’ve heard this monologue from patients countless times. My impression? The patient is always right. They’ve had the same body all their lives, and they know their reaction to central nervous system depressants. Listen to them and adjust your care.

Hangover after general anesthesia (HAGA) describes a patient who has a safe general anesthetic, but who then feels hungover, sedated, and wasted for a time period exceeding two hours afterwards. There is significant overlap between HAGA and postoperative nausea and vomiting (PONV).

The four established risk factors for PONV are: 1) the use of postoperative narcotic pain relievers, 2) female sex, 3) a non-cigarette smoker, and 4) a previous history of PONV.1 In my experience, these same four characteristics are risk factors for HAGA. Painful surgeries require more narcotics, which can lead to more nauseated patients. If the surgery isn’t painful, an anesthesia provider can work to eliminate postoperative narcotics, and minimize both PONV and HAGA.

With modern pharmacology and anesthetic techniques, HAGA should be uncommon. Propofol and sevoflurane are the mainstays of 21st century general anesthesia. Both are ultra-short acting medications that enable anesthesiologists to produce alert, awake patients within an hour of most general anesthetics.

Propofol has a quick onset and quick offset clinical effect, because the drug is highly lipid soluble and is rapidly distributed out of the bloodstream to other tissues of the body. When administration of propofol is discontinued, the initial fall in the plasma concentration is 50% due to this redistribution and 50% due to liver metabolism. The time to awakening after a 2-hour anesthetic is rapid (8-19 minutes).2 The elimination (hepatic) half-life is 3 to 12 hours, but propofol is not known to cause nausea. Hangover symptoms from propofol are rare. Sleepiness is the most common side effect, and this clears quickly.

Sevoflurane also has a quick onset and quick offset. Sevoflurane vapor is primarily eliminated via ventilation from the lungs. Because the drug has low solubility in the bloodstream, the pulmonary elimination is rapid, and only 5% of sevoflurane remains in the body to be metabolized by the liver and excreted via the kidneys. Pertinent mild side effects of sevoflurane include nausea/early 25%, vomiting/early 18%, dizziness/early 4%.3 These incidences of nausea and vomiting are higher than for propofol, so utilization of propofol over sevoflurane seems prudent for patients with a history of HAGA or PONV. However, because propofol is a sedative/hypnotic and does little to provide surgical analgesia, the addition of either a potent vapor such as sevoflurane or a narcotic is often necessary.

Over the years I’ve examined previous anesthetic records for many patients with a history of HAGA. The most common findings in these old records are relative overdoses of narcotics, be it fentanyl, Dilaudid, morphine, or any another narcotic. My impression is that some anesthesia providers rely on a set recipe for their narcotic dosing, and that they do not adequately alter or adjust this recipe for patients who are small, petite, elderly, or teetotalers. Narcotics are often indicated during surgery when surgical stimulus peaks, or near the conclusion of surgery to insure a patient has an adequate systemic narcotic effect and won’t wake up in agony. When a patient has a history of HAGA or PONV, I recommend minimizing the amount of intraoperative IV narcotics. Additional IV narcotics can be added post-extubation if the patient complains of significant pain.

Anesthesia providers typically judge anesthetic dosing depending on: a) patient weight, b) patient age, and c) the patient’s vital signs (i.e. high blood pressure and/or heart rates are treated by increasing doses of drugs, and low blood pressures are treated with decreasing drug administration).

A patient’s weight can be misleading. Multiple studies support that drug doses should be based on lean body weight (LBW) rather than their total weight.4,5 A 5-foot-6-inch obese patient may weight 200 pounds but have an estimated LBW of 150 pounds. Injected drug doses need to reduced by a factor of 150/200, or ¾.

Patients at extremes of age, e.g. geriatric or neonatal patients, can have significantly reduced requirements for injected anesthetic drugs. I refer the reader to textbook chapters on pediatric and geriatric anesthesia for evidence.

Utilizing increased anesthesia depth to treat hypertension or tachycardia is appropriate if the diagnosis is inadequate depth of anesthesia. If in your clinical assessment you’re administering an adequate level of anesthesia, then it’s appropriate to treat hypertension or tachycardia with antihypertensive agents or beta blockers rather than adding extraneous anesthetic depth or narcotics.

Is there science to confirm the existence of excessive anesthesia dosing? In a February 2018 Stanford Grand Rounds lecture, Dr. Daniel Sessler of the Cleveland Clinic presented data that hypotension is a risk factor for perioperative myocardial injury. Per Dr. Sessler’s unpublished data gleaned from electronic medical records on thousands of patients, one-third of intraoperative hypotension occurs during the time period between the induction of anesthesia and the surgical incision. During this time period, general anesthesia doses are unopposed by surgical stimulus. An inference from this data is that lesser amounts of general anesthetic drugs are required between induction and incision. Options to lower the anesthetic doses pre-incision include: a) less or no narcotic until the time of incision, b) utilizing 60% nitrous oxide without sevoflurane until incision, or c) utilizing sevoflurane without any nitrous oxide until incision. My preference is a combination of options a) and c), i.e. minimizing or avoiding narcotics until incision, and avoiding nitrous oxide until incision.

Conflicting data exist regarding redheaded patients and general anesthesia. A 2004 study of 10 redheads and 10 controls showed the inhaled desflurane requirement in redheads was significantly greater than in dark-haired women.6 This conclusion was refuted in a 2010 prospective study of 468 patients which showed no significant difference in recovery times, pain scores or quality of recovery scores in patients with red hair.7

Whenever possible it’s advisable for the surgeon to inject local anesthesia near the surgical site, or the anesthesiologist to use local anesthetic via a nerve block or a neuroaxial block to minimize postoperative pain.

Should we use intraoperative BIS monitors to guide minimalization of intraoperative anesthetics and narcotics? Although the idea is intriguing, I’m not aware of any data to support that BIS monitors provide a significant solution to the problem of intraoperative overmedication.

When a patient has a past history of HAGA or PONV, prior to surgery I discuss a metaphorical postoperative teeter-totter. On one end of the teeter-totter, the patient will have minimal postoperative pain but will be at risk for the systemic side effects of IV narcotics, namely sedation and nausea. On the opposite end of the teeter-totter, the patient will have some postoperative pain but will also benefit from lower systemic side effects of IV narcotics, namely lower levels of sedation and nausea. I tell the patient that after the surgery, in the Post Anesthesia Care Unit, they will be awake and able to make their own decisions whether they desire additional doses of intravenous narcotics or not, with the full knowledge that extra doses of narcotics may bring extra risk of sedation and nausea.

Can anything be done to predict the risk of HAGA? I attempt to identify teetotalers preoperatively. I routinely ask every patient, “Do you drink alcohol at times?” Their answers vary from, “No, I do not drink at all,” to “Yes, once or twice a month,” to “Yes, two glasses of wine every day.” It’s been my experience that patients who never drink alcohol (the most prevalent central nervous system depressant in the world) are more sensitive to anesthetic medications. It’s easy to postulate that a teetotaler’s brain is more sensitive to CNS depressants, and that their hepatic metabolism is less efficient clearing CNS depressants than a patient who ingests alcohol or other CNS depressants daily.

This column conveys what I’ve learned based on my clinical experiences over decades. When you attend to patients with a past history of hangover after general anesthesia, try the suggestions discussed above:

  1. Take a history and correctly identify patients with a past history of hangover after general anesthesia.
  2. Utilize propofol > sevoflurane for patients who are petite, who never drink alcohol, or give a history of being sensitive to CNS depressants.
  3. Administer significantly less IV narcotics to patients who are petite, who are elderly, who never drink alcohol, or give a history of being sensitive to CNS depressants.
  4. Administer intravenous doses based on lean body weight, not the actual weight, on obese patients.
  5. Administer lower doses of narcotics to patients at extremes of age, e.g. geriatric patients and the very young.
  6. Regarding intraoperative hypertension and/or tachycardia, if the anesthetic depth is already adequate, consider treating with antihypertensive medications or beta blockers rather than adding additional anesthetic.
  7. Decrease the amount of anesthesia you administer between the induction of anesthesia and surgical incision.
  8. Utilize local anesthetic/regional blocks to minimize postoperative pain as appropriate.
  9. Ask patients “Do you drink alcohol at times?” For teetotalers, utilize decreased doses, particularly decreased doses of narcotics.

These patients will likely fare better in your hands than what they’ve experienced after previous surgeries, and they will rank you above the historical control of anesthetists who’ve overdosed them in the past.

References:

  1. Apfel CC et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999 Sep;91(3):693-700.
  2. http://www.pdr.net/drug-summary/diprivan?druglabelid=1719#11
  3. http://www.pdr.net/drug-summary/Ultane-sevoflurane-32
  4. Lemmens HJ . Perioperative pharmacology in morbid obesity. Curr Opin Anaesthesiol.2010 Aug;23(4):485-91.
  5. Chassard D et al. Influence of bodycompartments on propofol induction dose in female patients. Acta Anaesthesiol Scand. 1996 Sep;40(8 Pt 1):889-91.
  6. Liem EB et al. Anesthetic requirement is increased in redheads. 2004 Aug;101(2):279-83.
  7. Myles PSBuchanan FFBain CR. The effect of hair colour on anaesthetic requirements and recovery time after surgery. Anaesth Intensive Care.2012 Jul;40(4):683-9

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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