AVOIDING PREVENTABLE ERRORS IN ANESTHESIA – 14 TIPS

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

Latest posts by the anesthesia consultant (see all)

One goal of theanesthesiaconsultant.com is to make the practice of anesthesia safer. The practice of anesthesia on healthy patients is quite safe, but we want to do everything we can to avoid preventable errors.

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The safety of anesthesia on ASA I and II patients has been compared to the safety record of commercial aviation. Few passengers board an airplane and worry they will die before they land at their destination. But planes do crash, and so do anesthetized patients.

In August 2107 the journal Anesthesiology published the study “Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage,” authored by Christian M. Schulz MD et al. . This was an important study which documented what experienced anesthesiologists already know—although our specialty has never been safer, preventable deaths still occur.

The study analyzed the United States Anesthesia Closed Claims Project database of 10,546 malpractice claims between 2001-2013. A total of 266 cases of brain damage or death during anesthesia care in the operating room under the care of a solo anesthesiologist occurred. Of these 266 cases, 198 (74%) had a situational error by the solo anesthesia provider. Malpractice payments were made in 85% of these situational error cases, compared to only 46% in other cases. The total of 198 patients in 12 years averaged more than16 preventable deaths per year.

What was the definition of a situational error? The article sited three types: perception, comprehension, and projection.

PERCEPTION ERROR. A failure to gather information via history, the patient’s chart, physical exam, diagnostic tests, imaging, or monitors, including the absence of monitors.

COMPREHENSION ERROR. The information was available, but there was a failure to understand and diagnose the significance of information obtained from history, physical exam, diagnostic tests, imaging findings, or monitors.

PROJECTION ERROR. A failure to forecast future events or scenarios based on a high-level understanding of a problematic situation.

Of the 198 situational errors, perception errors were most common (42% of the cases), followed by comprehension errors (29%) and projection errors (29%).

72% of the errors occurred during general anesthetics, 23% occurred during monitored anesthesia care, and 5% occurred during regional anesthetics.

The primary damaging event differed in the 198 error cases vs. the 68 other cases. In the 198 situational error cases, respiratory events were the dominant category (p<.001), including inadequate oxygenation/ventilation (24%), difficult intubation (11%), and pulmonary aspiration (10%). In the 68 non-error cases, cardiovascular events were the dominant category. All the anesthesiologists were single practitioners, that is, they were not part of an anesthesia care team with a nurse anesthetist.

The authors of the study made the following points in their discussion of the findings:

  1. Many perception errors stemmed from lack of or lack of attention to respiratory monitoring. Key respiratory monitors were pulse oximetry and end-tidal CO2 monitors.
  2. Other common perception errors were missing preoperative information, which led to inadequate preoperative evaluation.
  3. The most common comprehension error was failure to comprehend an ongoing clinical difficulty related to respiratory problems.
  4. Many projection errors involved lack of appreciation of difficult airways.
  5. Projection errors also included procedures taking place in inappropriate environments, such as very sick patients having surgery in an office or an outpatient surgery center.

The authors made the following suggestions to decrease preventable errors:

  1. Perception errors may be prevented by regular scanning and processing of all the information available prior to and during every anesthetic.
  2. A “call for help” and the use of cognitive aides (e.g. emergency checklists or an emergency manual) may help when a patient deteriorates.
  3. Situational awareness training can be addressed in anesthesia crisis resource management education, including simulation training.

There were limitations to the Schulz study. The assembled data was retrospective and nonrandom. The Anesthesia Closed Claims Project may not reflect the true incidence of situational errors in anesthesia practice in the United States. As well, the 198 patients found in this study are only those countable via the closed malpractice claims. The true number of uncaptured cases of preventable deaths is unknown.

I have a busy practice of medical-legal consultation. I evaluate 8-10 cases per year of preventable death or brain death, and I’m just one person with one medical-legal practice. I believe there are far more cases that exceed my reach.

The Schulz study listed 11 specific patient case examples of preventable errors. Based on these 11 cases, the multiple legal cases referred to me, my 31 years of practice, and my 25,000 personally administered anesthetics for all types of surgeries and patients, I’m qualified to give advice on how to decrease preventable errors in anesthesia. My advice follows:

  1. I see uninformed preoperative workups leading to errors. Be an outstanding preoperative physician. Your preoperative assessment of each patient needs to be complete and pertinent. Pay special attention to cardiac, respiratory, neurologic, and any other significant medical issues. If you’re uncomfortable with any lack of information, you must acquire that information before you begin an anesthetic. If you need a consultant such as a cardiologist, cancel the case and get a cardiac consult before you proceed.
  2. As part of your preoperative workup, ask every patient if they can climb two flights of stairs. Be wary when administering general anesthesia to any patient who cannot walk up two flights of stairs. If a patient develops shortness of breath at this modest exertion, this is evidence of a lack of cardiac or respiratory reserve. This requires preoperative workup to determine the diagnosis and to apply treatment prior to general anesthesia. Any patient who has significant knee, hip, foot, or back pain or who has claudication that prevents him or her from walking up two flights of stairs has not proven to you that they have adequate cardiac and/or respiratory reserve. A referral to a cardiologist/pulmonologist/internist for preoperative clearance testing may be indicated prior to surgery.
  3. Don’t let surgeons talk you into anesthetizing patients you believe are inadequately worked up for anesthesia. Don’t let surgeons talk you into anesthetizing patients using anesthesia techniques or anesthesia plans you’re not comfortable with. We give mock oral board exams to residents at Stanford, and a common exam question is to try to dupe the resident into doing something unsafe because the surgeon demanded it. The surgeon is not trained in anesthesiology. The surgeon does not pay your malpractice insurance, and he or she will not have to endure your malpractice lawsuit if the anesthetic goes awry.
  4. Don’t let surgeons talk you into anesthetizing patients in inappropriate locations or settings. Be careful anesthetizing sicker patients in offices or in freestanding outpatient surgery centers. These facilities lack ICUs, clinical labs, blood gases, respiratory therapists, radiology, and backup anesthesia professionals. Be wary of performing procedures which are too invasive or too extensive in these settings. Twenty years ago one of our orthopedic surgeons attempted to schedule an 80-year-old female for a total knee replacement in a freestanding outpatient surgery facility which had overnight capabilities. I refused to staff the case, and told him, “Cases like this—that’s why we have hospitals.” He hung up on me, but there were no further requests to schedule similar patients at that facility. There are pressures to perform increasingly difficult procedures on increasingly sicker patients in non-hospital settings. Resist these pressures. There can be no surgery without an anesthetic. Be consistent with the values you learned in your university residency program. These values haven’t changed—they’re called the standards of care—and they reflect what an adequately trained physician will do in any give situation. Stay within these standards of care, and you’re unlikely to ever lose a malpractice lawsuit.
  5. The highest number of malpractice cases I review involve airway disasters. Do not screw up airway management. This includes intubation, extubation, and mask ventilation. I’ve previously written on this topic, and I can’t emphasize it enough.
  6. Because the highest number of malpractice cases I review involve airway disasters, I’d advise you to commit the ASA Difficulty Airway Algorithm to memory. I recommend Dr. Phillip Larson’s approach to the difficulty airway, as presented in the Appendix to Richard Jaffe’s Anesthesiologists Manual of Surgical Procedures. Patients with airway emergencies deteriorate in minutes. Have a plan in mind before you begin.
  7. Because the highest number of malpractice cases I review involve airway disasters, I recommend you always have a videoscope available. All well-stocked hospital operating rooms will have a Glidescope or equivalent, but many freestanding outpatient surgery centers or office-based operating rooms will not. It’s not always possible to predict the difficulty of endotracheal intubation. If you work at facilities or offices without a videoscope, I recommend you carry a disposable single-use Airtraq in your briefcase. The devices are single-use, and can be invaluable or lifesaving when conventional laryngoscopy is unsuccessful.
  8. Keep a reference book of checklists for dealing with anesthesia disasters available in every anesthetizing location. My recommendation is the Stanford Anesthesia Cognitive Aid Group Emergency Aid. Should a disaster occur, all the steps to appropriate treatment are listed so that you can follow those steps.
  9. Review the Stanford Anesthesia Cognitive Aid Group Emergency Manual regularly, and memorize the steps to each algorithm. The checklists exist so that in a disaster clinicians will not forget any steps, but a solid anesthesiologist will know this information by heart. You had to learn all this information to pass your oral anesthesia board exam, so why would you allow yourself to forget them as your career proceeds? Why would you want to be anything less than the safest practitioner you can be?
  10. A high percentage of the malpractice cases I review involve obese patients. Be extra wary when attending to obese patients. Obese patients present multiple difficulties in terms of airway management, placement of anesthesia lines, safety of oxygenation and ventilation both in the operating room and postoperatively, and they also present increased challenges for your surgeon. Anesthetics on patients with a BMI > 30 are more difficult, and anesthetics on patients with a BMI >40 or >50 are always challenging. I refer you to a previous column on the risks of obese patients for anesthesia.
  11. If you’re ever wondering whether or not to place an arterial line for a non-cardiac case, I’d recommend you place one. I was a cardiovascular anesthetist at Stanford for 15 years, and during that time I placed countless radial arterial lines prior to induction. The procedure is relatively painless, and for the sickest patients the benefit/risk ratio is high. The second-to-second feedback regarding hypotension or hypertension can be essential in patients with limited cardiac reserve, in trauma patients, or in patients with shock. An arterial line will be much more difficult to place if you wait until your patient is already hypovolemic, vasoconstricted, or hypotensive. And if the patient’s arms are tucked or if the patient is in a position other than supine, you’ll have restricted access to the radial artery intraoperatively. My advice: if you’re pondering whether or not to place an arterial line prior to inducing a sick patient, just do it.
  12. Be vigilant. The maintenance phase of anesthesia can at times be long, tedious, and boring, but it’s mandatory we stay vigilant for developing problems. Scan all patient monitors and all aspects of the patient during anesthesia care. Look for trends, e.g. increases or decreases in blood pressure or heart rate. Note any decrease in oxygen saturation, airway pressures, or end-tidal CO2 patterns. Diagnose and treat any abnormalities early in their development.
  13. Don’t struggle alone. Call for help early if your patient deteriorates. In anesthesia residency programs, each resident has multiple faculty members and other residents to assist him or her if a patient becomes acutely ill. In community practice there is almost always a second anesthesiologist or a second acute care physician in the facility to help. A second pair of hands can be invaluable in assisting airway or vascular procedures. A second mind is useful in confirming diagnoses and therapies are correct. An anecdote from my own anesthesia practice: an 80-year-old patient developed severe hypertension leading to frothing pulmonary edema just prior to extubation at the conclusion of a twenty-minute elbow surgery. My colleague in the next operating room left his stable anesthetic, arrived in my room, and placed an arterial line while I tended to the heart and lung emergency. Once the arterial line was placed, I was able to acutely titrate a sodium nitroprusside drip to normalize the blood pressure, decrease the afterload, and regain adequate oxygenation. The patient recovered fully. Without my partner’s help, it’s likely the patient would have died of hypoxemia.
  14. I’ve seen several cases of undetected hemorrhagic shock. Don’t be afraid to speak up to your surgeon. If your surgeon is working in the abdomen or the chest and your patient develops an increasing heart rate and a decreasing blood pressure, this could be the presentation of hemorrhage. The surgeon needs to know if the vital signs are deteriorating. If major hemorrhage occurs, you’ll need to insert a second large-bore IV line, get help, and order a Massive Transfusion Pack from the blood bank.

The Schulz study was an important publication. Preventable errors do occur in anesthesia. It’s up to us to do everything we can to make the incidence of preventable errors in our practice approach zero. You’ll keep your patients safe, and you’ll stay away from bad outcomes and malpractice lawsuits.

 

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:

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AVOIDING AIRWAY DISASTERS IN ANESTHESIA

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

Latest posts by the anesthesia consultant (see all)

Every anesthesia practitioner dreads airway disasters.  Anesthesiologists and nurse anesthetists are airway experts, but anesthesia professionals are often the only person in the operating room capable of keeping a patient alive if the patient’s airway is occluded or lost. Hypoxia from an airway disaster can lead to brain damage within minutes, so there is little time for human error.

A fundamental skill is the ability to assess a patient’s airway prior to anesthesia. One must assess whether the patient will pose: 1) difficult bag-mask ventilation, 2) difficult supraglottic/laryngeal mask airway placement, 3) difficult laryngoscopy, 4) difficult endotracheal intubation, or 5) difficult surgical airway.

Of critical importance is #1) above, that is, recognizing the patient who will present difficult mask ventilation. Conditions that make for difficult bag-mask ventilation are uncommon, and usually can be detected during physical examination. Despite the importance of expertise in endotracheal intubation, I teach residents and trainees that the most important airway skill is bag-mask ventilation. Every year I encounter several patients who present unanticipated difficult intubations. In each of these patients, I’m able to mask ventilate the patient to keep them oxygenated while I try various strategies and techniques to successfully place an endotracheal tube or a laryngeal mask airway.

Most anesthesia airway disasters aren’t merely difficult intubations, but scenarios that are classified as “can’t intubate, can’t ventilate.” In these “can’t intubate, can’t ventilate” situations, the anesthesiology professional has only minutes to restore oxygenation to the patient or else the risk of permanent brain damage is very real.

The American Society of Anesthesiologists Difficult Airway Algorithm is a guide for anesthesia practitioners regarding how proceed in airway management. The algorithm is detailed, complex, comprehensive, and defines the standard of care in any medical-legal battle concerning hypoxic brain damage due difficult airway clinical cases. The algorithm is so detailed, complex, and comprehensive that some would say it’s impossible to remember every step in the acute occurrence of an airway disaster.

A simplified approach has been touted.

Dr. C. Philip Larson, Professor Emeritus, Anesthesia and Neurosurgery, Stanford University, and Professor of Clinical Anesthesiology at UCLA, and previous Chairman of Anesthesiology at Stanford, was one of my teachers and mentors for both endotracheal intubation and fiberoptic intubation. In a Letter to the Editor of the Stanford Gas Pipeline in May, 2013, Dr. Larson wrote, “there is no scientific evidence that anesthesia is safer because of the ASA Difficult Airway Algorithm.  While an interesting educational document, I question the daily clinical value of this algorithm, even in its most recent form (Anesthesiology 2013; 118:251-70). The ASA Difficult Airway Algorithm was developed by committee and has all the problems that result when done that way.  It is complex, diffuse, multi-dimensional, and all-encompassing such that it is not an instrument that one can easily adopt and practice in the clinical setting.”

Dr. Larson recommends a system of Plans A-D, a system he published in Clinical Anesthesiology, editors Morgan GE, Mikhail MS, Murray MJ, Lange Medical publication, 4th edition, 2006, pp 104-5, and in Current Reviews in Clinical Anesthesiology (2009; 30:61-72), and also in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014). An outline of the system is as follows:

A.  Plan A is direct laryngoscopy an intubation using a Miller or MacIntosh blade.

B.  If Plan A is unsuccessful, Plan B includes use of video laryngoscopy with a GlideScope or similar device.

C.  If Plan B is unsuccessful, Plan C is placement of an LMA with intubation through that LMA using a fiberoptic bronchoscope.

D.  “If Plans A-C fail,” Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “one needs Plan D.  The first and perhaps the most prudent option is to cancel the proposed operation, terminate the anesthetic, and wake the patient up. The operation would be rescheduled for another day, and at that time an awake fiberoptic intubation technique would be used.  Alternatively, if the operation cannot be postponed, then the surgeon should be informed that a surgical airway (i.e.: tracheostomy) must be performed before the planned operation can commence.  To date, utilization of Plan D because of failure of Plans A-C has not occurred.”

Dr. Larson wrote that the airway skills in Plan A – C should be practiced regularly on patients with normal airways. I agree with Dr. Larson that in managing difficult airways, a practitioner needs a short list of procedural skills that he or she is expert at rather that a large array of procedures that they rarely use (such as the alternative intubation techniques using light wands or blind nasal techniques, or invasive airway procedures such as retrograde wires passed through the cricothyroid membrane or transtracheal jet ventilation through a catheter). It’s wise for anesthesiologists to regularly hone their techniques of video laryngoscopy (Plan B) and fiberoptic intubation via an LMA (Plan C) on patients with normal airways, to remain expert with these skills.

Regarding Plan B, an important advance is the availability of portable, disposable video laryngoscopes such as the Airtraq, a guided video intubation device. In my career I sometimes work in solo operating room suites distant from hospitals. In these settings, the operating room is usually not be stocked with an expensive video scope such as the GlideScope, the C-MAC, or the McGrath 5. I carry an Airtraq in my briefcase, and if the need for Plan B arises I am prepared to utilize video laryngoscopy at any anesthetizing location. I suggest the practice of carrying an Airtraq to any anesthesiologist who gives general anesthetics in remote locations.

Regarding emergency surgical rescue airway management, Dr. Larson recently published a Letter to the Editor in the American Society of Anesthesiologists Newsletter, February 2014, entitled, Ditch the Needle – Teach the Knife. In this letter, Dr. Larson wrote:

“in life-threatening airway obstruction, … an emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. It should be deleted from the ASA Difficult Airway Algorithm. I have participated in seven cricothyrotomies in emergency airway situations, and all of the patients left the hospital without any neurological injury or complications from the cricothyrotomy. The risk-benefit ratio is markedly in favor the knife technique…. With a knife, or scissors, one cuts quickly either vertically or horizontally below the thyroid cartilage and there is the cricothyroid membrane or tracheal rings. The knife is inserted into the trachea and turned 90 degrees, and an airway is established. At that point, a small tube of any type can be inserted next to the knife. The knife technique is much safer because there is virtually nothing that one can harm by making an incision within two inches or less in the midline of the neck, and it can be performed in less than 30 seconds. In contrast, the needle is fraught with complications, including identifying the trachea, making certain that the needle is entirely in the trachea and does not move ( to avoid subcutaneous emphysema when an oxygen source is established), establishing a pressurized oxygen delivery system (which will take more than five minutes even in the most experienced circumstances), and avoiding causing a tension pneumothorax… I know of multiple cases of acute airway obstruction where the needle technique was attempted, and in all cases the patients died. I know of no such cases when a cricothyrotomy was used as the primary treatment of acute airway obstruction.”

A final note on the awake intubation of patients with a difficult airway: In hindsight in any difficult airway case, one often wishes they had secured an endotracheal tube prior to the induction of general anesthesia. The difficult problem is deciding prior to a case which patient has such a difficult airway that the induction of general anesthesia should be delayed until after intubation. In anesthesia oral board examinations it may be wise to say you would perform an awake intubation on a difficult airway patient rather than risk the “can’t intubate, can’t ventilate” scenario the examiner is probably poised to skewer you with. In medical malpractice lawsuits, plaintiff expert witnesses in anesthesia airway disaster cases often testify that a brain-dead patient’s life would have been saved if only the anesthesiologist had performed awake intubation rather than inducing general anesthesia first and then losing the airway. The key question is: how does one decide which patient needs an awake intubation? As an anesthesia practitioner, if you performed awake intubations on one out of 50 cases because you were worried about a difficult airway, you would delay operating rooms and surgeons multiple times per year because of your caution. You will not be popular if you do this. In my clinical practice and in the practice of the excellent Stanford anesthesiologists I work with, the prevalence of awake intubation is very low. I estimate most anesthesiologists perform between zero and two awake intubations per year. The most common indications include patients with severe ankylosing spondylitis of the cervical spine, congenital airway anomalies, and severe morbid obesity. Dr. Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “I do anesthesia for most of the patients with complex head and neck tumors, and I find fewer and fewer indications for awake fiberoptic intubation. As long as the lungs can be ventilated by bag-mask or LMA, which is true for almost all sedated patients, Plan C is easier, quicker and safer than awake fiberoptic intubation both for the patient and the anesthesia provider.  In experienced hands, Plan C can be completed in less than 5 minutes, and one can become proficient by practicing in normal patients. I have done hundreds of Plan C’s, many under difficult circumstances, without a single failure or complication.  Obviously, no technique will encompass every conceivable airway problem, but mastering Plans A-D and awake oral and nasal fiberoptic intubation will meet the needs of anesthesia providers in almost all circumstances.”

May you never experience the  emotional trauma of an airway disaster. Become an expert in bag-mask ventilation, always have access to a video laryngoscope or an Airtraq, and consider  Dr. Larson’s  Plan A-D system, described in detail in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014).

 

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 ricknovak.com by clicking on the picture below:  

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