DOCTOR BY DAY, SCI-FI WRITER BY NIGHT

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

This week the Palo Alto (California) Weekly ran a feature story on Rick Novak and Doctor Vita

Doctor by day, sci-fi novelist by night

Longtime Atherton resident spotlights AI and medicine in books

Dr. Rick Novak poses for a portrait at Stanford Hospital in Palo Alto on May 23. Photo by Magali Gauthier/The Almanac

Between his time in the operating room, teaching, and raising his three sons, Atherton resident Dr. Rick Novak has found time to write two novels.

Novak, 65, an anesthesiologist at the Waverley Surgery Center in Palo Alto, recently published his latest, “Doctor Vita,” a story about an artificial intelligence (AI) physician module that goes awry.

It’s a science fiction novel that explores how technological breakthroughs like artificial intelligence and robots will affect medical care — and already have.

The Almanac, an Embarcadero Media publication which serves Menlo Park, Atherton, Woodside, and Portola Valley California, featured a story “Fiction or the Future?” on Rick Novak and Doctor Vita the same week.

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GRADY HARP REVIEWS DOCTOR VITA. “A SPLENDID AND TIMELY NOVEL”

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997
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Grady Harp, Amazon Hall of Fame Top 100 Reviewer

April 20, 2019

Once again Rick Novak serves up a virulent novel that addresses an ongoing change in medicine that worries most of us – the growing dependence on robotics in surgery and the dehumanization of medicine: doctor patient interaction is altered by EMR and IT reporting of visits to insurance companies and the warmth of communication suffers. Rick takes this information to create a story about the extremes of AI in the form of a glowing globe that is Dr Vita and the struggle computer scientist/anesthesiologist Dr Lucas assumes as he tries to save medicine from the extremes of the ‘new age’ called FutureCare. As expected, Rick’s recreation of the tension in the OR and in interaction of the physicians is on target: his own experiences enhance the veracity of the story’s atmosphere.

Rick Novak writes so extremely well that likely has answered the plea of his readers to continue this `hobby’. He is becoming one of the next great American physician authors – think William Carlos Williams, Theodore Isaac Rubin, Oliver Wolf Sacks, Richard Selzer, and also the Brits Oliver Wendell Holmes et al. Medicine and writing can and do mix well in hands as gifted as Rick Novak. Highly Recommended. Grady Harp, April 19

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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 most popular posts for laypeople on The Anesthesia Consultant include:

THE FIRST CHAPTER OF DOCTOR VITA BY RICK NOVAK

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

robotic-procedures

The first chapter of Doctor Vita by Rick Novak opens with a scene unlike any you’ve ever read before.

Chapter 1    THE BRICKLAYER

Alec Lucas’s first contact with FutureCare came in operating room #19 at the University of Silicon Valley Medical Center, where his patient Elizabeth Anderson blinked into the twin suns of the surgical lights hanging from the ceiling. A clear plastic oxygen mask covered Elizabeth’s nose and mouth, her cheeks were pale and tear-stained, and a strand of gray hair protruded from a blue paper bonnet. Her hand trembled as she reached up to remove the mask.

“I’m scared,” she said.

“I’m not,” said Dr. Lucas, who was her anesthesiologist. A green paper mask covered his face, but his pale blue eyes sparkled at her. He hummed to himself as he injected a dose of midazolam into Elizabeth’s IV to relax her.

“Am I crazy to go through this?” she said. “A 78-year-old lady with cancer?”

“We’re hoping your cancer can be cured with surgery,” Alec said. “Right now you’re doing great. Everything is perfect. Have a wonderful dream.” Elizabeth had cancer of the stomach, and presented today for robot-assisted laparoscopic surgery to remove half her stomach. It was a huge surgery—a risky surgery. Alec wondered why they were doing this operation on this lady. He questioned the aggressive strategy for a woman this old, but his job was to anesthetize, not to philosophize.

He’d seen presurgery anxiety like hers hundreds of times. The best way to cure her fears was to get her off to sleep. He injected doses of propofol and rocuronium into her intravenous line. The drugs flowed into Elizabeth’s arm, and within ten seconds her eyes closed. He inserted the lighted blade of a laryngoscope into her mouth, and visualized the white and shining upside-down “V” of her vocal cords, hovering in a sea of pink tissue. He slid a hollow plastic tube between the cords and into the blackness of the trachea beyond. Then he activated the ventilator, which blew a mixture of oxygen and sevoflurane through the tube into her lungs.

“I haven’t worked with you before, Dr. Lucas,” said the circulating nurse, who stood at the patient’s side. “My name is Maggie.”

“Of course you’ve never worked with me,” he said. “I told the nursing supervisor I never wanted to work with Maggie.” Then he winked at her and said, “We haven’t worked together because today is my first day on staff here. I’ve been at the University of Chicago since my first day of medical school. After fifteen years of shoveling snow, it was time to give California a try.”

Alec looked up as the surgeon, Xavier Templeton, entered the room. A tall scrawny man, Templeton had pale hairless matchstick arms that looked better hidden within a surgical gown. His bushy eyebrows met in the midline, and his left eye squeezed in an involuntary tic. Templeton’s hands wouldn’t touch Elizabeth Anderson’s skin or stomach today. His hands would control two levers on a console worthy of a spacecraft, and each move he made would be translated into the movement of a five-armed machine named the Michelangelo III, also known as The Bricklayer.

The five slender mechanical arms of The Bricklayer, dull gunmetal gray in color, dangled like the legs of a giant spider above Elizabeth Anderson’s abdomen. Each arm was draped in clear plastic to keep The Bricklayer sterile when it entered her body through tiny incisions.

Alec accepted his role of goaltender at the Pearly Gates. His assignment was to keep Elizabeth Anderson asleep and alive, while Templeton and The Bricklayer resected her tumor.

Twenty minutes into the surgery, Xavier Templeton sat on a chair in the corner of the room with his back to the operating table, and peered into a binocular stereo viewer. His hands maneuvered two levers on the console before him. On the operating table, the five robot arms reached into the abdomen though five one-centimeter incisions. One of the arms held a camera on a thin metal rod, movable at the surgeon’s control. A seventh-year resident worked as a surgical assistant, and attached appropriate operating instruments to the other 18-inch-long robot arms.

The two surgeons murmured to each other in quiet voices. Alec watched the surgery on a large flat screen video monitor that hung above him. He saw pink tissues, robot fingers moving, and a lot of irrigating and blunt dissection. The surgery was going well, and Alec made only minor adjustments in his drug doses and equipment as needed.

Then one thing changed.

One of the robot fingers on the video screen convulsed in staccato side-to-side slicing movements of its razor-sharp tip. A clear plastic suction tube exiting from the patient’s abdomen lurched and became an artery of bright red blood. The scarlet tube emptied into a bottle two feet in front of Alec. In sixty seconds the three-liter bottle was full of blood. Fifty-eight seconds prior to that, Alec was on his feet and both hands were moving. A flip of a switch sent a stream of fluid through the biggest IV into the patient. He turned off all the anesthesia gases and intravenous anesthetic medications.

“Big time bleeding, Dr. Templeton,” Alec shouted to the surgeon.

As fast as he could infuse fluid into two IVs, Alec could not keep up with the blood loss draining into the suction tube. The blood pressure went from normal to zero, and a cacophony of alarms sounded from the anesthesia monitoring system.

Templeton descended from his perch on the far side of the room, and put on a sterile gown and gloves. He took a scalpel from the scrub tech, and in one long stroke made an incision down the midline of the abdomen from the lower end of the breastbone to the pubic bone. With two additional long swipes, the left and right sides of Elizabeth Anderson parted. A red sea rose between them. The surgical resident and the scrub tech held suction catheters in the abdomen, but the stream of blood bubbled upward past the catheters. Templeton cursed and reached his right hand deep to the posterior surface of the abdominal cavity, feeling for the blood vessel on the left side of the spinal column. He found it, and squeezed the empty and pulseless aorta.

Alec looked at the monitors. The blood pressure was zero, and the electrocardiogram showed the heart was whipping along at a rate of 170 beats per minute. His patient had one foot in the grave. “Have you got control up there?” he screamed at Templeton.

“God damn it! I’m squeezing the aorta between my fingers,” Templeton answered. “As soon as I can see, I’ll put a clamp on the vessel. The bleeding is everywhere. I can’t see a damn thing.” Templeton’s face, mask, hat, and gown were drenched with the blood of Elizabeth Anderson. His unibrow was a red and black dotted line.

“Fire up the Maytag,” Alec said to Maggie. “Call the blood bank and activate the massive transfusion protocol.” Alec bent over the Maytag, a rapid blood infusion device with a bowl the size of a small washing machine. He turned the Maytag to its top flow rate. The machine hummed and spun, and the basin of IV fluid emptied into Elizabeth Anderson through a hose as wide as a small hot dog.

Despite the infusion of fluid, her blood pressure peaked at a dismal 65/40. “Have you found the hole yet?” he said to Templeton.

“Torn aorta. There are multiple holes—the aorta’s leaking like a sprinkler hose,” Templeton said without looking up. His left eye was blinking and squeezing repeatedly as he worked. “It’s terrible. The inferior vena cava is shredded and the blood from the lower half of her body is pouring out into her abdomen. The blood is everywhere.” Blink, squeeze. “Her vessels are falling apart like tissue paper.”

An orderly ran into the operating room carrying a red plastic beer cooler. Alec grabbed the cooler and popped off the top. Inside were six units of packed red blood cells, six units of fresh frozen plasma, and six units of platelets from the blood bank. “Check all the units and let’s get them flowing,” he said to Maggie.

Maggie picked up each bag and double-checked the patient’s name and the unit numbers with a second nurse, and then she handed the entire cooler to Alec. He drained each of the units of blood products into the basin of the Maytag, and the bowl hummed and pumped the blood into Elizabeth Anderson. The blood pressure began to climb, but one look at the crimson suction tubes exiting the patient’s stomach told Alec they were still in trouble. The bleeding wasn’t slowing. Blood was exiting faster than he could pump it in.

“We need a second cooler of blood products stat!” he said. Maggie picked up a telephone and relayed the order to the blood bank.

Alec looked at the surgical field, and the patient’s blood was everywhere—on Templeton’s face, hands, gown, on the surgical drapes and on the floor. It was everywhere but where it needed to be—inside her blood vessels. Templeton’s resident was jamming a suction catheter into the abdomen next to Templeton’s fingers, trying to salvage as much blood as he could.

“Damn it,” Templeton said. “She’s still bleeding, and now she’s bleeding pink piss water. I can see through her blood, it’s so dilute. How much fluid have you given her?”

“Six units of blood, six units of plasma, six units of platelets, and eight liters of saline.”

Alec glanced at the monitors and saw that her blood pressure had plateaued at a near-lethal level of 40/15.

“Her blood isn’t clotting anymore,” Templeton said. “The blood’s oozing and leaking everywhere I place a suture.”

Alec palpated her neck, and there was no pulse. “She has no blood pressure and no pulse,” he said. “We need to start CPR.”

Templeton’s resident placed the palms of his hands on Elizabeth Anderson’s breastbone and began chest compressions. The patient’s heart rate of 180 beats per minute slowed to 40 beats per minute, with premature beats and pauses between them. After twenty seconds of a slow irregular rhythm, her heartbeat tracing faded into the quivering line diagnostic of ventricular fibrillation.

Alec injected 1 milligram of epinephrine, and screamed, “Bring in the defibrillator.”

A second nurse pushed the defibrillator unit up to the operating room table. Templeton charged the paddles, applied them to the patient’s chest, and pushed the buttons. Elizabeth Anderson’s body leapt into the air as the shock of electrical energy depolarized every muscle of her body. All eyes turned to the ECG rhythm, and it was worse than ever.

Flat line.

“Damn it. Give me the scalpel back,” Templeton said. He carved a long incision between the ribs on the left side of Elizabeth Anderson’s chest, and inserted his hand into her thorax.

“I have her heart in my hand and I’m giving her direct cardiac massage,” he said. Alec looked at the monitors, and the direct squeezing of the heart was doing nothing. The blood pressure was still zero, and now blood was oozing from the skin around her IV sites, as well as from the surgical wounds in her abdomen.

Elizabeth Anderson’s heart was empty. Her blood vessels were empty. Her blood pressure had been near-zero for twenty-five minutes.

“What do you think, sir, should we call it?” Templeton’s resident said.

Templeton pulled his hand out of Elizabeth Anderson’s chest, and looked at the clock. “I pronounce her dead, as of 8:48 a.m. Damn, damn, damn it!”

Alec reached over and turned off the ventilator. The mechanical breathing ceased, and there was nothing left to do. He looked down at Elizabeth Anderson’s bloated face. Two strips of clear plastic tape held her eyes fastened shut, and her cheeks were as white as the bed sheet she rested on. A length of pink tape held the breathing tube fixed to her upper lip, and blood oozed from her nose and from the membranes between her teeth. This lady walked into the University of Silicon Valley Medical Center today hoping for a surgical miracle, and instead she was going to the morgue looking like this.

Xavier Templeton peeled his gloves off. “Goddamn it! The fricking robot went berserk. Sliced into the artery like a goddamned hedge trimmer. Now I have to tell the family she’s dead. Goddamn damn it!” He scowled in Alec’s direction. “Are you coming with me, Dr. Lucas?”

Alec nodded a yes. He looked at the gloomy outline of The Bricklayer’s arms, and then back at Templeton. Templeton was a fool to blame the medical device for his own ineptitude. The machine could do no wrong on its own.

This was the surgeon’s fault. Alec had heard it all before. Accept compliments and deflect all blame—it was an adage as old as the profession of surgery.

Templeton commanded The Bricklayer. And The Bricklayer was no better than the human hands that led it.

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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 most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

Coming in 2019, from All Things That Matter Press: DOCTOR VITA, Rick Novak’s second novel

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

ai-medical-1-orig

 

How do you imagine the future of medical care? Cherubic young doctors holding your hand as you tell them what ails you? Genetic advances or nanotechnology gobbling up cancerous cells and banishing heart disease? Rick Novak describes a flawed future Eden where the only doctor you’ll ever need is Doctor Vita, the world’s first artificial intelligence physician, endowed with unlimited knowledge, a capacity for machine learning, a tireless work ethic, and compassionate empathy.

artificial-intelligence-in-medicine

In this science fiction saga of man versus machine, Doctor Vita blends science, suspense, untimely deaths, and ethical dilemma as the technological revolution crashes full speed into your healthcare.

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Set on the stage of the University of Silicon Valley Medical Center, Doctor Vita is the 1984 of the medical world– a prescient tale of Orwellian medical advances.

 

CARTOON — IS ANESTHESIA AN ART?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

THIS ORIGINAL ANESTHESIA CARTOON WAS PUBLISHED IN THE CALIFORNIA SOCIETY OF ANESTHESIOLOGISTS BULLETIN, VOLUME 52, NUMBER 2, APRIL-JUNE 2003.

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IS ANESTHESIA AN ART OR A SCIENCE? WAS  NIETZSCHE  CORRECT THAT ‘WHAT DOES NOT KILL ME MAKES ME STRONGER?”

In 2018, anesthesiologists consider surgeons our colleagues, and we seek and expect collegial relationships with them. I’ve heard surgeons say, “The patient is moving, dammit,” but the frequency of this sort of angry retort is less now than it was in the 1980s when I began my anesthesia career.

Do anesthesiologists have surgeries which last 10 hours? Yes, we do, and that’s a long time to remain vigilant.

It’s likely that tortured artists create an abundance of wonderful art, and it’s just as true that anesthesiologists hardened by stressful cases and challenging conditions become the most skilled anesthesiologists.

You won’t see us crying, as Dr. Baker is doing in panel 4, but the anesthesiologist’s rapid heart rate and the adrenaline rush in high pressure operating room situations accompany the growth of every anesthesiologist from inexperience trainee to seasoned professional.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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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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CARTOON FROM THE 1999 AMERICAN SOCIETY OF ANESTHESIOLOGISTS ART CONTEST

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

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The year was 1999, the technology stock market was exploding, and businessmen in Silicon Valley were getting richer by the hour. Meanwhile, back at the metaphor, anesthesiologists practiced their essential healing profession, and hoped HMOs and hospital administrators would not decrease their anesthesia quantum wage any further.

The cartoon won an Honorable Mention award at the ASA national meeting in 1999.

The original is a 24 inch X 36 inch panel which hangs in the office at my home.

Rick Novak, MD

 

P.S. I do believe it’s healthy for physicians to express themselves in print, in art, and via the spoken word.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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:

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SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER FIVE

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

5) BOB DYLAN DRIVE

In Northern Minnesota, a “Ranger” is an inhabitant of the mining towns along the Mesabi, Vermillion, and Cuyuna Iron Ranges. Unlike a mountain range, a Minnesota iron range has no elevated topography, no grand vistas and no snow-capped peaks. An iron range is a geological phenomenon, named for the deposits of rich iron-laden minerals just beneath the earth’s surface. Rangers take great pride in their iron mines. They’ll tell you the American ships, tanks, and planes which won World Wars I and II were constructed from steel that originated in these Minnesota mines. No tunnels are required to mine Minnesota ore—a mere scraping of the top layer of trees and topsoil is all that’s needed to expose the largest deposits of iron-containing rock in the United States.

Johnny and I passed the open pit of the Pillsbury Mine, five miles outside of Hibbing. Deep in the concavity of mines like this one, electric shovels the size of small office buildings excavated the iron-containing taconite rock, while the largest dump trucks on Earth carried 240-ton loads of rock to the mining factories on the edges of pit.

Johnny pointed to a solitary billboard standing in the woods on the left side of the highway, and said, “Whoa, check that out.” The billboard depicted a giant fetus in utero. The caption read, Hello world. My heart was beating 18 days after conception.

“Hmm. Disturbing,” Johnny said. “What’s the point of that?”

“Some folks up here don’t believe in abortion. They believe life begins in the womb. I guess they pay for billboards to try to sway people to their way of thinking.”

Two more curves up the road, the town of Hibbing spread out before us. A row of boxy stucco homes stood shoulder to shoulder, their canted roofs covered with fresh snow. A silver water tower bearing the stenciled name HIBBING crested a hilltop behind them. Our journey was at an end.

Bob Dylan once wrote, “Hibbing’s a good ol’ town… I ran away from it when I was 10, 12, 13, 15, 15 ½, 17 an’ 18. I been caught an’ brought back all but once.” I followed a similar path. I blew out of this town years ago, and clawed my way to a better life in California. I vowed never to return. That was before I had a son, a son who needed Hibbing.

I turned onto Howard Street, the main thoroughfare, and drove along the downtown strip of commercial buildings. Neon lights flashed the names of two banks, three restaurants, three taverns, and a liquor store. Six inches of new-fallen snow covered the surface of the two-laned street. Our tires made a scrunching sound as we drove. Mounds of ice and snow lined the perimeter of the road like levees isolating the street from the storefronts.

The vista was familiar, and it saddened me. Hibbing was unchanged from the Januarys of my youth. A woman dressed in a bulky goose-down parka crossed Howard Street in front of us, her scarf trailing in the wind behind her. I slowed to let her pass. She tested the snow-covered surface with exacting steps. Johnny followed the parka-clad woman’s progress in wordless wonder.

I drove the 12-block length of Howard Street and made a left turn onto 1st Avenue, the second of Hibbing’s two main business routes. Similar to Howard Street, 1st Avenue was home to three gas stations, four more bars, and two liquor stores.

“What do you think?” I said.

“There’s not much here,” Johnny said. “It looks like a ghost town. Black and white. Dark buildings and white snow. Lots of bars and liquor stores.”

“Alcohol is a tonic against the tedium. It’s a long winter up here.”

“Iron miners drink a lot?”

“As long as there have been mining towns, there have been mining towns with taverns. But Hibbing is different. There are a lot of educated people here. Remember, this is the biggest urban area between Duluth and Winnipeg.”

Johnny laughed. “That’s not saying much, Daddy-O.”

I turned off 1st Avenue and drove through six blocks of humble residential neighborhoods until I reached 7th Avenue, a narrow tunnel between rows of stark leafless trees. Stocky two-story homes lined up behind the trees like chess pieces behind pawns. Windows were miniscule. Walls were thick. The buildings were efficient barricades for holding in heat against brutal conditions. Hibbing houses weren’t built for style; they were built to protect people from bitter cold.

After five or six blocks, the 7th Avenue street signs changed, and read Bob Dylan Drive. I parked the car when we reached the corner of 24th Street and Bob Dylan Drive. The corner house was a two-story grey cube lacking a single gable. Foot-long icicles hung from the roofline. No sign or placard designated the structure as a famous building.

“Why are we stopped here?” Johnny said.

“This was Bob Dylan’s house.”

“This was where he was born?”

“No. He was born in Duluth, 75 miles south of here. His parents moved to this house when Dylan was a boy. His real name was Robert Zimmerman, and this was his home back in 1959 when he graduated from Hibbing High School.”

“So it’s not a museum or anything.” Johnny craned his neck to take in the particulars of the scene.

“No. It’s someone’s residence. I don’t know who lives here now, but it’s just a regular house.”

As I spoke, a man came out of the front door. He tightened the hood of his parka against the wind and aimed a shovel at the snow on the walkway. After his second shovelful, he stopped and looked up at us in our bashed-in BMW. A $120,000 German sports car with a smashed-in front end and California license plates couldn’t be commonplace in Hibbing in January. On the other hand, I suspect an out-of-town vehicle perusing the old Zimmerman home was not unusual. Muslims made pilgrimages to Mecca. Dylan fans made pilgrimages to Hibbing.

The shoveler wore his hood pulled down over his eyebrows and a brown scarf wrapped snug over his mouth. Only his eyes were exposed to the frigid air. He continued to stare at Johnny and me.

Behind my windshield, I felt like a goldfish inside an aquarium. To ease the awkwardness of the moment, I waved at the man. The resident of 2425 Bob Dylan Drive only exhaled steam into the frigid Minnesota air. He did not wave back.

“Friendly guy,” Johnny said.

“Cut him some slack. I’ll bet every day some dude from New York, Pennsylvania, Illinois, England or Italy knocks on this guy’s door and asks him if they can take a tour of the house. It must get old.”

“Let’s get out of here,” Johnny said.

I put the car in gear and drove thirty seconds down the road to the intersection of Bob Dylan Drive and 21st Street. To our right, an imposing three-story red brick fortress sprawled over four square blocks. It was easily the largest building in town.

Johnny craned his neck up at the structure, and said, “What’s this?”

“This is your new school.”

“It looks like a castle. How can they have such a monster school in such a little town?”

“A hundred years ago the town of Hibbing was located two miles north of here. When the mining companies discovered the richest supply of iron ore in the United States in the soil below the existing town, they cut a deal. The mining companies agreed to move the entire village and build Hibbing this wonderful high school in the new location as a reward for being relocated. C’mon, let’s go take a look.”

We walked up the front steps of the high school. I touched the brass railing with my bare hand, just like I had when I was 17 years old. At that moment, I was proud of my roots and proud of my alma mater. The front door was unlocked, and we stepped inside. The entryway was adorned with a tiled mosaic floor, a majestic marble staircase, and original oil paintings and murals on the walls depicting the history of the Iron Range.

“It looks like a museum,” Johnny said.

“See that plaque? This building is on the National Register of Historic Places. Wait until you see the auditorium.”

We walked to the end of the main hallway and passed through a set of double doors into the auditorium, an Art Deco wonder adorned by cut-glass chandeliers built in Czechoslovakia, and modeled after the ornate Capitol Theater in New York City. With a capacity of 1,800, the auditorium could seat every student in the school at once.

“This is where I received my high school diploma. And this is where Bob Dylan first performed and sang in public. They say he banged on the piano like a Little Richard clone.”

Johnny said nothing. He was biting the nails of his right hand, and he looked nervous.

“You OK?” I said.

“I don’t know. Now that I see this place, I’m getting worried. What if it doesn’t work out for me here? I mean, wherever I go, I’m still Johnny Antone. What if I’m in the middle of the pack here, just like I was in Palo Alto? What if we moved here for nothing?”

“You’ve got what it takes, Johnny. You’ll do great here. Let’s go. I’ve got something else to show you.” I led him out the front entrance of the school, and pointed across the street to a white colonial mansion on the corner of Bob Dylan Drive and 21st Street. It was twice the size of any house we’d seen in town. The front lawn was an expansive half-acre of drifted snow.

“That’s Uncle Dom’s house,” I said.

“Nice.”

“It’s one of the most impressive homes in town. When I was a schoolboy, doctors were the wealthiest people, and Dr. Dominic Scipioni was the top surgeon in Hibbing.”

We crossed the street together. Dom’s front walk was covered by a foot of crusted snow, unbroken by a single footprint. Johnny tip-toed up the path, his Nike Air Jordans sinking in and filling with snow on every step. “Dom isn’t doing a great job of keeping the snow off his walk,” he said.

“He doesn’t live here anymore, that’s why we got the place. Dom has homes in Arizona and Montana. He keeps this family house for the nostalgia of the old homestead.”

“What’s the deal with this Uncle Dom, anyway?” Johnny said. “Is he your uncle, or is he my uncle?”

“He’s nobody’s uncle. Dom’s not related to any of us, but he’s always treated me like family. Dr. Dom was my role model and mentor ever since I was a teenager.”

I bent over and peeled back the corner of the welcome mat. A shiny steel key lay underneath. “This is a sweet deal for us. We get one of the best houses in town, two blocks from the hospital and across the street from the high school, no questions asked. It’ll be our Minnesota man-cave.”

Johnny followed me into the house. The interior was meat-locker cold. We could see the water vapor of our breath. A lifelong ectomorph, I loathed hypothermia. I turned the thermostat up to 72 degrees and switched on the lights in the living room. “I recommend you proceed at once to the den in the basement. Dom has three big screen televisions, side by side by side. You can watch the NBA, the NHL, and the PGA Tour at the same time, by the mere effort of swiveling your neck a few degrees. And you want to know the best thing about Dom’s house?”

“What’s that?”

“There’s no one here to yell at you.”

“I’m with you there, Dad.” Johnny descended the stairs into the basement.

I toured the living room. Dom’s house lacked the towering ceilings of our glassed-in California home. The space felt claustrophobic with its tiny square windows, dark paneled walls, and smoke-stained brown-bricked fireplace. I knew every knot-hole in this room from my previous lifetime here, when Dom’s family was my family. Once upon a time, this room represented the height of luxury to me.

I walked over to the framed black-and-white photograph I knew would be standing on the fireplace mantle. The photo portrayed a young man and a young woman dressed in formal attire. The dark-haired girl wore a square-necked white dress, and held a broad bouquet of flowers. Her lips were closed, and she had a solemn, far-away look in her eyes. The man wore a tuxedo and a goofy smile that was incongruous with the woman’s apparent gloom.

A flood of grief overcame me. I’d traveled all day, and this picture was the tortured endpoint to my journey. It was Dom’s house, and Dom could decorate the place as he pleased. Some people preferred to put their memories on their fireplace mantles. Some memories were better left hidden.

The boy in the picture was Nico Antone. And the girl? She was from another lifetime. I’d shoveled dirt over this unsmiling girl years ago. She was dead, and I needed her to stay dead.

*
*
*
*

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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER FOUR

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

4) HIGHWAY 61 VISITED

I drove the black bullet of my BMW up Minnesota Highway 61, one hour north of Duluth and two hours short of the Canadian border. Johnny and I flew in from San Francisco to the Twin Cities that morning, and picked up the car from an interstate driving service in Minneapolis.

Our send-off in California was bitter. Alexandra dropped us off at the curb at San Francisco International Airport. She gave Johnny a big hug and said, “I love you, John-John. Call me every night.”

“Love you too, Mom,” he said. I watched their exchange with intrigue. Although he was eager to move thousands of miles away from her, Johnny still loved his mother. What can you say? She was the best mom he’d ever had.

As for me, I wasn’t going to profess any love this morning. Alexandra faced me, her eyes vacant and cold. “Are you going to be OK without us?” I said.

“I’ll be better than OK without you,” she said, her voice dripping with its customary arrogance. “If I’m lucky, you’ll never come back.” She grabbed the door handle of her Aston Martin, jutted her chin toward the sky and said, “Go.”

That’s the way it ended. I watched her drive off, and I was jolted by an unexpected surge of glee. I felt an unfamiliar sense of freedom, like a captive hawk unhooded and released from its tether. I had no idea when I would see her again, and I wasn’t in a hurry to find out.

Ten hours later, Johnny and I were driving north on a spectacular Minnesota winter day, with the blue expanse of Lake Superior sprawling ocean-like on our right and the setting sun disappearing behind the infinite expanse of pines on our left. I detoured up Highway 61 for the novelty of the famous road, so my son could witness the world’s largest freshwater lake. The scenery was world class, but for me the highlight was spending time with Johnny uninterrupted by the distractions of a television, an Xbox, or cell phone calls. Exiled from California, Johnny had no friends except me, and I liked it that way.

He slumped in the passenger seat and stared out the side window. Despite the winter temperatures, he’d rolled down his window and the icy breeze from Highway 61 fluttered through his hair. I was in control of the music. For this occasion, it had to be Bob Dylan. I cued up “Highway 61 Revisited,” and blasted the title song though the speakers. I belted out the lyrics in a nasal twang: “Well Abe says, ‘Where do you want this killin’ done,’ God says, ‘Out on Highway 61.’” My “61” came out as a screeching “sexty-waawn,” mimicking Dylan to the best of my ability.

“Bob Dylan wrote that song about this highway?” Johnny said.

“He did.”

“It’s a pretty creepy lyric. And you’re screaming it out like it’s an anthem. He’s singing about killing a son?”

“It’s from the Old Testament. God told Abraham to sacrifice his only son.”

“So? Did he kill his son?”

“No. He was prepared to do it, to obey God, but at the last minute God sent an angel to stop him. Instead of killing his son, Abraham sacrificed a ram.”

Johnny shook his head. “What kind of song is that? Sorry, Dad. I can’t get into the Dylan thing. It’s so hard to listen to the guy’s voice. That screeching is pretty awful.”

“Bob Dylan is one of the most imitated vocalists of the last hundred years. He gave every singer with a less-than-perfect voice a blueprint of how to sneer and twist off syllables.”

“He’s all mumbles to me.”

“Try to get past the sound of his voice, and listen to the words. Dylan was the first songwriter to turn poetry into popular music.”

“Who cares about poetry?”

“What is rap and hip-hop music but poetry? What do Jay Z or Kanye West do but chant some simple rhymes over a drum beat?”

Johnny looked unconvinced.

“Bob Dylan changed music forever. Before Dylan, the top singers were crooners like Frank Sinatra and Elvis Presley, guys with silky voices who performed songs written by unknown people. Then along came Dylan, coughing out “Blowin’ in the Wind” with a voice like sandpaper on wood. He jammed his songs into your ears with that raspy nasal twang, and crossed you up with changes in inflection no one ever heard before.”

“Why would anyone ever listen to that?”

“Great songs. ‘The Times They Are A-Changin’,’ ‘Mr. Tambourine Man,’ ‘Like a Rolling Stone.’ Songs that influenced every writer that followed after him.”

“It doesn’t make sense to me. How can a guy who changed the world come out of all this?” Johnny said, waving his hands at the endless forests. “From up here in the sticks?”

“God only knows where genius is born, but education had something to do with it. Hibbing High School. The same classrooms and hallways you’ll be in tomorrow.”

I spun the steering wheel to the left as we departed Highway 61 and veered west toward the heart of the Superior National Forest. Lake County Highway 15 was a curving two-lane highway that slalomed over gentle hills and carved through wilderness untouched by 21st-Century development. It connected the two metropolises of Silver Bay and Hoyt Lakes, each with a population of about 2,000. The road was smooth and the setting was desolate. We hadn’t seen another car in ten minutes. I compressed the accelerator pedal and watched the speedometer climb. “Hang on, son. We’re going for triple digits.”

When our speed hit 100 miles per hour, I looked over at Johnny. There was no trace of fear—he was loving it.

A sudden blaze of brown fur streaked across the road as the deer jumped out of the forest 100 yards in front of our car. “Shit!” I yelled, and stomped on the brakes so hard I thought my foot would break through the floorboard. Our car fishtailed counterclockwise. The rear wheels made a skid into the dirty snow on the side of the road, and our front fender slammed into the deer’s flank. I heard the crunch of crumbling steel, and saw the deer’s white tail slide up the windshield and over the top of the car. The airbags deployed, and twin balloons of white fabric blotted out the sun. The rear of the car wracked into something solid and stopped with a resounding thump.

I reached down and turned off the ignition. My hands were shaking. We’d hit the deer broadside at 100 mph. Highway 15 was now graced with one dead deer, one smashed-up BMW, and two happy-to-be-alive Antones. I took census of my four limbs and my vital functions. I didn’t seem to be injured. I feared for Johnny. I elbowed my air bag aside, and looked over at the passenger seat. There was movement behind Johnny’s air bag. I pushed the fabric aside, and saw my son crouched forward with his head between his knees.

“Are you all right?” I said.

Johnny was hyperventilating—a violent wind entered and exited his gaping mouth. Blood dripped from the right side of his chin. “Are you nuts, Dad?” he screamed. “You almost killed me. That was the scariest thing I’ve ever seen.”

I was reeling. What kind of father was I? I’d almost offed us both. “I’m sorry,” I said. “I didn’t think…”

You didn’t think? Do you ever think? Oh, what the hell am I doing up here?” Johnny buried his face in his hands and wailed, “Everybody I know is in California. My mother is thousands of miles away. I’m up here in the woods with you, stuck in a ditch in outer Mongolia. We’re going to freeze to death and die right here. I should never have left home.”

I didn’t know what to say. I started to reach out toward my son to comfort him, but Johnny grew more agitated, turned away, and wrestled with the airbag until he found the door latch. He pushed the door ajar, and burst out into the sub-freezing air outside.

I opened my own door and twisted my way out of the car. The right front quarter of the vehicle was buckled like an accordion. The deer lay mangled on the roadside at the rear of the car, its glassy eyes staring skyward into the void. Blood seeped from its ears, nose, and mouth. Its thorax was buckled, concave and deformed.

What a waste.

Behind me, Johnny said. “Dead deer. Totaled car. Stranded in the middle of nowhere. Great job, Dad.”

“It all happened so fast…”

“No. You were driving like a maniac, and now we’re stuck. We’re so stuck. There’s no people in these woods but lumberjacks. Lumberjacks who would be hunting this deer if you hadn’t killed it.” Johnny shook his head. He stuck out his jaw, square and resolute. “I’m done. I changed my mind. I want to go home.”

I’d heard enough. “No. We’re going to Hibbing,” I barked. “It’s what you and I decided to do. Together, that’s what you and I decided.”

“I’m un-deciding.”

“It’s too late for that. I’m pulling rank on you. We’re in Minnesota, and we’re staying in Minnesota.” I walked back to the driver’s door, unsheathed a small Swiss Army knife from my key chain, stabbed the point of the blade into the airbag, and slashed a 10-inch gouge in the material. I squeezed the remainder of the air out, compressed the bag into a dense lump the size of a basketball, and stuffed it back into its housing inside the steering wheel. I repeated the same treatment on the passenger airbag, and pushed the deflated fabric back into the dashboard.

“Get in,” I commanded.

“You don’t understand, Dad. What’s the point of getting into this wreck of a car, marooned ass-end first in a snow bank?”

I ignored his sky-is-falling attitude, and pushed the ignition button. The engine sprang to life. I floored the accelerator pedal, and listened to the roar of the motor echo off the virgin pines around us.

“Get in,” I repeated.

Johnny looked both ways on the deserted highway, and his shoulders slumped. He climbed into the passenger seat, with a look of hopeless resignation etched on his face. We were miles from the nearest town, and the deformed car was our only hope to limp out of the wilderness. I shifted the transmission into Drive and wondered if the right front tire would move within the mangled fender. With a lurch, the BMW rolled forward out of the snow bank. Lucky us. I whistled through my teeth and turned the automobile back onto Highway 15 for the last leg of our trip toward Hibbing.

I vowed that the next time I saw God, I’d run a little slower. Abraham sacrificed a ram instead of killing his son.

I settled for a deer.

*
*
*
*

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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

SERIALIZATION OF THE DOCTOR AND MR. DYLAN … CHAPTER THREE

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

3) QUEEN ALEXANDRA APPROXIMATELY

I drove my black BMW M6 convertible up the semicircular driveway to our Palo Alto home after work, and parked behind my wife’s silver Aston Martin One-77. Together, the value of the two cars approximated the gross national products of some third world nations. Our home was a 7,000-square-foot Tuscan villa built on a hilltop west of the Stanford University campus. The Antone estate encompassed three acres of tranquility, and towered above an urban area of seven million Californians, most of whom were mired in less-than-tranquil rush hour traffic at that very moment.

Our living room featured thirty-foot-high ceiling-to-floor windows overlooking San Francisco Bay. The décor included opulent white Baker couches no one ever sat on and a Steinway grand piano no one ever played. I sped through the formal room at flank speed. I couldn’t remember ever spending more than five minutes hanging out in this museum piece of showroom design.

I carried a large bag of Chinese take-out food from Chef Chu’s, and set it down on the stainless steel countertop of our spotless, never-used kitchen. I made a beeline for the refrigerator, popped the top off a Corona, and chugged half the bottle. I was still vibrating from my day in the operating room. I looked out the French doors toward the back patio.

Alexandra was lying on a lounge chair and sipping a tall drink through a straw. A broad-brimmed Panama hat graced her swirling mane of black hair. She wore a white one-piece swimming suit. It was an unseasonably warm day for January, and my wife never missed an opportunity to bronze her lanky limbs.

I walked up behind Alexandra, wrapped my arms around her neck, and kissed her left cheek. She held a cell phone against her right ear, and she pushed me away while she continued her conversation. I frowned and said nothing. Was it so hard for Alexandra to pretend she loved me? I sank into a second chaise lounge beside her, closed my eyes and listened.

“That property is overpriced at $6.5 million,” she said. “I know we can get it for 6.2. Put in the bid tonight and tell the seller they need to decide by tomorrow morning or the deal’s off. Got it? Call me back when they cave. Ciao.”

Alexandra set her phone down and lit a Marlboro Light 100. She inhaled with a violent effort, exhaled the smoke through her nostrils, dragon-like, and turned toward me. She wore broad Ray-Ban sunglasses. I couldn’t tell if she was looking at me or if she was looking out over San Francisco Bay, a vista Alexandra may well have considered far more interesting.

“How are you?” she said.

“I had a busy day. Today I was in the neuro room…”

Her phone rang again, and she waved me off while she took the call. My heart sank anew. She listened for an extended time and then she said, “I’ll be there at 5. No problem. Thanks.” She hung up and thrust her fist into the air. “Got a whale on the line,” she said. “There’s a couple from Taiwan who want to see the Jorgensen house tonight. Their agent drove them by the property this morning. They are very, very interested, and very, very wealthy. It’s an all-cash deal. A blank check.” She took a second long drag on her cigarette, and leaned toward me. At this angle, I could see my own reflection dwarfed in the lenses of her sunglasses. “This is big, Nico.”

“How much is the Jorgensen house listed for?”

“Just under 8 mill. That’s a quarter of a million dollar commission for yours truly.”

Her monomaniacal pursuit of money baffled me. Alexandra Regina Antone was one of America’s top real estate agents. Because of her explosive earning power, we lived in one of the nation’s most expensive residential neighborhoods, a zip code where Silicon Valley’s multimillionaire CEO’s and venture capitalists lorded in their castles. The residential properties Alexandra bought and sold for her clients were in the $3 million to $10 million range, and she earned a 3% commission on each sale. She sold one or two houses each month, and her income for the past year topped $9 million.

Alexandra’s salary dwarfed mine. None of my medical peers lived in this kind of luxury. To Alexandra, another $240,000 commission was headline news. It wasn’t about the cash—this was about the glory of Alexandra and her talent. It was about the Queen of Palo Alto rising higher and higher on the pedestal she’d erected for herself.

“So, you were telling me about your day,” Alexandra said, as she stretched her arms toward the sky and stifled a yawn.

“I did a craniotomy with Judith Chang. One case. It took all day.”

She took a final drag on her Marlboro, shivered in disgust, and said, “Judith Chang is such a stiff. Always bragging about her robotic daughters. I don’t know how you can do that job, locked in a windowless room with her hour after hour.” Alexandra had zero interest in listening to medical stories. She changed the topic at once. “Did you hear about Johnny’s report card?”

“I did. He’s pretty upset. Johnny wishes his grades were better. I wish his grades were better. He said you yelled at him.”

“Johnny’s a slacker. God knows I tried to light a fire under him years ago, but you taught him how to watch ESPN instead of pushing academics.”

“He said you called him a lazy shit.”

“I did. He is a lazy shit.”

“He’s your son, for God’s sakes. Johnny loves you and looks up to you. How do you think he feels when his mother says that?”

“I don’t give a fuck how he feels. Johnny needs to hear it, and he needs to change. Clue in! You don’t seem to get it, either. You think he’s fine just the way he is. Well he isn’t, Nico. Johnny’s a spoiled brat, living in luxury on top of this hill. He has no incentive to work hard. He thinks he can live off my money forever.”

Alexandra was dogmatic about the pathway to success. She was an unabashed academic snob—a graduate of Dartmouth College and Harvard Business School—and she’d have tattooed her Ivy League diplomas across her cleavage if she hadn’t been too vain to disfigure her silicone orbs. I wasn’t going to fight with her—I never won.

I shifted gears. “Dr. Chang had an interesting take on Johnny’s grades. She said Johnny could get into any college he wanted to if we lived in South Dakota.” I explained how Dr. Chang’s nephew from Sioux Falls was accepted to Princeton.

Alexandra removed her hat, shook out her hair, and took off her sunglasses to reveal flashing brown eyes. “For a change, Judith Chang is right. Johnny’s chances for success are slim on his current path. He has no chance at the Ivy League coming out of Palo Alto with his B average.” She chewed on the earpiece of her Ray-Bans as she contemplated. “Why don’t we send him to Minnesota to live with Dominic?”

“You’re kidding,” I said. My Uncle Dominic had a home near the Canadian border, in Hibbing, Minnesota, where I graduated from high school. Hibbing was a great place if you wanted to hunt partridge or ice fish for walleye pike, but the tiny village was a subarctic outpost light-years removed from the opulence Johnny grew up with in California.

“I’m not kidding. Johnny needs a gimmick for college admissions, and he has none. Hibbing could be his ticket.”

“He can’t just move up there with Dominic. Johnny’s 17 years old. And Dominic moved to Arizona. His house is empty.”

“Then take a year off. Go up there with him. Get your ass out of that windowless tomb of an operating room and take your son back to your childhood home.”
I frowned. “What about you?”

“Are you kidding? I’m not going anywhere. My friends are here, my job is here. But you go right ahead, Nico.”

Now it was my turn to stare off at the blue expanse of San Francisco Bay. Move back to the Iron Range of Northern Minnesota, to the land of rusted-out Fords and beer-swilling Vikings fans? What had my marriage come to? Before Johnny was born, Alexandra and I used to sit in these same chairs and drink margaritas together. Naked dips in this same pool led to nights of laughter and hot sex. Our current sex life had declined to hall sex, when I murmured “fuck you” under my breath after Alexandra walked past me in the hallway on her way to the second bedroom where she slept alone.

Alexandra was unrelenting. “Don’t give Johnny an option. Tell him you’re taking him to Minnesota to turn his life around, get some A’s, and graduate number one in his class from Hibbing High School. Call Dominic tonight and make the arrangements. It’ll be the best decision you’ve ever made. Trust me.”

Trust me. Alexandra could sell bikinis to Eskimos. “You’re OK with your husband and son moving 2,000 miles away?” I said.

She wrapped her arms around herself in an absurd parody of self-love and said, “Of course I’ll miss you.” Then she laid back onto the chaise lounge, the top third of her breasts busting out of her swimsuit top. She knit her hands behind her head, pushed her cleavage out into the January sunshine, and grinned in silence.

I watched the spectacle of her arching self-absorption and winced. Move 2,000 miles away? I was 2,000 miles away from this woman already.

“Hey guys,” came a voice from behind us. Johnny was home from school. He walked onto the patio and stood between us. My mood improved at once. Our son was tall and muscular with perfect skin, dark wavy hair, and striking blue eyes. He wore his usual uniform of gym shorts and an oversized T-shirt. My love for Johnny was unlike any emotion I’d ever felt. Romantic love for a woman was a wonderful abyss—the subject matter of a million songs, books, movies, and television shows. I’d watched romantic love drift off into the ozone as years passed, but with my son I was in love forever. If Alexandra and I ever divorced, I’d carry on. If my son ever shut me out, I’d need electroshock therapy.

Johnny wasn’t smiling. His shoulders drooped, his chin scraped his chest, and his gaze was locked onto the slate tiles under his well-worn Nike athletic shoes.

“How’s the Boy with the B’s doing?” Alexandra said.

Johnny regarded her through hooded eyes—James Dean with a cause. His upper lip curled skyward in a look of contempt. He was already smoldering from a bad day, and she was throwing kerosene on his fire.

She forged on, hawking optimism now. “Dad and I have a great plan for you that should make your report card problem of no consequence.”

“Great plan?” Contempt turned to suspicion.

“Johnny, are you happy that your grades rank you in the middle of the pack at your school?” she said.

“You know I’m not,” he sneered. I didn’t have a 42-inch monitor displaying Johnny’s vital signs, but I knew my son’s blood pressure was escalating.

“Would you like to be accepted into a top college?”

“Duh. Of course, Mom.”

“What if we told you there was a way for you to graduate at the top of your class and go on to one of America’s best colleges?”

“I’d say you were smoking too much weed.”

“No weed.”

“How am I going to jump to the head of my class at Palo Alto Hills High?”

“Not Palo Alto Hills High School, Johnny. Hibbing High School.”

Johnny looked from me to his mother and back again. “You two are messed up. Hibbing? Where the hell is that?”

“Hibbing is in Northern Minnesota. It’s where your dad grew up. It could be worse. We’re not sending you off to some military school in the badlands of Utah where you don’t know anyone. Your dad will move to Minnesota with you.”

“That’s ridiculous… Dad?” he said, panic in his voice.

I opened my mouth, but Alexandra didn’t give me a chance to weigh in. “There are consequences for your lack of effort in school, Johnny,” she said. “We want you to get out of Palo Alto and compete for grades with the sons and daughters of some iron ore miners. Right, Nico?” She turned to me for affirmation.

Johnny’s jaw sagged. “Dad?” he said again.

“I’m overdue for my sabbatical at the University,” I said. “My Uncle Dominic has a house in Hibbing. With your brains, your test scores, and a lot of hard work, you could be a top student up there. Instead of being a middle-of-the-pack Palo Alto student, you could be….” At this point I decided to gamble and appeal to my son’s ego and vanity, “You could be the valedictorian.”

“Can the best students from a school like that get into a top college?”

“They can. When I was a senior at Hibbing High, two kids were accepted to Harvard. It’s got to be the best high school in the northern half of Minnesota.”

“Whoa. Harvard?”

“Yes, Harvard.”

Johnny looked over at his mother. She smirked, as if she’d single-handedly masterminded a strategic maneuver worthy of Machiavelli.

“I’ll have to think about this,” Johnny said.

“I’ve got to shower and get ready for my meeting,” Alexandra said. “Nico, you guys are on your own for dinner. Johnny, I’m sure you’ll love Minnesota.” She rolled off her lounge chair as Johnny covered his eyes and pressed his thumbs into his temples.

She walked away, and I admired the swagger of her slender hips and the bounce of her long tresses. I never got tired of looking at Alexandra, but it wasn’t much fun living with a woman whose best friend was her mirror.

I turned to Johnny. “Want some Chinese food?” I said.

“I’ll eat it in my room, Dad. I have a ton of homework. I’m really pissed off about everything and I don’t want to talk anymore. First I get the crappy report card, and now you guys want to ship me off to the Yukon. All you guys care about is grades. You don’t give two shits about whether I’m happy or not.”

“That’s not true.”

“It is true. Just leave me alone. I’m going to my room. This B-student has a date with Hamlet.” Johnny walked away, and I let him go. My B-student son needed more dates with the Danish prince.

I dished out a plate of Szechwan prawns and General’s Tso’s chicken, and popped the top off a second Corona. The Golden State Warriors were playing the Miami Heat at 6 p.m. A second Corona, some Schezwan prawns, and the basketball game sounded like a decent evening.

After halftime, Johnny came shuffling down the hallway. He stretched out on the couch opposite me, and opened his laptop. He was humming to himself, and his fingers were flying.

I was happy to see he’d cheered up. “Feeling better?” I said.

“Yep. The Chinese food hit the spot.”

I waited for more conversation, but none was forthcoming. The Warriors connected on an alley-oop and an outrageous dunk. Johnny didn’t look up.

“How’s Amanda?” I said, trying to stoke up a dialogue. Amanda Feld was Johnny’s girlfriend, a petite cross-country runner who gazed at Johnny like he was a Greek god. She hadn’t been over for a couple of weeks, and Johnny hadn’t brought up her name for longer than that.

“Amanda’s history,” Johnny said.

“History?”

“I broke up with her a month ago, Dad.”

“What happened?”

“Nothing happened. It didn’t work out.”

“She was cute.”

“Yep.”

I waited for more of an explanation, but none came. Amanda’s fate paralleled all the other breakups of the past year, when Johnny ended relationships with Samantha the cheerleader, Emily the debate star, and Jenna the girl across the street. Johnny seemed to attract girls by repelling them. The less interest he showed, the more the women orbited him. I was envious.

Johnny said, “The report card and class rank bullshit really wore me down today. Why should my whole future revolve around some alphabet letters on a page?”

“It doesn’t. Your life is much more than your grades.”

“Yeah, like what?”

I pointed my two forefingers at my son just like I had a thousand times in his life, and said, “You’re a great kid. Don’t ever forget it.”

“Why do you always have to say that to me, Dad?”

“Because it’s true. I want you to imprint it in your brain and never doubt it.”

“Even if I can’t get an A in one class?”

“Even if you can’t get one A.”

“I want to get A’s. All A’s. But transferring to Minnesota?” Johnny tapped the screen of his laptop and said, “I’m looking at the Weather Channel website. It’s minus five degrees and snowing in Hibbing right now.”

“Yep. That’s why I left. In the winter the sun sets at 3:30 in the afternoon.”

“That’s insane.”

“It ain’t California.”

He shook his head. “I’m going to sleep.”

“Good night, son. I love you.”

“Love you, too,” Johnny said, and then he headed off toward his room.

I welcomed the tranquility from the two beers. My eyelids grew heavy, and I faded toward unconsciousness. My cell phone rang and woke me. I didn’t recognize the number. I answered the call, and a male voice said, “Alexandra?”

“No, this is her husband’s number. Who’s calling?”

There was a click as the line went dead. The heaviness in my eyelids was gone. I found myself mistrusting my wife.

Again.

I woke in the middle of the night. I’d dozed off in my chair in front of the flickering television. A Seinfeld rerun was playing. I turned off the TV, tried my best to stay asleep, and stumbled down the hallway toward my bedroom. The door to Alexandra’s bedroom was open, and her bed was untouched. I looked at my watch. It was 2:07 a.m.

A surge of annoyance ran through me. Where the devil was she at 2 o’clock in the morning on a Thursday night? My hopes for a quick return to slumber were dashed. I was full of adrenaline, and I wasn’t going back to sleep anytime soon. I walked into her room and laid down on her bed. The familiar smell of her hair from the pillows jolted me. It had been a long time since we’d touched the same sheets together.

I heard a car door slam outside. A minute later, Alexandra stood in the bedroom doorway. She carried her high heel shoes in one hand and wore a black spaghetti strap cocktail dress. Those spectacular legs were glistening from mid-thigh on down.

She was startled to see me. “What are you doing in my room?” she said.

“Waiting up. Where were you?” My voice quivered with resentment.

“Oh, Jesus, Nico. I’m not a sixteen-year-old girl, and you’re not my dad. I went out with the girls and had a couple of drinks and some laughs. It was fun. You should try it sometime.”

“I don’t believe you.”

“Believe whatever you want. Can you get out of my room now so I can go to sleep?”

I turned on the overhead lights, and examined the illuminated spectacle of Alexandra Antone. Her arms were crossed, and she was smirking down at me. A streak of red lipstick stretched from her upper lip across her right cheek. Was she was playing kissy-face with the girls?

I lost it. “Are you playing me?” I said.

“What are you talking about?”

“Are you playing me for a fool? Who were you with?”

She turned her back on me and walked into her closet. “You are such a buzzkill,” she called out. “You always hate it when I have fun. I have a life. I’m sorry you’re jealous.”

I ran to her like a wild bull. I grabbed her by the arm and swung her around to face me.

“Are you having an affair?” I screamed.

Dull eyes stared back at me. Alexandra blinked twice, shook her head in disgust, and said, “No, I’m not. And get your hands off of me, Nico. You’re still the same small-town hick you’ve always been.”

Her defiance infuriated me further. “I’m sick of you, and I’m sick of our bogus marriage.”

She laughed at me and said, “You need to find somebody else. Someone who likes listening to your boring medical stories. Someone who wants to cook meat and potatoes for you. Someone who enjoys staying home and watching TV with you.”

“I’m married to you. I’m not finding anybody else while I’m your husband.”

“Are you my husband, Nico? Or my dependent?”

I saw flames. I picked up her six-foot-tall cast iron coat rack and rammed the shaft through the closet wall. The metal hung there, cleaving the room between us.

“Are you crazy?” Her shriek was ear-splitting.

“At least I’m not a whore.” With those words, I’d crossed the line. As of that moment, I knew I could no longer live with the woman. “If you want to stay out half the night like a tramp, don’t bother to come home at all.”

“I’m not going anywhere,” she screeched. “You’re the one who needs to move out. I paid for this damn house.”

The hardwood floor creaked behind me, and a voice bellowed, “Shut the fuck up! Both of you!” It was Johnny, standing in the doorway in his undershorts. My world stopped. Alex and I stared at our son, and no words were offered.

Alexandra spoke at last. She said, “Whatever. Can you two get out of my bedroom now?”
Johnny shook his head and disappeared into the darkness of his own room. I was so embarrassed and furious I found it hard to breathe. The two most important relationships in my life were imploding before my eyes. I left Alexandra’s room, and she shut her door behind me. I leaned against the closed door of Johnny’s bedroom and said, “I’m sorry, son. I’m sorry you had to hear that.”

“Then stop talking about it,” he said. I waited there for five minutes. He made no further sound. I walked away, back to my isolation in the master bedroom.
I lay in the dark with a pillow over my eyes and replayed what had just gone down. My life was ridiculous. My separate-evening, separate-bedroom, give-your-husband-shit-whenever-possible marriage was ridiculous. How could Johnny have a healthy adolescence under these circumstances?

I had no answers. I was angry, depressed, and reeling. I reached into the drawer of my bedside table, pulled out my bottle of Ambien, popped two, and chased them with a swallow of water from last night’s glass. I was an expert at anesthesia, even when I was the patient.

The next day I dragged myself through five routine surgeries although I was so angry it took all my will to concentrate on my craft. When I returned to my house that evening, Johnny was stretched out in my lounge chair. He was watching TV and typing into his laptop. He’d been asleep when I left for work that morning, so I hadn’t seen him since the screaming session in the hallway. Alexandra was nowhere to be seen.

“Hey, Dad,” Johnny said without looking up.

“Hello, son. Did you get some sleep after that whole episode last night?”

“I did. Mom gave me a ton of crap this morning for swearing at her and being disrespectful.” His face soured. If there was more to say, he wasn’t going there. He closed the laptop and said, “Other than that, it was a good day. I’ve been researching a lot of stuff about Hibbing on the Internet.”

He had my attention.

“That was excellent Chinese food last night, wouldn’t you agree?” he said.

“It was.”

“It’ll be our last decent Chinese food for awhile, Dad. I don’t think there’ll be any outstanding Chinese restaurants up there in Hibbing. I want to do it.”

“Do it?”

“I want to get away from Palo Alto Hills High, away from Amanda Feld, and away from Mom.
I want to go to Minnesota. Will you take me?” He held out his hand toward me. I stared at it and contemplated the implications of the gesture. Johnny was an impulsive kid, capable of making radical and irrational decisions in a heartbeat, but he’d never made a decision that impacted his life to this degree.

“You mean it?”

“I do. Can you walk away from your anesthesia job?”

“Well…” My thoughts were jumbled as I pondered the coin spinning through the air. Heads, I honored my love for my son and joined him in this adventure. Tails, I maintained my love for the warmth of California and my stable university job.

The tipping point was Alexandra. She was a toxic presence in my life. More than a marital separation, I needed an exorcism. It wasn’t a question of love. I didn’t even like her.
The coin landed on heads. I clasped Johnny’s outstretched hand and said, “Let’s do this, son. Let’s move.”

“Can’t wait, Daddy-O,” Johnny said.

“I’ll call Uncle Dominic in the morning and set things up.”

Johnny smiled and repeated again, “Can’t wait.”

*
*
*
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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 ricknovak.com by clicking on the picture below:  

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CALIFORNIA SOCIETY OF ANESTHESIOLOGISTS ONLINE FIRST: BOOK REVIEW OF THE DOCTOR AND MR. DYLAN AND INTERVIEW WITH THE AUTHOR

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

This post is a link to an article originally published in the California Society of Anesthesiologists Online First Blog, Authored by Dr. Michael Champeau (current Treasurer of the American Society of Anesthesiologists, as of October 2017): Book Review of THE DOCTOR AND MR. DYLAN

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

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An Anesthesia Suspense Novel by Rick Novak, MD – An Interview with the Author

I’m writing to recommend a page-turning suspense novel that stars a physician anesthesiologist as its protagonist. Authored by CSA Member and former District 4 Delegate Rick Novak, MD, The Doctor and Mr. Dylan is a mystery novel recently published by Pegasus Books that centers on the professional and personal rivalries between physician anesthesiologist Nico Antone and nurse anesthetist Bobby Dylan.

Most of us are too busy with our careers to even imagine spending our personal time reading a medical novel, but the first lines of The Doctor and Mr. Dylan will convince you this book is unlike those you’ve read before:

My name is Dr. Nico Antone. I’m an anesthesiologist, and my job is to keep people alive. Nothing could inspire me to harm a patient. Alexandra Antone was my wife. Alexandra and I hadn’t lived together for nearly a year. I dreaded every encounter with the woman. I wished she would board a boat, sail off into the sunset, and never return. She needed an urgent appendectomy on a snowy winter morning in a small Minnesota town. Anesthetist options were limited.

Life is a series of choices. I chose to be my wife’s doctor. It was an opportunity to silence her, and I took it.

The Doctor and Mr. Dylan is a medical thriller, a legal thriller, and an ode to musical icon Bob Dylan, all interwoven into a single plot line. In brief, Dr. Nico Antone is unhappily married and imagines a life without his tormenting wife, a Silicon Valley real estate tycoon whose income far outstrips his own. He’s also convinced that his son, a teenager enrolled at Palo Alto Hills High, would gain an advantage in college admissions if their family moved to the rural Midwest.  As a result, Dr. Antone moves with his son Johnny to Hibbing, Minnesota in hopes that he will graduate at the top of his class and be accepted into a prestigious Ivy League university. Johnny becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged nurse anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. The operating room death of Mrs. Antone rocks their world, and the anesthesiologist stands trial for murder—a murder he believes Mr. Dylan committed.

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 few will see coming. The prose is witty and funny, and I found myself chuckling repeatedly at unexpected times.

The book brings the issue of independent nurse anesthetist practice to a national audience, and the conflict that this at some times engenders drives the plot. Most of all, The Doctor and Mr. Dylan is a head-scratching mystery, guaranteed to keep you riveted until the last page. I read the last third of the book in a single post-midnight sitting, not able to wait for the resolution.

By way of full disclosure, Dr. Novak is one of my partners in the Associated Anesthesiologists Medical Group in Palo Alto. He has spent the past thirty-plus years at Stanford, where he served as an intern, a resident in internal medicine, an emergency room faculty member, an anesthesia resident, and finally as an Adjunct Clinical Associate Professor of Anesthesia. Rick’s writing career blossomed in the role of Deputy Chief of Anesthesia at Stanford, where he authored a monthly column on private practice anesthesia in the department newsletter. As a friend, colleague and reader, I recently interviewed Rick to gain insight into his new writing career:

Q: How long did it take you to write the novel?
A: Three years. One year to write the manuscript, one year to edit it and improve the storytelling, and one year to obtain an agent who then sold it to Pegasus Books.

Q: When did you find time to write?
A: I wrote late at night, early in the mornings, on rainy weekends and on sunny weekends—whenever I had a free hour with my laptop. I had a compulsion to write the story that first year. I didn’t sleep much.

Q; Why did you choose to write fiction?
A: I’ve been penning creative short stories, skits, and speeches since high school. I had written more than seventy non-fiction columns in the Stanford anesthesia department newsletter over the past twelve years, but I wanted to write something more substantial and more entertaining. I believe a lot of people are curious about anesthesia, and I know there are stories to be told.

Q: Describe the style of this book.
A: My aim was to write a fast-paced page-turner that would appeal to both non-medical as well medical audiences. After the first draft, I edited the manuscript and cut out every scene and every sentence that wasn’t essential to the story. My style is conversational. The book is written in the first person and it reads as if the narrator is telling you an oral story. The dialogue is genuine—characters talk the way people really converse in an operating room, in a tavern, or in a courtroom.

Q: What can an anesthesiologist learn from the book?
A: First off, it’s a mystery that anesthesiologists and physicians will have an advantage in solving, because of our experience and training. Beyond that, you’ll learn about life and medicine in small town Minnesota, you’ll learn about the history and legend of Bob Dylan, who grew up in Hibbing, Minnesota, and you’ll learn to love the memorable characters who populate the pages.

Q: Any advice to other aspiring anesthesiologist authors?
A:

  1. Write what you enjoy writing, whether your dream is to create fiction or medical non-fiction. I’ve spent thousands of hours writing columns for the Stanford anesthesia department, for my website, and penning this novel, yet not one minute of the time felt like work to me.
  2. I chose to read 15 – 20 books on the art of writing fiction and also on the business of querying an agent. I didn’t have the inclination or the time to enroll in a Creative Writing Master’s of Fine Arts program, so these resource books were my database for learning. I also picked the brain of every published author I ever met, in an effort to learn the craft and the business.
  3. You’ll need perseverance, because the publishing industry is based in New York City, not California, and every one of us is an unknown in their industry. I received 207 rejections from agents before I was offered a contract, and I think that’s not an atypical experience for most first-time authors.
  4. Once you’ve completed and polished your manuscript, invite every friend who has any interest to read it and critique it. You don’t want your first critical audience to be an agent or a publishing house. Get as much as advice and input as you can before you submit your work to the professionals.
  5. Read a lot of the genre you’re interesting in writing, to develop an feel for what successful plotting, pacing, and dialogue look like.
  6. And lastly, read The Doctor and Mr. Dylan … to see what kind of tale a fellow anesthesiologist weaves about operating rooms, courtrooms, murder, music, success, failure, life, and love in our 21st century world.

Read further articles on the California Society of Anesthesiologists Online First Blog at http://members.csahq.org/blog

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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THE DOCTOR AND MR. DYLAN HITS #1 BESTSELLING ANESTHESIA BOOK IN THE WORLD AT AMAZON.COM

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

On October 2, 2014, my debut novel The Doctor and Mr. Dylan was the number one bestselling Anesthesiology book in the world on Amazon.com Kindle.

Click on this image of the book to reach the Amazon webpage:

 

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REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
prabha venugopal (chicago, il USA) – See all my reviews
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Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

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 mgrossman@pioneerpress.com, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak

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 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.

 

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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

“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.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”

By

allan mishra

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.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

DSC04882_edited

DR. NOVAK’S DEBUT NOVEL: THE DOCTOR AND MR. DYLAN

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997
Published in 2017:  The second edition of THE DOCTOR AND MR. DYLAN, a legal mystery which blends anesthesiology and the legacy of Nobel laureate Bob Dylan.

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

41wlRoWITkL

Why does an anesthesiologist write a novel?

Anesthesiology is fascinating. We anesthetize patients for operations of every kind, from cardiac, brain, and abdominal surgeries to trauma and organ transplant surgeries. We anesthetize people of all ages from newborns to one-hundred-year-olds, relieve the pain of childbirth and chronic malignancies, and attend to all types of individuals from millionaires to the homeless. No one knows the breadth of human suffering and recovery better than a physician, and no physician sees a wider range of patients than an anesthesiologist.

The story of The Doctor and Mr. Dylan deals with an anesthesia complication, a crumbling marriage, a son’s quest for elite college admission, and a courtroom drama, all set in Bob Dylan’s hometown of Hibbing, Minnesota.

Stanford professor Dr. Nico Antone leaves the wife he hates and the Stanford 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’ FargoThe 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.

The opening pages to THE DOCTOR AND MR. DYLAN follow:

CHAPTER 1) GOING, GOING, GONE

            first-degree murder n. an unlawful killing which is deliberate and premeditated (planned, after lying in wait, by poison or as part of a scheme)

My name is Dr. Nico Antone. I’m an anesthesiologist, and my job is to keep people alive. Nothing could inspire me to harm a patient. Alexandra Antone was my wife. Alexandra and I hadn’t lived together for nearly a year. I dreaded every encounter with the woman. I wished she would board a boat, sail off into the sunset, and never return. She needed an urgent appendectomy on a snowy winter morning in a small Minnesota town. Anesthetist options were limited.

Life is a series of choices. I chose to be my wife’s doctor. It was an opportunity to silence her, and I took it.

Before her surgery, Alexandra reclined awake on the operating room table. Her eyes were closed, and she was unaware I’d entered the room. She was dressed in a faded paisley surgical gown, and she looked like a spook—her hair flying out from a bouffant cap, her eye makeup smeared, and the creases on her forehead looking deeper than I’d ever seen them. I stood above her and felt an absurd distance from the whole situation.

Alexandra opened her eyes and moaned, “Oh, God. Can you people just get this surgery over with? I feel like crap. When is Nico going to get here?”

“I’m three feet away from you,” I said.

Alexandra’s face lit up at the sound of my voice. She craned her neck to look at me and said, “You’re here. For a change I’m glad to see you.”

I ground my teeth. My wife’s condescending tone never ceased to irritate me. I turned away from her and said, “Give me a few minutes to review your medical records.” She’d arrived at the Emergency Room with abdominal pain at 1 a.m., and an ultrasound confirmed that her appendix was inflamed. Other than an elevated white blood cell count, all her laboratory results were normal. She already had an intravenous line in place, and she’d received a dose of morphine in the Emergency Room.

“Are you in pain?” I said.

Her eyes were dull, narcotized—pinpoint pupils under drooping lids. “I like the morphine,” she said. “Give me more.”

Another command. For two decades she’d worked hard to control every aspect of my life. I ignored her request and said, “I need to go over a few things with you first. In a few minutes, I’ll give you the anesthetic through your IV. You won’t have any pain or awareness, and I’ll be here with you the whole time you’re asleep.”

“Perfect,” she oozed.

“When you wake up afterward, you’ll feel drowsy and reasonably comfortable. As the general anesthetic fades and you awaken more, you may feel pain at the surgical site. You can request more morphine, and the nurse in the recovery room will give it to you.”

“Yes. More morphine would be nice.”

“During the surgery you’ll have a breathing tube in your throat. I’ll take it out before you wake up, and you’ll likely have a sore throat after the surgery. About one patient out of ten is nauseated after anesthesia. These are the common risks. The chance of anything more serious going wrong with your heart, lungs or brain isn’t zero, but it’s very, very close to zero. Do you have any questions?”

“No,” she sighed. “I’m sure you are very good at doing this. You’ve always been good at making me fall asleep.”

I rolled my eyes at her feeble joke. I stood at the anesthesia workstation and reviewed my checklist. The anesthesia machine, monitors, airway equipment, and necessary drugs were set up and ready to go. I filled a 20 cc syringe with the sedative propofol and a second syringe with 40 mg of the paralyzing drug rocuronium.

“I’m going to let you breathe some oxygen now,” I said as I lowered the anesthesia mask over Alexandra’s face.

She said, “Remember, no matter how much you might hate me, Nico, I’m still the mother of your child.”

Enough talk. I wanted her gone. I took a deep breath, exhaled slowly, and injected the anesthetic into her intravenous line. The milky whiteness of the propofol disappeared into the vein of her arm, and Alexandra Antone went to sleep for the last time.

CHAPTER 2) A PHARMACIST’S SON IN SOUTH DAKOTA

Eight months earlier

My cell phone pinged with a text message from my son Johnny. The text read:

911 call me

I was administering an anesthetic to a 41-year-old woman in an operating room at Stanford University, while a neurosurgeon worked to remove a meningioma tumor from her brain. I stood near my patient’s feet in an anesthesia cockpit surrounded by two ventilator hoses, three intravenous lines, and four computer monitor screens. Ten syringes loaded with ten different drugs lay on the table before me. My job was to control my patient’s breathing, blood pressure, and level of unconsciousness, but at that moment I could only stare at my cell phone as my heart rate climbed.

                                                                       911 call me

911? My son was in trouble, and I was stuck in surgery, unable to leave. I wanted to contact Johnny as soon as possible, but my patient was asleep, paralyzed, and helpless. Her life was my responsibility. I scanned the operating room monitors and confirmed that her vital signs were perfect. I had to make a decision: should I call him now, or attend to my anesthetic and call after the surgery was over? My patient was stable, and my son was in danger. I pulled out my cell phone and dialed his number. He picked up after the first ring….

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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.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

ON PEDIATRIC ANESTHESIA: THE METRONOME

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

The Russell Museum of Medical History and Innovation at Massachusetts General Hospital presented an audio recording of The Metronome at Perspectives on Anesthesia, at Boston City Hall Plaza as part of HUBweek, Boston’s festival of innovation, in October 2017.

THE METRONOME, a poem by Richard Novak, M.D.     (as published in ANESTHESIOLOGY, Mind to Mind Section 2012: 117:417).

metronome medical

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.

 

 

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

TOM JOAD THE ANESTHESIOLOGIST

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Tom Joad the Anesthesiologist, by Rick Novak, MD, is a contemporary poem inspired by the final words by the protagonist Tom Joad in The Grapes of Wrath, by John Steinbeck.

Tom Joad the Anesthesiologist

by Rick Novak, M.D.

I’ll be all around in the dark—I’ll be everywhere.
Wherever you can look—wherever there’s a motorcycle accident, a Cesarean section, a heart transplant, I’ll be there.
Wherever there’s a cop dragging a knifed-up gang member into the E.R., I’ll be there.
I’ll be there when the surgeon screams and when the new mother laughs,
When the 100-year-old gets his hernia mended and when the 4-year-old gets his tonsils out—I’ll be there, too.
Ma, it’s just what I do.
It’s what we all do.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

*
*
*
*

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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

AN ANESTHESIA ANECDOTE: AN INEPT ANESTHESIA PROVIDER CAN KILL A PATIENT IN LESS THAN TEN MINUTES

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

An inept anesthesia provider can lose a patient’s life in less than ten minutes.

NEWSPAPER HEADLINE:  “ANESTHESIOLOGIST KILLS PREGNANT MOTHER DURING EMERGENCY SURGERY”

 

What follows is a true story, with the names changed to protect the identities of the individuals…

THE CASE:  At 1:30 a.m. during the 14th month of his anesthesia training, Dr. Tony Andrews had been on duty inside the hospital since 7:00 a.m. the previous day–a total of 19 hours already.  He’d spent most of that time inserting epidural anesthetics into the lower backs of laboring women on the obstetrics ward.  He went to sleep in his on-call room shortly after midnight, exhausted and hopeful that he’d sleep until dawn.

No such luck.  The telephone woke him up–the caller was Jennifer Rogers, an obstetrician with a busy private practice.  “I need you,” she said.  “I have a patient named Naomi Jordan who’s in labor with new onset of vaginal bleeding and late decels.  I need to do a stat C-section.”

A layman’s translation of Jennifer’s sentence was this:  Naomi Jordan was a laboring mother who was bleeding from her vagina.  Her baby’s heart rate was dropping to dangerously low levels (known as decelerations, or decels) during the late phase of each uterine contraction.  Dr. Rogers needed to do an emergency cesarean section, that is, she needed to cut open the lower abdomen of the mother, cut open the uterus (the medical term for the womb), and deliver the baby before the mother’s bleeding endangered the baby’s health.  An emergency cesarean section meant Dr. Andrews wouldn’t get back to sleep for three hours, minimum.

“How much blood has she lost?” he mumbled, trying not to fall back asleep.

“No more than a cup so far, but the bleeding could accelerate within minutes.”

“I’ll be there in a minute.”  Every cesarean section required an anesthetic–that’s why Dr. Rogers called Dr. Andrews.  He was sleeping in the hospital to be immediately available for urgent obstetric anesthetics.  He turned on the room light and rubbed my eyes.  His wrinkled blue scrubs served as both pajamas and surgical attire.  He put his sneakers back on and set out down the hallway to find his new patient.

Once Dr. Andrews was on his feet, the prospect of emergency surgery jolted him like a double espresso.  By the time he reached Naomi Jordan’s room, his head was clear and he’d forgotten what time of night it was.

Naomi Jordan was a round-faced black woman in her 20’s.  She was sitting up in bed and panting her way through a labor contraction.  She flared her lips and bared her teeth to endure the pain and grunted out, “Ow, ow, ow,” with each exhaled breath.  Naomi did little to hide her suffering, and paid no attention to Andrews when he entered the room.  A gray-haired labor and delivery nurse stood at the bedside.  The nurse held one hand on Naomi’s shoulder and focused her eyes on the fetal monitor screen that traced the baby’s heart rate.

Dr. Andrews opened the patient’s chart to skim through the pertinent details.  Naomi was 25 years old and healthy.  She was 9 months pregnant with her first child.  Her current weight was 185 pounds, and she was 5 feet 4 inches tall.  She’d been in labor for four hours, and her progress had been unremarkable until the last thirty minutes.

He sat down on the bed next to the patient, and said, “Hi, Ms. Jordon, I’m Dr. Andrews, one of the anesthesiologists who will be with you during your cesarean section.”  What he didn’t say was, “I’m a partially-trained anesthesiologist.”  It was his objective to appear confident and competent–she didn’t have to know he still had almost a year before he finished his training.  She didn’t have to know that his calm appearance was a guise that hid any uncertainty due to his inexperience.

Sweat dripped down Naomi’s cheeks and forehead.  Her eyes were dilated and wild.  She replied, “My baby girl.  I just want my baby to be all right.”

“We’ll do everything we can,” he said.  “You’re going to need be asleep for the surgery.  For most cesarean sections, anesthesiologists give an injection in the lady’s back–a spinal anesthetic–to numb you from your chest down.  But because you’re bleeding from below, that’s not a safe option.”

“I can see my baby as soon as I wake up, right?”

“Yes you can.  I’ll give you medicine into your I.V., and you’ll fall asleep in seconds.  When you wake up, the surgery will be finished.”  Dr. Andrews rattled through a brief explanation of the common risks, which included post-operative pain, nausea, and a sore throat from the breathing tube that I would place after she lost consciousness.  “It’s common for the bleeding to stop once you’ve delivered your baby.  It’s not likely that you’ll receive a blood transfusion, but if I need to give you blood to keep you safe, I will.”

She nodded her head and shivered.  “I’m scared to death,” she said.

“I’m not.  I’ll take good care of you.” He touched the back of her hand, and said, “I’ll be right back.”

He stepped out of her room to find a telephone.  This was his second and final year of anesthesia residency training, and he was the sole anesthesiologist on the obstetrics ward at 1:40 in the morning.   He had a faculty backup, Dr. Luke Harrington, who was at his home, presumably asleep.  It was time to end Dr. Harrington’s slumbers.

Dr. Andrews called Dr. Harrington and explained the urgent clinical situation.  Dr. Harrington said, “If she’s bleeding, she’ll need a general anesthetic.  I’ll be right in.”

When patients have significant bleeding, the volume of blood in their arteries and veins is depleted.  For most cesarean sections, anesthesiologists prefer to give a regional anesthetic (either a spinal anesthetic or an epidural anesthetic), that leaves the patient awake but numb from the nipples down.  Neither a spinal nor an epidural can be safely administered in a patient who is actively bleeding.  Spinal and epidural anesthetics relax the sympathetic nervous system and dilate both arteries and veins, lowering the blood pressure further.  Dilating arteries that are already emptied because of bleeding is dangerous, and can lead to cardiac arrest or death.

Dr. Andrews hung up the phone and returned to Naomi’s bedside.  The nurse was disconnecting the fetal monitors and readying the bed for transport to the operating room.  Together they rolled the gurney down the hallway, and into the operating room.  A surgical scrub technician and an operating room nurse were waiting for them inside the OR.  The nurses and Dr. Andrews pulled surgical masks over their faces.  Only Naomi Jordan stayed unmasked.  Her hands shook and her voice cracked.  “Is my baby still all right?  She’s going to be O.K., isn’t she?”

“We’re going to move ahead and deliver her as soon as we can,” Dr. Andrews said.  He hung her I.V. bottle on a pole next to the anesthesia machine and said, “Can you please move over from your bed to the operating room table?”

With a loud grunt and a louder moan, Naomi wiggled herself to her right from the hospital bed onto the narrow O.R. table.  She left behind a two-foot-wide circular stain of blood on the sheets of her bed–evidence of ongoing vaginal bleeding.  The sight of the pool of blood fed Dr. Andrews’ sense of urgency.  It looked like more than a cup had spilled onto the sheets.  How much blood had she lost?

He used his stethoscope to listen to Naomi’s chest, and confirmed that her heart tones and breath sounds were normal.  He asked her to open her mouth, and assessed how easy it would be to insert a breathing tube after he anesthetized her.  She had a short neck and a thick tongue, but otherwise he didn’t note anything exceptional about her mouth or airway.  Dr. Andrews went about his routine and attached a blood pressure cuff to her arm, electrocardiogram stickers to her chest, and an oximeter probe to her finger.

Her heart rate was fast at 120 beats per minute.  The elevated heart rate could be secondary to her anxiety, but it could be because her bleeding was ongoing and her heart was working hard to pump a depleted blood volume to her vital organs.

Her blood pressure was 100/55, a lower value than the last reading of 115/60 ten minutes earlier.  The low blood pressure worried him–it could be further evidence that her blood vessels were emptying as she continued to bleed.  The pulse oximeter on her finger gave a reading of 100%, indicating that her arterial blood was 100% saturated with oxygen–a good sign.

Naomi looked like she was ready to sit up and run out of the room.  “It’s freezing in here,” she said, glancing around the room at the anesthesia machines and the array stainless steel surgical tools laid out on the scrub table.  “I’m so scared.  Can’t my mom be in here with me?”

“No,” Dr. Andrews said as he loaded my syringes with anesthetic drugs.  “When patients are going to be asleep, it’s not safe for family to be in here observing.  You’re going to be all right.”

The operating room nurse pulled up Naomi’s gown and began painting the bulbous abdomen with Betadine, an iodine disinfectant soap.  Dr. Rogers entered the room. She was a trim, attractive woman in her thirties.  She grabbed Naomi’s left hand and wiped away the tears from her patient’s eyes. “We’ll take great care of you,” she said.  Naomi blinked hard and closed her eyes.

A female scrub tech unfolded a large blue sterile paper drape, and set it down over Naomi’s abdomen to cover the Betadine-painted skin.  The scrub tech’s job was to hang the drapes to isolate the surgical field, and after that to hand sterile instruments to the surgeon during the surgery. She handed one edge of the drape to Andrews, and he applied clamps to secure the drape to two tall metal poles to the left and right of the patient’s shoulders.  This configuration formed a wall of blue paper with Naomi’s head and the anesthesiologist on one side of the barrier, and the sterile surgical field on the opposite side.  Dr. Rogers reentered the operating room.  She’d left to scrub her hands, and now she donned the sterile gown and gloves of her trade.  She took her position on the left side of the patient’s abdomen, and looked Dr. Andrews in the eye.  “Are you ready to get her asleep?” she asked him.

“I’m still waiting for Dr. Harrington,” he said. “Otherwise I’m ready to go.”  He turned to the nurse and said, “Call the general O.R. and the ICU.  Find out if any other anesthesiologists are available to assist me.”

“Will do,” she said, and she picked up a phone.

It was 1:55 a.m.  Dr. Andrews had checked the necessary anesthesia equipment, and it was all present and in order: breathing tubes, laryngoscopes needed for inserting a breathing tube, multiple syringes loaded with anesthetic drugs, and the anesthesia machine capable of delivering mixtures of oxygen, nitrous oxide, and the potent anesthetic vapor called isoflurane.

He looked down at the spheres of sweat beading up on Naomi’s forehead.  She was breathing oxygen through a clear plastic mask.  Each time she exhaled, water vapor fogged the clear plastic of the mask in front of her mouth.

The surgeon looked at the clock and said, “I don’t have any monitor of the fetal heart tones at this point, so I have no idea if the baby’s all right.  The patient is still bleeding.  We need to get the kid out.”

Dr. Andrews’ head was spinning.  Where was Dr. Harrington?  Tony Andrews was 31 years old and had been an M.D. for over five years, but he’d never been in this exact situation without a faculty anesthesiologist before.  He was confident– he had plenty of medical experience. This was his second year of anesthesia residency training, and he’d administered about eight hundred anesthetics in the preceding thirteen months.  He’d done dozens of general anesthetics for cesarean sections just like this one, but he’d never done one alone.  He was nervous as hell, but was he certain that he could handle starting this case without Dr. Harrington in attendance?  The problem was . . . it was too risky to wait any longer.  The baby’s life was at stake.  The mother’s life was at stake.

The nurse interrupted his train of thoughts.  “The main O.R. has two fresh trauma patients,” she said.  “They don’t have any extra anesthesiologists to come up and help you.  And the ICU phone is busy.”

Dr. Andrews inhaled a big breath and blew it out through pursed lips.  He could think of no other alternative.  “O.K., I’m going ahead,” he said to the surgeon.  She nodded in affirmation.

“I need you to give the patient cricoid pressure as she goes to sleep,” Dr. Andrews said to the operating room nurse.  Cricoid pressure is a medical maneuver whereby an assistant presses down firmly on a specific spot on the patient’s anterior neck, called the cricoid cartilage.  This action compresses the patient’s esophagus below.  Compressing the esophagus prevents regurgitation of stomach contents into the throat and mouth.  The stomach of a pregnant woman empties slowly, and the anesthesiologist must assume the stomach is full of undigested food.  Regurgitated vomit in the patient’s airway and lungs can be lethal.

The letters A-B-C, abbreviations for the words Airway-Breathing-Circulation, summarize the management of every acute medical situation.  As soon as Naomi went to sleep and couldn’t breathe on her own, she needed an airway tube.  That’s the anesthesiologist’s job–Dr. Andrews was the only one in the operating room with the training and ability to insert the endotracheal tube.

He injected 20 milliliters of the hypnotic drug sodium pentothal into her I.V. over a three-second span of time, and then injected 4 milliliters of the muscle-paralyzing drug succinylcholine.

“You’re doing great.  Everything’s going to be all right,” he said to Naomi, a wish as much as a promise.  The nurse located the cricoid cartilage on Naomi’s neck, and pressed downward.

Sodium pentothal is a rapid-acting drug that induces unconsciousness.  Naomi’s eyes closed ten seconds after the injection.  The second drug, succinylcholine, also known as “sux,” is an ultra fast-acting muscle relaxant.  Intravenous sux renders all the muscles in the body flaccid within a minute.  This paralysis makes it possible for the anesthesiologist to insert a lighted instrument called a laryngoscope into a patient’s mouth, visualize the vocal cords in the patient’s larynx (the medical name for the voice box), and place a hollow breathing tube through the vocal cords into the trachea (the medical name for the windpipe).  The paralysis also makes it impossible for the patient to breathe on her own.

The operating room was quiet except for the beeping of Naomi’s pulse on my monitoring equipment.  Everyone was waiting for Dr. Andrews.  Surgery could not begin until he inserted the breathing tube.

Thirty seconds after he injected the sux, every muscle of Naomi’s body began to shiver in involuntary paroxysms.  The widespread contraction-then-paralysis of every skeletal muscle of Naomi’s body is a phenomenon known as fasciculation, a well-known and expected side effect of sux.  Watching an otherwise motionless patient fasciculate is a creepy experience–the patient’s body moves as if demon forces were tunneling beneath the surface of the skin.

Once the fasciculation ceased, Dr. Andrews knew his patient was paralyzed.  His heart thundered as he removed her oxygen mask.  He turned on the light on my laryngoscope and gripped the metal handle in his left fist.  After she fell asleep, Naomi’s lips and tongue collapsed against each other, obstructing any view of her teeth or inside her mouth.  Dr. Andrews first job was to pry the mouth open and insert the lighted metal laryngoscope blade between her incisors.  He followed the light as it illuminated her mouth and throat.  He was looking for the pearly white vocal cords that guarded the windpipe.  His initial search was futile–all he could see were the flabby pink tissues of her tongue and throat.  He pulled harder the laryngoscope handle in an effort to lever open the airway, but he still saw nothing but pink flesh.  He began to breathe faster, and sweat poured from his underarms.

At that moment, Dr. Andrews heard the sound that strikes terror into every anesthesiologist’s heart–a descending musical scale keeping time with every one of Naomi’s heartbeats.

The descending musical notes came from the medical monitoring device known as a pulse oximeter.  The pulse oximeter is the most vital and important monitor in any acute care medical setting.  The pulse oximeter records its signal from a clip placed across the tip of a patient’s finger.  One side of the clip is a red light emitting diode (LED), and the other side of the clip is a receptor that quantifies the amount of red light that passes through the patient’s fingertip.  A computer in the pulse oximeter filters out all the signals except for red light that pulsates.  The only source for pulsating red light in the fingertip is blood in the small arteries.  The pulse oximeter converts red hue of the pulsating arterial blood to a percentage of oxygen saturation in the blood, based on how red the blood is:

More oxygen in the blood => redder blood => an increased oxygen saturation of 90% or greater => the patient is safe.

Less oxygen => darker purple blood => an oxygen saturation lower than 90% => the patient’s life is in danger.

The pulse oximeter emits a beep tone with every measured heartbeat.  As Naomi’s oxygen saturation declined below 90%, the beeping note decreased in pitch.  As her lips turned blue before his eyes, the descending chromatic scale of the pulse oximeter announced that the blood in her fingertip contained less oxygen.  This also meant her heart and brain were receiving less oxygen.

At the same time, the rate of the oximeter beeps increased to over 130 beats per minute. Dr. Andrews’ own heart rate was higher than Naomi’s.  Naomi Jordon and her baby were dying in his hands, and it was up to him to step it up and save her.  It was up to Dr. Andrews to insert the breathing tube.

Instead, he panicked.

He repeated the same futile attempts to visualize her vocal cords.  He reinserted the same metal laryngoscope into her mouth and followed the illuminated trail of its flashlight bulb.  He was still looking for the two pearly white vocal cords and the blackness of the tracheal lumen between them.

Instead, all he saw were folds of pink tissues.

The menacing notes of the oximeter beeps descended further.  The patient was out of oxygen.  Dr. Andrews pushed the metal laryngoscope deeper into her throat in a desperation move to find the trachea.

“Can’t you intubate her?” Dr. Rogers asked.

Dr. Andrews was too stuck in his predicament to answer.  The pulse oximeter tone was deeper than he’d ever heard it.  He glanced up at the machine, and saw that the oxygen saturation was in the 50’s.

Incompatible with life.

I’ve killed her, he thought, and the vivid image of a newspaper headline filled his head: “ANESTHESIOLOGIST KILLS PREGNANT MOTHER DURING EMERGENCY SURGERY.”  At that second, Dr. Tony Andrews would have given anything to escape from that mess with Naomi Jordon alive and well.

Stupefied by failure, he didn’t know what else to do except to keep trying over and over to put the tube in.

THE RESCUE:  At that moment, Dr, Tony Andrews’ luck turned.  The outer door to the operating room opened, and Dr. Luke Harrington ran in, wearing the non-surgical attire of blue jeans and a faded blue polo shirt.  Street clothes were never allowed in the sterile confines of an operating room.  Dr. Harrington observed the chaotic scene through the operating room window that faced in from the outside hallway, and figured out there was no time for a wardrobe change.

Instead of screaming at me or asking questions, Dr. Harrington said, “Take the laryngoscope out of her mouth NOW.  Let’s put the anesthesia mask back over her face.”

Dr. Andrews complied.

“Hold the mask with two hands,” he said.  “Fit it in a good seal over her face, and I’ll squeeze the ventilation bag.”

Dr. Andrews pressed the clear plastic mask over her mouth and nose and held it in an airtight fashion, with one hand at 3 o’clock and one hand at 9 o’clock over each of her cheeks.  Dr. Harrington squeezed the ventilation bag, and by this technique they were able to force 100% oxygen through her upper airway into her lungs via bag-mask ventilation.

Of course, Dr. Andrews thought.  She was dying and turning blue.  I was supposed to stop the futile attempts to put in a breathing tube, and just do this.  Pump in oxygen via the facemask.

Dr. Andrews held his breath and looked up at the vital sign monitors.  Her oxygen saturation hung low, still in the 60’s.  Dangerously low.

His mouth was so dry that he couldn’t swallow.

Dr. Harrington remained impassive.  If he was worried, he wasn’t showing it.  He fixed his eyes on the oximeter numerical readout.

For the next sixty seconds Dr. Andrews’ mind echoed, God, please, God please. . . .  A full minute went by, and then note-by-note the beep tone of the oximeter rose in pitch, and the numeric readout climbed in parallel.  From 60%, the oxygen saturation rose to 66%, . . . 72%, . . . 83%, then 93%.

They’d done it!  With an oxygen saturation greater than 90%, her brain and heart were now receiving an adequate supply of oxygen.  The surgeon peered over the drapes at us.  She was still holding her scalpel dormant.  She couldn’t start the cesarean section until the anesthesiologists had safely placed the endotracheal tube.

Dr. Harrington asked Dr. Andrews, “What happened when you tried to intubate her?”

“I couldn’t see anything but pink tissues.”

Dr. Harrington lifted the mask away from her face, and opened her mouth to look inside.  He frowned and nodded.  “Let’s change her head position.  Get me two white towels.”

He had Dr. Andrews lift up Naomi’s shoulders, while he stuffed two folded white towels behind her neck.  Naomi Jordan’s head extended backwards and her mouth fell open for the first time.

“Looks better.  Try it again,” Dr. Harrington said. Dr. Andrews was surprised that he’d want him try again, since he’d done nothing right so far.  He wondered why Dr. Harrington didn’t just take over.

The patient’s oxygen saturation was up to 100%.   Dr. Harrington pushed another 10-milliliter bolus of sodium pentothal into the IV to keep Naomi asleep, and Dr. Andrews opened her mouth to try again.  This time, as he advanced the laryngoscope blade and light into her mouth, the anatomical landmarks were more obvious.  Past the base of her tongue, he located the epiglottis, the pink flap of tissue that closed off the windpipe each time she swallowed.  He was elated–he hadn’t seen any recognizable structures my last time in.  The larynx, the gateway to the trachea, lay just beneath the epiglottis.  Since neither light nor vision can travel in a curve, he needed to lift up the epiglottis to see past it.  He pulled hard on the laryngoscope handle toward the ceiling.  To his relief and amazement, he saw the black hole of the tracheal opening.

“I’ve got it,” Dr. Andrews said, his voice cracking.

“Here’s the tube,” Dr. Harrington said, as he handed Dr. Andrews the clear plastic endotracheal tube. Dr. Andrews fed the tube through her mouth, past the epiglottis and into the trachea.  Dr. Harrington injected 8 milliliters of air from an empty syringe into a portal on the tube.  This inflated a balloon near the distal tip of the tube, which formed a seal against the inner walls of Naomi’s trachea.

Dr. Harrington connected the endotracheal tube to the hoses from the anesthesia machine, and squeezed the ventilation bag.  The patient’s chest expanded. Dr. Andrews pressed his stethoscope against her chest and listened.  The breath sounds were prominent and conclusive.  The endotracheal tube was in the correct place.

“You can cut,” Dr. Harrington said to the surgeon.

Dr. Rogers turned her attention to the patient’s lower abdomen, and made a swift horizontal incision above the pubic bone.  Her assistant retracted the tissue layers as Dr. Rogers cut deeper inside the body.  Within five minutes, she’d controlled all the bleeding and exposed the anterior wall of the uterus.  A second incision cleaved the womb, and she reached inside to pull the baby out.  Within 30 seconds, she’d delivered the baby, cut the umbilical cord, and handed the baby off to the team of pediatricians ready to resuscitate her.

The anesthesiologists’ work wasn’t over after they placed the breathing tube.  They turned on a mixture of 50% nitrous oxide in 50% oxygen, and dialed in a 0.6% mixture of the anesthetic gas isoflurane.  These gases would keep Naomi asleep as the surgeon worked to sew her back together.

Across the room the pediatricians ventilated the baby with oxygen by mask.  Within 5 minutes the baby was pink and crying.  “Apgar scores are 2 and 9,” the pediatric resident said.  The Apgar score is a rating from 0 to 10, calculated one minute after birth and again at 5 minutes, used to quantify how healthy and vital the baby is.  The score is a sum of 0 – 2 points each for five different criteria, including Activity, Pulse, Grimace, Appearance, and Respirations.  The baby’s 5 minute Apgar score of 9 was nearly a perfect 10, and a sign that the baby had survived the birthing process without apparent harm.

Dr. Andrews thanked Dr. Harrington for his timely arrival. Dr. Andrews’ hands were still shaking, supercharged with the adrenaline that had poured into his system over the last hectic hour.

Sixty minutes later, the surgeon closed the last surgical incision, concluding the cesarean section. Dr. Andrews turned off the anesthetic gases.  Naomi Jordan opened her eyes, and Dr. Andrews removed the breathing tube.

“Is my baby girl here?” she asked.

“She’s right here,” Dr. Andrews said, and the pediatrician handed the infant to her mother.  Naomi cried tears of joy.  It was all Dr. Andrews could do to keep from crying along with her.

Dr. Harrington had rescued all three of them:  Naomi, her baby daughter, and Tony Andrews.

LESSONS LEARNED:  The Naomi Jordan story highlights three key issues:  1) the crucial importance of airway management, 2) surgery and anesthesia have risk, and(3) the problem of inexperienced anesthesia practitioners performing medical care they are not fully capable to handle.

(1)  The crucial importance of airway management:  Losing control of an unconscious patient’s airway is a hazard that every anesthetist dreads, every day, in every operating room.  Indeed, the most important skill an anesthesia provider learns is not how to administer powerful sleep drugs, but how to keep patients alive and well under the influence of powerful sleep drugs.  All major anesthetic drugs and gases cause profound depression of breathing and/or cardiac function.

Keeping the anesthetized patient’s airway open via a mask or a laryngeal mask airway or a breathing tube is a critical skill for every anesthesia provider.   If the airway closes, the brain is deprived of oxygen.  Irreversible brain damage can occur after as little as four minutes without oxygen.

(2)  The risks involved in surgery and anesthesia:  Deep down, every surgical patient has the same worry:  How safe is surgery and anesthesia?

Methods of evaluating anesthetic mortality are inexact and controversial.  In 1999 the Institute of Medicine published their report entitled To Err is Human: Building a Safer Health Care System.  In this report, the Committee on Quality of Health Care in America stated that, “anesthesia is an area in which very impressive improvements in safety have been made.”  The Committee cited anesthesia mortality rates that decreased from 1 death per 5,000 anesthetics administered during the 1980s, to 1 death per 200,000-300,000 anesthetics administered in 1999.  Keep in mind that this statistic reflects the frequency of all patients, healthy or ill, who die in the operating room.

This conclusion that anesthesia mortality has plummeted is not universal.  When mortality is defined as any death occurring within 48 hours following surgery, the statistics are much different.  In 2002, anesthesiologist Dr. Robert S. Lagasse of the Albert Einstein College of Medicine in New York published a study in Anesthesiology, the specialty’s leading journal, that challenged the Institute of Medicine report.

Lagasse presented data on surgical mortality from two academic New York hospitals between the years 1992 and 1999.  Mortality was defined as any death occurring within 48 hours following surgery.  There were 351 deaths in 184,472 surgeries–an overall surgical mortality rate of 1 death per 532 cases. Keep in mind that these were deaths within 48 hours–not deaths in the operating room.

Deaths related to anesthesia errors were much less–only 14 deaths out of 184,472 surgeries–a rate of 1 death per 13,176 cases.   Lagasse’s anesthesia-related mortality rate of 1 per 13,176 surgeries was significantly different that the Institute of Medicine’s rate of 1 death per 200,000-300,000 surgeries.  Lagasse wrote, “We must dispel the myth that anesthesia-related mortality has improved by an order of magnitude. Science does not support this claim.”

Lagasse compared anesthesia to the aviation industry: “The safety of airline travel, for example, has increased dramatically in this century, but since the 1960s there has been minimal improvement in fatality rates.  This may be due to the effect that improved safety technology has had on air traffic density.  Technology has made it possible to meet production pressures of the commercial airline industry by allowing more takeoffs and landings with less separation between aircraft.  With this increased aircraft density comes increased danger, thereby offsetting potential improvements in safety.  This may be analogous to the practice of anesthesiology in which improvements in medical technology have led to increased anesthetic management of older patients with significantly more concurrent disease.”

Today’s surgery patients are sicker than ever.  About 5% of all surgical patients die within one year of surgery.  For patients over the age of 65 years, 10% of all surgical patients die within one year of surgery.

Naomi Jordan was healthy, and a cesarean section is a common surgical procedure.  But her case was an emergency procedure, and general anesthesia for cesarean section is known to be a high risk for airway problems because pregnant women have narrowed upper airways, decreased oxygen reserves, and stomachs that do not empty normally.  A 2003 study showed that a difficult or failed intubation following induction of general anesthesia for cesarean section was the number-one factor in anesthesia-related maternal complications.

Because of this, the use of general anesthesia for cesarean sections has declined.  In a Harvard study published in 1998, only 3.6% to 7.2% of cesarean sections were done under general anesthesia.  Difficult intubations were frequently unexpected, as was the case for Naomi Jordan, and one failed intubation resulted in the mother’s death.

Whenever possible, the safest anesthetic choice for cesarean section is a spinal or an epidural block, in which the anesthetist injects a local anesthetic drug via a needle inserted in the low back area.  This numbs the mother from her nipples to her toes, and she stays awake and breathes on her own during surgery.

(3) Inexperienced anesthesia practitioners performing medical care they are not fully capable to handle:  During the first twelve months of a physician’s anesthesia residency, each trainee is closely mentored and restricted to easier surgeries if possible.  Each year in July, new residents enter each residency program and existing residents are advanced from first-year residents to second-year residents, while second year residents become third-year residents.  Each July, every anesthesia trainee faces a new tier of responsibilities and more challenging cases.  The Naomi Jordan case occurred in August, when Dr. Tony Andrews was inexperienced and less than two months into the more challenging second year of residency.  In a teaching hospital, July and August are the least desirable months to be a patient.

Within a few years of Dr. Andrews’ incident, the hospital he trained at changed its staffing, and made it mandatory that an anesthesia faculty member stayed in the hospital all night.  Inexperienced residents would never be called on to handle emergencies alone–a good idea that grew out of the Naomi Jordan case and others.  In addition, the American Board of Anesthesiology added an additional year of required training to all anesthesiologist residencies, so every anesthesiologist left their residency with a minimum of three years of training post-internship instead of just two.

Prior to the Naomi Jordan case, Dr. Andrews was both inexperienced and cocky–a bad combination.  He screwed up the management of her airway, but Dr. Harrington rescued him, and the outcome was excellent. If Dr. Andrews had harmed Naomi Jordan, he would have been known as the anesthesiologist that bumped off a healthy patient.  Despite his previous 800 uneventful anesthetics up to that night, he would be remembered for the one that went bad.  The Naomi Jordan case taught Dr. Andrews a lesson he never forgot.  While he never lost control of another patient’s airway in his years of anesthesia practice after the Jordan case, that wasn’t the lesson he learned.  The lesson Dr. Andrews learned was a lesson every anesthesia provider eventually comes to accept:

You’re only as good as your last anesthetic

 

The most popular posts for laypeople on The Anesthesia Consultant include:

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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

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What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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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 ricknovak.com by clicking on the picture below:  

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