AN ANESTHESIOLOGIST’S SALARY

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

How much money does an anesthesiologist earn? What is a physician anesthesiologist’s salary in today’s marketplace?

screenshot2011-07-26at3-30-41pm

Let me begin by offering two anecdotes:

  • I was an invited visiting anesthesia professor at a major university this year, and following one of my lectures an anesthesiology resident approached me for a discussion. During our conversation he revealed that his student loan debt was $300,000. In 2014 the published average student loan debt for a physician was $183,000. I believe a higher estimate is not unusual, particularly if the student doctor attended private medical school and/or college.
  • I recently received an email from a medical student who was considering anesthesia as a career specialty, but his concern was: is the bottom about to fall out for anesthesiologists’ salaries? Should he perhaps avoid a career in anesthesiology?

Each anecdote concerns the issue of how much anesthesiologists earn, and what will that number be in the future?

The good news for the future of anesthesia careers is that the number of surgeries in the United States is expected at increase as the Baby Boomers age. The demand for anesthesia services will grow. Who will provide these services, and what will they be paid?

How much money do anesthesiologists currently make?

It depends.

If you do a Google search on this question, most of the published answers vary from $275,000 to $360,000 per year.

This sounds like a lot of money, but recall that to reach that salary, an anesthesiologist must finish 4 years of medical school and a 4-year anesthesia residency. At a minimum these young anesthesiologists are 30 years old. The deferred gratification is significant. Had they gone to work after college at age 22 and been promoted in a business job for 8 years, that individual might own a home, be saving for their children’s college educations, and would not have the debt from 4 years of medical school.

Let’s assume an individual does persevere and finish their anesthesia residency at age 30, and is now seeking an anesthesia job with that aforementioned average salary of $275,000 to $360,000 per year.

The first question: is that advertised salary a number prior to deductions for the big three of pension plan, health insurance, and malpractice insurance? If an anesthesiologist earns $300,000 per year, but must subtract these three expenses (let’s estimate pension plan at $45,000, health insurance at $24,000, and malpractice insurance at $20,000) then the income drops to $300,000 minus $89,000 = $211,000 per year, or $17,583 per month before taxes. Subtract again for student loan payments, and the income level continues to decrease. So a critical first question to ask is if the big three benefits are/are not part of the promised salary.

What specific factors determine how high the anesthesiologist’s salary will be? An operating room anesthesia practice is somewhat akin to being a taxi cab driver. You earn income for each ride/anesthetic, and your income depends on how many rides/anesthetics and how long they last. More complex anesthetics such as cardiac cases pay more, but the largest determiner is the duration of time one spends giving the anesthesia care. If you work in a physician anesthesiology practice where an MD stays with each surgical patient 100% of the time, then the only way to increase income is to do more cases or more hours. If you work in a practice which utilizes an anesthesia care team, where one physician anesthesiologist may supervise, for example, 4 Certified Registered Nurse Anesthetists (CRNAs), then a physician’s income is increased because he or she is billing for and supervising care for multiple concurrent surgeries.

Different payers pay different sums per unit time. The top payers are insured patients of less than Medicare age (<65 years old). Among the lowest payers are uninsured patients (who often pay zero), Medicaid and Medicare patients, and Worker’s Compensation patients. Medicare patients routinely pay only 13-20 cents on the billed dollar, and Medicaid pays even lower, so a practice heavy with Medicare and Medicaid patients will compensate their anesthesiologists poorly. Insurance companies (i.e. Blue Cross, Blue Shield, Aetna, United Healthcare) pay whatever rate they have contracted with that anesthesia group. If a particular insurance company pays a low rate, an anesthesia group may refuse to sign a contract with that insurance company. This leaves the anesthesiologist out-of-network with that company, which can mean a higher payment or co-payment for the patient as a result of the insurance company’s refusal to negotiate a fair reimbursement.

Just as taxi cab drivers are being supplanted by Uber and Lyft, cheaper models of anesthesia care are popping up, and the penetration of these models into the future marketplace is unknown. One model is having a CRNA do the anesthetic independently without any physician anesthesiologist present. This is currently legal in 27 states (see map). At the current time, in my home state of California, independent CRNA practice is legal, but the penetration of this model in the marketplace is very minimal. The Veterans Affairs hospitals are currently pondering a move to allow CRNAs to practice independently without any physician anesthesiologist present. You can expect to see a higher penetration of the anesthesia care team, where one physician anesthesiologist may supervise, for example, 4 CRNAs, and a decrease in practices where an MD anesthesiologist stays with each patient 100% of the time.

To be blunt, my impression is that the future marketplace is unlikely to pay for a physician anesthesiologist to do solo anesthesia care for each and every surgical patient.

In the current marketplace a young graduate anesthesiologist may enter one of several different models of anesthesia practices. Each has a different level of salary expectation. The various models are listed below, in roughly a higher-income-per-anesthesiologist to lower-income-per-anesthesiologist order:

  1. A single-specialty anesthesia group that shares income fairly. This group may be as small as 5 or as large as hundreds of physician anesthesiologists, with or without additional CRNAs. Such a group usually has an exclusive contract with a hospital or hospitals to provide all anesthesia services, which can include trauma, obstetrics, and 24-hour emergency room coverage. A very large single-specialty anesthesia group may contract with many hospitals in a geographic area. In a single-specialty model, that single-specialty group receives all the anesthesia billings, and the income is divided, usually in some form of “eat-what-you-provided” formula. Those MDs who worked the most receive a proportional increase in their income. A new MD may have a one-year try-out before they become a partner, after which they are entitled to an equal income per unit time. This model where anesthesiologists are partners, is typically more lucrative than models where the anesthesiologists are employed by another entity. A survey by Medscape on anesthesiologists’ salaries in 2016 showed that male self-employed anesthesiologists (model #1) earned an average income of $413,000, while male anesthesiologist employees (see models #2 – #8 below) earned an average income of $336,000.
  2. A single-specialty anesthesia group in which a chairman (or a small oligopoly of MDs) collect the money, and then employ and grant a salary to everyone below them in the company. New hires are paid less, often with no potential to increase their income. This type of system preys on junior anesthesiologists.
  3. A multispecialty medical group. A multispecialty medical group has a bevy of primary care physicians who refer internally to their specialist surgeons, who then utilize their internal group of anesthesiologists. This is a secure job for anesthesiologists because the stream of cases is guaranteed by the physicians within their multispecialty group. A disadvantage is that incomes from lower paying specialties (primary care MDs) and higher paying specialties (i.e. cardiologists, surgeons, and anesthesiologists) are pooled. The lower paying specialists usually have their salaries raised, and the anesthesiologists will be subsidizing them.
  4. An HMO. In California the Health Maintenance Organization (HMO) Kaiser Permanente has a large share of the marketplace. The entity known as the Permanente Medical Group is the multispecialty integrated medical group which works at the Kaiser hospitals and clinics. The reimbursement model will be similar to that described in #3 above.
  5. University anesthesia groups. A university employs MDs as a multispecialty medical group, and the model is similar to #3 above. A difference is that university groups have various taxes and fees on their income that go to the betterment and growth of the medical school and the university hospital system. In addition, some university hospitals provide care to indigent populations that may have higher percentage of poor payers such as Medicaid or uninsured patients.
  6. National anesthesia companies. In this model, a national company obtains the anesthesia contract for a hospital or multiple facilities, and then that national company hires and employs anesthesiologists. The company bills for the anesthesia services provided, pays their employee anesthesiologists whatever sum they’ve agreed to pay them, and the difference between the received monies and the owed salaries is profit that goes to stockholders of the national company. This model is problematic for our specialty, because a percentage of the anesthesia fees goes to stockholders who had zero to do with performing the professional service.
  7. Veteran’s Affairs (VA) hospital anesthesia groups. At the present time, VA hospitals are staffed by anesthesiologists who are employees of the VA system. As mentioned above, there are politicians pushing for the VA to allow CRNAs to practice independently, unsupervised by physician anesthesiologists. The American Society of Anesthesiologists is opposed to this change, believing that our veterans deserve physician anesthesiologists.
  8. Locum tenens assignments. These are part-time, week-long, or month-long anesthesia duties, paid for at a daily rate. A typical fee for a full day’s work may be a pre-tax payment of $1200/day (not including the big three of pension, health or malpractice insurance).

As stated above, the good news for the future of anesthesia careers is that the number of surgeries in the United States is expected at increase as the Baby Boomers age. The demand for anesthesia services will grow. The unknown fiscal factors for the future of our specialty are:

  1. What will insurers/Medicare/Medicaid/the Affordable Care Act pay for these anesthesia services? Will a single payer government health plan ever arrive, and if it does what will anesthesiologists be paid?
  2. Who will be giving these services? Physician anesthesiologists, anesthesia care teams involving physician anesthesiologists plus CRNAs, anesthesia care teams involving physician anesthesiologists plus Anesthesia Assistants, or independent CRNAs?
  3. The American Society of Anesthesiologists is attempting to rebrand the practice of anesthesiology with the concept of the Perioperative Surgical Home (PSH), in which physician anesthesiologists are responsible for all aspects of preoperative, intraoperative, and postoperative medical care for patients around the time of surgery. This expanded role includes preoperative clinics and postoperative pain control and medical management. To what degree can/will the PSH change the job market for graduating anesthesiologists?

In any case, as I wrote on the Home Page of theanesthesiaconsultant.com website, “the profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.” If a college student or a medical student is truly interested in a career in anesthesia, I remain encouraging to them, regardless of these uncertainties regarding the future.

 

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?

 

 

*
*
*
*

Check out . . . THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

 

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

DSC04882_edited

 

 

 

DENTAL ANESTHESIA DEATHS . . . GENERAL ANESTHESIA FOR PEDIATRIC PATIENTS IN DENTAL OFFICES

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

GENERAL ANESTHESIA FOR DENTAL OFFICES CASE PRESENTATION: A 5-year-old developmentally delayed autistic boy has multiple dental cavities. The dentist consults you, a physician anesthesiologist, to do sedation or anesthesia for dental restoration. What do you do?

gauge-needles-used-intramuscular-injection_d9f6cc4b150fa44

DISCUSSION:  Children periodically die in dental offices due to complications of general anesthesia or intravenous sedation. Links to recent reports include the following:

3-year-old girl dies in San Ramon, CA after a dental procedure in July 2016.

A 14-month-old child, scheduled to have 2 cavities filled, dies in an Austin, TX dental office. The dentist and an anesthesiologist were both present.

A 6-year-old boy, scheduled to have teeth capped at a dental clinic, has anesthesia and dies after the breathing tube is removed.

Another 6-year-old boy, scheduled to have a tooth extracted by an oral surgeon, dies after the oral surgeon administers general anesthesia.

Pediatric dentists use a variety of tactics to keep a typical child calm during dental care. The child is encouraged to view a movie or cartoon while the dental hygienist or dentist works. The parent or parents are encouraged to sit alongside their child to provide emotional support. If a typical child requires a filling for a cavity, the dentist can utilize nitrous oxide via a nasal mask with or without local anesthesia inside the mouth.

These simple methods are not effective if the child has a developmental delay, autism, behavioral problems, or if the child is very young. Such cases sometimes present to a pediatric hospital for anesthetic care, but at times the child will be treated in a dental office. Possible anesthesia professionals include a physician anesthesiologist, a dental anesthesiologist, or an oral surgeon (who is trained in both surgery and anesthesia).

 

HOW WOULD A PHYSICIAN ANESTHESIOLOGIST ANESTHETIZE A CHILD IN A DENTAL OFFICE?

There are a variety of techniques an anesthesiologist might use to sedate or anesthetize a young child. The correct choice is usually the simplest technique that works. Alternative methods include intramuscular sedation, intravenous sedation, or potent inhaled anesthetics.

 

ANESTHESIA INDUCTION:

The first decision is how to begin the anesthetic on an uncooperative child. Options for anesthesia induction include:

  1. Intramuscular sedation. A typical recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine. These three medications are drawn up in a single syringe and injected into either the deltoid muscle at the shoulder or into the muscle of the anterior thigh. Ketamine is a general anesthetic drug that induces unconsciousness and relieves pain. Midazolam is a benzodiazepine which induces sleepiness and decreases anxiety. Ketamine can cause intense dreams which may be frightening. Midazolam is given because it minimizes ketamine dreams. Atropine offsets the increased oral secretions induced by ketamine. Within minutes after the injection of these three drugs, the child will become sleepy and unresponsive, and the anesthesiologist can take the child from the parent’s arms and bring the patient into the operating room. Most anesthesiologists will insert an intravenous catheter into the patient’s arm at this point, so any further doses of ketamine, midazolam, or propofol can be administered through the IV.
  2. Oral sedation with a dose of 0.5-0.75 mg/kg of oral midazolam syrup (maximum dose 20 mg). If the child will tolerate drinking the oral medication, the child will become sleepy within 15- 20 minutes. At this point, the anesthesiologist can take the patient away from the parent and proceed into the operating room, where either an intravenous anesthetic or an inhaled sevoflurane anesthetic can be initiated.

 

MONITORING THE PATIENT:

  1. The patient should have all the same monitors an anesthesiologist would use in a hospital or a surgery center. This includes a pulse oximeter, an ECG, a blood pressure cuff, a monitor of the exhaled end-tidal carbon dioxide, and the ability to monitor temperature.
  2. The anesthesiologist is the main monitor. He or she will be vigilant to all vital signs, and to the Airway-Breathing-Circulation of the patient.

 

MAINTENANCE OF ANESTHESIA:

  1. Regardless of which anesthetic regimen is used, oxygen will be administered. Room air includes only 21% oxygen. The anesthesiologist will administer 30-50% oxygen or more as needed to keep the patient’s oxygen saturation >90%.
  2. Intravenous sedation: This may include any combination of IV midazolam, ketamine, propofol, or a narcotic such as fentanyl.
  3. Local blocks by the dentist. The dentist may inject local anesthesia at the base of the involved tooth, near the superior alveolar nerve to block all sensation to the upper teeth, or near the inferior alveolar nerve to anesthetize all sensation to the lower jaw.
  4. Inhaled nitrous oxide. The simplest inhaled agent is nitrous oxide, which is inexpensive and rapid acting. Used alone, nitrous oxide is not potent enough to make a patient fall asleep. Nitrous oxide can be used as an adjunct to any of the other anesthetic drugs listed in this column.
  5. Potent inhalation anesthesia (sevoflurane). Most dental offices will not have a machine to administer sevoflurane. (Every hospital operating room has an anesthesia machine which delivers sevoflurane vapor.) Portable anesthesia machines fitted with a sevoflurane vaporizer are available. A colleague of mine who worked full time as a roving physician anesthesiologist to multiple pediatric dental offices leased such a machine and used it for years. The advantages of sevoflurane are: i) few intravenous drugs will be necessary if the anesthesiologist uses sevo, and ii) the onset and offset of sevo is very fast—as fast as nitrous oxide. The administration of sevoflurane usually requires the use of a breathing tube, inserted into the patient’s windpipe.
  6. The anesthesiologist will be present during the entire anesthetic, and will not leave.

 

AWAKENING FROM ANESTHESIA:

  1. With intramuscular and/or intravenous drugs, the wake-up is dependent on the time it takes for the administered drugs to wear off or redistribute out of the blood stream. This may take 30-60 minutes or more following the conclusion of the anesthetic.
  2. With inhaled agents such as sevoflurane and nitrous oxide, the wake-up is dependent on the patient exhaling the anesthetic gas. The majority of the inhaled anesthetic effect is gone within 20-30 minutes after the anesthetic is discontinued.
  3. The patient must be observed and monitored until he or she is alert enough to be discharged from the medical facility. This can be challenging if a series of patients are to be anesthetized in a dentist’s office. The medical staff must monitor the post-operative patient and also attend to the next patient’s anesthetic care. It’s imperative that the earlier patient is awake before the anesthesiologist turns his full attention to the next patient.

 

THE ANESTHETIC FOR OUR CASE PRESENTATION ABOVE:

  1. The anesthesiologist meets the parents and the patient, and explains the anesthetic options and procedures to the parent. The parent then consents.
  2. The anesthesiologist prepares the dental operating room with all the necessary equipment in the mnemonic M-A-I-D-S, which stands for Monitors and Machine, Airway equipment, Intravenous line, Drugs, and Suction.
  3. The anesthesiologist injects the syringe of ketamine, midazolam, and atropine into the child’s deltoid muscle. The child becomes sleepy and limp within one minute, and the anesthesiologist carries the child into the operating room.
  4. All the vital sign monitors are placed, and oxygen is administered via a nasal cannula.
  5. An IV is started in the patient’s arm.
  6. The dentist begins the surgery. He or she may inject local anesthesia as needed to block pain.
  7. Additional IV sedation is administered with propofol, ketamine, midazolam, or fentanyl as deemed necessary.
  8. When the surgery is nearing conclusion, the anesthesiologist will stop the administration of any further anesthesia. When the surgery ends, the anesthesiologist remains with the patient until the patient is awake. The patient may be taken to a separate recovery room, but that second room must have an oxygen saturation monitor and a health care professional to monitor the patient until discharge.

CHALLENGES OF DENTAL OFFICE ANESTHESIA:

  1. You’re do all the anesthesia work alone. If you have an airway problem or an acute emergency, you’ll have no other anesthesia professional to assist you. Your only helpers are the dentist and the dental assistant.
  2. The cases are difficult, otherwise you wouldn’t be there at all. Every one of the patients will have some challenging medical issue(s).
  3. You have no preop clinic, so you don’t know what you’re getting into until you meet the patient. I’d recommend you telephone the parents the evening before, so you can glean the past medical and surgical histories, and so you can explain the anesthetic procedure. Nonetheless, you can’t evaluate an airway over the phone, and on the day of surgery you may encounter more challenge than you are willing to undertake.
  4. It’s OK to cancel a case and recommend it be done in a hospital setting if you aren’t comfortable proceeding.
  5. The anesthesiologist usually has to bring his or her own drugs. The narcotics and controlled substances need to be purchased and accounted for by the anesthesiologist with strict narcotic logs to prove no narcotics are being diverted for personal use. All emergency resuscitation drugs need to be on site in the dental office or brought in by the anesthesiologist.
  6. If a sevoflurane vaporizer is utilized, dantrolene treatment for Malignant Hyperthermia must be immediately available.

 

BENEFITS OF DENTAL OFFICE SEDATION AND GENERAL ANESTHESIA:

  1. The parents of the patients are grateful. The parents know how difficult dental care on their awake child has been, and they’re thankful to have the procedures facilitated in a dental office.
  2. The dentist and their staff are grateful. They don’t have a method to safely sedate such patients, and are thankful that you do.
  3. Most cases are not paid for by health insurance, rather they are cash pay in advance.

 

HOW SAFE IS ANESTHESIA AND SEDATION IN A DENTAL OFFICE?

No database can answer the question at present. In 2013 the journal Paediatric Anesthesia published a paper entitled Trends in death associated with pediatric dental sedation and general anesthesia. (1) The paper reported on children who had died in the United States following receiving anesthesia for a dental procedure between1980-2011. Most deaths occurred among 2-5 year-olds, in an office setting, and with a general or pediatric dentist (not a physician anesthesiologist or dental anesthesiologist) as the anesthesia provider. In this latter group, 17 of 25 deaths were linked with a sedation anesthetic.

Another study analyzed closed claims databases of 17 malpractice claims of adverse anesthesia events in pediatric patients in dental offices from 1992 – 2007. (2) Thirteen cases involved sedation, 3 involved local anesthesia alone, and 1 involved general anesthesia. 53% of the claims involved patient death or permanent brain damage. In these claims the average patient age was 3.6 years. Six cases involved general dentists as the anesthesia provider, and 2 involved local anesthesia alone. The adverse event occurred in the dental office in 71% of the claims. Of the 13 claims involving sedation, only 1 claim involved the use of vital sign monitoring. The study concluded that very young patients (≤ 3-years-old) were at greatest risk during administration of sedative and/or local anesthetic agents. The study concluded that some practitioners were inadequately monitoring patients during sedation procedures. Adverse events had a high chance of occurring at the dental office where care is being provided.

If general anesthesia or deep sedation are performed in a dental office, the anesthetist must practice with the same vigilance and standards of care as they would in a hospital or surgery center. Either a physician anesthesiologist, an oral surgeon (acting as both the dental surgeon and the anesthetist), or a dental anesthesiologist may perform the anesthesia. There are no data at this time to affirm that a physician anesthesiologist is the safest practitioner in this setting.

Note: This column addressed the office practice of pediatric dental anesthesia as seen from a physician anesthesiologist’s point of view.

References:

(1) Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6.

(2) Chicka MC et al, Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent.2012 May-Jun;34(3):231-8.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

13 MAJOR CHANGES IN ANESTHESIOLOGY IN THE LAST TEN YEARS

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

Let’s look at 13 major changes in the last ten years of anesthesiology, and give a letter grade to mark the significance of each advance:

final_ten_year_graphic_gif

 

SUGAMMADEX – The long awaited reversal agent for neuromuscular paralysis reached the market in 2016, and by my review, the drug is wonderful. I’ve found sugammadex to reverse rocuronium paralysis in less than a minute in every patient who has at least one twitch from a nerve stimulator. The dose is expensive at about $100 per patient, but at this time that’s cheaper than the acquisition costs for neostigmine + glycopyrrolate. The acquisition cost of neostigmine + glycopyrrolate at our facilities exceeds $100, and this combination of drugs can take up to 9 minutes to reverse rocuronium paralysis. Sugammadex reversal can make the duration of a rocuronium motor block almost as short acting as a succinylcholine motor block, and sugammadex can also eliminate complications in the Post Anesthesia Care Unit due to residual postoperative muscle paralysis. Grade = A.

 

SHORTAGES OF GENERIC INTRAVENOUS DRUGS – Over the last five years we’ve seen unexpected shortages of fentanyl, morphine, propofol, ephedrine, neostigmine, glycopyrrolate, meperidine, and atropine, to name a few. These are generic drugs that formerly cost pennies per ampoule. In the current marketplace, generic manufacturers have limited the supplies and elevated the prices of these medications to exorbitant levels. I wish I’d had the foresight and the money ten years ago to invest in a factory that produced generic anesthetic drugs. Grade = F.

 

THE PERIOPERATIVE SURGICAL HOME – The American Society of Anesthesiologists has been pushing this excellent concept for years now—the idea being that a team of physician anesthesiologists will manage all perioperative medical care from preoperative clinic assessment through discharge, including intraoperative care, postoperative care and pain management in the PACU, the ICU, and the hospital wards. The goal is improved patient care with decreased costs. It’s not clear the idea has widespread traction as of yet, and the concept will always be at odds with the individual aspirations of internal medicine doctors, hospitalists, intensivists, surgeons, and certified nurse anesthetists, all who want to make their own management decisions, and all who desire to be paid for owning those decisions. Grade = B-.

 

MULTIMODAL PAIN MANAGEMENT FOLLOWING TOTAL JOINT REPLACEMENTS – The development of pain management protocols which include neuroaxial blocks, regional anesthetic blocks, local anesthetic infiltration by surgeons, oral and intravenous pain medications, have advanced the science of pain relief for total knee and total hip replacements. The cooperation between surgeons, anesthesiologists, and internal medicine specialists to develop the protocols has been outstanding, the standardized checklist care has been well accepted, and patients are benefiting. Grade = A.

 

ULTRASOUND GUIDED REGIONAL ANESTHESIA – Regional anesthetic blocks are not new, but visualizing the nerves via ultrasound is. The practice is becoming widespread, and the analysis of economic and quality data is ongoing. Ultrasound guided regional anesthesia is a major advance for painful orthopedic surgeries, but I worry about overuse of the technique on smaller cases for the economic benefit of the physician wielding the ultrasound probe. A second concern is the additive risk of administrating two anesthetics (regional plus general) to one patient. I’ve reviewed medical records of patients with adverse outcomes related to regional blocks, and I’m concerned ultrasound guided regional anesthesia may be creating a new paradigm of postoperative complications, e.g. prolonged nerve damage or intravascular injection of local anesthetics. In the future I look forward to seeing years of closed claims data regarding this increasing use of regional anesthesia. Grade = B.

 

VIDEOLARYNGOSCOPY – The invention of the GlideScope and its competitors the C-MAC, King Vision, McGrath and Airtraq videolaryngoscopes was a major advance in our ability to intubate patients with difficult airways. My need for fiberoptic intubation has plummeted since videolaryngoscopy became available. I’d recommend that everyone who attempts traditional laryngoscopy for endotracheal intubation have access to a video scope as a backup, should traditional intubation prove difficult. Grade = A.

 

ANESTHESIOLOGIST ASSISTANTS (AAs) – The American Society of Anesthesiologists is championing the idea of training AAs to work with physician anesthesiologists in an anesthesia care team model. A primary reason is to combat the influence and rise in numbers of Certified Registered Nurse Anesthetists (CRNAs) by inserting AAs as a substitute. Not a bad idea, but like the Perioperative Surgical Home, the concept of AAs is gaining traction slowly, and the penetration of AAs into the marketplace is minimal. To date there are only ten accredited AA education programs in the United States. Grade = B-.

 

CHECKLISTS – We now have pre-incision Time Outs, pre-induction Anesthesia Time Outs, and pre-regional anesthesia Block Time Outs. It’s hard to argue with these checklists. Even if 99.9% of the Time Outs change nothing, if 0.1% of the Time Outs identify a miscommunication or a laterality mistake, they are worth it. Grade = A.

 

ANESTHESIA ELECTRONIC MEDICAL RECORDS (EMRs)– The idea is sound. Everything in the modern world is digitalized, so why not medical records? The problem is the current product. There are multiple EMR systems, and the systems cannot communicate with each other. Can you imagine a telephone system where Sprint phones cannot communicate with AT&T phones? The current market leader for hospitals is Epic, a ponderous, expensive system that does little to make the pertinent information easier to find in medical charts. For acute care medicine such as anesthetic emergencies, the medical charting and documentation in Epic gets in the way of hands-on anesthesia care. In the past, when I administered 50 mg of rocuronium, I simply wrote “50” in the appropriate space on a piece of paper. In Epic I have to make at least 4 mouse clicks to do the same thing. This Epic entry cannot be made on a touch screen because the first rocuronium window on the touch screen is a three-millimeter-tall box, too small for a finger touch. I’d like to see Apple or Google develop better EMR software than we have at present. Perhaps the eventual winning product will be voice activated or will involve easy touch screen data entry and data access. And all EMR systems should interact with each other, so patient privacy medical information can be portable. Grade = C-.

 

THE ECONOMICS OF ANESTHESIA – When I began in private practice in 1986, most successful anesthesiologists joined a single-specialty anesthesia group. This group would cover a hospital or several hospitals along with nearby surgery centers and offices. The group would bill for physician services, and insurance companies would reimburse them. Each physician joining the group would endure a one or two-year tryout period, after which he or she became a partner. Incomes were proportional to the number of cases an individual attended to. The models are changing. Smaller anesthesia groups are merging into larger groups, better equipped to negotiate with healthcare insurers and ObamaCare. More and more healthcare systems are employing their own anesthesiologists. In a healthcare system, profits are pooled and shared amongst the varying specialists. This model is not objectionable. Anesthesiologists share the profits with less lucrative specialties such as internal medicine and pediatrics, but the anesthesiologists are assured a steady flow of patients from the primary care physicians and surgeons within the system. The end result is less income than in a single-specialty anesthesia group, but more security. Grade = B.

 

THE SPECTER OF A BAN ON BALANCE BILLING – In a perfect world all physician groups would be contracted with all health insurance companies, at a monetary rate acceptable to both sides. Unfortunately there are insurance company-physician group rifts in which an acceptable rate is not negotiated. In these instances, the physician provider for a given patient may be out of network with the patient’s insurer, not because of provider greed (as portrayed by some politicians and insurers) but because the insurance company did not offer a reasonable contracted rate. Some politicians believe physician out-of-network balance billing should be outlawed. This would give unilateral power to insurance companies. Why would an insurance company offer a reasonable rate to a physician provider group, if the insurance company can pay the physicians a low rate and the new law says the physicians have no alternative but to accept it as payment in full? The no-balance-billing politicians will portray patients as victims, but if they succeed in changing the laws, physicians will become victims. Physicians as well as consumers must unite to defeat this concept. Grade = F.

 

CORPORATE ANESTHESIA – National companies are buying multiple existing anesthesia groups and changing the template of our profession in America. The current physician owners of a practice can sell their group to a publically traded national company for a large upfront payoff. The future salaries of anesthesiologists of that group are then decreased, and the rest of the profit formerly garnered by the physicians goes instead to the bottom line of the national company’s shareholders. If this model becomes widespread, the profession of anesthesiology will morph into a job populated by moderately reimbursed employees. Grade = D.

 

INDEPENDENT PRACTICE FOR CRNAs – Anesthesiology is the practice of medicine. In a two-year training program, an ICU nurse can learn to administer propofol and sevoflurane, and how to intubate most patients, and become a CRNA. It takes a physician anesthesiologist to manage complex preoperative medical problems, intraoperative complications, and postoperative medical complications. I understand rural states such as Montana and the Dakotas cannot recruit enough physician anesthesiologists to hospitals in their smallest towns, but for states like California to legalize independent anesthesia practice for CRNAs is unconscionable. Grade = D.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

ANESTHESIA ERRORS: MALPRACTICE OR NOT?

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

If a patient suffers a bad outcome after anesthesia, did the anesthesiologist commit malpractice? If there was an anesthesia error, was it anesthesia malpractice?

medical-malpractice-anesthesia-errors-1-638

 

Not necessarily. There are risks to every anesthetic and every surgery, and if a patient sustains a complication, it may or may not be secondary to substandard anesthesia care.

Let’s look at the most common reasons for anesthesia malpractice claims. In a study by Ranum,(1) researchers examined a total of 607 closed claims from a single national malpractice insurance company over five years between 2007 and 2012. The most frequent anesthesia-related injuries reported were:

  1.   Teeth damage — 20.8 percent of the anesthesia medical malpractice claims
  2.   Death — 18.3 percent
  3.   Nerve damage — 13.5 percent
  4.   Organ damage — 12.7 percent
  5.   Pain — 10.9 percent
  6.   Cardiopulmonary arrest — 10.7 percent

When the minor claims for teeth damage are omitted, claims for death and cardiopulmonary arrest account for nearly one in four closed claims for anesthesiologists. This shows the severe nature of anesthesia bad outcomes.

How can we discern whether a bad patient outcome is a risk for a malpractice claim?

There are four elements to a medical malpractice claim. They are as follows (2):

  1. Duty to care for the patient. The anesthesiologist must have made a contract to care for the patient. The anesthesiologist meets the patient, takes a history, reviews the chart, does a pertinent physical exam, and discusses the options for anesthetic care. The anesthesiologist then obtains informed consent from the patient to carry out that plan, and the duty to care for the patient is established.
  2. Negligence occurs if the anesthesiologist failed in his or her duty to care, that is, he or she performed below the standard of care. The standard of care is defined as the level of care expected from a reasonably competent anesthesiologist. If a lawsuit is eventually filed, anesthesiology expert witnesses will testify for both the defense and the plaintiff as to what the standard of care was for this case. If the defendant anesthesiologist performed below the standard of care, they are vulnerable to losing the lawsuit.
  3. The plaintiff must prove the negligence was a proximate cause of the injury to the patient. If a lawsuit is eventually filed, expert witnesses will argue how and why the negligence was linked or was not linked to the adverse outcome.
  4. The injury or loss can be measured in monetary compensation to the plaintiff.

Let’s look at two fictional case studies to demonstrate how a bad outcome may or may not be related to anesthesia malpractice:

CASE ONE: A 70-year-old man is scheduled to have laparoscopic abdominal surgery for a partial colectomy to remove a cancer in his large intestine. Prior to his surgery he has a complete history and physical by his internal medicine doctor, and the results of that workup are in the medical chart. The patient medical history is positive for hypertension, hyperlipidemia, and obesity. His Body Mass Index, or BMI, is elevated at 32. His blood pressure is 140/85, and his physical exam is otherwise unremarkable. Prior to the surgery, the anesthesiologist requests clearance from a cardiologist. The cardiologist performs an exercise stress echocardiogram, which is read as normal. The anesthesiologist plans a general anesthetic, and obtains informed consent from the patient. During the informed consent, the anesthesiologist tells the patient that risks involving the heart, the lungs, or the brain are small but not zero. The patient accepts these risks.

The surgery and anesthesia proceed uneventfully. The patient is awakened from general anesthesia and taken to the Post Anesthesia Care Unit. The patient is drowsy and responsive, with a blood pressure of 100/60, a heart rate of 95, a respiratory rate of 16, a temperature of 36.0 Centigrade, and an oxygen saturation of 96% on a face mask delivering 50% oxygen. A Bair Hugger blanket is applied to warm the patient, and morphine sulfate 2 mg IV is given for complaint of abdominal pain.

Thirty minutes later, the patient develops acute shortness of breath, and his oxygen saturation drops to 75%. The anesthesiologist sees him and evaluates him. The cause of the shortness of breath and drop in oxygen level are unclear. The concentration of administered oxygen is increased to 100%, but the patient acutely becomes unresponsive. The anesthesiologist intubates the patient’s trachea, and begins ventilating him through the breathing tube. The patient is still unresponsive and has a cardiac arrest. Despite all Advanced Cardiac Life Support treatments, the patient dies.

An expert witness later reviews the chart, and finds the anesthesia management to be within the standard of care prior to, during, and after the surgery. There was no negligence that caused the cardiac arrest. Why did the patient die? The post-mortem exam, or autopsy, in a case like this could show a pulmonary embolism or a myocardial infarction, either of which can occur despite excellent anesthesia care. The patient was elderly, overweight, and hypertensive. Abdominal surgery and general anesthesia in this patient population are not without risk, even with optimal anesthetic care.

CASE TWO: A 55-year old female is scheduled for a facelift at a freestanding plastic surgery center operating room. Her history and physical examination are normal except that she is 5 feet tall and weighs 200 pounds, for a BMI=39. The anesthesiologist plans a general anesthetic, and obtains informed consent from the patient. After the induction of general anesthesia with propofol and rocuronium, the anesthesiologist is unable to place the endotracheal tube in the patient’s windpipe. He tries repeatedly in vain, and during this time the woman’s oxygen saturation drops to dangerous levels below 70%, and remains low for over five minutes. He eventually places the tube successfully. The surgery is cancelled, and the woman fails to wake up. She is transferred to a local hospital and admitted to the intensive care unit. A neurologic workup confirms that she has anoxic brain damage, or brain death.

This is a case where an overweight but otherwise healthy woman walked into a surgery center for an elective surgery, and emerged brain dead. Per the donor card in the patient’s wallet, the family agreed to donate the patient’s organs. Was this outcome due to malpractice? Yes. The anesthesiologist performed below the standard of care, because he failed to keep the patient oxygenated during the multiple attempts to place the breathing tube. An expert witness for the plaintiff testifies that a reasonably competent anesthesiologist would understand and follow the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm, and use alternate techniques to keep the patient oxygenated should the endotracheal tube placement be technically difficult. (These techniques include bag-mask ventilation, placement of a laryngeal mask airway, or use of a video laryngoscope). The failure to keep the airway open and the failure to keep the patient oxygenated led to the anoxic brain damage. An expert witness for the defense concurs with this opinion, and the anesthesiologist’s malpractice insurance company settles the case by paying the patient’s family.

Complications can occur before, during, or after anesthesia. The overwhelming majority of physician anesthesiologists manage their patients at or above the standard of care. When an adverse outcome occurs there may very well be no negligence or malpractice, and one should expect the legal system to award little or no malpractice award payments.

Does that mean that if the standards of care are adhered to, then there will be no malpractice payment following a bad outcome? Unfortunately, the data say no.

The ASA Closed Claims Project collects closed anesthesia malpractice claim results from the 1970s to the present. From 1975-79, 74% of anesthesia lawsuits resulted in payment. From 1990-99 this proportion declined to 58%. Much of this positive change may be explained by improvements in standards of care, i.e. the change to the routine monitoring of pulse oximetry and end-tidal carbon dioxide levels. In the 1970s, 51% of the lawsuits in which standards of care were met resulted in payment. In the 1990s only 40% of the lawsuits in which standards of care were met resulted in payment, but 40% is not zero.(3)

Other facts about medical malpractice lawsuits: About 93% of malpractice claims close without going to a trial. The average claim that goes to trial involves a 3 to 5 year process.(4) Of the cases that go to trial, 79% of verdicts are for the defendant physician.(5)

Medical errors do occur. Physicians are human. How common are medical errors in anesthesiology? It’s hard to quantitate. Medical errors that do not result in closed malpractice claims are not tabulated.

The issue of medical errors is currently a hot topic. A report published in the The British Medical Journal this week stated that if medical error was a disease, it would rank as the third leading cause of death in the United States, trailing only heart disease and cancer. Medical error was defined as an unintended act of either omission or commission, or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient. The authors calculated a mean rate of death from medical error of 251 ,454 cases per year. The authors pointed out that death certificates in the U.S., used to compile national statistics, currently have no facility for acknowledging medical error. The ICD-10 coding system has limited ability to record or capture most types of medical error. The authors recommended that when a medical error resulted in death, both the physiological cause of the death and the related problem with delivery of care should be captured.(6)

Do anesthesiologists commit any of these medical errors? Undoubtedly. What does this mean if you are a patient scheduled for surgery and anesthesia? You should have every expectation your board-certified physician anesthesiologist will practice at or above the standard of care. The chances that you will become an adverse outcome statistic are small, but those chances are not zero.

See my column Do Anesthesiologists Have the Highest Malpractice Insurance Rates? to learn more about malpractice risks and anesthesiologists.

 

References:

  1. Ranum D, et al, Six anesthesia-related medical malpractice claim statistics. Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer, Journal of Healthcare Risk Management Volume 34,Issue 2,pages 31–42,
  2. Tsushima WT, Nakano KK, Effective Medical Testifying: A Handbook for Physicians, 1998, Butterworth-Heinemann.
  3. Posner KL: Data Reveal Trends in Anesthesia Malpractice Payments. ASA Newsletter68(6): 7-8 & 14, 2004.
  4. Chesanow N, Malpractice: When to Settle a Suit and When to Fight. Medscape Business of Medicine, Sept 25, 2013.
  5. Jena AB,, Outcomes of Medical Malpractice Litigation Against US Physicians. Arch Intern Med.2012 Jun 11;172(11).
  6. Makary MA, Daniel M, Medical Error—the Third Leading Cause of Death in the U.S., BMJ, 2016;353:i2139.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

LARGE-VOLUME LIPOSUCTION: IS IT SAFE?

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

I work in a private practice setting in Palo Alto, California, and liposuction is one of the most common plastic surgery procedures performed. The accepted definition of a large-volume liposuction is a total aspirate of greater than 4 liters.

liposuction-fat

Seventy percent of the total aspirate is fat, so if a total volume of 4 liters is harvested, the total volume of fat is 0.7 X 4, or 2.8 liters. Each liter of liposuction fat weighs approximately 2 pounds, so the weight removed in a 4-liter total-aspirate liposuction is 2.8 liters X 2 pounds/liter = 5.6 pounds.

The current accepted upper limit for fat removed in an outpatient liposuction is 5 liters, so the maximum weight of fat removed would be 5 liters X 2 pounds/liter = 10 pounds.

Early in my career, in the late 1980’s, liposuction was a bloody procedure. Prior to surgery healthy outpatients donated their own autologous blood, which they received intraoperatively to treat the expected hemorrhage which accompanied liposuction.

In the late 1980’s, American dermatologist Jeffery Klein introduced the tumescent technique for liposuction, in which dilute solutions of epinephrine and lidocaine were injected into the subcutaneous tissues prior to liposuction. This technique induced vasoconstriction and resulted in decreased blood loss, and made transfusion and post-operative anemia rare.

The volume of tumescent solution injected by the surgeon is roughly equivalent to the total volume expected to be aspirated from the patient. For a large-volume liposuction, 4 – 7 liters of tumescent solution may be injected into the body areas to be suctioned. The tumescent solution includes 1 mg of epinephrine and 20 ml of 1% lidocaine (200 mg lidocaine) per one liter of Lactated Ringers. The complication of local anesthetic toxicity from lidocaine is rare. The maximum dose of lidocaine should be kept < 35 mg/kg, or < 2450 mg for a 70 kg (154 pound) patient. If the surgeon injects six liters, this will total only 1200 mg of lidocaine. Symptoms of epinephrine toxicity are also rare.

Preanesthetic assessment and patient selection are key for safe large-volume liposuction procedures. All patients are ASA I or II, and have stable medical histories. Our facility requires each patient to weigh less than 250 pounds, or to have a BMI < 36. Preoperative labs and ECGs are done only as needed, per standard Ambulatory Surgery Center policies. The procedures are done under general endotracheal anesthesia, and can last from 3 to 8 hours. Our facility, the Plastic Surgery Center in Palo Alto, has two operating rooms. At times the second room is not occupied, and a solo anesthesiologist is the only anesthesia professional present on site and must be prepared to handle any and all emergencies.

A protocol for large-volume liposuction at our facility is as follows:

  1. General anesthesia is induced. An endotracheal tube rather than a supraglottic airway is used. Many procedures involve both supine and prone positioning because anterior and posterior parts of the body are liposuctioned. A Foley catheter is inserted into the bladder.
  2. After prepping and draping, the surgeon injects the tumescent solution into the areas to be liposuctioned. The total volume of the injectate must not exceed 10 liters. In most cases, the total volume of the injectate does not exceed 6 liters.
  3. The liposuction proceeds. The typical aspirate is a mixture of fat and tumescent fluid, with minimal bloody or reddish tinge. The total volume of fat aspirated is not to exceed 5 liters. The ratio of fat/total aspirate in each container is 0.7. If a total of 7 liters of liposuction aspirate is harvested, the total volume of fat is 7 X 0.7, or 4.9 liters.
  4. Fluid intake and output must be balanced. The total intake includes 6 liters of tumescent Lactated Ringers, plus intravenous fluids. Usually the volume of intravenous fluid is kept to less than 1 liter. The output equals the total aspirate volume of 7 liters in this case, plus the urine output. If the urine output is less than 0.5 ml/kg/hour, the diuretic furosemide 10 mg can be administered IV.
  5. Maintaining normothermia is challenging. Large-volume liposuction usually requires exposure of the patient’s body surface from the lower thorax to the knees to room air temperature. Twin Bair Huggers are used to warm both the lower and upper non-operative fields of the patient’s body.
  6. At the conclusion of surgery, constricting garments are applied to the patient’s body to reduce edema and bleeding. General anesthesia is continued until these garments are applied.
  7. Patients are discharged home after a typical PACU time of 75-120 minutes.

 

How safe is large-volume liposuction?

Palo Alto plastic surgeon George Commons and anesthesiologist Bruce Halperin published a retrospective review on 631 consecutive patients from 1986–1998 who underwent liposuction procedures of at least 3 liters total aspirate.(1) Total aspirate volumes ranged from 3 to 17 liters. Complications consisted of minor skin injuries and burns, allergic reactions to garments, and postoperative seromas. Only four patients of 631 (0.6%) developed serious complications, including four patients with mild pulmonary edema and one patient who developed pneumonia postoperatively. These patients were treated appropriately and had uneventful recoveries.

A retrospective study from Germany reported on 2275 large-volume liposuction patients from 1998-2002 in which there were 72 cases of severe complications (3.1%), including 23 deaths.(2) The most frequent complications were bacterial infections (necrotizing fasciitis, gas gangrene, and sepsis), hemorrhage, perforation of abdominal viscera, and pulmonary embolism. Fifty-seven of the 72 complications were clinically evident within the first 24 postoperative hours. Risk factors for the development of severe complications were insufficient standards of hygiene, infiltration of multiple liters of tumescent solution, permissive postoperative discharge, selection of unfit patients, and lack of surgical experience, especially regarding the identification of complications. The striking 1% mortality rate of this series documents that liposuction was dangerous in Germany between 1998 and 2002.

A review of 127,961 cosmetic surgery cases in the U.S. in 2016 showed a 0.9% complication rate in liposuction patients. Overweight patients (BMI = 25-29.9) and obese patients (BMI ≥ 30) were both independent risk factors for post-operative infection and venous thromboembolism.

In a series from Illinois, 69 of 4534 (1.5 percent) of liposuction patients in experienced a postoperative complication.(4) Both the liposuction volume and the patient’s BMI were significant independent risk factors. Liposuction volumes in excess of 100 ml per unit of body mass index were an independent predictor of complications (p < 0.001).

In experienced hands, the major morbidity of large-volume liposuction should be low—no more than the complication rates of 0.6 – 1.5% reported from the United States above. As long as there are patients who desire less fat in their thighs, hips, buttocks, abdomen, knees, arms, or necks, there will be a demand for liposuction. Large-volume liposuction requires an anesthesia professional who’s comfortable managing the perioperative medicine. If you’re considering this surgical procedure, my recommendation is to seek both a surgeon and an anesthesia team who are well trained and experienced.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

THE PERILS OF INTERNET MEDICINE

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 printing press was the most influential invention of the last millennium. Now individuals use computers to search for Internet medical knowledge.

THE PRINTING PRESS AND THE REFORMATION . . . , THE INTERNET AND MEDICAL KNOWLEDGE

The book 1000 years, 1000 People by Agnes and Henry Gottlieb identifies Johannes Gutenberg as the most influential person during the millennium 1000-1999 AD.Gutenberg invented the movable-type printing press in the 1440’s. The Printing Revolution played a key role in the onset of the Renaissance, the Protestant Reformation, the rise in literacy, and the spread of ideas and learning throughout the world. The Bible in 1455 was the first book printed in mass quantities, and Christianity was forever changed. Prior to the printing press, the clergy of the Roman Catholic Church possessed most of the handwritten copies of the Bible. Parishioners didn’t read the Bible—their priests did. Sunday sermons were weekly tutorials teaching church-goers the lessons inside the Bible. As soon as the Bible was printed in large quantities, the masses had access to read the book themselves, and the masses had the opportunity to question the Catholic Church’s interpretations. In 1517 Martin Luther published The Ninety-Five Theses and nailed them to the door of the Wittenberg Church, a development acknowledged to have begun the Protestant Reformation, and the Catholic Church’s monopoly on Christian dogma was challenged.

Beginning in the 1990’s a comparable world-changing event occurred, as the widespread ownership of inexpensive and powerful personal computers allowed individuals to access the Internet. According to the Internet World Stats website in the 21 years since 1995, Internet use has grown 100-fold, and currently one-third of the world’s population has online access.

Just as the printing press made the Bible available to the masses, the Internet makes medical knowledge available to the masses. Prior to the Internet, medical knowledge was primarily confined to medical textbooks and journals, read exclusively by medical professionals. A few non-medical professionals wrote articles in magazines, newspapers, and encyclopedias to explain medical facts, diagnoses, and therapy to the lay public, but the overwhelming majority of the information was only presented to doctors and nurses in the form of medical books and journals.

The Internet has expanded the availability of medical information. Tens of thousands of medical websites exist, and laypeople surf the Internet for medical facts daily.  Bupa Health Plus  conducted a study in twelve countries, and found nearly 50% of the people seeking medical information on the Internet do so to make a self-diagnosis, and 75% of these individuals did nothing to check the accuracy of the online medical advice. In addition, some patients seek medical knowledge to decide whether they need to see a doctor or not.

Nowadays when patients arrive at a doctor’s office for an initial visit regarding a problem, it’s not uncommon for them to be armed with plentiful information on what their diagnosis might be, what their diagnostic workup should be, and what treatment options they want to have. Nowadays when patients arrive at the hospital for surgery, it’s not uncommon for them to be armed with abundant information on their disease, their pending operation, and even their anesthesia options.

Prior to the Internet, patients had to trust in the knowledge and experience of their doctors to direct the appropriate diagnostic and therapeutic regimen. Now it’s routine for patients to do their Internet homework before they see the doctor.

Some medical websites are invaluable. The National Library of Medicine website PubMed lists the abstracts of all medical publications online for free. Physicians can search by author’s name or other key words. Lay people can access and search medical information with this powerful tool as well.

Other websites are less reliable. There is no quality control regarding medical information on the Internet. Anyone can put medical information on a Web server, and the information posted may be incorrect or outdated. Medical websites may present fraudulent or deceptive information, often in an attempt to sell a product or a service. How can the public discern whether the medical information on the Internet is reliable? In his article Snake Oil: The Accuracy of Medical Information on the Internet Snake Oil: The Accuracy of Medical Information on the Internet, Dr. VN Reddy lists the following advice regarding choosing medical websites:

  1. Ask your doctor to suggest sites he or she thinks are well-written and accurate.
  1. Browse the medical professional organizations’ websites. For example, the American Society of Anesthesiologists or the American Academy of Pediatrics.
  1. Browse public-health websites, such as those by the Center for Disease Control, the World Health Organization, or the National Institutes of Health.
  1. Check each website you read for the author’s name and qualifications and the date when the page was last revised.

A  National Institutes of Health website identifies the following key points to determine whether an online source of medical information is reliable:

  1. Any website should make it easy for you to learn who is responsible for the site and its information.
  2. If the person or organization in charge of the website did not write the material, the website should clearly identify the original source of the information.
  3. Health-related websites should give information about the medical credentials of the people who have prepared or reviewed the material on the site.
  4. Any website that asks you for personal information should explain exactly what the site will and will not do with that information.
  5. The U.S. Food and Drug Administration and Federal Trade Commission are federal government agencies that help protect consumers from false or misleading health claims on the Internet.

The Internet is a valuable tool to expand your medical knowledge. I use it every day, and I probably learn more from the Internet than from any other source. However, this valuable tool must come with a disclaimer. In the 20th Century we were warned, “don’t believe everything you read in the newspaper. Today that advice can be expanded to “don’t believe everything you read on the Internet.” Read only reputable medical websites for your medical information, and above all, rely on your own doctor(s) to manage your medical problems.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

WAS JUSTICE ANTONIN SCALIA’S DEATH FROM OBSTRUCTIVE SLEEP APNEA?

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

Justice Antonin Scalia’s death was unexpected. I’ve never examined Justice Scalia, never had access to his medical records, and have no information other than what has been published over the Internet regarding the events of the last 24 hours of his life. According to published news reports, APNewsBreak: Justice Scalia Suffered From Many Health Problems, the Justice suffered from obstructive sleep apnea (OSA), chronic obstructive pulmonary disease, and hypertension.

220px-antonin_scalia_scotus_photo_portrait

As an experienced anesthesiologist, I’ve personally watched over 25,000 patients sleep during my career. Thousands of these patients carried the diagnosis of OSA. I’ve witnessed first hand what happens when a patient with OSA obstructs their airway and stops breathing during sleep.

Obstructive sleep apnea is a chronic condition of cyclic obstruction of the upper airway during sleep, usually combined with excessive daytime sleepiness and loud snoring.Apnea is the medical word for the suspension or stopping of breathing. Observation of at least five obstructive events (apneic events) per hour of sleep during a formal sleep study is a minimal criterion for diagnosing OSA in adults.

Let’s discuss a hypothetical male patient. He is 79 years old, overweight, and has a thick neck. Perhaps he is a Supreme Court Justice, and perhaps he is not. Because of his age and his body habitus, he’s at risk for the diagnosis of OSA, but we have no knowledge of any sleep study to document this.

We’re going to sedate this patient for a medical procedure. Intravenous sedative drugs will include some combination of a benzodiazepine such as Versed, a narcotic such as fentanyl, and a hypnotic such as propofol. The procedure does not require a breathing tube, so we’ll administer the sedation and be vigilant regarding what happens to the patient’s vital signs. As with all anesthetics, the patient will be fully monitored for heart rate, blood pressure, oxygen saturation, respiratory rate, and exhaled carbon dioxide level.

This is what happens when we administer strong sedatives to this hypothetical male patient who is 79 years old, overweight, and who has a thick neck:

  1. With the onset of sleep, the rate of breathing becomes slower and the volume of each breath decreases.
  2. Because of the decrease in ventilation, the oxygen saturation level will drop.
  3. As anesthesiologists, we administer oxygen via nasal cannula or via a mask, and the oxygen saturation will increase to a safe level again.
  4. If we progress to administering deeper sedation, the patient’s airway will obstruct. Typically this occurs because the base of the tongue drops back and occludes the airway, or redundant tissue in the oral pharynx relaxes and occludes the airway. With partial obstruction, we hear the patient snore, but ventilation continues. With total obstruction, the patient’s chest moves in an attempt to draw in a breath, but there is no ventilation through the obstructed upper airway.
  5. If this airway obstruction is not remedied, the oxygen saturation will drop below a safe level of 90%. At these low blood oxygen levels, the brain and heart will be deprived of necessary oxygen. A prolonged low blood oxygen level can lead to life threatening cardiac dysrhythmias or a cardiac arrest.
  6. With a physician anesthesiologist present, the airway obstruction is relieved by applying a jaw lift, extending the patient’s neck, inserting an oral airway, or inserting an airway tube.
  7. Without an anesthesiologist present, the patient could die.

In a related scenario, what if our hypothetical male patient who is 79 years old, overweight, and who has a thick neck doesn’t have medical sedation, but rather has a long busy day at 4,400 feet of altitude, and perhaps consumes alcohol with its attendant sedative effects, along with perhaps a sleeping pill or an oral narcotic analgesic taken to relieve the symptoms of a painful shoulder ailment? All of these factors (fatigue, altitude, alcohol, medications) serve to make a patient more sedated. Heavy sleep accompanied by snoring ensues. The partial airway obstruction of snoring progresses to the total airway obstruction of obstructive sleep apnea. The blood oxygen level drops, the heart is denied adequate oxygen delivery, and the patient suffers a cardiac arrhythmia and then a cardiac arrest.

Is this a “heart attack?”

Every one of us will die one day, and every one of our deaths will be accompanied by a heart that ceases to beat. The cause of the “heart attack” will differ for each of us. If someone has significant narrowing of a major coronary artery and attempts to run up a mountain, this event may increase the oxygen demand of the heart and precipitate a lethal heart rhythm. When a hypothetical male patient who is 79 years old, overweight, and who has a thick neck dies in the middle of the night, you can bet the cessation of the heart beat was due to airway obstruction and inadequate oxygen to the heart.

According to APNewsBreak, on the morning the Justice was found dead “a breathing apparatus was found on the night stand next to Scalia’s bed when his body was found, but he was not hooked up to it and it was not turned on.” Most likely this was a CPAP machine, or a Continuous Positive Airway Pressure machine. A CPAP machine includes a mask which the patient straps over their nose or over their nose and mouth prior to going to sleep. The CPAP machine delivers a stream of compressed air via a hose to the nose mask or the full-face mask, splinting the airway to keep it open under air pressure so unobstructed breathing becomes possible. The main problem with a CPAP machine is non-compliance, that is, the patient refuses to wear it. This was seemingly the case with Justice Scalia’s last night.

A take home message from this column is to respect the specter of OSA in your own life and in the lives of your loved ones. If you are a physician, respect the specter of OSA in your patients. Persons with an increased risk of OSA include people older than 60 years of age, patients with hypertension, prior strokes, heart failure, atrial fibrillation, obesity, or the metabolic syndrome including hyperlipidemia and diabetes. The most common symptoms are excessive daytime sleepiness and loud snoring. Persons who fit this profile should undergo a formal sleep study to screen for OSA. Most formal sleep studies require overnight monitoring of breathing patterns and oxygen saturation. The studies are not cheap, so screening every elderly obese snorer in America would be expensive. However, a diagnosis of OSA can lead to a cascade of effective therapies, including:  1) an oral orthodontic appliance to keep the jaw advanced, or 2) a continuous positive airway pressure machine to be worn while sleeping, or 3) airway surgeries on the palate, uvula, mandible, and/or maxilla, or 4) aggressive treatment of the OSA comorbidities of obesity, hypertension, and diabetes.

The American Academy of Sleep Medicine estimates that 25 million Americans may have OSA, and up to 90 percent of these patients are undiagnosed.

Questions will continue to swirl around the circumstances of Justice Antonin Scalia’s death. Was there a pillow over his head, as was first described by John Poindexter, the owner of the ranch who first discovered Scalia’s body? Were sedating medications or alcohol present in his bloodstream? Why did Presidio County Judge Cinderela Guevara pronounce Scalia dead of natural causes without even seeing the body? Why was no autopsy ordered? Was the Justice murdered, as if this was the plot of some John Grisham legal thriller?

We may never know the answers to these questions, but query most any anesthesiologist about the likelihood that OSA was involved in the death of Justice Antonin Scalia, and the answer you will get is . . .

“Yes, with a high degree of medical probability, obstructive sleep apnea is what killed Justice Antonin Scalia.”

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

DOES GENERAL ANESTHESIA CAUSE DEMENTIA?

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

 

Does exposure to general anesthesia cause dementia?

In a word, “No.”

dementia2075

A landmark study published in Anesthesiology Dokkedal U et al, Cognitive Functioning after Surgery in Middle-aged and Elderly Danish Twins. Anesthesiology. 2016 Feb;124(2):312-21  answers this question. Dokkedal studied 8,503 middle-aged and elderly Danish twins. Results from cognitive tests were compared in twins in which one sibling was exposed to surgery and the other was not. A history of major surgery was associated with a negligibly lower level of cognitive functioning, but there was no difference by interpair analysis, that is, when compared to their twin. There was no clinically significant association of major surgery and anesthesia with long-term cognitive dysfunction, suggesting that factors other than surgery and anesthesia, such as preoperative cognitive functioning and underlying diseases, were more important for cognitive functioning in mid- and late life than surgery and anesthesia.

(For readers who are not medical professionals, cognitive function includes reasoning, memory, attention, and language, the attainment of information and, thus, knowledge. Alzheimer’s disease and dementia equate to a chronic loss of these cognitive functions.)

Because Dokkedal’s study looked at a large number of patients, and each of these patients had a twin, it is considered a statistically powerful study.

A second recent study published in the same month, (Sprung J et. al., Association of Mild Cognitive Impairment With Exposure to General Anesthesia for Surgical and Nonsurgical Procedures: A Population-Based Study. Mayo Clin Proc. 2016 Feb;91(2):208-17)  examined 1731 Minnesota residents aged 70 – 89. Of these, 536 out of the 1731 developed Mild Cognitive Impairment (MCI) during a median follow-up of 4.8 years. All of their anesthesia records for surgeries after the age of 40 were reviewed. The authors found no significant association between the cumulative exposure to surgical anesthesia after 40 years of age and the development of Mild Cognitive Impairment.

In an editorial accompanying the Dokkedal study, (Avidan MS, Evers AS, The Fallacy of Persistent Postoperative Cognitive Decline, Anesthesiology. 2016 Feb:124(2);255-258.) Avidan and Evers wrote, “It is similarly tragic when adults older than 50 yr forego quality of life-enhancing surgery based largely on hypothesis-generating cohort studies and a post hoc ergo propter hoc fallacy dating to a 1955 report by Bedford in the Lancet, which suggested that persistent Postoperative Cognitive Decline was a concern following complaints from patients and their families regarding problems with cognitive function after surgery. . . . older patients should today be reassured that surgery and anesthesia are unlikely to be implicated in causing persistent cognitive decline or incident dementia.”

This editorial exposes the fallacy of post hoc ergo propter hoc, i.e. after this, therefore because of this, which has in the past led individuals to postulate that because a patient shows cognitive decline after surgery and anesthesia, that the cognitive decline must have been caused by surgery and anesthesia.

The authors of the editorial also admit that the first time detection of cognitive decline or dementia can be noted postoperatively for several reasons, including 1) cognitive decline or dementia are common in an aging population, approximately 50% of patients over the age of 60 undergo surgery, and the cognitive decline or dementia may first be detected at a time following surgery; 2) the preoperative trajectory of cognitive decline or dementia is rarely assessed, and postoperative cognitive decline or dementia is a continuation of the preoperative decline; 3) rapid onset cognitive decline or dementia can occur, and at times this decline will manifest and coincide with the time following surgery and anesthesia; and 4) it is difficult to change a firmly held conviction of past researchers, clinicians, and the general public that cognitive decline or dementia are caused by surgery and anesthesia.

The take home message is this: If you or one of your loved ones are over the age of 60 and need a surgical procedure to improve the quality of life, there should be no reluctance to have the surgery because of the fear of postoperative cognitive decline or dementia.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

12 THINGS TO KNOW AS YOU NEAR THE END OF YOUR ANESTHESIA TRAINING

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 most difficult challenge for any anesthesiologist is the transition from the end of anesthesia residency into the beginning of your first job. You’re on your at the hospital, sometimes on weekend nights, and sometimes at 3 a.m.

In “Subterranean Homesick Blues” Bob Dylan wrote, Twenty years of schoolin’ and they put you on the day shift. 

For anesthesiologists, it’s more like twenty-five years of training and they put you on the night shift. Alone.

bobdylanlookwiki

Every anesthesiologist walks a long road before they finish their education. This includes thirteen years to finish high school, four years of college, four years of medical school, a year of internship, three years of anesthesia residency training, and possibly an extra year of a subspecialty fellowship.

When I finished my training I was naïve about what was around the corner. I had no physicians in my family and no older physicians as close friends. I learned my lessons in real time on the front lines. As you near the end of that twenty-fifth year of education, here’s a list of twelve things you should know before you leave the cocoon of academia and venture out into the job market as an anesthesiologist:

  1. Your professors won’t find you a job. Their role is to teach anesthesia, to take care of patients, and to do research. They are not guidance counselors. Most of them are academics who either enjoy teaching or who enjoy the university faculty lifestyle. If they knew of or coveted a private practice job themselves, they would have taken one themselves long ago. You’ll likely have to find a job yourself. Your professors are of significant value when you are being considered for a specific job, because they can give your prospective employer a positive evaluation of you.
  2. You’ll find job listings on the Internet. Apply for jobs you have interest in. Don’t be surprised if most of these posted jobs have a problem such as low pay, an undesirable location, a dead end career track, or (let me say it again) low pay. The more jobs you look into, the better you’ll understand the marketplace. You’ll learn from every unsuccessful inquiry. Why are jobs posted on Internet sites usually inferior jobs? See #4 below.
  3. The best job opportunities are communicated by word of mouth. For example, imagine that an excellent group needs a new anesthesiologist with an emphasis in regional anesthesia. Members of that group will communicate with acquaintances at local university training programs or with top national university training programs, and ask for the names of recommended candidates. You want people to recommend you. It’s an old boy’s club of sorts (except that it includes men and women). You’ll get called up when the old boys agree that you’re the one they want.
  4. If there’s a hospital location or an anesthesia group you’re particularly interested in, but they are not advertising a job opening. don’t waste your time writing them a letter with your curriculum vitae attached. The letter will be discarded. Instead, make phone calls. Find out who the leader of the group is, and call the operating room or the anesthesia company’s phone number. If they are unavailable, leave a message. Repeat in a week or so until you make contact. If they never call you back, so be it. But if you apply this strategy to multiple different jobs, you will connect with a real human voice, and you’ll have the opportunity to sell yourself over the phone.
  5. Make as many personal contacts as you can with anesthesiologists who are already in private or community practice. Ask them questions when you can, and once you’ve landed a new job, connect with one of your new colleagues so they can serve as your mentor for the early career years. You’ll need to transition from a trainee mentored by professors to a graduated anesthesiologist mentored by a doctor who’s already out there in anesthesia practice.
  6. Retain at least one close contact with a former faculty member, so you can ask questions of them as well after you are out in community practice. The theme here is build bridges with new colleagues, and never burn bridges with your old teachers.
  7. You’ll have to pass your board examinations. My advice is to read every word of Miller’s Anesthesia prior to your oral boards. It’s a terrific book, and this is the one time in your career that you’ll be motivated to have encyclopedic knowledge of your specialty.
  8. Along with book learning, find opportunities to take mock oral exams from faculty at your training program. Stanford conducts twice-yearly mock oral exams, using the identical format that the American Board of Anesthesiology uses. See my column ADVICE FOR PASSING THE ORAL BOARD EXAMS IN ANESTHESIOLOGY. If you read Miller’s Anesthesia and undergo mock oral training, you’ll pass the board exams and you’ll become board-certified in anesthesiology—a requirement for all top shelf jobs.
  9. Think “Airway – Airway – Airway.” Airway –Breathing – Circulation, or A – B – C, describes the core management of critical care situations in the operating room, the emergency room, or the ICU. Of these three, the one that can get a new graduate (or any anesthesiologist) in a heap of trouble in less than five minutes is a botched airway. Be extremely careful and vigilant regarding all issues of airway management, both at times of intubation and extubation. Faulty judgment which leads to three minutes of hypoxia for your patient could severely harm your patient and change your life. Learn the ASA Difficult Airway Algorithm, and read AVOIDING AIRWAY DISASTERS IN ANESTHESIA. Avoid an airway disaster at all costs.
  10. Find a reliable recipe for each common type of anesthetic, hone it, and stick to it. The early career years are not about doing “interesting” anesthetics, they are about doing safe, predictable anesthetics with safe outcomes.
  11. Private practice surgeons are fast. Avoid the high doses of narcotics and muscle relaxants you used on those tediously long university cases. These will be overdoses in private practice, and your patients will be slow to wake up.
  12. Learn how anesthesia billing is done. Learn how money is distributed to new anesthesiologists in a prospective job, and how your income will change over the years at that job. A quality job will have a path to partnership, where you will earn as much as the senior members of the group do at this point in time.

 

Good luck, happy job searching, and may your patients all be safe!

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

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

You’re scheduled to anesthetize an NFL quarterback for a shoulder arthroscopy and rotator cuff repair. The patient earns $20 million dollars per year for throwing footballs. Would you feel comfortable inserting a needle into his neck to do a regional anesthetic? Would you feel comfortable doing an interscalene block on an NFL quarterback as part of his anesthetic?

0122667001423075661_filepicker

Regional anesthesia is a growing frontier in modern clinical anesthesia, in part because of the availability of ultrasonic imaging to help us direct needle placement. The subspecialty of regional anesthesia has blossomed. Listening to some of its disciples, it would seem that nearly every orthopedic surgery procedure can benefit from an ultrasonic regional block for intraoperative and postoperative pain control.

Anesthesiology News (Hardman D, July 2015, 41:7) recently reviewed the topic of nerve injury after peripheral nerve block. Data shows that the risk for permanent or severe nerve injury after peripheral nerve blocks is low. Per the article, the prevalence of permanent injury rates as defined by a neurologic abnormality present at or beyond 12 months after the procedure, ranges from 0.029% to 0.2%.

Low, but not zero.

There is a high incidence of temporary postoperative neurologic symptoms after arthroscopic shoulder surgery, whether the patient received a regional block or not. The incidence of temporary neurologic symptoms during the first week ranged as high as 16% to 30%. Most of these involved minor sensory symptoms such as paresthesias and dysesthesias.

An incidence of 16% to 30% is a remarkably high number.

Data from a clinical registry at the Mayo Clinic for total shoulder arthroplasty from 1993 to 2007 demonstrated a peripheral nerve injury rate of 3.7% following general anesthesia in contrast to a peripheral nerve injury rate of 1.7% in patients who received an interscalene block (Sviggum HP, et al. Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia. Reg Anesth Pain Med. 2012;37:490-494). It’s striking that the patients with general anesthesia had MORE peripheral nerve injuries than patients who had an interscalene block.

Over 97% of the patients who developed peripheral nerve injury recovered completely or partially at 2.5 years after the procedure. Seventy-one percent experienced full recovery, which means that 29% did not experience full recovery.

Given this information, would you give the NFL quarterback a general anesthetic or would you include an interscalene block?

I submit that no anesthesia provider would feel comfortable inserting a needle in the neck of this $20 million-dollar-a-year man. No anesthesia provider would feel comfortable doing an interscalene block for his shoulder arthroscopy. Why not? Even though the above data show that peripheral nerve injury can occur following shoulder arthroscopy with either general or interscalene anesthesia, the anesthesiologist will likely be sued only if he or she performs the interscalene anesthesia.

A plaintiff lawyer will be quick to link the needle in the patient’s neck to the nerve damage, if the damages are the NFL player’s inability to earn his $20 million per year, and the anesthesiologist will be sued. If there is peripheral nerve injury following a general anesthetic, expect the surgeon to be sued.

It’s that simple. With peripheral nerve injury following general anesthesia, the surgeon will incur the medical malpractice risk because shoulder arthroscopy has its own risks for nerve injury. Risks include: 1) traction on the brachial plexus due to positioning during surgery, 2) irrigating fluid extravasation causing tissue edema compressing the brachial plexus and peripheral nerves, or 3) arthroscopic portals damaging nerves.

Ultrasound-guided blocks have many advantages, but there is no sufficient evidence demonstrating a lower neurologic complication rate with this technique.(Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).

The explosion of regional anesthesia is relatively recent, and the medical malpractice fallout of this explosion is yet to be understood. We may find a trail of anesthesia closed claims related to nerve injuries that lasted over one year, especially if the patient did not receive explicit informed consent that permanent nerve damage was a risk of the nerve block.

If the risk of a limb-harming peripheral nerve injury is prohibitive for an NFL player, why is the risk acceptable for the rest of our patients? Is it because an accountant or a fireman who is a recreational tennis player or golfer is less likely to sue the anesthesiologist if a peripheral nerve injury occurs?

A 2007 survey of academic regional anesthesiologists indicated that nearly 40% of respondents did not disclose the risks of long-term and disabling neurologic injury prior to performing peripheral nerve blocks.( Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11)

It’s more difficult to sell an “optional” peripheral nerve block if you disclose to the patient the risks for long-term nerve damage. However, if you do not disclose the risks of long-term nerve damage, you will be vulnerable to a lawsuit should nerve damage occur.

We’ll need to review the anesthesia closed claims data for peripheral nerve injuries in five or ten years time to see how many successful lawsuits were generated by the current crescendo in the performance peripheral nerve blocks. Until that time, I recommend honest and complete informed consent to all your patients regarding the non-zero risks of permanent nerve damage related to peripheral nerve blocks.

 

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

 

 

WOULD YOU GIVE AN NFL QUARTERBACK A PERIPHERAL NERVE BLOCK?

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

 

 

HOW COMMON ARE CARDIAC ARRESTS DURING SURGERY AND 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

 

How common are cardiac arrests during surgery? Uncommon, but the incidence is not zero and the outcome is usually dire.

ventricular fibrillation

In 2004 the Japanese Society of Anesthesiologists reported 2,443 cardiac arrests (6.34 per 10,000 anesthetics) and 2,638 deaths (6.85 per 10,000 anesthetics) among 3,855,384 anesthetics. The majority of deaths were due to preoperative health complications (64.7%) and surgical problems (23.9%). The main preoperative problem leading to death was hemorrhagic shock, and the main surgical problem leading to death was excessive surgical bleeding. The incidence of cardiac arrest totally attributable to anesthesia mismanagement was low (0.47 per 10,000 anesthetics), and anesthesia mismanagement was responsible for only 1.5% of deaths. (1)

The American College of Surgeons National Surgical Quality Improvement database from 2005 to 2007 documented the incidence of intraoperative cardiac arrest in non-cardiac surgery as 7.22 per 10,000 cases. Intraoperative blood loss, represented by the amount of blood transfused, was the most important risk factor. Patients receiving over 10 units of blood had greater than 10 times the risk of those receiving 1-3 units of blood. Two other significant risk factors were emergency surgery and the patient’s preoperative health as assessed by the American Society of Anesthesiologists (ASA) physical status ranking. Of the 262 patients with intraoperative cardiac arrests, 44% died within 24 hours and 62% died within 30 days. (2)

From 2010 to 2013 the National Anesthesia Clinical Outcomes Registry reported the risk of intraoperative cardiac arrest as 5.6 per 10,000 cases. Fifty-eight percent of these patients died. The incidence of cardiac arrest increased with age and ASA physical status ranking, with the majority occurring in patients with an ASA physical status of 3-5. (3)

Physicians from a Thai teaching hospital reviewed 44,339 emergency surgery patients from 2003 to 2011, and found the incidence of perioperative cardiac arrest in emergency surgery was 163 per 10,000 cases. Risk factors were age 2 years or younger, an ASA physical status of 3-4, risky anatomic sites of surgery (upper abdomen, intracranial, intrathoracic, cardiac, or major vascular), cardiac or respiratory comorbidities, and shock prior to anesthesia. (4)

A Brazilian study documented a higher incidence of perioperative cardiac arrest in children than in adults. From 1996 to 2004, 15,253 anesthetics were performed in children. There were 35 cardiac arrests (22.9 per 10,000) and 15 deaths (9.8 per 10,000). Risk factors for cardiac arrest were children under one year of age, emergency surgery, ASA physical status 3-5, and general anesthesia. There were 11 cardiac arrests related to anesthesia care. Seventy-one per cent of these were caused by airway management/respiratory events, and 28% were caused by medication-related events. There were zero deaths attributed to anesthesia. (5).

What does all this mean?

If you’re an anesthesia provider, know that that the risk of cardiac arrest during surgery and anesthesia is low. The average reported incidence is in the ballpark of 6 to 7 per 10,000 cases, higher in children (22.9 per 10,000), and highest in emergency surgeries (163 per 10,000).

A busy anesthesiologist doing his or her own cases performs 1000 anesthetics per year. A predicted experience would be one cardiac arrest every 6-7 years, or 4-5 cardiac arrests in a 30-year career. A physician anesthesiologist supervising four CRNAs in four operating rooms could do four times as many cases per year, so a predicted incidence would be 16-20 cardiac arrests in a 30-year career.
Anesthesiologists should be prepared to promptly manage cardiac arrests in the patients at highest risk, which include: those with extensive bleeding and transfusion requirements; patients in shock; emergency surgeries; particularly emergency surgeries involving the upper abdomen, craniotomies, cardiac, intrathoracic, and major vascular vessels; patients with preoperative physical status limitations (ASA physical status 3-5); and children under one year of age.

In 30+ years of administering approximately 25,000 anesthetics I’ve seen cardiac arrests in three cases, for a personal anecdotal incidence of 1.2 per 10,000. All were in the high-risk categories above. One patient was in hemorrhagic shock prior to surgery because of an acute bleed from a ruptured aortic aneurysm, one patient was undergoing aortic artery bypass surgery, and one patient was a sick end-stage renal disease dialysis patient undergoing vascular surgery.

If you’re a patient, realize that your risk of having a cardiac arrest under anesthesia is low. If you have any of the risk factors described above, your risks are higher. Trust that the surgeon and physician anesthesiologist who take care of you will be well prepared, aware of this data, and will take excellent care of you while you are asleep.

In the future, physician anesthesiologists will have an abundance of “Big Data” on clinical issues such as this one. The ASA and its affiliate, the Anesthesia Quality Institute (AQI), are compiling the National Anesthesia Clinical Outcomes Registry (NACOR), which has been designated as a Qualified Clinical Data Registry (QCDR) by the Centers for Medicare & Medicaid Services for Physician Quality Reporting System (PQRS).

Can we lower the incidence of perioperative cardiac arrest? Perhaps, as we gain more understanding of risk factors. But as the Baby Boomer population in the United States ages, there will be more old patients, more patients with multiple medical problems, and more emergency surgeries on older, sicker patients.
Anesthesiologists will continue to be challenged.

References:
1. Irita K, et al. Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review. Masui. 2004 Mar;53(3):320-335.

2. Goswami S, Brady JE, Jordan DA, Li G. Intraoperative cardiac arrests in adults undergoing noncardiac surgery: incidence, risk factors, and survival outcome. Anesthesiology. 2012 Nov;117(5):1018-26.

3. Nunnally ME, O’Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth Analg. 2015 Feb;120(2):364-70.

4. Siriphuwanun V, et al. Incidence of and factors associated with perioperative cardiac arrest within 24 hours of anesthesia for emergency surgery. Risk Manag Healthc Policy. 2014 Sep 4;7:155-62. doi: 10.2147/RMHP.S67935. eCollection 2014.

5. Gobbo Braz L, et al. Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital. Paediatr Anaesth. 2006 Aug;16(8):860-6.

 

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

 

 

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.”

*
*
*
*

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

 

 

DSC04882_edited

THE ACHILLES’ HEEL OF ANESTHESIOLOGY… WHAT IS THE GREATEST THREAT TO OUR SPECIALTY?

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

Anesthesiology is a wonderful profession, as I have described in many previous posts on theanesthesiaconsultant.com. But nothing is perfect, and anesthesia has one threat which could in time undermine the entire specialty. What is this threat? What is anesthesiology’s Achilles’ heel?

No, it’s not the nurse anesthetists, nor the stress of covering surgeries in the middle of the night, nor the stress of saving patients who are trying to die in front of our eyes during acute care emergencies.

Our Achilles’ heel is that we don’t have our own patients.

Primary care doctors have a bevy of patients who return to see them at regular intervals. Specialists and surgeons have a clinic full of patients who are referred to them from primary care physicians. Health care systems are acquiring primary care providers and top specialists as rapidly as they can, to assemble a sizable network of covered lives. This network of patients will serve to keep their clinics and hospitals full and profitable.

In the operating rooms, the patients are brought in by the surgeons. Anesthesia providers, be they physician anesthesiologists or nurse anesthetists, are tasked with providing safe and quality anesthesia care. Anesthesia providers are at best consultants, and at worst, “worker bees” called upon to provide a service.

Which of the following are commodities?

  1. Crude Oil
  2. Copper
  3. Soy beans
  4. Anesthesia services
  5. All of the above

Consider the answer to be E.

To hospital administrators and CEOs, anesthesia “worker bees” can be considered an expense or a commodity, somewhat similar to registered nurses, orderlies, surgical technicians, or even janitors. We can be regarded as a commodity because, like the nurses, technicians, and janitors, patient referrals do not originate with us. To a hospital CEO, each surgeon is an asset who brings surgical patients to surgery, whereas each anesthesia provider may be thought of as a worker necessary to do surgery.

Note that anesthesiologists who specialize in pain medicine in a clinic setting can be exceptions to this discussion. Pain specialists can generate their own patients from their clinics on which to do pain-relieving procedures. In their operating room role they more resemble the niche of a surgeon than that of an anesthetist.

In the current medical economy, when a hospital CEO, a health care system, or a surgery center is looking for anesthesia coverage, a priority is to acquire quality service of these anesthesia “worker bees” at the lowest possible cost. The hospital CEO, health care system, or surgery center may then grant an exclusive contract to the cheapest provider. This exclusive contract may go to a national anesthesia company, rather than the anesthesiologists currently on staff, or this exclusive contract may go to a newly hired anesthesia chairman, empowered to hire a new staff of anesthesiologists or nurse anesthetists at a budget rate.

You may be an outstanding anesthesiologist, but you are replaceable. Your anesthesia group may be an outstanding group, but your whole group is replaceable.

There are problems even if your group has an exclusive contract. Per the California Society of Anesthesiologists’ Dr. Keith Chamberlain, negative aspects of an anesthesia exclusive contract include:

  • “You can lose an exclusive contract. Anesthesia job security is based on quality, service, and (more recently) cost. Today, 80 per cent of anesthesia groups receive some subsidy from hospitals, which are strongly motivated to reduce it. Competitors often approach hospitals with business plans that eliminate the subsidy, and the decision for the hospital often comes down to cost. If your hospital privileges are tied to an exclusive contract, your ability to continue to practice will depend on your relationship with the new contract holder.
  • The contract holder will eventually experience pressure from the hospital to contract with its payers. There may be a phrase in the contract about “cooperation” with payers. Frequently this means that the contract holder must agree to a contract rate—good or bad.
  • If case volume or the number of anesthetizing locations increases, the contract may insist on the availability of additional providers, regardless of OR inefficiency or payer mix.
  • Many standard contracts allow either party to terminate without cause on 90 days following the first anniversary.”

(http://members.csahq.org/blog/2014/07/21/dont-count-exclusive-contract)

An Internet search documents specific examples of anesthesiology groups losing their jobs around the United States:

  • From Oregon, in 2010: “Turmoil at Good Samaritan: Up to 23 anesthesiologists will lose their jobs in September when Legacy Good Samaritan ends its contract with the Oregon Anesthesiology Group. The hospital plans to replace the doctors with nurse anesthetists. Unhappy physicians and their supporters have raised concerns about whether the switch puts cost savings ahead of patient safety (nurses make less than docs). Legacy spokesman Brian Terrett says the hospital will gain more control but not benefit financially from the transition because anesthesia costs are billed to patients. He added that the nurse anesthetists will be fully credentialed and supervised by doctors.” Willamette Week: July 7, 2010(https://www.oregon-crna.org/site/content/23-anesthesiologists-will-lose-their-jobs-september)
  • From the state of Virginia, in 2015: “A conflict between Riverside Regional Medical Center and its former anesthesia company has escalated to the point that Riverside is unable to perform open-heart surgery until April 23. Riverside did not renew its contract with Virginia Anesthesia and Perioperative Care Specialists and last week brought a new anesthesia company on board…. What happened? Riverside Regional Medical Center ended a long-standing relationship with a local anesthesiology group, Virginia Anesthesia and Perioperative Care Specialists, and contracted with a national management company, Soma Health Partners, effective April 7. Texas-based Soma is bringing in new anesthesiologists because, contractually, the local company’s employees cannot join the new company for two years.”( http://www.dailypress.com/news/dp-local_riverside_0415apr15,0,5448759.story?track=rss)
  • From California, in 2011: In her blog, A Penned Point, Dr. Karen Sibert writes “At Kaweah Delta Medical Center in Visalia, hospital administrators put out the anesthesia contract for competitive bidding in 2011, and the all-MD anesthesia group that had held the contract for years lost out to Somnia.  A new anesthesiology chief came on board, and a care team model with nurse anesthetists took over.” (http://apennedpoint.com)

What can anesthesiologists do to respond to this Achilles’ heel threat and create better job security? To reduce the urge for a hospital CEO to displace their current anesthesia providers, you need to:

  1. Provide the highest quality of medical care to your hospital and surgery centers.
  2. Provide high service to your hospital and surgery centers.
  3. Maintain high quality professional relationships with surgeons, other physician specialties, and administrators, so there is little incentive to demand a change.
  4. Become involved in hospital medical committees and politics, both for self-preservation and because these are roles typically filled by physicians, not nurse anesthetists.
  5. Avoid greed in negotiations over contracted rates and hospital stipends. By all means acquire the best deal you can, but realize that unreasonable expectations for monetary reimbursement may give the CEO an incentive to seek bids from a national anesthesia company or an alternative anesthesia group.
  6. Consider moving toward the new Perioperative Surgical Home model, as advocated by the American Society of Anesthesiologists. The PSH is a means for anesthesiologists to become valuable preoperative and postoperative necessities for their health care system, rather than just operating room anesthesia providers (which are easier to replace).

Hospital administrators and CEOs are trained to manage the bottom line. They will consider all reasonable means to reduce expenses. Be aware that your anesthesia group can be seen as a replaceable commodity. Consider points 1 – 6 above, and try not to give your hospital administrator a reason to look elsewhere for anesthesia coverage.

 

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

 

 

ON BECOMING AN ANESTHESIOLOGIST… WHAT PERSONAL CHARACTERISTICS ARE ESSENTIAL TO BECOME A SUCCESSFUL 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

What are the personal characteristics of a successful anesthesiologist? You’ve found The Anesthesia Consultant website, so you have some interest in anesthesia. Perhaps you’ve heard that anesthesiologists earn a comfortable living.

Per wikiprofessionals.org: “According to figures from the U.S. Department of Labor, the lowest 10% of anesthesiologists earn under $135,110 per year, whereas the top 10% earn up to $408,000 per year. The median annual earnings, defined as that figure where half the experienced anesthesiologists earn less than that amount and half earn more, is $292,000. Anesthesiologists’ salaries are among the highest of all U.S. professions.”

Perhaps you’re wondering if anesthesiology is a potential vocation for you, your child, your cousin, or your niece. The truth is: a career in anesthesia involves unique demands that most people would not seek, tolerate, or ever grow accustomed to.

Nonetheless, I believe no medical specialty is more fascinating than anesthesiology. Based on thirty years as an anesthesiologist, here’s my checklist of ten qualities necessary to succeed in this profession.

You must have:

  1. Calmness under intense pressure. I’ve experience countless emergency moments where patients dropped their heart rate or blood pressure dangerously low, increased their heart rate or blood pressure dangerously high, hemorrhaged from an artery, lost their airway, or in some other unexpected way sustained a life-threatening event. An anesthesiologist must remain focused and decisive at these moments. An anesthesiologist must choose the correct diagnostic and therapeutic moves to save the patient’s life. An operating room emergency is not a time for screaming, temper tantrums, or freezing. An operating room emergency is a time for calm, assertive action.
  2. Vigilance during long periods of quasi-boredom. In between those emergency occurrences, an anesthesiologist must remain attentive without becoming bored or distracted. The motto of the American Society of Anesthesiologists is one word: Vigilance. During surgery, much of our job is to observe. One day I brought my 15-year-old son into the operating room with me to observe surgery, hoping he would respect the complex nature of my job. Instead his impression afterward was, “Dad, most of the time you don’t really do much of anything. You watch monitor screens, talk to the surgeon and the nurses, and listen to music.” One of my partners overheard this analysis and remarked, “If you see an anesthesiologist working hard, then you’ve really got a problem!”
  3. Superior skills with your hands. There are no tests during college pre-med classes or medical school clerkships to quantify an individual’s fine motor skills. Many doctors with superior manual dexterity migrate toward operative specialties like surgery or anesthesia. But not all anesthesiologists are equal. Some resident anesthesia doctors are less skillful than others at various anesthesia procedures such as placing breathing tubes into windpipes, inserting catheters into veins and arteries, injecting nerve blocks near peripheral nerves, or injecting spinals and epidurals into the lumbar spine. Residents have dropped out of our specialty altogether because they were not confident with the required procedural skills.
  4. The patience and motivation to persist through 25-27 years of training. In the song Subterranean Homesick Blues, Bob Dylan wrote, “Twenty years of schooling and they put you on the day shift.” In anesthesiology, twenty years of schooling earns you both the dayshift and the night shift. Your education will consist of thirteen years through high school, four years of college, four years of medical school, one year of internship, three years of anesthesia residency, and probably an extra one or two years of fellowship specialization. This cascade of years stretches your education past the age of thirty. You must to be accepting of delayed gratification. During the last of those twenty-five years, when you owe $250,000 in educational debt and are roaming hospital hallways at three a.m., your college classmates who chose business careers are at home sleeping in a house they’ve already purchased.
  5. A tolerance for sleeplessness. You must have the ability to thrive during early mornings and late nights. Scheduled surgeries start early in the morning, usually at 0730. Prior to that hour, anesthesiologists meet, evaluate, and obtain consent from their first patient, and then bring the patient to the operating room and safely render them unconscious. Not all cases start at sunrise—surgical patients get sick around the clock. Emergency surgeries may start at midnight or three o’clock in the morning. Anesthesiologists must be tolerant of fatigue and still be able to work unimpaired.
  6. Compulsive attention to detail. All aspects of anesthesia care, including a) the review of a patient’s medical condition prior to surgery, b) the planning and conduct of the anesthetic, and the management of medical conditions and c) complications immediately after surgery, require the anesthesiologist to avoid mistakes of any kind and to strive for near-perfection. Psychiatrists often diagnose OCD (obsessive-compulsive disorder) in patients. It’s probable that most anesthesiologists have a least a touch of OCD.
  7. Thick skin. You cannot be too hard on yourself, even though anesthesiologists are not allowed to have a bad day. A bad day in this career could mean a dead patient, a comatose patient, or a patient who was supposed to be discharged home instead lying in an intensive care unit on a ventilator. You’re human, and you may make a mistake. That mistake may have no consequence or it may cost a patient dearly. If a patient suffers a bad outcome secondary to a mistake you make, you’ll have to endure the emotional toll. There are stories of anesthesiologists who quit the specialty, become addicts, or commit suicide because a patient suffered a bad outcome. You can’t succumb.
  8. Excellent communication skills. You must be someone who can sell yourself to a patient in ten minutes. Anesthesiologists typically have ten minutes before surgery to interview a patient, examine them, obtain their consent, and gain their trust. The patient will be anxious. You need to assess and manage both their medical and their emotional needs at this demanding moment. An anesthesiologist’s patients are unconscious most of the time, but not all the time. If you want a medical career with zero awake hours of patient contact, consider pathology instead of anesthesiology. A successful anesthesiologist must also cooperate with different teams of surgeons, nurses, and medical techs every day. Surgeon personalities come in all varieties—some are demanding, some are condescending, and some are bullies. You have to work effectively with all types of surgeons, whether you admire that individual’s personality or not.
  9. Intelligence. Admission to anesthesia residency positions is very competitive. In 2014 there were only 1,049 anesthesia PG-1 (Post-Graduate Year 1) residency positions in the United States and 1,836 individuals who applied for these positions. Nearly 50% of applicants—all of them medical school seniors or medical school graduates—failed to land a position in anesthesia. (Ref: Results and Data, National Resident Matching Program 2014 http://www.nrmp.org/wp-content/uploads/2014/04/Main-Match-Results-and-Data-2014.pdf)
  10. A love for helping people. Every physician must have this. We spend years memorizing facts about physiology, disease, and pharmacology, but a successful doctor must care about each patient as an individual. Empathy for patients before, during, and after the day of their surgery and anesthesia is essential.

These are ten qualities I look for in an outstanding anesthesiologist. The next time you need surgery, I’d advise you to look for and expect the same qualities in the man or woman who will anesthetize you.

 

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

 

 

BLOOD PRESSURE DROPS TO 85/45 FOLLOWING THE INDUCTION OF ANESTHESIA: WHAT DO YOU DO?

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

CLINICAL CASE: You’re scheduled to anesthetize a healthy 55-year-old female for an appendectomy. Her blood pressure is 150/90 on admission. In the operating room, you induce anesthesia with your standard recipe of 2 mg of midazolam, 100 mcg of fentanyl, 200 mg of propofol, and 40 mg of rocuronium, and intubate the trachea. Five minutes after induction and 15-30 minutes before the surgical incision will occur, her blood pressure drops to 85/45. Is this a problem? What will you do? What level of hypotension is acceptable to you?

Low blood pressure in surgery

DISCUSSION: During surgery, anesthesiologists balance their administration of drugs to the level of surgical stimulation the patient is experiencing. The placement of an endotracheal tube is an intense stimulus to an awake patient, but only a moderate stimulus to an anesthetized patient. After the placement of an endotracheal tube, a lag time of fifteen minutes to thirty minutes or more occurs prior to surgical incision. During this interval, the blood pressure sometimes sags.

Let’s look at the anesthesia literature to learn what has been described about this problem.

David Reich, et al of Mt. Sinai Hospital in New York queried the computerized anesthesia records of 4,096 patients undergoing general anesthesia and analyzed the incidence of hypotension in the period immediately after induction. (Predictors of hypotension after induction of general anesthesia Anesth Analg. 2005 Sep;101(3):622-8). The median blood pressure (MAP) was determined before anesthesia induction, during the first 5 minutes after induction, and also the period from 5-10 minutes after induction. Hypotension was defined as either (1) a mean arterial blood pressure (MAP) decrease of >40% and MAP

Statistically significant predictors of hypotension after anesthetic induction included: ASA III-V, baseline MAP

Dr. Reich wrote, “association with mortality alone was not reported in the manuscript but was nearly statistically significant (P = 0.066). The majority of our colleagues apparently believe that transient hypotension is inconsequential to outcomes. Although limited by the problems associated with retrospective studies, the results of our study provide preliminary evidence that runs counter to the prevailing wisdom regarding transient severe hypotension during general anesthesia.”

What level of hypotension is unsafe for patients?

The effects of hypotension in nonsurgical subjects was studied in 1954 (Finnerty, FA, Cerebral Hemodynamics during Cerebral Ischemia Induced by Acute Hypotension1 Clin Invest. 1954 Sep; 33(9): 1227–1232). Young and old experimental subjects were subjected to increasing degrees of hypotension until clinical signs of cerebral ischemia developed. Hypotension was induced by intravenous administration of the anti-hypertensive medication hexamethonium. The authors discovered a linear relation between pre-hypotensive blood pressure and the level of induced hypotension that produced clinical signs of cerebral ischemia such as yawning, sighing, staring, confusion, inability to concentrate, inability to perform simple commands, nausea, dizziness, and involuntary body movements. Their data revealed that the safe level of hypotension was no lower than about 2/3 of the resting blood pressure before inducing hypotension. At 2/3 of their pre-procedure MAP, patients reached a threshold of clinical cerebral ischemia, with onset of yawning, sighing, staring, confusion, inability to concentrate, and inability to carry out simple commands. Because these studies were done on unanesthetized humans, it’s impossible to equate the data to patients with surgical anesthesia. Surgical patients have a different etiology for their hypotension, as well as reduced cerebral oxygen consumption from general anesthetic drugs. This explains why most surgical patients fail to manifest any cerebral damage resulting from episodes of hypotension occasionally following the induction of anesthesia.

The problem of hypotension and refractory hypotension following induction of anesthesia is currently being studied in an ongoing clinical trial at the University of Iowa. (ClinicalTrials.gov identifier: NCT02416024, contact Kenichi Ueda, MD, kenichi-ueda@uiowa.edu). Induction agents in this study will include 1.5 mg/kg propofol, 2 mcg/kg fentanyl, 100 mg lidocaine, and 0.6 mg/kg rocuronium. Inhaled anesthetic will be sevoflurane at 0.5 MAC with 5L/min of 100% oxygen starting at mask ventilation till 10 minutes after tracheal intubation. Blood pressure will be measured by a brachial cuff prior to induction and every minute after intubation for 10 minutes. If the systolic pressure drops below 90 mmHg or more than 25% from baseline, the patient will be classified in the study as “Hypotensive.” Conversely, if the patient’s systolic blood pressure does not drop below 90 mmHg more than 25% from baseline within 10 minutes of intubation, the patient will be classified as “Not Hypotensive.” In attempt to bring systolic blood pressure up to above 90 mmHg or more than 25% from baseline in “hypotensive” patients, the anesthetic provider will use 100 mcg of phenylephrine (or 5 mg ephedrine if heart rate < 50 bpm) within 10 minutes of intubation. If over 200 mcg of phenylephrine (or 10 mg ephedrine) has been used without a return of the systolic brachial blood pressure >90 mmHg or more than 25% from baseline, the patient will be classified in the study as “Refractory Hypotensive.” Look for the results of this trial to be published in years to come.

Based on the data reviewed in this column, it seems advisable to maintain a patient’s mean arterial pressure at or above a level of 2/3 of their baseline pressure. What if the patient’s baseline blood pressure in their outpatient clinic notes is 120/80 (MAP=93) yet in the pre-operative room on admission to surgery their blood pressure is 150/90 (MAP=110)? This is not an uncommon occurrence, as blood pressure often spikes secondary to the inevitable anxiety which accompanies a pending surgery. Is the anesthesia provider compelled to maintain the blood pressure at 2/3 of 110 = 73 after induction, or compelled to maintain the blood pressure at 2/3 of 93 = 62 after induction? I can find no specific data to answer this question. In my experience, after the administration of 2 mg of intravenous midazolam the hypertensive 150/90 often decreases to the 120/80 (MAP=93) range. With this MAP = 93 value as the baseline blood pressure, 2/3 X 93 = 62 would be the lowest level of MAP I’d feel comfortable with. We’re trained to treat post-induction hypotension with a vasopressor. Typically phenylephrine 100 mcg will increase the pressure to its preinduction level. Some patients require more than one dose of phenylephrine.

Let’s return to the management of your Clinical Case above.

  1. You choose to administer a dose of phenylephrine 100 mcg IV, and the blood pressure returns to 110/70. You maintain general anesthesia depth with the inhaled anesthetic sevoflurane at 0.5 MAC with 5L/min of 100% oxygen.
  2. Five minutes later the blood pressure drops to 85/45 again, and you repeat a dose of phenylephrine 100 mcg IV.
  3. When the surgery begins, the blood pressure increases to 150/90, and you treat by increasing anesthesia depth.
  4. Note that per the Reich data above, the incidence of hypotension increased with higher doses of fentanyl at induction (5-5.0 mcg/kg fentanyl vs. 0-1.5 mcg/kg fentanyl). I’ve found that the lower dose range of fentanyl, specifically zero fentanyl at induction, works very well for many patients. Incremental doses of propofol alone blunt the transient hypertensive response to laryngoscopy and intubation, and the lack of fentanyl leads to less hypotension in the ten minutes post-intubation. Appropriate levels of narcotics are then titrated in when surgery commences and the surgical stimulus increases. Also per Reich’s data, for patients age 50 or older who are ASA III-V, or for patients who present with a baseline pre-operative MAP.

 

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

 

 

WILL YOU HAVE A BREATHING TUBE DOWN YOUR THROAT DURING YOUR SURGERY?

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

One of the most common questions I hear from patients immediately prior to their surgical anesthetic is, “Will I have a breathing tube down my throat during anesthesia?”

The answer is: “It depends.”

placing anesthesia breathing tube

Let’s answer this question for some common surgeries:

KNEE ARTHROSCOPY: Common knee arthroscopy procedures are meniscectomies and anterior cruciate ligament reconstructions. Anesthetic options include general anesthesia, regional anesthesia, or local anesthesia. Most knee arthroscopies are performed under a general anesthetic, in which the anesthesiologist injects propofol into your intravenous line to make you fall asleep. After you’re asleep, the most common airway tube used for knee arthroscopy is a laryngeal mask airway (LMA). The LMA in inserted into your mouth, behind your tongue and past your uvula, to a depth just superior to your voice box. The majority of patients will breath on their own during surgery. The LMA keeps you from snoring or having significant obstruction of your airway passages. In select patients, including very obese patients, an endotracheal tube (ETT) will be inserted instead of an LMA. The ETT requires the anesthesiologist to look directly into your voice box and insert the tube through and past your vocal cords. With either the LMA or the ETT, you’ll be asleep and will have no awareness of the airway tube except for a sore throat after surgery. A lesser number of knee arthroscopies are performed under a regional anesthetic which does not require a breathing tube. The regional anesthetic options include a blockade of the femoral nerve located in your groin or numbing the entire lower half of your body with a spinal or epidural anesthetic injected into your low back. A small number of knee arthroscopies are done with local anesthesia injected into your knee joint, in combination with intravenous sedative medications into your IV. Why are most knee arthroscopies performed with general anesthesia, which typically requires an airway tube? Because in an anesthesiologist’s hands, an airway tube is a common intervention with an acceptable risk profile. A light general anesthetic is a simpler anesthetic than a femoral nerve block, a spinal, or an epidural anesthetic.

Laryngeal Mask AIrway (LMA) Tube

 

Endotracheal Tube (ETT)

NOSE AND THROAT SURGERIES SUCH AS TONSILLECTOMY AND RHINOPLASTY: Almost all nose and throat surgeries require an airway tube, so anesthetic gases and oxygen can be ventilated in and out through your windpipe safely during the time the surgeon is working on these breathing passages.

ABDOMINAL SURGERIES, INCLUDING LAPAROSCOPY: Almost all intra-abdominal surgeries require an airway tube to guarantee adequate ventilation of anesthetic gases and oxygen in and out of your lungs while the surgeon works inside your abdomen.

CHEST SURGERIES AND OPEN HEART SURGERIES: Almost all intra-thoracic surgeries require an airway tube to guarantee adequate ventilation of anesthetic gases and oxygen in and out of your lungs while the surgeon works inside your chest.

TOTAL KNEE REPLACEMENT AND TOTAL HIP REPLACEMENT: The majority of total knee and hip replacement surgeries are performed using spinal, epidural and/or nerve block anesthesia anesthesia to block pain to the lower half of the body. The anesthesiologist often chooses to supplement the regional anesthesia with intravenous sedation, or supplement with a general anesthetic which requires an airway tube. Why add sedation or general anesthesia to the regional block anesthesia? It’s simple: most patients have zero interest in being awake while they listen to the surgeon saw through their knee joint or hammer their new total hip into place.

CATARACT SURGERY: Cataract surgery is usually performed using numbing local anesthetic eye drop medications. Patients are wake or mildly sedated, and no airway tube is used.

COLONOSCOPY OR STOMACH ENDOSCOPY: These procedures are performed under intravenous sedation and almost never require an airway tube.

HAND OR FOOT SURGERIES: The anesthesiologist will choose the simplest anesthetic that suffices. Sometimes the choice is local anesthesia, with or without intravenous sedation. Sometimes the choice will be a regional nerve block to numb the extremity, with or without intravenous sedation. Many times the choice will be a general anesthetic, often with an airway tube. An LMA is used more frequently than an ETT.

CESAREAN SECTION: The preferred anesthetic is a spinal or epidural block which leaves the mother awake and alert to bond with her newborn immediately after childbirth. If the Cesarean section is an urgent emergency performed because of maternal bleeding or fetal distress, and there is inadequate time to insert a spinal or epidural local anesthetic into the mother’s lower back, a general anesthetic will be performed. An ETT is always used.

PEDIATRIC SURGERIES: Tonsillectomies are a common procedure and require a breathing tube as described above. Placement of pressure ventilation tubes into a child’s ears requires general anesthetic gases to be delivered via facemask only, and no airway tube is required. Almost all pediatric surgeries require general anesthesia. Infants, toddlers, and children need to be unconscious during surgery, for emotional reasons, because their parents are not present. The majority of pediatric general anesthetics require an airway tube.

CONCLUSIONS: The safe placement of airway tubes for multiple of types of surgeries, in patients varying from newborns to 100-year-olds, is one of the reasons physician anesthesiologists train for many years.

Prior to surgery, some patients are alarmed at the notion of such a breathing tube invading their body. They fear they’ll be awake during the placement of the breathing tube, or that they’ll choke on the breathing tube.

Be reassured that almost every breathing tube is placed after your unconsciousness is assured, and breathing tubes are removed prior to your return to consciousness. A sore throat afterward is common, but be reassured this is a minor complaint that will clear in a few days.

If you have any questions, be sure to discuss them with your own physician anesthesiologist when you meet him or her prior to your surgical procedure.

 

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

 

 

THE TOP 10 MOST STRESSFUL JOBS IN AMERICA versus THE TOP 10 MOST STRESSFUL SITUATIONS IN ANESTHESIOLOGY PRACTICE

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

Anesthesia has been described as 99% boredom and 1% panic. Is anesthesiology one of America’s most stressful jobs? Not according to prominent Internet media sources.

Careercast.com listed the Top 10 Most Stressful Jobs in America in 2015, and those jobs were:

  1. Firefighter
  2. Enlisted Military Personnel
  3. Military General
  4. Airline Pilot
  5. Police Officer
  6. Actor
  7. Broadcaster
  8. Event Coordinator
  9. Photo Journalist
  10. Newspaper Reporter.

ABCnews.go.com listed the Top 10 Most Stressful Jobs in America in 2014, and those jobs were:

  1. Working Parents
  2. Deployed Military Personnel
  3. Police Officer
  4. Teacher
  5. Medical Professionals (The article highlighted surgeons for their need to constantly focus, psychiatrists for their need to intently listen, dentists for being on their feet all day, and interns for their lack of sleep).
  6. Emergency Personnel (The article highlighted firefighters and emergency medical technicians).
  7. Pilots and Air Traffic Controllers
  8. Newspaper Reporters
  9. Corporate Executive
  10. Miner

Salary.com listed the Top 10 Most Stressful Jobs in America, and those jobs were:

  1. Military Personnel
  2. Surgeon
  3. Firefighter
  4. Commercial Airline Pilot
  5. Police Officer
  6. Registered Nurse in an Emergency Room
  7. Emergency Dispatch Personnel
  8. Newspaper Reporter
  9. Social Worker
  10. Teacher

“Anesthesiologist” is absent from every list. This is a public relations failure for our specialty. The challenges and stressors anesthesia professionals face every day are seemingly unknown to the media and the populace.

I’ll admit there are pressures involved with being a taxi driver, a news reporter, a photo journalist, an events coordinator, or a public relations executive. Being a working parent is a challenge, although in Northern California where I live millions of adults are working parents because both husbands and wives have to work to pay hefty Bay Area living expenses. But none of these jobs involve the risk and possibility of their clients dying each and every day.

Every surgical patient requires the utmost in vigilance from their physician anesthesiologist in order to prevent life-threatening disturbances of Airway-Breathing-Circulation. The public perceives surgeons as holding patients’ life in their skilled hands, and they are correct. But most surgeons spend the majority of their work time in clinics and on hospital wards attending to pre-operative and post-operative patients. On the 1 – 3 days a week most surgeons spend operating, they are joined in the operating room by anesthesiologists who attend to surgical patients’ lives every day.

Surgeons in trauma, cardiac, neurologic, abdominal, chest, vascular, pediatric, or microsurgery specialties have intense pressure during their hours in the operating room, but each time they don their sterile gloves and hold a scalpel, an anesthesiologist is there working with them.

What follows is my own personal “Top 10 Most Stressful” list, a list of the Most Stressful Anesthesia Situations based on my thirty years of anesthesia practice. Anesthesia practice has been described as 99% boredom and 1% panic, (http://theanesthesiaconsultant.com/is-anesthesia-99-boredom-and-1-panic) and the 1% panic times can be frightening. Read through this list. I believe it will convince you that the job of an anesthesiologist deserves to be on everyone’s Top 10 Most Stressful Jobs list.

TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB

  1. Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
  1. Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
  1. An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
  1. Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
  1. Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
  1. Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
  1. Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
  1. An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
  1. Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
  1. The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.

So goes my list of Top 10 List of Stressful Anesthesia situations. If you’re an anesthesia professional, what other cases would you include on the list? Which cases would you delete? How many of these situations have you personally experienced?

This Top 10 Stressful Situations in Anesthesiology list should be enough to convince you that “Anesthesiologist” belongs on everyone’s Most Stressful Jobs list.

I would reassemble the Top 10 List of Most Stressful Jobs to be as follows:

The Anesthesia Consultant’s List of Top 10 Most Stressful Jobs

  1. Enlisted military personnel
  2. Military general in wartime
  3. Police Officer
  4. Firefighter
  5. Anesthesiologist
  6. Surgeon
  7. Emergency Room Physician
  8. Airline Pilot
  9. Air Traffic Controller
  10. Corporate Chief Executive Officer

HOW DO YOU START A PEDIATRIC ANESTHETIC WITHOUT A SECOND 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

Clinical Case: In your first week in community practice post-residency and fellowship, you’re scheduled to anesthetize a 4-year-old for a tonsillectomy. You’ll start the anesthetic without an attending or a second anesthesiologist. How do you start a pediatric anesthetic alone?

 

Discussion: During residency it’s standard to initiate pediatric cases with an attending at your right hand to mentor and assist you through the induction of anesthesia. The second pair of hands is critical—one of you manages the airway for the inhalation induction, and the second anesthesiologist starts the IV. In community practice you’ll have to manage all this yourself.

A significant percentage of pediatric anesthetics are performed in regional hospitals and surgery centers rather than in pediatric tertiary hospitals. How does the community practice of pediatric anesthesia differ from pediatric anesthesia in residency?

In community practice you’ll likely telephone the parents the night prior to surgery to discuss the anesthetic. It’s uncommon for a 4-year-old and his family to visit any pre-anesthesia clinic. You’ll take a history over the phone from the parents, explain the basics of anesthetic care, and answer any questions they have.

On the morning of surgery you’ll meet the parents and the child. It’s likely you’ll prescribe an oral midazolam premedication. You’ll set up your operating room with appropriate sized pediatric equipment, heeding the M-A-I-D-S mnemonic for Machine and Monitors-Airway-IV-Drugs-Suction.

What about a request from the mother and/or father to accompany the child into the operating room? This author advises against bringing parents into the O.R. Instead premedicate the child to minimize the emotional trauma of separation from the parent(s), and explain that the duration of time from when they hand you their child to when the gas mask is applied will only be a few minutes.

It’s common to induce anesthesia with the child in a sitting position. The one most important monitor you can place prior to induction is the pulse oximeter. Once unconsciousness is attained, the child is laid supine and a pretracheal stethoscope, the ECG leads, and the blood pressure cuff are applied. If you’re not using a pretracheal stethoscope during mask inductions, let me recommend it to you. No other monitor gives you immediate information on the patency of the airway like the stethoscope does. You can remedy partial or total airway obstruction more promptly than if you wait for oxygen desaturation or end-tidal CO2 changes.

Most children have an easy airway and require no more than occasional positive airway pressure via the mask to keep spontaneous ventilation open. Young children scheduled for tonsillectomy sometimes carry the diagnosis of obstructive sleep apnea (OSA) based on a clinical history of snoring, noisy breathing, or daytime somnolence. It’s uncommon for these patients to have a formal sleep study to document OSA. OSA children may have more challenging airways and have an increased incidence of partial airway obstruction during inhalation induction.

In residency I was taught to supplement the potent volatile anesthetic (halothane in decades past) with 50-70% nitrous oxide. Because the blood:gas partition coefficient of sevoflurane is 0.65, comparable to nitrous oxide’s 0.45, anesthetic induction with sevoflurane alone is nearly as fast as sevoflurane-nitrous oxide. The addition of nitrous oxide to the induction mix is unnecessary, and using an FIO2 of 1.0 affords an extra cushion of oxygen reservoir if the airway is difficult or if the airway is lost.

How will you start the IV after induction? There are several options: 1) You can ask the surgeon or a nurse to start the IV. In my experience, neither surgeons nor O.R. nurses are as skilled in starting pediatric IV’s as an anesthesiologist is, so I don’t recommend this plan; 2) You can ask the surgeon or the O.R. nurse to hold the mask and manage the airway while you start the IV. This option is safe if the airway is easy and you trust the airway skills of the other individual; 3) You can stand at your normal anesthesia position, hold the mask over the patient’s airway with your left hand, and ask the nurse to bend the patient’s left arm back toward you. The nurse tourniquets the patient’s arm at the wrist, and with your right hand you perform a one-handed IV start in the back of the patient’s left hand; 4) The option I feel most comfortable with is to fit mask straps behind the patient’s head, and secure the mask in place with the four straps after the patient is fully anesthetized (when their eyes have returned to a conjugate gaze). While the straps hold the mask in place, you listen to the patient’s breathing via the pretracheal stethoscope to assure yourself that the airway is patent. Then move to the left-hand side of the table and start the IV in the child’s left arm. The typical length of time away from the airway should be less than one minute. If the child has no obvious veins, fit the automated blood pressure cuff (in stat mode) on top of the tourniquet on the upper arm. The BP cuff is a superior tourniquet and the inflated cuff makes it easier to find a suitable vein.

Once the IV is in place, proceed with intubating the patient. In community practice the surgical duration of tonsillectomies can be very short, so the choice of muscle relaxant is important. Succinylcholine carries a black box warning for non-emergent use in children, and should not be used for elective intubation. You can: 1) administer rocuronium and later reverse the paralysis with neostigmine plus atropine; 2) administer a dose of propofol, e.g. 2 mg/kg, which blunts airway reflexes enough to allow excellent intubating conditions in most patients; or 3) you can do perform two laryngoscopies, the first to inject 1 ml of 4% lidocaine from a laryngotracheal anesthesia (LTA) kit, and another 30 seconds later to place the endotracheal tube in the now-anesthetized trachea. Some anesthesiologist/surgeon teams prefer an LMA rather than an endotracheal tube. LMA use for tonsillectomy is not routine in our practice, but one advantage is that an LMA does not require paralysis for insertion.

What if you’re working alone and your patient develops acute oxygen desaturation with airway obstruction and/or laryngospasm during inhalation induction before any IV has been placed? What do you do?

If you anesthetize enough children you will have this experience, and it can be frightening. The immediate management is to inject succinylcholine 4 mg/kg plus atropine 0.02 mg/kg intramuscularly, usually into the deltoid. Then you do your best to improve mask ventilation using an oral airway or LMA if necessary. The oxygen saturation may dip below 90% for a short period of time while you wait for the onset of the intramuscular paralysis. Once muscle relaxation is achieved, ventilation should be successful and the oxygen saturation will climb to a safe level. The trachea can then be intubated, and an IV can be started following the intubation.

If such a desaturation occurs, should you cancel the case? It depends. I’d recommend cancelling the case if: 1) the duration of the oxygen saturation was so prolonged that you are worried about hypoxic brain damage; or 2) gastric contents are present in the airway and you are concerned with possible pulmonary aspiration.

Working pediatric cases alone is rewarding as well as stressful. Nothing in my practice brings me as much joy as walking into the waiting room following a pediatric case to inform parents their child is awake and safe. The parents are relieved, and watching the mother-child reunion minutes later in the Post Anesthesia Care Unit is a heart-warming experience.

Not all anesthesiologists will choose to do pediatric cases during their post-residency career. If you will be anesthetizing children alone in community practice, it’s a good idea toward the end of your anesthesia residency or fellowship to ask your pediatric anesthesia attending keep their hands off during induction, so you can hone your skills managing both the airway and IV. That way you’ll be ready and capable of inducing a child alone after you leave training.

 

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

 

 

AIRWAY LAWSUITS

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

At weddings you’ll often hear a Bible verse that reads, “And now these three remain: faith, hope and love. But the greatest of these is love.” (1 Corinthians 13:13) A parallel verse in the bible of acute care medicine would read, “Emergencies are managed by airway, breathing, and circulation. But the greatest of these is airway.” The objective of this column is to help you avoid airway lawsuits.

 

Every health care professional learns the mantra of airway-breathing-circulation. Anesthesiologists are the undisputed champions of airway management. This column is to alert you that avoiding even one airway disaster during your career is vital.

Following my first deposition in a medical-legal case years ago, I was descending in the elevator and a man in a suit asked me what I was doing in the building that day. I told him I’d just testified as an expert witness. He asked me what my specialty was, and I told him I was an anesthesiologist. The whistled through his teeth and smirked. “Anesthesia,” he said, “Huge settlements!”

I’ve consulted on many medical malpractice cases which involved death or brain damage, and airway mishaps were the most common etiology. It’s possible for death or brain damage to occur secondary to cardiac problems (e.g. shock due to heart attacks or hypovolemia), or breathing problems (e.g. acute bronchospasm or a tension pneumothorax), but most deaths or brain damage involved airway problems. Included are failed intubations of the trachea, cannot-intubate-cannot-ventilate situations, botched tracheostomies, inadvertent or premature extubations, aspiration of gastric contents into unprotected airways, or airways lost during sedation by non-anesthesia professionals.

Google the keywords “anesthesia malpractice settlement,” and you’ll find multiple high-profile anesthesia closed claims, most of them related to airway disasters. Examples from such a Google search include:

  1. The Chicago Daily Law Bulletin featured a multimillion-dollar verdict secured by the family of a woman who died after being improperly anesthetized for hip surgery. The anesthesiologist settled prior to trial, resulting in the family being awarded a total of $11.475 million for medical negligence. The 61-year-old mother and wife was hospitalized in Chicago for elective hip replacement surgery.  Because of a prior bad experience with the insertion of a breathing tube for general anesthesia, she requested a spinal anesthetic. Her anesthesiologist had trouble inserting a needle for the spinal anesthesia, so he went ahead with general anesthesia. The anesthesiologist was then unable, after several attempts, to insert the breathing tube. He planned to breathe for her through a mask and let her wake up to breathe on her own.  A second anesthesiologist came into the room and decided to attempt the intubation. He tried but was also unsuccessful. Finally, a third anesthesiologist came into the operating room and tried inserting the breathing tube several times. He too was unsuccessful. All of the attempts at inserting the tube caused the tissues in her airway to swell shut, blocking off oxygen and causing cardiac arrest. She suffered severe brain damage and died.
  2. $20 Million Verdict Reached in Medical Malpractice Lawsuit Against Anesthesiologist. A jury returned a $20 million verdict in an anesthesia medical malpractice lawsuit filed by the family of a woman who died during surgery when bile entered her lungs. The wrongful death lawsuit alleged that the anesthetists failed to identify that the victim had risk factors for breathing fluid into her lungs, despite the information being available in her medical record. The victim was preparing to receive exploratory surgery to determine the cause of severe stomach pains when she received the anesthesia. Once anesthetized, she began breathing bile into her lungs. She then later died. The jury awarded $20 million in favor of the plaintiff.
  3. A $35 million medical malpractice settlement was matched by only one other as the largest settlement for a malpractice case in Illinois, and the most ever paid by the County of Cook for a settlement of a personal injury case. The client, a 28-year-old woman, suffered severe brain damage from the deprivation of oxygen resulting from the failure of an anesthesiologist to properly secure an intubation tube. The client, immediately following the occurrence, was in a persistent vegetative state from which the likelihood of recovery was virtually nil. Miraculously, she regained much of her cognitive functioning, although still suffering from significant physiological deficits requiring attendant care for the rest of her life.
  4. Anesthesia Death Results in $2 Million Settlement: 36-Year-Old Man Dies From Anesthesia Mishap Following Elective Hernia Repair Surgery. The plaintiff’s decedent was a 36-year-old man who died secondary to respiratory complications following an elective hernia repair. During the pre-operative anesthesia evaluation, the defendant noted the patient had never been intubated and had required a tracheostomy for a previous surgery. The defendant decided to administer general endotracheal anesthesia with rapid sequence induction. The surgery itself was without incident. Following extubation, the patient began to have difficulty breathing. The patient desaturated. The surgeon was called back to the OR to perform  a tracheostomy, however, there was no improvement in the patient’s oxygenation and he continued to have asystole. Subsequently, he went into respiratory arrest and coded. The code and CPR were unsuccessful, and the patient was pronounced dead.

Per Miller’s Anesthesia, failure to secure a patent airway can result in hypoxic brain injury or death in only a few minutes. Analysis of the American Society of Anesthesiologists (ASA) Closed Claims Project database shows that the development of an airway emergency increases the odds of death or brain damage by 15-fold. Although the proportion of claims attributable to airway-related complications has decreased over the past thirty years since the adoption of pulse oximetry, end-tidal-CO2 monitoring, and the ASA Difficult Airway Algorithm, airway complications are still the second-most common cause of malpractice claims. (Miller’s Anesthesia, Chapter 55, Management of the Adult Airway, 2014).

In 2005, in the ASA-published Management of the Difficult Airway: A Closed Claims Analysis (Petersen GN, et al, Anesthesiology 2005; 103:33–9), the authors examined 179 claims for difficult airway management between 1985 and 1999. The timing of the difficult airway claims was: 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery. Death or brain damage during induction of anesthesia decreased 35% in 1993–1999 compared with 1985–1992, but death or brain damage from difficult airway management during the maintenance, emergence, and recovery periods did not decrease during this second period. There is no denominator to compare with the numerator of the number of closed claims, so the prevalence of airway disasters was unknown.

Awake intubation is touted as the best strategy for elective management of the difficult airway for surgical patients. Fiberoptic scope intubation of the trachea in an awake, spontaneously ventilating patient is the gold standard for the management of the difficult airway. (Miller’s Anesthesia, Chapter 55, Management of the Adult Airway, 2014). Awake intubation is a useful tool to avert airway disaster on the oral anesthesiology board examination. Dr. Michael Champeau, one of my partners, has been an American Board of Anesthesiology Senior Examiner for over two decades. He tells me that oral board examinees choose awake intubation for nearly every difficult airway. This is wise–it’s hard to harm a patient who is awake and breathing on their own. Is the same strategy as easily implemented outside of the examination room? In actual clinical practice, an awake intubation may be a tougher sell. Awake intubations are time-consuming, require patience and understanding from the surgical team, and can be unpleasant to a patient who will be conscious until the endotracheal tube reaches the trachea–an event which can cause marked coughing, gagging, hypertension and tachycardia in an under-anesthetized person. As anesthesia providers, we perform hundreds of asleep intubations per year, and only a very small number of awake intubations. Inertia exists pushing anesthesia providers to go ahead and inject the propofol on most patients, rather than to take the time to topically anesthetize the airway and perform an awake intubation. But if you’ve ever lost the airway on induction and wound up with a “cannot intubate-cannot ventilate” patient, you’ll understand the wisdom in opting for an awake intubation on a difficult airway patient.

I refer you to Chapter 55 of Miller’s Anesthesia for a detailed treatise on the assessment and management of airways, which is beyond the scope of this column. In addition to the reading of Chapter 55, I offer the following clinical pearls based on my 30 years of practice and my experience at reviewing malpractice cases involving airway tragedies:

  1. Become skilled at assessing each patient’s airway prior to anesthesia induction. Pertinent information may be in the old chart or the patient’s oral history as well as in the physical examination. Red flags include: previous reports of difficulty passing a breathing tube, a previous tracheostomy scar, morbid obesity, a full beard, a receding mandible, inability to fully open the mouth, rigidity of the cervical spine, airway tumors or masses, or congenital airway deformities.
  2. Learn the ASA Difficult Algorithm and be prepared to follow it. (asahq.org/…/ASAHQ/…/standards-guidelines/practice-guidelines-for- management-of-the-difficult-airway.pdf‎).
  3. Become skilled with all critical airway skills, particularly mask ventilation, standard laryngoscopy, video laryngoscopy, placement of a laryngeal mask airway (LMA), fiberoptic intubation through an LMA, and awake fiberoptic laryngoscopy.
  4. Read the airway strategy recommended in the Appendix to Richard Jaffe’s Anesthesiologist’s Manual of Surgical Procedures, an approach which utilizes a cascade of the three critical skills of (A)standard laryngoscopy, (B)video laryngoscopy, and (C)fiberoptic intubation through an LMA. For a concise summary of this approach read my column Avoiding Airway Disasters in Anesthesia (http://theanesthesiaconsultant.com/2014/03/14/avoiding-airway-disasters-in-anesthesia).
  5. If you seriously ponder whether awake intubation is indicated, you probably should perform one. You don’t want to wind up with a hypoxic patient, anesthetized and paralyzed, who you can neither intubate nor ventilate.
  6. If you’re concerned about a difficult intubation or a difficult mask ventilation, get help before you begin the case. Enlist a second anesthesia provider to assist you with the induction/intubation.
  7. Take great care when you remove an airway tube on any patient with a difficult airway. Don’t extubate until vital signs are normal, the patient is awake, the patient opens their eyes, and the patient is demonstrating effective spontaneous respirations. An airway that was routine at the beginning of a surgery may be compromised at the end of surgery, due to head and neck edema, airway bleeding, or swollen airway structures, e.g. due to a long anesthetic with a prolonged time in Trendelenburg position.
  8. If you’re a non-anesthesia professional administering conscious sedation, never administer a general anesthetic sedative such as propofol. A combination of narcotic and benzodiazepines can be easily reversed by the antagonists naloxone and flumazenil if oversedation occurs. There is no reversal for propofol. Airway compromise from oversedation due to propofol must be managed by mask ventilation by an airway expert.

In its 1999 report, To Err Is Human:  Building a Safer Health System, the Institute of Medicine recognized anesthesiology as the only medical profession to reduce medical errors and increase patient safety. With the pulse oximeter, end-tidal-CO2 monitor, a myriad of airway devices, and the Difficult Airway Algorithm, the practice of anesthesia in the twenty-first century is safer than ever before. Let’s keep it that way.

Faith, hope, and love. The greatest of these is love.

Airway, breathing, and circulation. The greatest of these is airway. Your patient’s airway.

 

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

 

 

IS ANESTHESIA A CUSHY SPECIALTY?

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

Is anesthesia worthy of the House of God‘s assessment that it’s a cushy medical specialty? My answer, after thirty years of anesthesia practice, is … it depends.

Cover image of The House of God

Samuel Shem’s classic novel/satire of medicine, The House of God (published in 1978, more than two million copies sold), follows protagonist Dr. Roy Basch as he struggles through his year as an internal medicine intern. A second physician recommends Basch switch careers to one of six no-patient-contact specialties: Rays, Gas, Path, Derm, Eyes, or Psych. These names translate to radiology, anesthesia, pathology, dermatology, ophthalmology, and psychiatry. These specialties are touted as lower stress choices with superior lifestyles, where time with sick patients is minimized and the physician is more likely to be happy.

Is this true? Is anesthesia worthy of Samuel Shem’s assessment that it’s a cushy specialty?

My answer, after thirty years of anesthesia practice, is … it depends.

Let’s examine each of the six specialties regarding their perceived advantages:

• Radiology involves a career of peering at digital images of X-rays, MRIs, CT scans, or ultrasound studies. Patient contact is minimal. Because many of these tests are ordered in emergency rooms at all hours of the night, on-call radiologists work long hours and endure sleepless nights. As well, the subspecialty of Invasive Radiology has become a hands-on field that requires as much patient contact as most surgical specialties.
• Pathology involves a career of peering through a microscope, running a clinical lab to determine blood and urine chemistry results, or performing autopsies. Most of pathology requires zero contact with living patients. Most pathology work is done in daylight hours, and loss of sleep is unusual.
• Dermatology involves a career of seeing a multitude of patients (think 80 – 100 per day) in a busy clinic practice. Patient volume and patient contact are high. Each clinic visit is brief because only the specific skin lesions in question are fair game for physician-patient interrogation. Hospitalized patients are uncommon, there are few emergencies, and loss of sleep is unusual.
• Ophthalmology involves an office practice of examining the vision and eyes of patients, as well as an operating room practice of performing cataract, retinal, or corneal surgeries. Other than an occasional eye trauma surgery at a late hour, loss of sleep for ophthalmologists is unusual.
• Psychiatry involves an outpatient practice of verbal therapy and/or prescribing oral medications (e.g. antidepressants, anti-anxiety, or attention deficit hyperactivity disorder meds). Inpatient psychiatry is usually limited to patients with severe depression and psychotic diseases. Most emergencies are limited to patients with after-hours suicidal ideation or attempts. Loss of sleep is unusual.
• Anesthesiology involves providing unconsciousness and medical management to patients during all types of surgical interventions. Surgeries occur at all hours of the day and night. Loss of sleep is common, and job stress during select cases can be extreme. Let’s examine lifestyle issues of anesthesia practice in more detail:

An anesthesiologist and his or her awake surgical patient are only together for only 15 minutes prior to induction of anesthesia, during which time they exchange information on medical history and informed consent. This brief duration doesn’t exactly qualify for The House of God’s no-patient-contact list, but anesthesia does qualify as very-little-awake-patient contact. Minimal time with conscious patients appeals to physicians who don’t relish prolonged face-to-face patient interaction.

An image of your anesthesiologist playing tennis or golf and then waltzing into the operating room at leisure to do a simple surgery is mistaken. The presence of an anesthesiologist is imperative for nearly every emergency procedure. All emergency medical care follows the guideline of A-B-C, or Airway-Breathing-Circulation, and anesthesiologists are airway specialists nonpareil. Emergency room attendings and head and neck surgeons have certain airway skills, but no other specialty has the depth of airway expertise that anesthesiologists own. An anesthesiologist provides care for 500–1000 patients per year, and every one of these patients requires acute management of the airway to assure safe oxygenation and breathing.

Trauma surgery, childbirth, acute surgical disease from the emergency room, and organ transplant surgery are as common at night as in the daytime. An on-call anesthesiologist at a busy community hospital may arrive at 6:30 a.m., do seven or eight surgical anesthetics which last until dusk, and then remain in the hospital all night to perform several epidural anesthetics on laboring women, anesthetize an 80-year-old woman for surgery to relieve a bowel obstruction, and replace an endotracheal tube in a struggling patient in the intensive care unit as the sun comes up the following day. An on-call anesthesiologist at a university hospital may arrive at 6:30 a.m. and attend to a complex liver-transplant surgery which lasts 20 hours and concludes at 3 a.m. A cushy specialty? Hardly.

A lifestyle advantage for anesthesiologists is that we can work hard and play hard. It’s possible for an anesthesiologist to take weeks or months off at a time if their employer or anesthesia group approves. There’s no chronic patient care/patient follow up, no clinic overhead, and no clinic employee overhead. For these reasons an anesthesiologist can schedule multiple weeks without work or income more easily than a clinic doctor can. For these reasons it’s also possible for an anesthesiologist to work part time, i.e. two or three days each week. This scheduling flexibility is an excellent lifestyle advantage, and for this reason my answer to whether anesthesia is a cushy specialty is … it depends.

Some anesthesiologists choose to spend their career outside the operating room. Some specialize in pain management and see patients in outpatient pain clinics—selected patients are taken to the operating room non-urgently to receive pain-injection procedures such as epidural steroid injections, nerve blocks, or pain pump insertions. A small number of anesthesiologists run preoperative assessment clinics where they assess the medical status of patients prior to surgery. A small number of anesthesiologists supervise intensive care units and manage critically patients who require ventilators, cardio-active medications, and anesthesia sedation infusions.

I’d like to leave you with one image imprinted in your mind—that of an anesthesiologist toiling over an ill patient at 2 a.m. in a hospital. The patient may have survived a car crash, suffered a ruptured appendix, be delivering twin babies, or be the recipient of a lung transplant. Wherever there’s a sick patient who needs acute supervised unconsciousness, there’s an anesthesiologist present. In words John Steinbeck wrote at the conclusion of The Grapes of Wrath, Tom Joad tells his mother,

“I’ll be all around in the dark – I’ll be everywhere.
Wherever you can look – wherever there’s a fight, so hungry people can eat, I’ll be there.
Wherever there’s a cop beatin’ up a guy, I’ll be there.
I’ll be in the way guys yell when they’re mad.
I’ll be in the way kids laugh when they’re hungry and they know supper’s ready, and when the people are eatin’ the stuff they raise and livin’ in the houses they build – I’ll be there, too.”

This prompts me to pen parallel text regarding my specialty, entitled
Tom Joad the Anesthesiologist:

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

 

 

THE PERIOPERATIVE SURGICAL HOME HAS EXISTED FOR YEARS

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 American Society of Anesthesiologists is supporting an expansion of the role of anesthesiologists in the delivery of perioperative care in hospitals. This proposed model is called the Perioperative Surgical Home. The American Society of Anesthesiologists defines the Perioperative Surgical Home as “a patient centered, innovative model of delivering health care during the entire patient surgical/procedural experience; from the time of the decision for surgery until the patient has recovered and returned to the care of his or her Patient Centered Medical Home or primary care provider.”

 

It’s a sound idea, and it resembles a model that’s existed for decades outside the hospital. In an outpatient surgery center the Perioperative Surgical Home concept is carried out by an anesthesiologist who is the Medical Director. I can speak to this, as I’ve been the Medical Director at a busy surgery center only minutes from Stanford University in downtown Palo Alto, for the past 12 years.

A surgery center Medical Director is responsible for:

  • All preoperative matters, including preoperative medical assessment of patients, scheduling of block times, surgical cases, anesthesia assignments, and creation of protocols,
  • All intraoperative matters, including quality issues, efficiency and turnover of cases, and the economics of running a profitable set of operating rooms, and
  • All postoperative matters, including overseeing Post Anesthesia Care Unit (PACU) nursing care, post anesthesia medical decisions, and supervision of post-discharge follow up with patients.

All medical problems including complications, hospital transfers, and patient complaints, are routed through the anesthesiologist Medical Director.

A key difference between a surgery center and a hospital is scale. A busy hospital has dozens of operating rooms, hundreds of surgeries per day, and hundreds of inpatient beds. No one Medical Director can oversee all of this every day—it takes a team. At Stanford University Medical Center the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word “Perioperative” is appropriate, because anesthesia practice involves medical care before, during, and after surgery. A team of anesthesiologists is uniquely qualified to oversee preoperative assessment, intraoperative management, and post-operative pain control and medical care in the hospital setting, just as the solitary Medical Director does in a surgery center setting.

A second key difference between a surgery center and a hospital is that medical care is more complex in a hospital. Patients are sicker, invasive surgeries disturb physiology to a greater degree, and patients stay overnight after surgery, often with significant pain control or intensive care requirements. Again, a team of physicians from a Department of Anesthesia, Perioperative and Pain Medicine is best suited to supervise management of these problems.

The greatest hurdle to instituting the Perioperative Surgical Home model is pre-existing economic reality. In a hospital, other departments such as surgery, internal medicine, radiology, cardiology, pulmonology, and nursing are intimately involved in the perioperative management of surgery patients. Each of these departments has staff, a budget, income, and incentives related to maintaining their current role. Surgeons intake patients through their preoperative clinics, and may regard themselves as captains of the ship for all medical care on their own patients. Internal medicine doctors are called on for preoperative medical clearance on patients, and thus compete with anesthesia preoperative clinics. The internal medicine department includes hospitalists, inpatient doctors who may be involved in the post-operative management of inpatients. Invasive radiologists perform multiple non-invasive surgical procedures. Like their surgical colleagues, they may see themselves as decision makers for all medical care on their own patients. Cardiologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Pulmonologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Nurses are involved in all phases of perioperative care. If the chain of command among physicians changes, nurses must be willing partners of and participants with such change.

Why has the anesthesiology leadership role of a Medical Director evolved naturally at surgery centers while the Perioperative Surgical Home idea has to be sold to hospitals? At surgery centers the competing financial incentives of surgeons, internal medicine doctors, radiologists, pulmonologists, cardiologists, and nurses are minimal. In a freestanding surgery center, surgeons want to be able to depart for their offices following procedures, and welcome the skills that anesthesiologists bring to managing any medical complications that arise. Internal medicine doctors have no significant on-site role in surgery centers, although they are helpful office consultants for the anesthesiologist/Medical Director in assembling preoperative clearance for outpatients. Radiologists have no significant on-site role at most surgery centers—if they do perform invasive radiology procedures on outpatients, they too welcome the skills that anesthesiologists bring to managing medical complications that arise. Because there are no intensive care units at a surgery center, there is no role for pulmonary or cardiology specialists. Nursing leadership at a surgery center works hand-in-hand with the Medical Director to assure optimal nursing care of all patients.

Hospital administrators anticipate penetration of the Accountable Care Organization (ACO) model for payment of medical care by insurers. In the ACO model, a medical center receives a predetermined bundled payment for each surgical procedure. The hospital and all specialties caring for that patient negotiate what percentage of that ACO payment each will receive. A Perioperative Surgical Home may or may not simplify this task. You can bet anesthesiologists see the Perioperative Surgical Home as a means to increase their piece of the pie. Ideally the Perioperative Surgical Home will be a means to streamline medical care, decrease costs, and increase profit for the hospital and all departments. Anesthesiologists are rightly concerned that if they don’t take the lead in this process, some other specialty will.

Establishing the Perioperative Surgical Home is an excellent opportunity for anesthesiologists to facilitate patient care in multiple aspects of hospital medicine. To make this dream a reality across multiple medical centers, anesthesiology leadership must demonstrate excellent public relations skills to convince administrators and chairpeople of the multiple other specialties. I expect data on outcomes improvement or cost-control to be slow and inadequate to proactively provoke this change. It will take significant lobbying, convincing, and promoting. Change will require a leap of faith for a hospital, and such change will only be accomplished by anesthesia leadership that captures the confidence of the hospital CEO and the chairs of multiple other departments.

I’m impressed by the adoption of the Perioperative Surgical Home at the University of California at Irvine. I’ve listened to Zev Kain, MD, Professor and Chairman of the Department of Anesthesia and Perioperative Medicine lecture, and I’ve met him personally. He’s the prototype of the charismatic, intelligent, and convincing physician needed to convince others that the Perioperative Surgical Home is the model of the future.(http://www.anesthesiology.uci.edu/clinical_surgicalhome.shtml)

I expect the transition to the Perioperative Surgical Home to occur more easily in university or HMO hospitals than in community hospitals. It will be easier for academic or HMO chairmen to assign new roles to salaried physicians than it will be for community hospitals to control the behavior of multiple private physicians.

Anesthesiologists were leaders in improving perioperative safety by the discovery and adoption of pulse oximetry and end-tidal carbon dioxide monitoring. Can anesthesiologists lead the way again by championing the adoption of Perioperative Surgical Home on a wide scale? Time will tell. Is the Perioperative Surgical Home an optimal way to take care of surgical patients before, during, and after surgeries? I believe it is, just as the Medical Director is a successful model of how an anesthesiologist can optimally lead an outpatient surgery center. Those lobbying for the Perioperative Surgical Home would be wise to examine the successful role of anesthesiologist Medical Directors who’ve led outpatient surgery centers for years. The stakes are high. As intraoperative care becomes safer and the role of nurse anesthesia in the United States threatens to expand, it’s imperative that physician anesthesiologists assert their expertise outside the operating room.

 

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

 

 

HOW LONG WILL IT TAKE ME TO WAKE UP FROM GENERAL 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

One of the most frequent questions I hear from patients before surgery is, “How long will it take me to wake up from general anesthesia?”

 

The answer is, “It depends.”

Your wake up from general anesthesia depends on:

  1. What drugs the anesthesia provider uses
  2. How long your surgery lasts
  3. How healthy, how old, and how slender you are
  4. What type of surgery you are having
  5. The skill level of your anesthesia provider

In best circumstances you’ll be awake and talking within 5 to 10 minutes from the time your anesthesia provider turns off the anesthetic. Let’s look at each of the five factors above regarding your wake up from general anesthesia depends on:.

  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON WHAT DRUGS THE ANESTHETIST USES. The effects of modern anesthetic drugs wear off fast.
  • The most common intravenous anesthetic hypnotic drug is propofol. Propofol levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  • The most common inhaled anesthetic drugs are sevoflurane, desflurane, and nitrous oxide. Each of these gases are exhaled from the body quickly after their administration is terminated, resulting in rapid awakening.
  • The most commonly used intravenous narcotic is fentanyl. Fentanyl levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  • The most commonly used intravenous anti-anxiety drug is midazolam (Versed). Midazolam levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON HOW LONG YOUR SURGERY LASTS
  • The shorter your surgery lasts, the less injectable and inhaled drugs you will receive.
  • Lower doses and shorter exposure times to anesthetic drugs lead to a faster wake up time.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON HOW HEALTHY, HOW OLD, AND HOW SLENDER YOU ARE
  • Healthy patients with fit hearts, lungs, and brains wake up sooner
  • Young patients wake up quicker than geriatric patients
  • Slender patients wake up quicker than very obese patients
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON WHAT TYPE OF SURGERY YOU ARE HAVING
  • A minor surgery with minimal post-operative pain, such a hammertoe repair or a tendon repair on your thumb, will lead to a faster wake up.
  • A complex surgery such as an open-heart procedure or a liver transplant will lead to a slower wake up.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON THE SKILL LEVEL OF YOUR ANESTHETIST
  • Like any profession, the longer the duration of time a practitioner has rehearsed his or her art, the better they will perform. An experienced pilot is likely to perform smoother landings of his aircraft than a novice. An experienced anesthesiologist is likely to wake up his or her patients more quickly than a novice.
  • There are multiple possible recipes or techniques for an anesthetic plan for any given surgery. An advantageous recipe may include local anesthesia into the surgical site or a regional anesthetic block to minimize post-operative pain, rather than administering higher doses of intravenous narcotics or sedatives which can prolong wake up times. Experienced anesthesia providers develop reliable time-tested recipes for rapid wake ups.
  • Although I can’t site any data, I believe the additional training and experience of a board-certified anesthesiologist physician is an advantage over the training and experience of a certified nurse anesthetist.

YOUR WAKE UP FROM ANESTHESIA: EXAMPLE TIMELINE FOR A MORNING SURGERY

Let’s say you’re scheduled to have your gall bladder removed at 7:30 a.m. tomorrow morning. This would be a typical timeline for your day:

6:00            You arrive at the operating room suite. You check in with front desk and nursing staff.

7:00             You meet your anesthesiologist or nurse anesthetist. Your anesthesia provider reviews your chart, examines your airway, heart, and lungs, and explains the anesthetic plan and options to you. After you consent, he or she starts an intravenous line in your arm.

7:15             Your anesthesia provider administers intravenous midazolam (Versed) into your IV, and you become more relaxed and sedated within one minute. Your anesthesia provider wheels your gurney into the operating room, and you move yourself from the gurney to the operating room table. Because of the amnestic effect of the midazolam, you probably will not remember any of this.

7:30             Your anesthesia provider induces general anesthesia by injecting intravenous propofol and fentanyl, places a breathing tube into your windpipe, and administers inhaled sevoflurane and intravenous propofol to keep you asleep.

7:40            Your anesthesia provider, your surgeon, and the nurse move your body into optimal position on the operating room table. The nurse preps your skin with antiseptic, and the scrub tech frames your abdomen with sterile paper drapes. The surgeons wash their hands and don sterile gowns and gloves. The nurses prepare the video equipment so the surgeon can see inside your abdomen with a laparoscope during surgery.

8:00            The surgery begins.

8:45             The surgery ends. Your anesthesia provider turns off the anesthetics sevoflurane and propofol.

8:55             You open your eyes, and your anesthesia provider removes the breathing tube from your windpipe.

9:05             Your anesthesia provider transports you to the Post Anesthesia Care Unit (PACU) on the original gurney you started on.

9:10            Your anesthesia provider explains your history to the PACU nurse, who will care for you for the next hour or two. The anesthesia provider then returns to the pre-operative area to meet their next patient. Your anesthesia provider is still responsible for your orders and your medical care until you leave the PACU. He or she is available on cell phone or beeper at all times. No family members are allowed in the PACU.

10:40            You are discharged from the PACU to your inpatient room, or to home if you are fit enough to leave the hospital or surgery center.

YOUR WAKE UP FROM ANESTHESIA . . . TO REVIEW:

  1. Even though the surgery only lasted 45 minutes, you were in the operating room for one hour and 35 minutes.
  2. It took you 10 minutes to awaken, from 8:45 to 8:55.
  3. Even though you were awake and talking at 8:55, you were unlikely to remember anything from that time.
  4. You probably had no memory of the time from the midazolam administration at 7:15 until after you’d reached in the PACU, when your consciousness level returned toward normal.

I refer you to a related column AN ANESTHESIA PATIENT QUESTION: WHY DID IT TAKE ME SO LONG TO WAKE UP AFTER ANESTHESIA?”

 

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

 

 

HOW TO PREPARE TO SAFELY INDUCE GENERAL ANESTHESIA IN TWO 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

How do you prepare to induce general anesthesia in two minutes? You’re called to induce anesthesia for a patient being rushed to the operating room for emergency surgery. You arrive at the operating room only minutes before the patient is scheduled to arrive. I recommend you use the mnemonic M-A-I-D-S as a checklist to prepare yourself and your equipment.

 

 

M stands for MACHINE and MONITORS. Check out your anesthesia machine first. Determine the oxygen sources are intact, and that the circle system is airtight when the pop-off valve is closed and your thumb occludes the patient end of the circle. Make sure the anesthesia vaporizer liquid anesthetic level is adequate. Check out your routine monitors next. Determine that the oximeter, end-tidal gas monitor, blood pressure cuff, and EKG monitors are turned on and ready.

A stands for AIRWAY equipment. Make sure an appropriate-sized anesthesia mask is attached to the circle system. Determine that your laryngoscope light is in working order. Prepare an appropriate sized endotracheal tube with a stylet inside. Have appropriate-sized oral airways and a laryngeal mask airway (LMA) available in case the airway is difficult. Make sure you have a stethoscope so you can examine the patient’s heart and lungs.

I stands for IV. Have an IV line prepared, and have the equipment to start an IV ready if the patient presents without an intravenous line acceptable for induction of anesthesia.

D stands for DRUGS. At the minimum you’ll need an induction agent (e.g. propofol or etomidate) and a muscle relaxant (succinylcholine or rocuronium), each loaded into a syringe. You’ll need narcotics and perhaps a dose of midazolam as well. Cardiovascular drugs to raise or lower blood pressure will be available in your drug drawer or Pyxis machine.

S stands for SUCTION. Never start an anesthetic without a working suction catheter at hand. You must be ready to suction vomit or blood out of the airway acutely if the need arises.

For pediatric patients the M-A-I-D-S mnemonic is followed, but in addition the size of your anesthesia equipment must be tailored to the age of the patient. Let’s say your patient is 4 years old. For M=MACHINE, you may need a smaller volume ventilation bag and hoses. For M=MONITORS, you’ll need a smaller blood pressure cuff, a smaller oximeter probe, and a precordial stethoscope if you use one. For A=AIRWAY, you’ll need smaller endotracheal tubes and airways. For I=IV, you’ll need smaller IV catheters and IV bags.

As a last-second check before a pediatric anesthetic, I recommend you pull out each drawer on your anesthesia machine, and then on your anesthesia cart, one at a time. Scan the contents of each drawer to ascertain whether you need any of the equipment there before you begin your anesthetic.

If you have any suspicion that the patient’s airway is going to be difficult, I recommend you ask to have a video laryngoscope and a fiberoptic laryngoscope brought into the operating room.

Once the patient arrives, utilize time to assess the situation as any doctor does. Take a quick history and perform a pertinent exam of the vital signs, airway, heart, lungs, and also a brief neuro check. Assist in positioning the patient on the operating room table, supervise the placement of routine monitors, and begin preoxygenating the patient. Induce anesthesia when you are ready.

Never be coerced to rush an anesthesia induction if your anesthesia setup or the patient’s physiology are not optimized. And always utilize the mnemonic M-A-I-D-S as an anesthesia checklist to confirm that your equipment is ready.

 

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

THE EBOLA VIRUS, ANESTHESIA, AND SURGERY

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

A patient infected with the Ebola virus is admitted to your hospital’s intensive care unit. You are called to intubate the Ebola patient for respiratory failure. What do you do?

ebola medical ICU team

Discussion: The first patients infected with Ebola virus entered the United States in 2014. American physicians are inexperienced with caring for patients with this disease. Because of physicians’ commitments to care for the sick and injured, individual doctors will have an obligation to provide urgent medical care during disasters. This will include Ebola patients.

The American Society of Anesthesiologists (ASA) published Recommendations From the ASA Ebola Workgroup on October 24, 2014.

Select information in my column today is abstracted, copied, and summarized from this detailed publication. Let’s begin by reviewing some facts about the disease.

Ebola is an enveloped, single-stranded RNA virus, one of several hemorrhagic viral families first identified in a 1976 outbreak near the Ebola River in the Democratic Republic of the Congo.

Transmission of Ebola is via direct contact, droplet contact, or possibly contact with short-range aerosols. The virus is carried in the blood and body fluids of an infected patient (i.e. urine, feces, saliva, vomit, breast milk, sweat, and semen). Risky exposures include exposure of your broken skin or mucous membranes to a percutaneous contaminated sharps injury, to contaminated fomites (a fomite is an inanimate object or substance, such as clothing, furniture, or soap, that is capable of transmitting infectious organisms from one individual to another), or to infected animals.

The case definition for Ebola includes fever, an epidemiologic risk factor including travel to West Africa (or exposure to someone who has recently traveled there), and one or more of these symptoms: severe headache, muscle pain, vomiting, diarrhea, stomach pain, unexplained bleeding or bruising (appearing anywhere from 2 to 21 days after exposure), a maculopapular rash, disseminated intravascular coagulation, or multi-organ failure.

Although coughing and sneezing are not common symptoms of Ebola, if a symptomatic patient with Ebola coughs or sneezes on someone and saliva or mucus come into contact with that person’s eyes, nose or mouth, these fluids may transmit the disease. Ebola can survive outside the body on dry surfaces such as doorknobs and countertops for several hours. Virus in body fluids (such as blood) can survive up to several days at room temperature.

The treatment for Ebola is symptomatic management of volume status using blood bank products as indicated, and management of electrolytes, oxygenation, and hemodynamics.

Healthcare professionals must wear protective outfits when treating Ebola patients. Routine Personal Protective Equipment (PPE) must include the following (when properly garbed, there should be no exposed skin):

  1. Surgical hood to ensure complete coverage of head and neck,
  2. Single-use face shield (goggles are no longer recommended due to issues with fogging and difficulty cleaning),
  3. N95 mask,
  4. An impermeable gown (with sleeves) that extends at least to mid-calf or coverall without a one-piece integrated hood (consideration should be given to wearing a protective coverall layer under the impermeable gown, which allows for layered protection and progressively less contaminated layers when doffing),
  5. Double gloves (i.e., disposable nitrile gloves with a cuff that extends beyond the cuff of the gown), the cuff of the first pair is worn under the gown and the second cuff should be over the gown, impermeable shoe covers that go to at least mid-calf or leg covers (there must be overlap of the impermeable layers),
  6. Impermeable and washable shoes,
  7. An apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea.

Enhanced Precaution PPE is advised for aerosol generating procedures such as intubation, extubation, bronchoscopy, airway suction, and surgery. This is the recommended level of PPE for anesthesiologists. Enhanced Precaution PPE includes:

  1. Personal Air-Purifying Respirator (PAPR) with full face piece mask,
  2. A disposable hood that extends to the shoulders and is compatible with the selected PAPR,
  3. A coverall without one-piece hood,
  4. Triple gloves (i.e., disposable nitrile with a cuff that extends beyond the cuff of the gown), the cuff of the first pair is worn under the gown and the second cuff should be over the gown and taped, and a third pair of disposable extended cuff nitrile gloves,
  5. Impermeable and washable shoes,
  6. Impermeable shoe covers, and
  7. Duct tape over all seams.

PPE donning (i.e. dressing in PPE outfit) must be performed in the proper order and monitored by a trained observer using a donning checklist. There should be separate designated areas for storage and donning of PPE (an adjacent patient care area), one-way movement to the patient’s room, and an exit to a separate room or anteroom for doffing procedures and disposal.

Doffing (i.e. PPE removal) is a high-risk process that requires a structured procedure, a trained observer (also in PPE), and a designated removal area. Doffing needs to be a slow and deliberate process and must be performed in the correct sequence using a doffing checklist.

Let’s return to our original question. What about that stat intubation you were called to perform in the ICU?

Stat intubations are not to be attempted on Ebola patients by anesthesiologists until the physician has properly donned the Enhanced Precaution PPE outfit. This necessitates significant time. Full Enhanced Precaution PPE precautions are mandated regardless of an emergency status or acute deterioration in patient status. Fiberoptic bronchoscopes are not recommended as aerosolization will occur and adequate cleaning is difficult. All equipment brought into the patient’s room must remain there and will be unusable for an indefinite period of time. Due to the extended time necessary to properly don and doff Enhanced Precaution PPE, an intubation of an Ebola patient could potentially take ninety minutes or longer when accounting for proper donning and doffing procedures.

What about performing surgery and anesthesia on Ebola patients? Patients with severe active disease would not likely tolerate an operation due to the severity of their disease. Any decision to operate should weigh all risks and benefits, specifically the risk of death from the current severity of the Ebola disease, the risk of death from their surgical disease, and the risk of exposure to the operating room team against the likelihood of potential benefit of emergency surgery.

Every effort should be given to keeping the patient in their own isolation room, and moving surgical and anesthetic equipment to the bedside. If possible, all procedures should be performed in the patient’s room.  Every effort should be given to keeping the patient in their own isolation room and moving surgical and anesthetic equipment to the bedside.

If it’s not feasible to perform the procedure or surgery in the intensive care unit room, an operating room should be designated for the patient. Preferably, this operating room should be away from traffic flow, have an anteroom, and not be connected to a clean core.

Transportation to and from the operating room hallways near the designated operating room should be blocked off.  Adjacent operating rooms will be closed. Traffic flow must be limited to only essential personnel involved with the case. PPE must be donned prior to entering the patient’s room.

Recovery from anesthesia will occur in the operating room or the patient’s hospital room, and not in the Post Anesthesia Care Unit (PACU).

These are the recommendations regarding operating room anesthesia set-up:

  1. Drawers of the anesthesia machine should be emptied except for the bare minimum of supplies.
  2. All additional items from atop the machine removed.
  3. The drawers should not be accessed unless absolutely necessary.
  4. All paperwork/laminated protocols and non-essential items must be removed from the machine.
  5. The anesthesia cart should be removed from the room and will not be directly accessible once the patient enters.
  6. An isolation cart (stainless steel or other easily cleanable table) should be stocked with all anticipated medications, emergency medications, syringes, needles, I.V. fluids (multiple), I.V. supplies, arterial line supplies, tubing, suction catheters, NG tubes, endotracheal tubes of appropriate size, additional ECG electrodes, gauze, chlorhexidine or alcohol pads, saline flushes, an extra BP cuff, a sharps container, additional gloves, and any additional equipment and supplies which the anesthesia attending for the cases requests.

Once the patient enters the operating room, absolutely no entry or exit from the operating room will occur without following PPE protocols. As such, bathroom and personal needs should be attended to prior to transporting the patient.

These are recommendations from The American Society of Anesthesiologists Ebola Workgroup. American physicians hope the number of Ebola cases in the United States will approach zero. As anesthesiologists we hope we’ll never be called to intubate or perform anesthesia on a patient infected with Ebola, but we understand our commitment to care for the sick and injured, and we understand that we have an obligation to provide urgent medical care during disasters.

Every hospital in America is in the process of understanding and implementing the above procedures regarding the isolation and protection of healthcare providers from the Ebola virus. If an Ebola patient is admitted to your hospital, I refer you to the Association for Biosafety and Biosecurity.

 

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

 

 

TEN REASONS NURSE ANESTHETISTS (CRNAs) WILL BE A MAJOR FACTOR IN ANESTHESIA CARE IN THE 21ST CENTURY

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

 

My debut novel, The Doctor and Mr. Dylan features a nurse anesthetist in the starring role of Mr. Dylan. Nurse anesthetists have provided anesthesia care in the United States for nearly 150 years, and CRNs will be a major factor in the future.

41wlRoWITkL

In the beginning, anesthesia care for surgical patients was often provided by trained nurses under the supervision of surgeons, until the establishment of anesthesiology as a medical specialty in the U.S. in the 20th century.

Here are 10 reasons why certified registered nurse anesthetists (CRNAs) will be a major factor in anesthesia care in the 21st century:

1. Rural America is dependent on CRNAs to staff surgery in small towns underserved by MD anesthesiologists. CRNAs are involved in providing anesthesia services to about one-quarter of the American population that resides in rural and frontier areas of this country. Despite a significant rise in the number of anesthesiologists in recent years, there is no evidence that they are attracted to practice in rural areas.
2. Obamacare will increase the demand for mid-level healthcare providers, e.g. nurse practitioners, physician assistants, and nurse anesthetists. These mid-level providers are perceived as a cheaper alternative to MD health care.
3. Seventeen states have opted out of the requirement for physician supervision of CRNA anesthetics. These states are Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, California, Colorado, and Kentucky. In these states, it’s legal for a CRNA to give an anesthetic without a supervising anesthesiologist or surgeon.
4. For cost-saving reasons, hospital administrators will consider the lower hourly rate charged by CRNAs to be a saving over MD anesthesia care rendered by anesthesiologists alone.
5. Future trends such as the American Society of Anesthesiologists’ Perioperative Surgical Home or bundled payments to Accountable Care Organizations will seek out the cheapest way to manage anesthetic populations. A likely economic model for a healthy patient population is the anesthesia care team, e.g. a 4:1 ratio of four CRNAs supervised by one MD anesthesiologist. This model can be used to staff four simultaneous surgeries on four healthy patients having simple surgical procedures. More complex procedures such as open-heart surgery, brain surgery, major vascular surgery, or emergency surgery will be best served by MD anesthesia care. Extremes of age (e.g. neonates or very old patients) and patients with significant medical comorbidities will be best served by MD anesthesia care.
6. Certain regions of the United States, particularly the South and the Midwest, are already entrenched with anesthesia care team models of 3:1 or 4:1 CRNA:MD staffing because of anesthesiologist preference. An MD anesthesiologist’s income can be augmented by supervising three or four operating rooms with multiple CRNAs simultaneously. These physicians will have little desire to rid themselves of nurse anesthetists and to personally do only one case at a time by themselves.
7. The American Association of Nurse Anesthetists (AANA) presents a strong, well-funded lobby which promotes the continuing and increasing role of CRNAs in medical care in the United States.
8. The educational cost for a registered nurse to become a CRNA is significantly less than the cost of training a board-certified MD anesthesiologist. The median cost of a public CRNA program is $40,195 and the median cost of a private program is $60,941, with an overall median of $51,720.
9. A registered nurse can significantly increase their income by becoming a CRNA. A registered nurse with one year of intensive care unit or post-anesthesia care unit experience can become a CRNA with 2-3 years of CRNA schooling. The average yearly salary of a CRNA in America in 2011 was $156,642.
10. The increasing starring role of CRNAs in American fiction ☺. (See The Doctor and Mr. Dylan, below)

After perusing this list one might ask, are CRNAs and anesthesiologists equals?
No, they are not. Anesthesiologists are doctors, and their training of four years of medical school followed by a minimum of four years of anesthesia residency makes them specialists in all aspects of surgical medicine.

The American Society of Anesthesiologists’ STATEMENT ON THE ANESTHESIA CARE TEAM states “Anesthesiology is the practice of medicine including, but not limited to, preoperative patient evaluation, anesthetic planning, intraoperative and postoperative care and the management of systems and personnel that support these activities. In addition, anesthesiology includes perioperative consultation, the management of coexisting disease, the prevention and management of untoward perioperative patient conditions, the treatment of acute and chronic pain, and the practice of critical care medicine. This care is personally provided by or directed by the anesthesiologist.” (Approved by the ASA House of Delegates on October 26, 1982, and last amended on October 16, 2013)

Doctor J H Silber’s landmark study from the University of Pennsylvania documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. This study has been widely discussed. The CRNA community dismissed the conclusions, citing that the Silber study was a retrospective study. In a Letter to the Editor published in Anesthesiology, Dr. Bruce Kleinman wrote regarding the Silber data, “this study could not and does not address the key issue: can CRNAs practice independently?”

I’m not a fan of CRNAs working alone without physician supervision. In both my expert witness practice and in the expert witness practice of my anesthesia colleagues, we find multiple adverse outcomes related to acute anesthetic care carried out by non-anesthesiologists.

CRNAs will play a significant role in American healthcare in the future. That significant role will be best played with an MD anesthesiologist at their right hand.

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

 

 

WHAT ONE QUESTION SHOULD YOU ASK TO DETERMINE IF A PATIENT IS ACUTELY ILL?

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

What one question should you ask to determine whether a patient has a serious medical problem? What one question must you ask to determine whether urgent intervention is required?

Imagine this scenario: You’re an anesthesiologist giving anesthesia care in the operating room to your second patient of the day. The Post Anesthesia Care Unit (PACU) nurse calls you regarding your first patient who is in the PACU following appendectomy. The nurse says, “Your patient Mr. Jones is still nauseated and very sleepy. I’ve medicated him with ondansetron and metoclopramide as ordered, but he’s still nauseated and sleepy.”

That one question would be: “What are his vital signs?”(This is a bit of a trick question, since you are asking not one question, but four or five. It’s as if you’re down to your last request from the Genie from Aladdin’s lamp, and you’re wishing for more wishes. As Robin Williams’ Genie character said in Disney’s Aladdin, “Three wishes, to be exact. And ixnay on the wishing for more wishes. That’s all. Three. Uno, dos, tres. No substitutions, exchanges or refunds.” )

The traditional four vital signs are the blood pressure, heart rate, respiratory rate, and temperature. For anesthesiologists, surgeons, emergency room physicians, and ICU doctors, the fifth vital sign is the oxygen saturation or O2 sat. Some publications tout the pain score (on a 1-10 scale) as a fifth vital sign. While I subscribe to the pain score’s importance, it’s of less value in most acute care situations than the O2 saturation.

Let’s return to the patient scenario. You ask the nurse, “What are the patient’s vital signs?”

The nurse answers, “His heart rate is 48, his blood pressure is 88/55, his O2 sat is 100, and his respiratory rate is 16.”

You answer, “His heart rate is too low and so is his blood pressure. Let’s give him 0.5 mg atropine IV now.”

Five minutes later the nurse calls back. The heart rate increased to 72 and the blood pressure is 110/77. The patient’s symptoms resolved as the vital signs normalized.

Let’s look at a second scenario. You drop off a 48-year-old hysterectomy patient in the PACU. The patient is awake, and her initial vital signs are BP 120/64, pulse 100, respirations 18, and O2 saturation 99%. You return to the operating room to initiate care for your next patient for a laparoscopy. Thirty minutes later, the PACU nurse calls you to report your first patient has increasing abdominal discomfort. Her repeat vital signs are: BP 110/80, pulse 130, respirations 26, and O2 saturation 99%. You’re concerned an intra-abdominal complication is brewing. Five minutes later, the nurse reports a third set of vitals. The patient’s heart rate continues to rise to 140. Her blood pressure is now 82/40, her respirations are 30, and her skin has become cold and moist to the touch. She’s unable to speak coherently and is losing consciousness. You can not leave the patient you are anesthetizing, but you call a fellow anesthesiologist to evaluate the patient in person, and prepare her for emergent re-operation.

The patient’s initial vital signs were stable, but the downward trend of her vital signs were a harbinger of the serious complication. Eventually the symptoms of abdominal pain and decreasing consciousness appeared, and confirmed the diagnosis of intra-abdominal hemorrhage and impending shock. The increased heart rate, decreased blood pressure, and increased respiratory rate were red flags early on.

Abnormal vital signs can indicate that a patient is acutely ill. Equally important to the value of each vital sign is the temporal trend in the vital signs. A vital sign trend increasing or decreasing from the normal range can validate that the patient is becoming acutely ill.

You may be thinking, why is Dr. Novak telling me vital signs are important? Everybody know vital signs are, well … vital.

My message to you is to seek out the vital signs, all of them, as essential clues in all patients.

As anesthesiologists, we spend our entire intraoperative clinical career staring at a patient’s vital signs on a video screen. When the blood pressure goes up, we act. When the blood pressure goes down, we act. When the heart rate goes up, we act, and when the heart rate goes down, we act. When oxygen saturation trends downward, we act. Because most intraoperative patients are unconscious, the patient’s verbal history—the traditional clues regarding acute illness—are unavailable. We can not ask our patient questions to determine whether vital sign changes are associated with symptoms of chest pain, shortness of breath, or neurologic deficits. We’re accustomed to treating patients by normalizing their vital signs.

Other healthcare providers lack this perspective. Nurses and non-acute-care physicians such as family practitioners and internists can fill a patient’s history chock full of other details so thick that the vital signs are buried. The five or six vital sign numbers are often obscured in pages of text. Most physician and nursing notes in an electronic medical record (EMR) are lengthy, and are many are copied and pasted from previous encounters. Each patient interview is a quiz bowl of medical history answers. The five or six vital sign numbers are a needle in the haystack of a modern medical history. The EMR in a clinic or a hospital can serve to worsen this plight, as vital signs are recorded by nurses and entered into nursing documents on the computer, and treating physicians may have to dig to find the correct page that lists vital signs. One possible benefit of an EMR is a proposed safety system that requires, for any abnormal vital sign entered into the computer, the nurse to document they have verbally informed a physician of that abnormal value. This system would assure that abnormal values are never ignored, and that an MD will assess whether further diagnostic or therapeutic steps need to be taken.

Ferret out the vital signs. In my career as a clinical anesthesiologist and anesthesia expert witness, I can’t recall one significant complication that wasn’t foretold by an increased or decreased heart rate, blood pressure, respiratory rate, or temperature, a decreased O2 saturation, or an increased pain score.

Keep your eye on the vitals, and keep your patients out of trouble.

 

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

 

 

DO YOU NEED AN ANESTHESIOLOGIST FOR ENDOSCOPY OF YOUR ESOPHAGUS, STOMACH, AND UPPER GASTROENTEROLOGIC TRACT?

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

Do you need an anesthesiologist for upper gastrointestinal endoscopy? In the aftermath of Joan Rivers’ tragic death following an upper endoscopy procedure at a New York outpatient surgery center, every news bureau is discussing this topic. Because I have no inside information on Joan Rivers’ medical care during her procedure, I will not judge her physicians, rather I will attempt to answer the specific question:

Do you need an anesthesiologist for an upper gastrointestinal endoscopy?

The answer to the question is:  it depends.  It depends on 1) your health, 2) the conscious sedation skills of your gastroenterologist, and 3) the facility you have your endoscopy at.

1)  YOUR HEALTH. The majority of endoscopies in the United States are performed under conscious sedation.  Conscious sedation is administered by a registered nurse, under specific orders from the gastroenterologist.  The typical drugs are Versed (midazolam) and fentanyl.  Versed is a benzodiazepine, or Valium-like medication, that is superb in reducing anxiety, sleepiness, and producing amnesia.  Fentanyl is a narcotic pain reliever, similar to a short-acting morphine.  The combination of these two types of medications renders a patient sleepy but awake.  Most patients can minimal or no recollection of the endoscopy procedure when under the influence of these two drugs.  I can speak from personal experience, as I had an endoscopy myself, with conscious sedation with Versed and fentanyl, and I remembered nothing of the procedure.

If you are a reasonably healthy adult, you should be fine having the procedure under conscious sedation.  Patients with high blood pressure, diabetes, asthma, obesity, mild to moderate sleep apnea, advanced age, or stable cardiac disease are have conscious sedation for colonoscopies in America every day, without significant complications.

Certain patients are not good candidates for conscious sedation, and require an anesthesiologist for sedation or general anesthesia.  Included in this category are a) patients on large doses of chronic narcotics for chronic pain, who are tolerant to the fentanyl and are therefore difficult to sedate, b) certain patients with morbid obesity, c) certain patients with severe sleep apnea, and d) certain patients with severe heart or breathing problems.

2)  THE CONSCIOUS SEDATION SKILLS OF YOUR GASTROENTEROLOGIST.  Most gastroenterologists are comfortable directing registered nurses in the administration of conscious sedation drugs.  Some, however, are not.  These gastroenterologists will disclose this to their patients, and recommend that an anesthesiologist administer general anesthesia for the procedure.

3) THE FACILITY YOU HAVE YOUR ENDOSCOPY AT.  Most endoscopy facilities have nurses and gastroenterologists comfortable with conscious sedation.  Some do not.  The facility you are referred to may have a consistent policy of having an anesthesiologist administer general anesthesia with propofol for all endoscopies.  If this is true, they should disclose this to you, the patient, before you arrive for the procedure.  A facility which always utilizes general anesthesia means that you, the patient, will incur one extra physician bill for your procedure, from an anesthesiologist.

I refer you to an article from the New York Times, which summarizes the anesthesiologist-propofol-for-endoscopy phenomenon in the New York region in 2012:

One last point: If the drugs Versed and fentanyl are used, there exist specific and effective antidotes for each drug if the patient becomes oversedated. The antagonist for Versed is Romazicon (flumazenil), and the antagonist for fentanyl is Narcan (naloxone). If these drugs are injected promptly into the IV of an oversedated patient, the patient will wake up in seconds, before any oxygen deprivation affects the brain or heart.

Propofol, however, has no specific antagonist. Propofol only wears off as it is redistributed out of the blood stream into other tissues, and its blood level declines. A propofol overdose can cause obstruction of breathing, and/or depression of breathing, such that the blood oxygen level is insufficient for the brain and heart. The Food and Drug Administration (FDA) mandates that a Black Box warning be included in the packaging of every box of propofol. That warning states that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”

Anesthesiologists are experts at using propofol. I administer propofol to 99% of my patients who are undergoing general anesthesia for a surgical procedure. Anesthesiologists are experts at managing airways and breathing. Individuals who are not trained to administer general anesthesia should never administer propofol to a patient, in a hospital or in an outpatient surgery center.

I serve as the medical director of an outpatient surgery center in Palo Alto, California. We perform a variety of orthopedic, head and neck, plastic, ophthalmic, and general surgery procedures safely each year. In addition, our gastroenterologists perform thousands of endoscopies each year. I review the charts of the endoscopy patients as well as the surgical patients prior to the procedures, and in our center, approximately 99% of endoscopies can be safely performed under Versed and fentanyl conscious sedation, without the need for an anesthesiologist attending to the patient.

If you have an endoscopy, ask questions. Will you receive conscious sedation with drugs like Versed and fentanyl, or will an anesthesiology professional administer propofol? You deserve to know.

 

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

 

 

HERBAL MEDICINES, SURGERY, AND 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

An otherwise healthy 50-year-old female patient takes three herb pills daily: gingko, kava, and ginseng. What do you do when this patient needs elective surgery for an ACL reconstruction two days from now? Do you cancel surgery and stop the herbal medicines, or should you proceed?

My goal is to give you practical advice on how to proceed in the real world of anesthesia and surgical practice. We all know herbal medicines are out there. Do they matter? What is the evidence that herbal medicines affect surgical outcomes in an adverse way?

Many commonly used herbal medicines have side effects that affect drug metabolism, bleeding, and the central nervous system. In 2002 35% of Americans used complementary alternative medicine (CAM) therapies, and visits to CAM practitioners exceeded those to American primary care physicians (Tindle et al: Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med 2005; 11:42). CAM practitioners include homeopathic medicine, meditation, art, music, or dance therapy, herbal medicines, dietary supplements, chiropractic manipulation, osteopathic medicine, massage, and acupuncture.

The finest review of herbal medicines and anesthesia is Chapter 33 in Miller’s Anesthesia, 7th Edition, 2009, authored by Ang-Lee, Yuan, and Moss. The authors write, “Many patients fail to volunteer information regarding herb and alternative medicine pills unless they are specifically asked about herbal medication use. Scientific knowledge in this area is still incomplete. There are no randomized, controlled trials that have evaluated the effects of prior herbal medicine use on the period immediately before, during and after surgery.” They go on to say, “preoperative use of herbal medicines has been associated with adverse perioperative events,” and “Because herbal medicines are classified as dietary supplements, they are not subject to preclinical animal studies, premarketing controlled clinical trials, or postmarketing surveillance. Under current law, the burden is shifted to the U.S. Food and Drug Administration (FDA) to prove products unsafe before they can be withdrawn from the market.”

The authors reviewed nine herbal medicines that have the greatest impact on perioperative patient care: echinacea, ephedra, garlic, Ginkgo biloba, ginseng, kava, saw palmetto, St. John’s wort, and valerian. These nine pills represent 50% of the herbal medicines sold in the United States.

The same authors published a paper entitled “Herbal Medicines and Perioperative Care.” (JAMA 2001; 286:208). The following table is reproduced from that journal article, and describes relevant effects, perioperative concerns, and recommendations for eight of the most common herbal medicines:

Echinacea
Boosts immunity. Allergic reactions, impairs immune suppressive drugs, can cause 
immune suppression when taken long-term, could impair wound 
healing. Discontinue as far in advance as possible, especially for transplant patients or those with liver dysfunction.

Ephedra (ma huang) Increases heart rate, increases blood pressure. Risk of heart attack, arrhythmias, stroke, interaction with other drugs, kidney stones. Discontinue at least 24 hours before surgery.

Garlic (ajo)
Prevents clotting. Risk of bleeding, especially when combined with other drugs that inhibit clotting. Discontinue at least 7 days before surgery.

Ginko (duck foot, maidenhair, silver apricot). Prevents clotting. Risk of bleeding, especially when combined with other drugs that inhibit clotting. Discontinue at least 36 hours before surgery.

Ginseng
Lowers blood glucose, inhibits clotting. Lowers blood-sugar levels. Increases risk of bleeding. Interferes with warfarin (an anti-clotting drug). Discontinue at least seven days before surgery.

Kava (kawa, awa, intoxicating pepper). Sedates, decreases anxiety. May increase sedative effects of anesthesia. Risks of addiction, tolerance and withdrawal unknown. Discontinue at least 24 hours before surgery.

St. John’s wort (amber, goatweed, Hypericum, klamatheweed). Inhibits re-uptake of neuro-transmitters (similar to Prozac). Alters metabolisms of other drugs such as cyclosporin (for transplant patients), warfarin, steroids, protease inhibitors (vs HIV). May interfere with many other drug.s Discontinue at least five days before surgery.

Valerian
Sedates Could increase effects of sedatives. Long-term use could increase the amount of anesthesia needed. Withdrawal symptoms resemble Valium addiction If possible, taper dose weeks before surgery. If not, continue use until surgery. Treat withdrawal symptoms with benzodiazepines.

In their chapter in Miller’s Anesthesia, Ang-Lee, Yuan, and Moss recommend that, “In general, herbal medicines should be discontinued preoperatively. When pharmacokinetic data for the active constituents in an herbal medication are available, the timeframe for preoperative discontinuation can be tailored. For other herbal medicines, 2 weeks is recommended. However, in clinical practice because many patients require nonelective surgery, are not evaluated until the day of surgery, or are noncompliant with instructions to discontinue herbal medications preoperatively, they may take herbal medicines until the day of surgery. In this situation, anesthesia can usually proceed safely at the discretion of the anesthesiologist, who should be familiar with commonly used herbal medicines to avoid or recognize and treat complications that may arise.”

The American Society of Anesthesiologists have no official standards or guidelines on the preoperative use of herbal medications. Public and professional educational information released by the American Society of Anesthesiologists suggest that herbals be discontinued at least 2 to 3 weeks before surgery.

To return to our original question, what do you do when your otherwise healthy 50-year-old female patient has been taking gingko, kava, and ginseng up to two days prior to her ACL reconstruction surgery? Gingko can cause increased bleeding, kava can cause increased sedation, and ginseng can cause decreased blood sugars and increased bleeding. You discuss the predicament with the patient’s surgeon. He’s not concerned that a possible increased risk of bleeding will affect this knee surgery. You decide the increased level of sedation and the possible decreased blood sugar risks are not prohibitive. (If you were worried, you could cut back slightly on the amount of central nervous system depressant drugs you utilize, and also run a 5% dextrose solution in the patient’s IV.)

An alternative choice would be to cancel the surgery for 2 weeks while the patient remains herb-free. The surgeon asks you, “Is there any data that postponing the surgery for two weeks will decrease the complication rate?”

You answer honestly and say, “There is no data. The American Society of Anesthesiologists suggests that herbals be discontinued at least 2 to 3 weeks before surgery.”

The surgeon says, “I want to do the case tomorrow. There’s no data compelling me to delay for two weeks. I accept whatever increased bleeding risk there may be. I’ve never had a patient have a bleeding complication from a knee surgery.”

You proceed with the surgery the next day. The patient does well, and has no complications.

Surveys estimate that:
a) 22% to 32% of patients undergoing surgery use herbal medications (Tsen LC, et al: Alternative medicine use in presurgical patients. Anesthesiology 2000; 93:148);
b) 90% of anesthesiologists do not routinely ask about herbal medicine use (McKenzie AG: Current management of patients taking herbal medicines: A survey of anaesthetic practice in the UK. Eur J Anaesthesiol 2005; 22:597); and
c) more than 70% of patients are not forthcoming about their herbal medicine use during routine preoperative assessment (Kaye AD, et al: Herbal medications: Current trends in anesthesiology practice—a hospital survey. J Clin Anesth 2000; 12:468).

The frequent use of herbal medicines in perioperative patients is real. How big a problem is it? Nobody knows. How frequently does one of your patients have an unexpected problem of increased bleeding, increased sedation, decreased blood sugar, unexpected cardiac arrhythmia or angina, or decreased immune function?

For an ACL reconstruction in a healthy patient, gingko, kava, and ginseng may pose little risk. For a craniotomy on a 70-year-old with coronary artery disease and diabetes, gingko, kava, and ginseng bay pose an increased risk, and warrant postponing the surgery for 2 weeks after holding the herbal medicines.

My advice is to take a careful history of herb medicine use from your patients, know (or look it up if you don’t remember) the potential side effects of each herbal medicine, and then on a case-by-case basis decide if it really matters if the surgery should be cancelled for 2 weeks.

That’s what doctors do. That’s what anesthesia consultants 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

 

 

SUCCINYLCHOLINE: VITAL DRUG OR OBSOLETE DINOSAUR?

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

Succinylcholine: vital drug or dinosaur? Succinylcholine (sux) has the wonderful advantage of rendering a patient paralyzed in less than a minute, and the discouraging disadvantage of a long list of side effects that make the drug problematic.

succinylcholine_chloride_10_med-21

A vial of succinylcholine

I would never begin an anesthetic without succinylcholine being immediately available. No other muscle relaxant supplies as rapid an onset of action and as short a duration of action. An intravenous dose of 1 mg/kg of succinylcholine brings complete paralysis of the neuromuscular junction at 60 seconds, and recovery to 90% of muscle strength in 9 – 13 minutes. (Miller’s Anesthesia, 7th Edition, 2009, Chapter 29, Pharmacology of Muscle Relaxants and Their Antagonists). If a patient has an acute airway disaster on induction such as laryngospasm or pulmonary aspiration, no drug enables emergency endotracheal intubation as quickly as succinylcholine. That said, I never use succinylcholine unless I have to. The drug has too many side effects and rocuronium is often a better choice. For an elective anesthetic on a patient who has fasted and has an empty stomach, one almost never needs to use succinylcholine. If you do use sux, you are exposing your patient to the following side effects:

1. Myalgias. Your patient complains to you the following day, “Doc, I feel like I was run over by a truck.” Because the majority of anesthetics are currently done on outpatients, and because you do not personally interview these patients the following day, you won’t be aware of the degree of muscle pain you’ve induced by using the depolarizing relaxant succinylcholine. Published data quantitates the incidence of post-succinylcholine myalgia as varying from 0.2 % to 89% (Brodsky JB, Anesthesiology 1979; 51:259-61), but my clinical impression is that the number is closer to 89% than it is to 0.2%. Myalgias aren’t life-threatening, but if you ever converse with your patient one day after succinylcholine and they complain of severe muscle aches, you’ll wish you’d chosen another muscle relaxant if possible.
2. Risk of cardiac arrest in children. Succinylcholine carries a black box warning for use in children. Rare hyperkalemia and ventricular arrhythmias followed by cardiac arrest may occur in apparently healthy children who have an occult muscular dystrophy. The black box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”
3. Hyperkalemia, with an average increase of 0.5 mEq in potassium concentration after intravenous succinylcholine injection.
4. Cardiac arrest in patients with a history of severe trauma, neurologic disease or burns. There’s a risk of cardiac arrest with succinylcholine use in patients with severe burns, major trauma, stroke, prolonged immobility, multiple sclerosis, or Guillian-Barré syndrome, due to an up-regulation of acetylcholine. The increase in serum potassium normally seen with succinylcholine can be greatly increased in these populations, leading to ventricular arrhythmia and cardiac arrest. There is typically no risk using succinylcholine in the first 24 hours after the acute injury.
5. Cardiac arrhythmias. Both tachy and bradycardias can be seen following the injection of succinylcholine.
6. Increase in intraocular pressure, a hazard when the eye is open or traumatized.
7. Increase in intragastric pressure, a hazard if gastric motility is abnormal or the stomach is full.
8. Increase in intracranial pressure, a hazard with head injuries or intracerebral bleeds or tumors.
9. Malignant Hyperthermia (MH) risk. The incidence of MH is low. A Danish study reported one case per 4500 anesthetics when triggering agents are in use (Ording H, Dan Med Bull, 43:111-125), but succinylcholine is the only injectable drug which is a trigger for MH, and this is a disincentive to use the drug routinely.
10. Prolonged phase II blockade. Patients who have genetically abnormal plasma butyrylcholinesterase activity have the risk of a prolonged phase II succinylcholine block lasting up to six hours instead of the expected 9 – 13 minutes. If you’ve ever had to stay in the operating room or post-anesthesia recovery room for hours with a ventilated patient after their surgery ended because your patient incurred prolonged blockade from succinylcholine, you won’t forget it, and you’ll hope it never happens again.

What does a practicing anesthesiologist use instead of succinylcholine? Rocuronium.

A 0.6 mg/kg intubating dose of the non-depolarizing relaxant rocuronium has an onset time to maximum block of 1.7 minutes and a duration of 36 minutes. The onset time can be shortened by increasing the dose to a 1.2 mg/kg, a dose which has an onset time to maximum block of 0.9 minutes and a duration of 73 minutes. These durations can be shortened by reversing the rocuronium blockade as soon as one twitch is measured with a neuromuscular blockade monitor. Thus by using a larger dose of rocuronium, practitioners can have an onset of acceptable intubation conditions at 0.9 X 60 seconds = 54 seconds, compared to the 30 seconds noted with succinylcholine, without any of the 10 above-listed succinylcholine side effects. The duration of rocuronium when reversed by neostigmine/glycopyrrolate can be as short as 20 – 25 minutes, a time short enough to accommodate most brief surgical procedures.

Now that sugammadex is commercially available, we can reverse rocuronium blockade in seconds, making rocuronium shorter in duration than succinylcholine.

Here is a list of surgical cases once thought to be indications for using succinylcholine, which I would argue are now better served by using a dose of rocuronium followed by early reversal with sugammadex:

1) Brief procedures requiring intubation, such as bronchoscopy or tonsillectomy.
2) Procedures which require intubation plus intraoperative nerve monitoring, such as middle ear surgery.
3) Procedures requiring intubation of obese and morbidly obese patients who appear to have no risk factors for mask ventilation.
4) Procedures requiring full stomach precautions and cricoid pressure, in which the patient’s oxygenation status can tolerate 54 seconds of apnea prior to intubation. This includes emergency surgery and trauma patients. Miller’s Anesthesia (Chapter 72, Anesthesia for Trauma) discusses the induction of anesthesia and endotracheal intubation for emergency patients who are not NPO and may have full stomachs. Either succinylcholine or rocuronium can be used, with succinylcholine having the advantage of a quicker onset and the 1.2 mg/kg of rocuronium having the advantage of lacking the 10 side effects listed above. The fact that succinylcholine takes 9 – 13 minutes to wear off makes it riskier than rocuronium, which can be reversed in seconds by sugammadex. Waiting for 9 minutes for a return to spontaneous respirations after succinycholine would be associated with severe hypoxia.

On the other hand, succinylcholine is the sole recommended muscle relaxant for:

1) Cesarean sections. Miller’s Anesthesia (Chapter 69, Anesthesia for Obstetrics) still recommends thiopental and succinylcholine for Cesarean sections that require general anesthesia, and I would be loath to disagree with our specialty’s Bible.
2) Electroconvulsive therapy (ECT) for depression. Miller’s Anesthesia (Chapter 79, Anesthesia at Remote Locations) recommends partial muscle relaxation during ECT, and recommends small doses of succinylcholine (0.5 mg/kg) to reduce the peripheral manifestations of the seizure and to prevent musculoskeletal trauma to the patient.
3) Urgent intubation or re-intubation in a patient when every second counts, e.g. a patient who is already hypoxic. A subset of this indication is the patient who is being mask-induced and becomes hypoxic and requires intramuscular succinylcholine injection.
4) Laryngospasm either during mask induction or post-extubation, in which the patient requires urgent paralysis to relax the vocal cords.

In conclusion, most indications for muscle relaxation are better handled by using the non-depolarizing drug rocuronium rather than succinylcholine. However, because of the four recommended uses for succinylcholine listed in the previous paragraph, none of us would ever practice anesthesia without a vial of succinylcholine in our drawer for immediate availability.

I try very, very hard to minimize my use of succinylcholine, and so should you. But to answer our original question… succinylcholine is still a vital drug and not a dinosaur at all.

 

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?

 

 

 

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

 

 

OPERATING ROOM BULLYING

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

Does operating room bullying occur? You’re a freshly trained, recently hired anesthesiologist at a new medical center. In your first week on your job, an attending surgeon in the operating room intimidates you, making aggressive, sarcastic, and critical comments such as, “Are you trying to kill my patient? Have you ever done this before? Why is it taking you so long to get this patient to sleep?” or “My patient just moved. Can’t you give anesthesia better than that? Maybe I’d better ask for a different anesthesiologist.”

Does this ever happen? Unfortunately it does. What do you do?

Bullying in the medical profession is common, particularly during training years. A 1990 study (Silver HK, Medical student abuse. Incidence, severity, and significance, JAMA 1990 Jan 26;263(4):527-32) found that 46.4 percent of students at one major medical school had been abused at some point. By the time they were seniors, that number rose to 80.6 percent. In an Irish study, 30% of junior hospital physician responders to a questionnaire claimed to have been subjected to one or more bullying behaviors. (Cheema S, Bullying of junior doctors prevails in Irish health system: a bitter reality, Ir Med J. 2005 Oct;98(9):274-5).

The traditional medical education hierarchy of attendings > fellows > residents > interns > medical students sets up a pecking order where senior physicians pick on junior colleagues. One might paraphrase the phenomenon as “Sh__ runs downhill.” Younger colleagues are expected to do more “scut,” that is more paper work, computer work, contacting of consultants, chasing down lab and scan results, early rounds and late rounds on patients, as well as to sleep overnight in hospitals.

As physicians become more senior and exit training programs, their lifestyle improves and junior doctors, physician assistants, nurse practitioners, or registered nurses do more of their work. The tradition of condescending behavior toward those less trained may continue. When condescension crosses the line into disruptive or inappropriate behavior, it becomes a problem. Abused physicians, nurses, or techs can become angry or depressed, lose self esteem, and their physical and emotional health may suffer. Disrespect and bullying compromise patient safety because they inhibit the collegiality and cooperation essential to teamwork, cut off communication, and destroy team morale.

Joint Commission studies have shown that communication failure between health care workers is the number one cause for medication errors, delays in treatment, and surgeries at the wrong site. A 2004 study of workplace intimidation by the Institute for Safe Medication Practices (ISMP) (www.ismp.org/pressroom/pr20040331.pdf) found that nearly 40 percent of clinicians have kept quiet or ignored concerns about improper medication rather than talk to an intimidating colleague.Rather than bring their questions about medication orders to a difficult doctor, these health care personnel said they would preferred to keep silent. Seven percent of the respondents said that in the past year they’d been involved in a medication error in which intimidation was at least partly responsible.

In 2009 the Joint Commission began requiring hospitals to have a “code of conduct that defines acceptable, disruptive, and inappropriate staff behaviors” and for its “leaders [to] create and implement a process for managing disruptive and inappropriate staff behaviors.” The rationale for the standard states: “Leaders must address disruptive behavior of individuals working at all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members.”

Stanford University Hospital where I work has adopted such a Medical Staff Code of Professional Behavior (found online at medicalstaff.stanfordhospital.org/bylaws/documents/Code_of_Behavior).

Excerpts from this document include:

“Inappropriate behavior” means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive, and subject to treatment as “disruptive behavior.” Inappropriate behavior include, but are not limited to, the following: Belittling or berating statements; Name calling; Use of profanity or disrespectful language; Inappropriate comments written in the medical record; Blatant failure to respond to patient care needs or staff requests; Personal sarcasm or cynicism; Lack of cooperation without good cause; Refusal to return phone calls, pages, or other messages concerning patient care; Condescending language; and degrading or demeaning comments regarding patients and their families, nurses, physicians, hospital personnel and/or the hospital.

“Disruptive behavior” means any abusive conduct including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.

Disruptive behavior by Medical Staff members is prohibited. Examples of disruptive behavior include, but are not limited to, the following: Physically threatening language directed at anyone in the hospital including physicians, nurses, other Medical Staff members, or any hospital employee, administrator or member of the Board of Directors; Physical contact with another individual that is threatening or intimidating; Throwing instruments, charts or other things.

This is how the Stanford policy deals with inappropriate or disruptive behavior:

          If this is the first incident of inappropriate behavior, the Chief of Staff (COS)or designee shall discuss the matter with the offending Medical Staff member, emphasizing that the behavior is inappropriate and must cease. The offending Medical Staff member may be asked to apologize to the complainant. The approach during this initial intervention should be collegial and helpful.

            Further isolated incidents that do not constitute persistent, repeated inappropriate behavior will be handled by providing the offending Medical Staff member with notification of each incident, and a reminder of the expectation the individual comply with this Code of Behavior.

          If the COS or designee determines the Medical Staff member has demonstrated persistent, repeated inappropriate behavior, constituting harassment (a form of disruptive behavior), or has engaged in disruptive behavior on the first offense, the case will be referred to the COS and/or the Committee on Professionalism (COP). The subject will be notified of this decision and given an opportunity to provide a written response both prior to and subsequent to meeting with the COS or COP.

            If it is determined that the subject has engaged in disruptive behavior, a letter of admonition will be sent to the offending member, and, as appropriate, a rehabilitation action plan developed by the COS and/or COP, with the advice and counsel of the medical executive committee as indicated. The assistance of the Wellbeing Committee may be offered at any stage of this process.

             If, in spite of this admonition and intervention, disruptive behavior recurs, the COS or designee shall meet with and advise the offending Medical Staff member such behavior must immediately cease or corrective action will be initiated. This “final warning” shall be sent to the offending Medical Staff member in writing.

            If after the “final warning” the disruptive behavior recurs, corrective action (including possible suspension or termination of privileges) shall be initiated pursuant to the Medical Staff bylaws of which this Code of Behavior is a part, and the Medical Staff member shall have all of the due process rights set forth in the Medical Staff bylaws.

What do you do when inappropriate or disruptive behavior occurs in your operating room? The specialty of anesthesia provides wonderful positives such as intellectual challenge, multiple different subspecialties, hands-on procedures, and solid financial reimbursement. A disadvantage of the specialty of anesthesia is that anesthesiologists are consultants who do not have their own patients. No patient goes to the hospital or surgery center solely to have an anesthetic. Patients are there for some invasive procedure that requires an anesthetic.

Because the patient “belongs” to the surgeon, some surgeons use this fact to lord power over the anesthesiology provider, the operating room nurses, and surgical technicians, as well as over the hospital administration. A busy surgeon with a hefty workload brings a great deal of revenue to the hospital or surgery center he or she chooses to operate at. Some surgeons feel entitled to exercise condescending behavior toward nurses and anesthesiologists who they perceive to be merely part of hospital or surgery center services. Some surgeons yell, cuss, and throw things. Some engage in more subversive behaviors such as ignoring questions, acting impatient, insulting colleagues or speaking to them in condescending tones. Only a small percent of surgeons are bad actors, but a small proportion can have a big impact.

In my 25-year anesthesia career I’ve seen multiple examples of verbally and emotionally abusive surgeons. In distant years most of these surgeons met little resistance to their behavior. Staff who opposed them were moved to different operating rooms, and more enabling nurses and techs were found. The enablers were quiet, agreeable, hard working, and rarely questioned the surgeon’s authority. Anesthesiologists who resisted surgeon bullying stopped working with that surgeon, per both the surgeon and the anesthesiologist’s wishes. Alternate anesthesia providers were tried until a subgroup of passive enabler anesthetists was found.

My advice to any anesthesiologist out there is: Don’t be an enabler. You are a highly trained physician, deserving of respect. If a surgeon has an episode of acting disrespectfully to you or to any of the other operating room staff, conclude your care of that current patient without a confrontation. After the case is finished, choose a time to hold a face-to-face conversation with the surgeon. The setting could be a hallway, in the locker room, or at some other location where no patient care is being done. Tell him or her that you find their behavior toward you unacceptable, and that they need to stop it. If you get pushback, and you probably will, you have several choices: 1) have a loud verbal argument, asserting your will against theirs, 2) grin, bear it, and stop complaining about the circumstance; 3) request your scheduler to never schedule you with this surgeon again; or 4) kick it upstairs to the chief of the department and/or the chief of the surgery department.

Which option should you choose?

1) gets you a boisterous unprofessional argument with an individual who will be resistant to change. 2) results in a long-term unacceptable solution for you and your professional esteem. 3) gets you off the hook but does nothing to change the situation for others in the operating room. Only 4) will set the wheels in motion toward significant change. Stay calm and confident and refer the incident up to senior physician administrators to evoke change. If the department chairs can not impact behavioral change, take the issue higher to the Chief of Staff.

A genuine problem occurs when a bullying surgeon leaves all major medical centers and starts his or her own surgery center where he or she is the Medical Director and his or her bad behavior goes unscrutinized. If you are working in such a setting, I’d advise you to find another place to give anesthetics. Without an unbiased administrator, the surgeon bullying behaviors will never go away.

You’ll be happier working in an operating room cured of disruptive behavior, and the real winners will be the patients, who will come and go through a hospital free of disruptive behavior and bullying.

 

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

 

 

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….

*
*
*
*

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

 

 

HOW TO SCREEN OUTPATIENTS PRIOR TO SURGERY

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

Screening prior to outpatient surgery is important. Over 70% of elective surgeries in the United States are ambulatory or outpatient surgeries, in which the patient goes home the same day as the procedure. There are increasing numbers of surgical patients who are elderly, obese, have sleep apnea, or who have multiple medical problems. How do we decide which 70% of surgical candidates are appropriate for outpatient surgery, and which are not?

For the past 16 years I’ve been the Medical Director at a busy Ambulatory Surgery Center (ASC) in Palo Alto, California. ASC Medical Directors are perioperative physicians, responsible for the preoperative, intraoperative, and postoperative management of ambulatory surgery patients. Our surgery center is freestanding, distanced one mile from Stanford University Hospital. The hospital-based technologies of laboratory testing, a blood bank, an ICU, arterial blood gas measurement, and full radiology diagnostics are not available on site. It’s important that patient selection for a freestanding surgery center is precise and safe.

The topic of Ambulatory Anesthesia is well reviewed in the textbook Miller’s Anesthesia, 7th Edition, 2009, Chapter 78, Ambulatory (Outpatient) Anesthesia. With the information in this chapter as a foundation, the following 7 points are guidelines I recommend in the preoperative consultation and selection of appropriate outpatient surgery patients:

  1. The most important factor in deciding if a surgical case is appropriate is not how many medical problems the patient has, but rather the magnitude of the surgical procedure. A patient may have morbid obesity, sleep apnea, and a past history of congestive heart failure, but still safely undergo a non-invasive procedure such as cataract surgery. Conversely, if the patient is healthy, but the scheduled surgery is an invasive procedure such as resection of a mass in the liver, that surgery needs to be done in a hospital.
  2. Because of #1, an ASC will schedule noninvasive procedures such as arthroscopies, head and neck procedures, eye surgeries, minor gynecology and general surgery procedures, gastroenterology endoscopies, plastic surgeries, and dental surgeries. What all these scheduled procedures have in common is that the surgeries (a) will not disrupt the postoperative physiology in a major way, and (b) will not cause excessive pain requires inpatient intravenous narcotics.
  3. One must screen patients preoperatively to identify individuals who have serious medical problems. Our facility uses a comprehensive preoperative telephone interview performed by a medical assistant, two days prior to surgery. The interview documents age, height, weight, Body Mass Index, complete review of systems, list of allergies, and prescription drug history. All information is entered in the patient’s medical record at that time.
  4. Each surgeon’s office assists in the preoperative screening. For all patients who have (a) age over 65, (b) obstructive sleep apnea, (c) cardiac disease or arrhythmia history, (d) significant lung disease, (e) shortness of breath or chest pain, (f) renal failure or hepatic failure, (g) insulin dependent diabetes, or (h) significant neurological abnormality, the surgery office is required to obtain medical clearance from the patient’s Primary Care Provider (PCP).    This PCP clearance note concludes with two questions: 1) Does the patient require any further diagnostic testing prior to the scheduled surgery? And 2) Does the patient require any further therapeutic measures prior to the scheduled surgery?
  5. For each patient identified with significant medical problems, the Medical Director must review the chart and the Primary Care Provider note, and confirm that the patient is an appropriate candidate for the outpatient surgery. The Medical Director may telephone the patient for a more detailed history if indicated. On rare occasions, the Medical Director may arrange to meet and examine the patient prior to the surgical date.
  6. Medical judgment is required, as some ASA III patients with significant comorbidities are candidates for trivial outpatient procedures such as gastroenterology endoscopy or removal of a neuroma from a finger, but are inappropriate candidates for a shoulder arthroscopy or any procedure that requires general endotracheal anesthesia.
  7. What about laboratory testing? Per Miller’s Anesthesia, 7th Edition, 2009, Chapter 78, few preoperative lab tests are indicated prior to most ambulatory surgery. We require a recent ECG for patients with a history of hypertension, cardiac disease, or for any patient over 65 years in age. If this ECG is not included with the Primary Care Provider consultation note, we perform the ECG on site in the preoperative area of our ASC, at no charge to the patient. All diabetic patients have a fasting glucose test done prior to surgery. No electrolytes, hematocrit, renal function tests, or hepatic tests are required on any patient unless that patient’s history indicates a specific reason to mandate those tests.

Utilizing this system, cancellations on the day of surgery are infrequent—well below 1% of the scheduled procedures. The expense of and inconvenience of an Anesthesia Preoperative Clinic are eliminated.

What sort of cases are not approved? Here are examples from my practice regarding patients/procedures who are/are not appropriate for surgery at a freestanding ambulatory surgery center:

  1. A 45-year-old patient with moderately severe obstructive sleep apnea (OSA) is scheduled for a UPPP (uvulopalatalpharyngoplasty). DECISION: NOT APPROPRIATE. Reference: American Society of Anesthesiologist Practice Guidelines of the Perioperative Management of Patients with OSA (https://www.asahq.org/coveo.aspx?q=osa). For airway and palate surgery on an OSA patient, the patient is best observed in a medical facility post-surgery. For any surgery this painful in an OSA patient, the patient will require significant narcotics, which place him at risk for apnea and airway obstruction post-surgery.
  2. A morbidly obese male (Body Mass Index = 40) is scheduled for a shoulder arthroscopy and rotator cuff repair. DECISION: NOT APPROPRIATE. Obesity is not an automatic exclusion criterion for outpatient surgery. Whether to cancel the case or not depends on the nature of the surgery. A shoulder repair often requires significant postoperative narcotics. The intersection of morbid obesity and a painful surgery means it’s best to do the case in a hospital. One could argue that this patient could be done with an interscalene block for postoperative analgesia and then discharged home, but I don’t support this decision. If the block is difficult or ineffective, the anesthesiologist has a morbidly obese patient requiring significant doses of narcotics, and who is scheduled to be discharged home. If this surgery had been a knee arthroscopy and medial meniscectomy it could be an appropriate outpatient surgery, because meniscectomy patients have minimal pain postoperatively.
  3. An 18-year-old male with a positive family history of Malignant Hyperthermia is scheduled for a tympanoplasty. DECISION: APPROPRIATE. A trigger-free general total-intravenous anesthetic with propofol and remifenantil can be given just as safely in an ASC as in a hospital.
  4. A 50-year-old 70-kilogram male with a known difficult airway (ankylosing spondylitis) is scheduled for endoscopic sinus surgery. DECISION: APPROPRIATE. In our ASC, for safety reasons, we have advanced airway equipment including a video laryngoscope and a fiberoptic laryngoscope. If a patient needs an awake intubation, we are prepared to do this safely. This case would be scheduled with a second anesthesiologist available to assist the primary anesthesia attending in securing the airway.
  5. An 80-year-old woman with shortness of breath on exertion is scheduled for a bunionectomy. DECISION: NOT APPROPRIATE. Although foot surgery is not a major invasive procedure, any patient with shortness of breath is inappropriate for ASC surgery. The nature of the dyspnea needs to be determined and remedied prior to surgery or anesthesia of any sort.
  6. A 6-year-old female born without an ear is scheduled for a 9-hour ear graft and reconstruction. DECISION: APPROPRIATE. With modern general anesthetic techniques utilizing sevoflurane and propofol, patients awake promptly. Even after long anesthetics, if the surgery is not painful, patients are usually discharged in stable condition within 60-90 minutes.

There are infinite combinations of patient comorbidities and types of surgeries. The decision regarding which scheduled procedures are appropriate and which are not is both an art and a science. The role of an anesthesiologist/Medical Director as the perioperative physician making these decisions is invaluable.

 

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

 

 

10 WAYS PRIVATE PRACTICE ANESTHESIA DIFFERS FROM ACADEMIC 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

Academic and private practice anesthesia differ. I’m fortunate to be a member of the clinical faculty in the Department of Anesthesia, Perioperative and Pain Medicine at Stanford University. Stanford is a unique academic hospital, staffed by both academic and private practice physicians. From 2001 until 2015, I served as the Deputy Chief of Anesthesia at Stanford, an elected officer who leads the private practice/community section of the anesthesia department.


IMG_0825

Stanford anesthesia residents frequently question me about how the world of private practice differs from academia. I began my writing career by penning a series of Stanford Deputy Chief Columns. These columns originated as a forum to educate residents using specific cases and situations I found unique to private practice.

Although some anesthesia residents continue in academic medicine, most pursue careers in community or private practice. In 2009, the Anesthesia Quality Institute published Anesthesia in the United States 2009, a report that summarized data on our profession. There were 41,693 anesthesiologists in America at that time, and the demographics of practice type were: academic/teaching medical center 43%, community hospital 35%, city/county hospital 11%, and ambulatory surgery center 6%. Per this data, the majority of American anesthesiologists practice outside of teaching hospitals.

How does community anesthesia differ from academic anesthesia? I’m uniquely qualified to answer this question. I’ve worked at Stanford University Hospital for 34 years, including 5 years of residency training and one year as an Emergency Room faculty member, but my last 25 years at Stanford have been in private practice with the Associated Anesthesiologists Medical Group.

Here’s my list of the 10 major adjustments residents face transitioning from academic anesthesia to private practice/community anesthesia:

  1. You’ll work alone. In academic medicine, faculty members supervise residents. In private practice, you’re on your own. This is particularly true in the middle of the night or when you are working in a small freestanding surgery center where you are the only anesthesia professional. In these settings, you have little or no backup if clinical circumstances become dire. An additional example is the performance of pediatric inhalation inductions. During residency training, a faculty member starts the IV while the resident manages the airway. In private practice you’ll do both tasks yourself. I’d advise you to adopt a senior member of your new anesthesia group as a mentor, and to question him or her in an ongoing nature regarding the nuances of your new practice. (Note that certain private practices, especially in the Midwest or Southeastern U.S., utilize Anesthesia Care Teams, where anesthesiology attendings supervise nurse anesthetists, but this model is less common in California).
  2. Income: your income will be linked to your production. The good news is that you’ll earn more money that you did as a resident. Your income will be linked to the amount of cases you do. You’ll earn more in a twelve-hour day than you do in a four-hour day, so you have an incentive to do extra cases. A job where newly hired physicians have equitable access to workload is desirable.
  3. Income: your income will be linked to the insurance coverage of your patients. Privately insured patients pay more than Medicare and Medicaid patients. You may earn more working a four-hour day for insured patients than you earn working twelve hours working for the government plans of Medicare and Medicaid. It’s too early to know how much Obamacare and the Affordable Care Act will alter physician salaries. A job with a low percentage of Medicare and Medicaid work is desirable.
  4. Vacations. You’ll have access to more vacation time than you did in academic training. Most jobs allow a flexible amount of weeks away from clinical practice, but you will earn zero money during those weeks. It will be your choice: maximize free time or maximize income.
  5. Recipes. You’ll tend to use consistent anesthesia “recipes,” rather than trying to make every anesthetic unique, interesting or educational, as you may have done in an academic setting. Community practice demands high quality care with efficient inductions and wakeups, and rapid turnovers between cases. Once you discover your best method to do a particular case, you’ll stick to that method.
  6. Continuing Medical Education (CME). In an academic setting, educational conferences are frequent and accessible. After your training is finished, you’ll need to find your own CME. In California the requirement is 50 hours of CME every 2 years. Your options will include conventions, weekend meetings, and self-study at home programs. Many physicians find at-home programs require less investment in time, travel, and tuition than finding out-of-town lectures to attend.
  7. Malpractice insurance. You’ll pay your own malpractice insurance. As a result, you’ll be intensely interested in avoiding malpractice claims and adverse patient outcomes. You’ll become well versed in the standards of care in your anesthesia community.
  8. No teaching. No one will expect you to teach during community practice. You may choose to lecture nurses or your fellow medical staff, but it’s not required.
  9. No writing. No one will expect you to write or publish scholarly articles. You may choose to do so, but you will be in the minority.
  10. 10.  Respect. You’ll experience a higher level of respect from nurses and staff at community hospitals and surgery centers than you receive during residency. Nurses and staff accept that you are fully trained and experienced, and treat you as such. Free food at lunch and breakfast is common. Some hospitals have comfortable physician lounges where medical staff members gather. Teams of physicians work together at the same community hospitals for decades, and form strong relationships with the nurses, techs, and their fellow medical staff. It feels terrific to collaborate with the same professionals week after week.

Academic training is an essential building block in every physician’s career. If and when you choose to venture beyond academia into community anesthesia, this column gives you some idea what to expect. I recommend you find a mentor to help you adjust to the challenges of your new practice setting, and I wish you good luck with the transition.

 

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

 

 

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

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?

 

 

*
*
*
*

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

 

 

OBAMACARE AND 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

Key questions in our specialty in 2014 related to Obamacare and anesthesia. This article was originally published in 2014, when Barack Obama was the President of the United States. A key question in our specialty at that time was “How will ObamaCare affect anesthesiology?” The following essay represents my thoughts as of 2014, prior to the Trump presidency.

I don’t have a crystal ball, but based on what I’ve read, what I’ve observed, and what I’m hearing from other physicians, these are my predictions on how ObamaCare will change anesthesia practice in the United States:

  1. There will be more patients waiting for surgery. Millions of new patients will have ObamaCare cards and coverage. A flawed premise of ObamaCare is that a system can cover more patients and yet spend less money.
  2. Reimbursement rates will be lower. How many anesthesiologists will sign up for Medicaid or Medicare-equivalent rates to care for patients? Large organizations such as university hospitals, Kaiser, Sutter, and other HMO-types will likely sign up for the best rate they can negotiate. As a result, their physicians will have increased patient numbers and lower reimbursement for their time. The insurance plans that patients purchase will have higher deductibles, and most patients will have to pay more out of pocket for their surgery and anesthesia. This will lead to patients delaying surgery, and shopping around to find the best value for their healthcare dollar.
  3. Less old anesthesiologists. Older anesthesiologists will retire early rather than work for markedly reduced pay.
  4. Less young anesthesiologists. The pipeline of new, young anesthesiologists will slow. Young men and women are unlikely to sign up for 4 years of medical school,  4 – 6 years of residency and fellowship, and an average of $150,000 of student debt if their income incentives are severely cut by ObamaCare.
  5. More certified nurse anesthetists (CRNAs). It seems apparent that ObamaCare is interested in employing cheaper providers of medical services. CRNAs will command lower salaries than anesthesiologists. The premise to be tested is whether CRNAs can provide the same care for less money. Expect to see wider use of anesthesia care teams and of independent CRNA practice. Expect the overall quality of anesthesia care to change as more CRNAs and less M.D.’s are employed.
  6. A two-tiered system. Anesthesiologists who have a choice will not sign up for reduced ObamaCare rates of reimbursement. Surgeons who have a choice will not sign up for reduced ObamaCare reimbursement. Expect a second tier of private pay medical care to exist, where patients will choose non-ObamaCare M.D.’s of their choice, and will pay these physicians whatever the physicians charge. This tier will provide higher service and shorter waiting times before surgery is performed. This tier will likely be populated by some of the finest surgeons–surgeons are unwilling to work for decreased wages. A subset of anesthesiologists will work in this upper tier of medical care, and these anesthesiologists will earn higher wages as a result.
  7. Will the Accountable Care Organization (ACO) model stumble as the Health Maintenance Organization (HMO) model did in the 1990’s? ObamaCare provides for the existence of ACO’s, which are hospital-physician entities designed to provide comprehensive health care to patients in return for bundled payments. In this model the surgeon, the anesthesiologist, and the hospital (i.e. nurses, pharmacy, and the medical device industry) will divide up the bundled surgical payment. In this model it’s essential that an anesthesiologist leader has a strong presence at the negotiating table. A worrisome issue with the ACO model, as it was with the HMO model, is the flow of money. Physicians will no longer be working for their patients, but will be working for the ACO. The  primary incentive will be to be paid by the ACO, rather than to provide the best care possible.
  8. Anesthesia leadership skills will change. The physician leader of each anesthesia group must be a powerful and effective politician and economic strategist. These traits are not taught during anesthesia residency, and these traits have nothing to do with being an outstanding clinician.
  9. What about the Perioperative Surgical Home (PSH)? The American Society of Anesthesiologists is proposing the model of the PSH, in which anesthesiologists will assume leadership roles managing patient care in the preoperative, intraoperative, and postoperative arenas. This is a desirable goal for our specialty. No physician is better equipped than an anesthesiologist to supervise patients safely through the perioperative period with the highest standards of quality and cost-control. The Perioperative Surgical Home is designed to work with the model of the Accountable Care Organization. How these systems of the Perioperative Surgical Home and the Accountable Care Organization will evolve remains to be seen. It will be the role for individual anesthesia physician leaders in each hospital to seize the new opportunities.  Rank and file anesthesiologists will likely follow their leadership.

10. Consolidation of anesthesia groups. Small anesthesia groups will likely merge into bigger groups in an effort dominate a clinical census, and therefore to negotiate higher reimbursement rates. In November, 2013, the 100-physician Medical Anesthesia Consultants Medical Group, Inc, of San Ramon, California was acquired by Sheridan Healthcare Inc, a 2,500-physician services company based in Florida. Per Sheridan’s CEO, John Carlyle, the acquisition “provides a platform that will accelerate our expansion in the California marketplace.” This was the largest merger in Northern California anesthesia history.

11. Requirement of more anesthesia clinical metrics. Government and insurance payors will require more metrics to document that the provided clinical care was excellence. A typical required metric may be a high percentage of patients who received preoperative antibiotics prior to incision, or a low percentage of patients free from postoperative nausea and vomiting. Each anesthesia groups will need to establish computerized data-capturing systems to present this information to payors. The effort to tabulate these metrics will be another incentive for anesthesia groups to merge into larger clinical entities.

In summary:  More patients, more cases, less money, more bureaucracy, less money, more CRNA providers, and less money. These are the challenges ObamaCare presents to anesthesiologists. Stay tuned. Legions of patients with ObamaCare cards will be knocking on hospital doors. The government is expecting enough anesthesiologists to sign up for ObamaCare contracts to make the new system successful. It’s impossible to tell what behaviors ObamaCare will incentivize. Each anesthesiologist has the benefit of 25+ years of education, and each anesthesiologist will make intelligent choices regarding their career and their time.

Bob Dylan once sang, “I ain’t gonna work on Maggie’s Farm no more.”

Time will tell if ObamaCare is Maggie’s Farm for physicians.

 

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

 

 

THE TOP 11 DISCOVERIES IN THE HISTORY OF 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

Important advances in the history of anesthesia changed the specialty forever. Humans have inhabited the Earth for 200,000 years, yet the discovery of surgical anesthesia was a recent development in 1846. For thousands of years most surgical procedures were accompanied by severe pain. The only strategies available to blunt pain were to give patients alcohol or opium until they were stuporous.

In the 21st Century, modern anesthesiologists utilize dozens of medications and apply sophisticated high-tech medical equipment. How did our specialty advance from prescribing patients two shots of whiskey to administering modern anesthetics?

In chronologic order, my choices for the 11 most important advances in the history of anesthesia follow below. I’ve included comments to expound on the impact of each discovery.

image069

1846. THE DISCOVERY OF ETHER AS A GENERAL ANESTHETIC. The first public demonstration of general anesthesia occurred at Harvard’s Massachusetts General Hospital in Boston, Massachusetts. Dr. William Morton, a local dentist, utilized inhaled ether to anesthetize patient Edward Abott.  Dr. John Warren then painlessly removed a tumor from Abbott’s neck.  Comment: This was the landmark discovery. From this point forward, painless surgery became possible.

1885. THE DISCOVERY OF INJECTABLE COCAINE AND LOCAL ANESTHESIA.  Cocaine was the first local anesthetic. Dr. William Halsted of Johns Hopkins University in Baltimore first injected 4% cocaine into a patient’s forearm and concluded that cocaine blocked sensation, as the arm was numb below but not above the point of injection. The first spinal anesthetic was performed in 1885 when Dr. Leonard Corning of Germany injected cocaine between the vertebrae of a 45-year-old man and caused numbness of the patient’s legs and lower abdomen. Comment: The discovery of local anesthesia gave doctors the power to block pain in specific locations. Improved local anesthetics procaine (Novocain) and lidocaine were later discovered in 1905 and 1948, respectively.

depositphotos_107354984-stock-photo-iron-vintage-glass-syringe-with

1896. THE DISCOVERY OF THE HYPODERMIC NEEDLE, THE SYRINGE, AND THE INJECTION OF MORPHINE. Alexander Wood of Scotland invented a hollow needle that fit on the end of a piston-style syringe, and used the syringe and needle combination to successfully treat pain by injections of morphine. Comment: The majority of anesthetic drugs today are injected intravenously. Such injections would be impossible without the invention of the syringe.

1905. DISCOVERY OF THE MEASUREMENT OF BLOOD PRESSURE BY BLOOD PRESSURE CUFF. Dr. Nikolai Korotkov of Russia described the sounds produced during auscultation with a stethoscope over a distal portion of an artery as a blood pressure cuff was deflated. These Korotkoff sounds resulted in an accurate determination of systolic and diastolic blood pressure. Comment: Anesthesiologists monitor patients repeatedly during every surgery. A patient’s vital signs are the heart rate, respiratory rate, blood pressure, and temperature. It would be impossible to administer safe anesthesia without blood pressure measurement. Low blood pressures may be evidence of anesthetic overdose, excessive bleeding, or heart dysfunction. High blood pressures may be evidence of inadequate anesthetic depth, or uncontrolled hypertensive heart disease.

8040085_intube_cuffed_endotracheal_tube_id_8_web_large

1913. DISCOVERY OF THE CUFFED ENDOTRACHEAL BREATHING TUBE. Sir Ivan Magill of England developed a technique of placing a breathing tube into the windpipe, and endotracheal anesthesia was born. Dr. Chevalier Jackson of Pennsylvania developed the first laryngoscope used to visualize the larynx and insert an endotracheal tube. Drs. Arthur Guedel and Ralph Waters at the University of Wisconsin discovered the cuffed endotracheal tube in 1928. This advance allowed the use of positive-pressure ventilation into a patient’s lungs. Comment: Surgery within the abdomen and chest would be impossible without controlling the airway and breathing with a tube in the trachea. As well, the critical care resuscitation mantra of Airway-Breathing-Circulation would be impossible without an endotracheal tube.

1934. THE DISCOVER OF THIOPENTAL AND INJECTABLE BARBITURATES. Dr. John Lundy of the Mayo Clinic in Rochester, Minnesota introduced the intravenous anesthetic sodium thiopental into anesthetic practice. Injecting Pentothal became the standard means to induce general anesthesia. Pentothal provided a more pleasant method of going to sleep than inhaling pungent ether. Comment: This was a huge breakthrough. Almost every modern anesthetic begins with the intravenous injection of an anesthetic drug. (Propofol has now replaced Pentothal)

1940. THE DISCOVERY OF CURARE AND INJECTABLE MUSCLE RELAXANTS. Dr. Harold Griffith of Montreal, Canada injected the paralyzing drug curare during general anesthesia to induce muscular relaxation requested by his surgeon. Although the existence of curare was known for many years (it was an arrow poison of the South American Indians), it was not used in surgery to deliberately cause muscle relaxation until this time. Comment: Paralyzing drugs are necessary to enable the easy insertion of endotracheal tubes into anesthetized patients, and paralysis is also essential for many abdominal and chest surgeries.

1950’s. THE DEVELOPMENT OF THE POST-ANESTHESIA CARE UNIT (PACU) AND THE INTENSIVE CARE UNIT (ICU). The shock and resuscitation units organized during World War II and the Korean War resulted in efficient care for the sick and wounded. After the wars, PACU’s and ICU’s were natural extensions of these battlefield inventions. Comment: In the PACU, a patient’s airway, breathing, and circulation are observed, monitored, and treated immediately following surgery. PACU’s decrease post-operative complications. In the ICU, Airway-Breathing-Circulation management perfected in the operating room is extended to critically ill patients who are not undergoing surgery.

1956. THE DISCOVERY OF HALOTHANE, THE FIRST MODERN INHALED ANESTHETIC. British chemist Charles Suckling synthesized the inhaled anesthetic halothane. Halothane had significant advantages over ether because of halothane’s more pleasant odor, higher potency, faster onset, nonflammability, and low toxicity. Halothane gradually replaced older anesthetic vapors, and achieved worldwide acceptance. Comment: Halothane was the forerunner of isoflurane, desflurane, and sevoflurane, our modern inhaled anesthetics. These drugs have faster onset and offset, cause less nausea, and are not explosive like ether. The discovery of halothane changed inhalation anesthesia forever.

1983. THE DISCOVERY OF PULSE OXIMETRY MONITORING. The Nellcor pulse oximeter, co-developed by Stanford anesthesiologist Dr. William New, was the first commercially available device to measure the oxygen saturation in a patient’s bloodstream. The Nellcor pulse oximeter had the unique feature of lowering the audible pitch of the pulse tone as saturation dropped, giving anesthesiologists a warning that their patient’s heart and brain were in danger of low oxygen levels. Comment: The Nellcor changed patient monitoring forever. Oxygen saturation is now monitored before, during, and after surgery. Prior to Nellcor monitoring, the first sign of low oxygen levels was often a cardiac arrest. Following the invention of the Nellcor, oxygen saturation became the fifth vital sign, along with pulse rate, respiratory rate, blood pressure, and temperature.

etco2-waveforms-i4

1986.  END-TIDAL CO2 MONITORING. In 1986 the American Society of Anesthesiologists mandated continual end-tidal carbon dioxide analysis be performed using a quantitative method such as capnography, from the time of endotracheal tube/laryngeal mask placement until extubation/removal or initiating transfer to a postoperative care location. The detection and monitoring of carbon dioxide gave immediate feedback whenever ventilation of the lungs was failing. For example, an endotracheal breathing tube placed in the esophagus instead of the tracheal would yield zero (or close to zero) carbon dioxide. The end-tidal CO2 device alarms immediately, the anesthesiologist recognizes the problem, and fixes it at once. The development of pulse oximetry and end-tidal CO2 monitoring were concurrent, and because of these twin discoveries, anesthesia care became markedly safer after the 1980’s

These are the top 11 discoveries in the history of anesthesia as I see them. What will be the next successful invention to advance our specialty?  A superior pain-relieving drug? A better inhaled anesthetic? An improved monitor to insure patient safety? Top scientists and physicians worldwide are working this very day to join this list. Good luck to each of them.

 

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

 

 

READING IN THE OPERATING ROOM

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

You’re an attending anesthesiologist. You enter another colleague’s operating room to give him a bathroom break during his 6-hour plastic surgery case, and you find him tapping on an iPad and reading in the operating room. What do you do?

Discussion:  Is it OK for the anesthesiologist to be reading in the operating room? Is it OK for him to be referencing the Internet? Answering email? Sending text messages on his smartphone? Or should that anesthesiologist be staring transfixed at the monitor screen for hour after hour, maintaining flawless vigilance?

In the Anesthesia Patient Safety Foundation Newsletter Summer 1995 edition, Dr. Matthew Weinger discussed the issue of reading in the operating room. He emphasized that there were no scientific data on the impact of reading on anesthesia provider vigilance or task performance. He cited data that anesthesiologists are ‘idle’ during 40% of routine cases. He asserted that “anesthesia providers read during these idle periods to prevent boredom, and that boredom was a problem of information underload, insufficient work challenge, and under-stimulation…Adding tasks to a monotonous job may decrease boredom and dividing attention among several tasks (time-sharing) may, in some circumstances, actually improve monitoring performance.” Weinger concluded that, “in the absence of controlled studies on the effect of reading in the operating room on anesthesia vigilance and task performance, no definitive or generalizable recommendations can be made. The decision must remain a personal one based on recognition of one’s capabilities and limitations. From a broader perspective, the anesthesia task including associated equipment must be optimized to minimize boredom and yet not be so continuously busy as to be stressful.”

In the Anesthesia Patient Safety Foundation Newsletter, Fall 2004 edition, Dr. Terri Monk opined that reading in the OR seriously compromised patient safety. She was opposed to reading for the following reasons:

  1. Reading diverts one’s attention from the patient.
  2. The patient is paying for the anesthesiologist’s undivided attention, and most well-informed patients want to know if the anesthesiologist plans to turn over a portion of their anesthesia care to a nurse or resident. If we are obliged to honestly answer that concern, then, shouldn’t we also be obliged to inform the patient that we plan to read during a portion of the anesthetic?
  3. Reading is medico-legally dangerous. Dr. Monk wrote, “Any plaintiff’s attorney would love to have a case in which the circulating nurse would testify, ‘Dr. Giesecke was reading when the cardiac arrest occurred. Yep, he was reading the Wall Street Journal. You know he has a lot of valuable stocks that he must keep track of.’ It is possible that if anesthesiologists informed their malpractice carriers that they routinely read during cases, the companies might raise premiums or cancel malpractice coverage.”
  4. The practice of reading in the OR projects a negative public image. Nurses, technicians, and surgeons may think the anesthesiologist is less professional.

A 2009 study looked at 172 selected general anesthetic cases in an academic medical center. Vigilance was assessed by the response time to a randomly illuminated alarm light. Reading was observed in 35% of cases. In the 60 cases that involved reading, providers read during 25  +/- 3% of maintenance time but not during induction or emergence. Vigilance to the alarm light was no different between readers and non-readers.

Miller’s Anesthesia (7th Edition, 2009, chapter 6) states, “Although it is indisputable that reading can distract attention from patient care, there are no data at present to determine the degree to which reading does distract attention, especially if the practice is confined to low-workload portions of a case. Furthermore, many anesthetists pointed out that reading as a distraction is not necessarily any different from many other kinds of activities not related to patient care that are routinely accepted, such as idle conversation among personnel.”

A 2012 study concluded there were no data concerning the effects of the use of laptops and smartphones in the operating theatre on anesthetist performance, and that these devices were now in frequent use. They discussed the use of laptops and smartphones in regards to the two pertinent issues of vigilance and multitasking. There were data that in some circumstances the addition of a secondary task (i.e. using a laptop or smartphone) during periods of low stimulation can improve vigilance and overall task performance, but the workload and the nature of the secondary task were critical. The authors made the following points regarding the nature of anesthesia work and the factors that affect performance in anesthesia:

  1. Anesthesia involves multi-tasking and the maintenance of situational awareness. Studies have shown that attending to a range of tasks simultaneously is a key characteristic of anesthetic practice, and that anesthetists are superior to non-anesthetists in performing additional tasks while monitoring patients.
  2. Anesthetists typically only glance at monitors. Covert observations of anesthetists in British Columbia revealed subjects spent less than 5% of their time observing the monitoring display. This was made up of brief glances (1.5 to 2 seconds duration) occurring 15 – 20 times during each 10-minute segment of time.
  3.    Anesthetic work is reduced during prolonged maintenance, potentially resulting in boredom and/or secondary activities being undertaken. The maintenance phase in some anesthetics (typically cases of longer duration, lower complexity and where the patient is stable) may be a time of low workload and infrequent task demands. In a study of 105 anesthesia clinicians, half reported being bored infrequently, but 90% admitted to occasional episodes of extreme boredom. Boredom can result in severely decreased vigilance if the anesthetist is suffering from sleep deprivation.
  4.    The authors concluded there was no evidence to support a blanket prohibition on the use of smartphones and laptops in the operating theatre, and there was good reason to avoid edicts that are not supported by solid evidence. They stated, “There is no doubt that reading or computer usage gives the appearance of being less attentive, even if there are no measurable effects on routine care…Computer and phone tasks that also require immediate responses appear to provide a greater risk than reading (whether from a book or screen). While boredom may be cognitively unpleasant, there is no evidence of anesthetist boredom (in the absence of sleep) harming patients.”

I recently attended the American Society of Anesthesiologists national convention in San Francisco. At the conclusion of the meeting, the ASA emailed me a full text edition of the Refresher Course lectures as an email attachment, in a format designed to be downloaded onto a computer. Like myself, more than 10,000 anesthesiologist attendees of the ASA meeting will now have access to the Refresher Course curriculum on their laptops or iPads. Will some of them read these Refresher Courses during the stable maintenance phases of anesthetics in their operating rooms? Perhaps.

Returning to the Clinical Case for Discussion above, what will you do about your colleague you discovered using his iPad in the operating room? My guess is, based on what has been published in the anesthesia literature, you’ll give him the bathroom break as intended, and say nothing about his use of the iPad in the operating room.

 

 

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

 

 

HOW TO WAKE UP PATIENTS PROMPTLY FOLLOWING GENERAL ANESTHETICS

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

Two patients arrive simultaneously in the recovery room following general endotracheal anesthetics. One patient is unresponsive and requires an oral airway to maintain adequate respiration. In the next bed, the second patient is awake, comfortable and conversant. How can this be? It occurs because different anesthetists practice differently. Some can wake up patients promptly, and some cannot.

 

Does it matter if a patient wakes up promptly after general anesthesia? It does. An awake, alert patient will have minimal airway or breathing problems. When it’s time to walk away from your patient in the recovery room, you’ll worry less if your patient is already talking to you and has minimal residual effects of general anesthesia. Whether the surgery was a radical neck dissection, a carotid endarterectomy, a laparotomy, or a facelift, it’s preferable to have your patient as awake as possible in the recovery room.

What can you do to assure your patients wake up promptly? A Pubmed search will give you little guidance. There’s a paucity of data or evidence in the medical literature on how to wake patients faster. You’ll find data on ultra-short acting drugs such as propofol and remifentanil. This data helps, but the skill of waking up a patient on demand is more an art than a science. Textbooks give you little advice. Anesthesiologist’s Manual of Surgical Procedures, (4th Edition, 2009), edited by Jaffe and Samuels, has an Appendix that lists Standard Adult Anesthetic Protocols, but there is little specific information on how to titrate the drugs to ensure a timely wakeup.

Based on 29 years of administering over 20,000 anesthetics, this is my advice on how to wake patients promptly from general anesthesia:

  1. Propofol. Use propofol for induction of anesthesia. You may or may not choose to infuse propofol during maintenance anesthesia (e.g. at a rate of 50 mcg/kg/min) but if you do, I recommend turning off the infusion at least 10 minutes before planned wakeup. This allows adequate time for the drug to redistribute and for serum propofol levels to decrease enough to avoid residual sleepiness.
  2. Sevoflurane. Sevoflurane is relatively insoluble and its effects wear off quickly when the drug is ventilated out of the lungs at the conclusion of surgery. I recommend a maintenance concentration of 1.5% inspired sevoflurane in most patients. I drop this concentration to 1% while the surgeon is applying the dressings. When the dressings are finished, I turn off the sevoflurane and continue ventilation to pump the sevoflurane out of the patient’s lungs and bloodstream. The expired concentration will usually drop to 0.2% within 5-10 minutes, a level at which most patients will open their eyes.
  3. Nitrous oxide. Unless there is a contraindication (e.g. laparoscopy or thoractomy) I recommend you use 50% nitrous oxide. It’s relatively insoluble, and adding nitrous oxide will permit you to utilize less sevoflurane. I recommend turning off nitrous oxide when the surgeon is applying the dressings at the end of the case, and turning the oxygen flow rate up to 10 liters/minute while maintaining ventilation to wash out the remaining nitrous oxide.
  4. Narcotics. Use narcotics sparingly and wisely. I see overzealous use of narcotics as a problem. Prior to inserting an endotracheal tube, it’s reasonable to administer 50 – 100 mcg of fentanyl to a healthy adult or 0 -50 mcg of fentanyl to a geriatric patient. A small dose serves to blunt the hemodynamic responses of tachycardia or hypertension associated with larynogoscopy and intubation. Bolusing 250 mcg of fentanyl prior to intubation is an unnecessary overdose. The use of ongoing doses of narcotics during an anesthetic depends on the amount of surgical stimulation and the anticipated amount of post-operative pain. You may administer intermittent increments of narcotic (I may give a 50-100 mcg dose of fentanyl every hour) but I recommend your final narcotic bolus be given no less than 30 minutes prior to the anticipated wakeup. Undesired high levels of narcotic at the conclusion of surgery contribute to oversedation and slow awakening. If your patient complains of pain at wakeup, further narcotic is titrated intravenously to control the pain. Your patient’s verbal responses are your best monitor regarding how much narcotic is needed. Your goal at wakeup should be to have adequate narcotic levels and effect, but no more narcotic than needed.
  5. Intra-tracheal lidocaine. I recommend spraying 4 ml of 4% lidocaine into the larynx and trachea at laryngoscopy prior to inserting the endotracheal tube. I can’t cite you any data, but it’s my impression that patients demonstrate less bucking on endotracheal tubes at awakening when lidocaine was sprayed into their tracheas. Less bucking enables you to decrease anesthetic levels further while the endotracheal tube is still in situ.
  6. Local anesthetics. Local anesthetics are your friends at the conclusion of surgery. If the surgeon is able to blunt post-operative pain with local anesthesia or if you are able to blunt post-operative pain with a neuroaxial block or a regional block, your patient will require zero or minimal intravenous narcotics, and your patient will wake up more quickly.
  7. Muscle relaxants. Use muscle relaxants sparingly. Nothing will slow a wakeup more than a patient in whom you cannot reverse the paralysis with a standard dose of neostigmine. This necessitates a delay in extubation until muscle strength returns. Muscle relaxation is necessary when you choose to insert an endotracheal tube at the beginning of an anesthetic, but many cases do not require paralysis for the duration of the surgery. When you must administer muscle relaxation throughout surgery, use a nerve stimulator and be careful not to abolish all twitch responses. Avoid long-acting paralyzing drugs such as pancuronium, as you will have difficulty reversing the paralysis if surgery concludes soon after you’ve administered a dose. Use rocuronium instead. Avoid administering a dose of rocuronium if you believe the surgery will conclude within the next 30 minutes—it may be difficult to reverse the paralysis, and this will delay wakeup.
  8. Laryngeal Mask Airway (LMA). When possible, substitute an LMA for an endotracheal tube. Wakeups will be smoother, muscle relaxants are unnecessary, and narcotic doses can be titrated with the aim of keeping the patient’s spontaneous respiratory rate between 15- 20 breaths per minute.
  9. Temperature monitoring and forced air warming. Cold is an anesthetic. Strive to keep your patient normothermic by using forced air warming. If your patient’s core temperature is low, wakeup will be delayed.

10. Consider remaining in the operating room after surgery until your patient is awake enough to respond to verbal commands. This is my practice, and I recommend it for safety reasons. In the operating room you have all your airway equipment, drugs, and suction at your fingertips. If an unexpected emergence event occurs, you’re prepared. If an unexpected emergence event occurs in an obtunded patient in the recovery room, your resuscitation equipment will not be as readily available. If your patient is responsive to verbal commands in the operating room, your patient will be wakeful on arrival in the recovery room.

Is this protocol a recipe? Yes, it is. You’ll have your own recipe, and your ingredients may vary from mine. You may choose to administer desflurane instead of sevoflurane. You may choose sufentanil, morphine, or meperidine instead of fentanyl. My advice still applies. Use as little narcotic as is necessary, and try not to administer intravenous narcotic during the last 30 minutes of surgery. If you use a remifentanil infusion, taper the infusion off early enough so the patient is wakeful at the conclusion of surgery.

The principles I’ve recommended here are time-tested and practical. Follow these guidelines and you’ll experience two heartwarming scenarios from time to time:  1) Patients in the recovery room will ask you, “You mean the surgery is done already? I can’t believe it,” and 2) Recovery room nurses will ask you, “Did this patient really have a general anesthetic?  She’s so awake!”

Your chest will swell with pride, and you’ll feel like an artist. Good luck.

 

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

HOW IS YOUR ANESTHESIA BILL CALCULATED?

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

How is your anesthesia bill calculated?

 

anesthesia billing

 

It depends. An anesthesiologist’s bill depends on several factors, including:

  1. The duration of the anesthesia care
  2. The complexity of the surgical procedure
  3. The insurance status of the patient

Let’s look at each of these factors in turn:

1. The duration of the anesthesia care.  Anesthesia provider bills are calculated by a simple formula:

Amount of Bill = (Number of Base Units + Number of Time Units) X the dollar value of a Unit.

Every anesthesia company assigns a monetary value to an anesthesia “Unit.” A “Unit” is a 15-minute length of time of anesthesia service. (The price of an anesthesia Unit varies. More on this topic later).

The total amount of an anesthesia bill depends largely on the duration of the anesthesia service, which depends on the duration of the surgery.

Anesthesia time begins when the anesthesia provider starts attending to the patient in the pre-operative area, and ends when the anesthesia provider transfers care to the post-anesthesia care unit (PACU) nurse or to the intensive care unit (ICU) nurse following the surgery.

For most surgeries, a typical timeline involves:

10-15 minutes of anesthesia exam in the pre-operative area,

5 minutes of time transporting the patient to the operating room,

5-10 minutes time inducing anesthesia,

10–40 minutes of time positioning, prepping, and draping the patient,

the entire surgical duration,

5-15 minutes of time to wake the patient up,

5-10 minutes of time to transport the patient to the PACU or ICU,

and 5-10 minutes time to sign the patient over to the nurse’s care in the PACU or ICU.

In the PACU, the anesthesiologist is responsible for the patient’s vital signs, pain control, nausea therapy, and the timing of the patient’s discharge from the PACU, even though the anesthesia billing time concluded when he or she signed the patient’s care to the PACU nurse. Typically the anesthesia provider returns to the pre-operative area to meet the next patient at this time, and the billing time for the next patient commences when the anesthesia provider begins attending to the next patient.

2. The complexity of the scheduled surgical procedure. The Base Unit value for any anesthetic varies with the complexity of the scheduled surgery. The Base Unit value can be as low as 3 Units for a simple procedure such as a finger or a toe surgery, or as high as 25 Units for open-heart surgery.  The Base Unit values are cataloged in a publication called the ASA (American Society of Anesthesiologists) Relative Value Guide. The Base Unit value reflects the degree of work and risk involved in the anesthetic management for each type of surgery.

3. The insurance status of the patient. The United States government sets a cap on how much Medicare and Medicaid patients can be billed. The dollar value per anesthesia Unit is severely discounted for Medicare and Medicaid patients to a number as low as one-fourth to one-fifth the amount a non-Medicare or Medicaid patient is billed.

                                                                                                                                               

FURTHER DISCUSSION…

THE PRICE OF AN ANESTHESIA UNIT: The price of an anesthesia Unit is set by the billing anesthesiologist and his or her anesthesia company. The price tends to be higher in major metropolitan centers, lower in rural areas, and lowest for Medicare patients. The price of an anesthesia Unit may vary from as high as $140/Unit in a major metropolitan area to a low of $20/Unit for a Medicare or a Medicaid patient.

EXAMPLE: Let’s look at a sample bill for an elbow surgery. The Base Unit value for elbow surgery is 3 Units. The surgery time was 1 hour, but the total anesthesia time from pre-operative area to the PACU sign out was 1 hour and 45 minutes. One hour and 45 minutes equals 7 Time Units. Let’s assume a Unit value price of $90/Unit.

Using the formula above,

Amount of Bill = (Number of Base Units + Number of Time Units)  X  the dollar value of a Unit.

OR

Amount of Bill = (3 Units + 7 Units) X $90/Unit = 10 X 90 = $900.

Will the anesthesia provider collect $900? Most likely not. Insurance companies negotiate with physicians, and the result of such negotiations may result in significant discounts paid on Unit values compared to billed rates. If the anesthesia group has a signed contract with an insurance company, the agreed reimbursement may be $60/Unit, and the maximal allowed bill would be $600.

In addition, if your insurance coverage requires you to pay for 20% of the bill, the insurance company may only pay 80%, or $480, and you will be expected to pay $120. If the anesthesiology company does not have a contract with the insurance provider, the insurance company will reimburse an out-of-network amount, usually less than the full $900, and you may be responsible for the balance of the bill (unless the anesthesia company is willing to discount the bill under these circumstances).

There are advantages of growing old. If you’re a Medicare patient, your anesthesia bill may total only $200:

(3 Units + 7 Units) X $20/Unit = 10 X 20 = $200.

COSMETIC SURGERY: Insurance companies do not pay for plastic surgeries such as liposuction, breast implants, or facelifts. Patients must pay the surgeon, operating room, and anesthesia bills in advance. Most anesthesiologists discount their customary rates in return for cash prepayment.

THE FUTURE: The nature of anesthesia billing may change in the future to embrace a concept known as “bundled payments.” Obamacare, or the Affordable Care Act, outlines provisions for bundled payments to hospitals rather than the traditional fee-for-service reimbursements described above. In a bundled payment model, the medical team will receive a lump sum from the government (or from an insurance company) for a surgical procedure. The medical center and physicians will negotiate and decide how to divide up the money between the surgeon, the anesthesiologist, and to the hospital (the hospital share will cover nurse salaries, technician salaries, supplies, and the overhead to run the hospital).

To date there is little data to support the advantage of bundled payments. The government hopes to save money by limiting what it pays out per procedure. Time will tell how prevalent this reimbursement model will be in the future of American healthcare economics.

When you buy retail goods, prices are available prior to purchase. With medical bills, you rarely know what the price of your medical care will be until you receive the bill weeks afterward. This is likely to change. There is momentum moving toward transparent pricing of medical fees, including listing of physician fees and facility fees prior to patient care. In the future you may have access to physician, hospital, and surgery center pricing to assist you in making your medical care choices.

SUMMARY: Your anesthesia bill will depend on how complex a surgery you are scheduled for, how long it takes to complete the procedure, and what kind of insurance coverage you have. Armed with this information, you may choose to contact your surgeon, the anesthesia company he or she works with, and your insurance company prior to your surgery to understand what your anesthesia bill is likely to be.

 

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

 

 

ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: ANESTHETIC TECHNIQUES

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 column is for non-medical laypeople, and pertains to the different types of anesthetic techniques used in the 21st century. See below:

GENERAL ANESTHESIA

A general anesthetic renders the patient asleep and insensitive to pain for surgery. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. Before the anesthetic, oxygen is administered by mask to fill the patient’s lungs with 100% oxygen. Most adult patients are given general anesthesia by intravenous injection, usually of the medication propofol. This injection causes the patient to lose consciousness within 10 – 20 seconds. This is called the induction of anesthesia. The maintenance of anesthesia during surgery is done by mixing an anesthesia gas or gases with the oxygen. Typical inhaled anesthesia gases are nitrous oxide, sevoflurane, or isoflurane. Sometimes a continuous infusion of intravenous anesthetic such as propofol is given as well. The choice and dose of drugs is done by the anesthesia attending, based on the patient’s size, age, the type of surgery, and the anesthesiologist’s experience.

Many patients are given prophylactic anti-nausea medication during the anesthetic. If postoperative pain is anticipated, the anesthesiologist can also administer intravenous narcotics such a morphine, meperidine (Demerol), or fentanyl.

Depending on the patient’s medical condition and type of surgery, the anesthesiologist may protect the patient’s airway during the general anesthetic by placing a breathing tube through the mouth, either an endotracheal tube (ET Tube) into the patient’s windpipe, or a laryngeal mask airway (LMA) just above the voice box.

At the conclusion of surgery, the general anesthetic gases and/or intravenous anesthetic infusion(s) are discontinued. The patient usually regains consciousness within 5 – 15 minutes. The patient is then transferred to the recovery room.

SPINAL ANESTHESIA

Spinal anesthesia is done by the injection of local anesthetic solution into the low back into the subarachnoid space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word subarachnoid translates to “below the arachnoid”. The arachnoid is one of the layers of the meninges covering the nerves of the spinal column. In the subarachnoid space lies the cerebral spinal fluid (CSF) which surrounds the spinal cord and brain. In a spinal anesthetic, the subarachnoid space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the subarachnoid space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from spinal anesthesia, the patient may either stay awake for surgery, or more often intravenous anesthesia is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement spinal anesthesia.

EPIDURAL ANESTHESIA

Epidural anesthesia is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.   Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given.  The catheter is removed at the end of surgery, or sometimes days later if continued epidural medications are administered for postoperative pain control.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the epidural space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from epidural anesthesia, the patient may either stay awake for surgery, or more often intravenous sedation is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement epidural anesthesia.

REGIONAL ANESTHESIA

Regional anesthesia is the injection of local anesthetic (either lidocaine or Marcaine) near a nerve to block that nerve’s function.  Examples of regional anesthesia include arm blocks (axillary block, interscalene block, subclavicular block), and leg blocks (femoral block, sciatic block, popliteal block, ankle block).  An advantage of regional anesthesia blocks is that the patient may remain awake for the surgery.  If desired, the anesthesia provider may administer intravenous sedation or general anesthesia in addition to the regional anesthetic, to allow the patient to sleep during the surgery–the advantage of this combined anesthetic technique is the regional anesthetic blocks all surgical pain and less sleep drugs are required.

INTRAVENOUS SEDATION ANESTHESIA

Some minor surgical procedures (for example: breast biopsies, eyelid surgery, some hernia surgeries) can be done with the combination of local anesthesia plus intravenous anesthesia sedation. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The anesthesiologist is present for the entire surgery, and administers intravenous sedatives as required for the patient’s comfort and the surgeon’s needs.  If the sedation is deep enough, the intravenous sedation will be termed general anesthesia. While the patient is sedated, the surgeon usually injects local anesthetics into the surgical site to block both surgical and post operative pain.

Vigilance by an anesthesiologist during intravenous sedation is also known as Monitored Anesthesia Care, or MAC.

PEDIATRIC ANESTHESIA

Because the separation of a young child from his or her parents can be one of the most distressing aspects of the perioperative experience, many children benefit significantly from oral preoperative sedation with midazolam. This relatively pleasant-tasting liquid is given by mouth about twenty minutes prior to the start of the anesthetic. Although the midazolam rarely causes children to fall asleep, it does reduce anxiety dramatically, allowing for a much smoother separation from parents. It also tends to cause a wonderful short term amnesia, so that the children often have no recollection of separating from their parents, or even of going to the operating room.
Although the initial anesthetic is usually administered via an intravenous infusion in adult patients, this approach requires starting an IV while the patient is still awake. This technique would be quite unpopular with younger children.  Most young children prefer to go to sleep breathing a gas, a technique known as an inhalation induction. This technique is used for almost all routine surgeries, but cannot safely be employed in certain rare situations, such as emergencies.

An inhalation induction consists of the child breathing a relatively pleasant smelling anesthetic vapor – usually sevoflurane – via a facemask for approximately 30 to 60 seconds. The child loses consciousness while breathing the gas, and the IV can then be started painlessly. Generally, the child continues to breath the gas throughout the duration of the surgery, either via the facemask or an endotracheal tube, depending on the duration and type of surgery. It is this breathing of the gas which keeps the child anesthetized. At the end of the surgery, the gas is discontinued, and the child begins to awaken.

Prior to awakening, children may be given either analgesics (pain medicines) or anti-emetics (drugs which reduce the likelihood of nausea and vomiting). The type of surgery will determine which of the many possible medications will be used for these purposes. The purpose of these medications is to make the child’s awakening as calm and pleasant as possible. Equally important in this regard is reuniting the child with his or her parents as quickly as possible.
Despite best attempts, it is important for parents to realize that children, especially those less than five years of age, often are somewhat cranky and irritable following anesthesia and surgery. We do our best to minimize this, but we cannot prevent it in all cases. Similarly, some children will experience postoperative nausea and vomiting despite receiving medications which are intended to prevent it.

 

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: