GOALIES AT THE PEARLY GATES
When you have surgery, do you care who administers your anesthetic?
An oft-repeated medical adage states: “anesthesia is 99% boredom and 1% panic.”
As an anesthesiologist who’s delivered over 50,000 hours of operating room care over 25 years, I can attest that the adage is true. Ninety-nine percent of the time, the anesthesia provider’s job requires vigilance during a patient’s stable progression of metronome heartbeats and regular breathing, but 1% of the time requires clear thinking and prompt action during moments of sheer panic. These stress-filled episodes of panic are unknown to the general public, yet represent ordeals that every anesthesia provider must rise above to protect their patients.
Webster’s Dictionary defines panic as “ an overwhelming feeling of fear and anxiety.” If you were to observe an anesthesiologist at work, you would see little or no evidence of overwhelming fear or anxiety. Even under dire emergencies, most anesthesia providers remain outwardly composed and efficient while they make the necessary diagnoses and apply the appropriate treatments. But anesthesiologists are human–no human can watch another human trying to die without feeling intense emotions. These emotions are fear and anxiety.
No field of medicine provides the stunning variety of anesthesia. Patients vary from neonates to centenarians, from laboring women to motor vehicle accident victims at three a.m., while surgeries vary from repair of a broken finger to the transplantation of a heart or a liver. Technologic advances have led surgeons to operate on older and sicker patients, and to attempt more complex surgeries than decades ago.
The operating room is an intense environment. Operating room medicine is pressure-packed for four reasons:
- Anesthetic drugs change the physiology of patients in profound ways.
- Surgeons do dangerous things to patients.
- Surgical patients have diseases. Some of these diseases are urgent or severe.
- Human beings make errors. This includes both surgeons and anesthesia providers.
Unbelievable events occur at unexpected times in operating rooms, and your anesthesia provider must keep you safe. He or she is in control of your airway, breathing, and circulation at every moment. Your anesthesia provider is your insurance policy against medical complications during surgery. Your anesthesia provider’s job is to play Goalie at the Pearly Gates, and keep you alive.
The individual administering your anesthesia can vary–your anesthesia provider may be:
- a medical doctor (an anesthesiologist),
- a certified registered nurse anesthetist (CRNA) or anesthesia assistant (AA) supervised by an anesthesiologist, or
- a CRNA working without anesthesiologist supervision.
In the United States, anesthesiologists personally administer 35% of the anesthetics. Anesthesia care teams, in which an anesthesiologist medically directs a team of AA’s or CRNA’s, administer 55% of the anesthetics. CRNA’s, working unsupervised, administer 10% of the anesthetics.
There are people who perceive anesthesia care to be so safe that it can be taken for granted. They are wrong. Anesthesia care is safest when a physician, a board-certified anesthesiologist, directs the anesthetic care. Published data shows that:
- Mortality rates after surgery are significantly lower when anesthesiologists direct anesthesia care.
- Failure-to-rescue rates (the rate of death after a complication) are significantly lower when anesthesiologists direct anesthesia care.
- Death rates and failure-to-rescue rates are significantly lower when board-certified anesthesiologists supervise anesthesia care, compared to when mid-career anesthesiologists who are not board-certified supervise anesthesia care.
“Failure-to-rescue” implies that the anesthesia provider wasn’t successful in preventing a 1% panic moment from turning into a death statistic. The phrase “failure-to-rescue” is a key theme of this book. Or more precisely, the phrase “successful rescue” is a key theme of this book. When unexpected events occur during surgery–the 1% panic moments–your anesthesia provider needs to make the correct diagnosis and apply the correct therapeutic intervention to successfully rescue you.
When you meet your anesthesia provider prior to surgery, you’re about to trust your life to a stranger. It matters who that stranger is. As a patient, do you have any control over who your anesthesia provider will be? If your surgery is an emergency at 2 a.m. when only one anesthesia provider is available, you will not. But for most surgeries, and all elective surgeries, you have choices.
Anesthesiologists must finish a minimum of 12 years of post-high school education–four years of college, four years of medical school, and four years of anesthesia internship and residency. Nurse anesthetists must finish a minimum of 7 or 8 years of post-high school education –four years of college, a minimum of one year of critical care nursing experience, and two to three years of anesthetist training. Anesthesia assistants must finish a minimum of 6 years of post-high school education–four years of college, and a 24-month program to obtain a Master’s degree as an anesthesia assistant.
Why would an individual choose to become an anesthesia provider? It’s rare for teenagers or college students to dream of themselves as anesthetists. Most popular television, movies, and fiction portray physicians in more conventional careers as surgeons, emergency room doctors, or in clinics. Only 4% of medical school graduates choose anesthesiology.
I believe that individuals who choose anesthesia for their medical career are individuals who love the adrenaline rush of acute medical care. Operating room anesthesia is a 180-degree turn from outpatient clinics, where practitioners take histories, order lab tests, write prescriptions for pills, and make appointments to see their patient weeks into the future. Instead of experiencing clinic visits over months or years, the anesthetic encounter is immediate care with immediate results. Instead of a clinic patient returning weeks later for a recheck, the anesthetic patient wakes up from their anesthetic, and is discharged to their home or their hospital bed within hours.
I had already completed a three-year residency in internal medicine before I began my years of anesthesia training. The diagnosis and treatment of complex medical patients appealed to me during internal medicine training, but I found the glacial pace of outpatient clinic care boring. When I worked along side anesthesiologists in the intensive care unit, I was wooed by their skills in placing breathing tubes, intravenous and intra-arterial catheters, and their apparent calmness no matter how ill any patient was. The world of acute care medicine is the world of airway, breathing, and circulation. No specialty mastered all three as completely as anesthesiologists did.
The beginning of specialty training in anesthesia brings both intimidating power and overwhelming challenge. For the first time in your life, your profession is to inject powerful medications into patients and watch them lose consciousness in seconds. Administering your first anesthetic is an unforgettable experience. One minute you are chatting with a patient, telling them to picture themselves relaxing on a beach in Hawaii, and the next minute you’ve rendered them unconscious and totally dependent on you to manage their airway, breathing, and circulation.
Moving from novice anesthesiologist trainee to experienced specialist requires hard work and patience. On the first day of my anesthesia residency, I was so green I didn’t even know which hoses connected my anesthesia gas machine to the patient. While learning the anesthesia profession, trainees must learn to endure the 99% boredom factor and glean their most valuable lessons during the 1% panic time. During my first week of training, after my patient was asleep with the breathing tube inserted and the anesthesia gases flowing, my faculty member, Dr. Gregory Ingham, said to me, “This procedure will take four hours.” He stood next to me for a minute or two in silence, then he said, “I hope you’re of a contemplative nature.”
Why would he say such a thing to a first-week trainee? I believe he said it because much of operating room anesthesia care is tedious vigilance over a stable situation. The anesthetist needs to cope with this fact, and hopefully even appreciate and enjoy the stability.
One week after my first exposure to Dr. Ingham, I was on call overnight in the hospital with him again. We had four consecutive emergency cases, all young healthy men with injuries suffered in motor vehicle or motorcycle accidents. Prior to the fourth case, at 2 a.m., I evaluated the patient and proposed my anesthetic plan. “Our patient is a healthy 25-year-old male except for his open femur fracture,” I said. “I thought we could do the anesthetic the same way we did the last three.”
Dr. Ingham nodded at me and sighed, “Richard, the patients are all different, but the anesthetics are all the same.”
Is this true? Why would he make a statement like this to an impressionable young trainee? There is a great deal of cynicism and battle fatigue in his comment, but a grain of truth. Patients are all different, and many anesthetics are similar, but not every anesthetic is identical. There are always choices for the anesthetist to make–crucial, life threatening decisions–every day, and on every case. Decisions are made before the surgery, during the stable phases of the anesthetic, and during the 1% of moments when the anesthetist’s mind is reeling.
Patients see none of this. Patients typically have ten minutes or less to meet their anesthesia provider. In the internal medicine clinic, patients are awake for 100% of their face-to-face time with their doctor, but before a surgery the anesthesiologist has only a brief encounter to gain their patient’s trust. In the internal medicine clinic, a large number of patients had chronic complaints that were difficult to cure: chronic pains, high blood pressure, obesity, or diabetes. The treatments were usually involved a prescription for pills. At the next office visit, the patient might feel better, but there was a significant chance that the patient would feel the same, or feel no better, or perhaps they have a new side-effect symptom from the pill you prescribed for them.
The anesthetic patient encounter is markedly different. Prior to the surgery, most patients are anxious but they treat their anesthesiologist with soaring respect. After the surgery, I find my patients are often gushing in their gratitude for the fact that I had delivered them safely back to consciousness. In contrast to my sometimes-disappointed medicine clinic patients, the anesthetic patients are so upbeat that they make me feel wonderful.
When I describe the elation of interacting with anesthesia patients, my best friend offers a simple explanation: “Of course your patients respect you before the surgery. You’re about to knock them unconscious. They’ll have no control and they’re completely dependent on you. They want you to like them. They want you to keep them alive.”
I believe that assessment is accurate. Every patient wants the same thing from their anesthesia provider. A successful, complication-free experience. And that’s what happens . . . almost every time.
Introducing … 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.
Publication date September 9, 2014 by Pegasus Books.
On October 2, 2014 THE DOCTOR AND MR. DYLAN became the world’s #1 bestselling anesthesia Kindle book on Amazon.com.
To reach the Amazon webpage, click on the book image below:
Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.
Bang-Up Debut Novel, November 16, 2014
By Norm Goldman “Publisher & Editor of Bookpleasures”
This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.
This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.
TwinCities.com PIONEER PRESS Entertainment
by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press firstname.lastname@example.org, January 4, 2015
“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)
Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.
Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.
Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.
The Physician’s Late-Night Reading List
Two Pritzker alums pen captivating tales
By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine
For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.
Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.
Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”
One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.
The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80
“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.
From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”
After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.
“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”
Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:
BOOK REVIEW “THE DOCTOR AND MR. DYLAN”
This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.
Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.
Rick, I can’t wait for your next book. Bravo!
Hibbingite writes twisted medical tale
HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.
Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.
“The dialogue is sometimes funny, and there are lots of plot twists,” he said.
Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.
“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”
Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.
This review is from: The Doctor and Mr. Dylan (Kindle Edition)
Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.
Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below: