WHAT’S NEW UNDER THE ANESTHESIA SUN? LETTER GRADES FOR 13 MAJOR CHANGES IN THE LAST TEN YEARS OF OUR PROFESSION:

 

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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.

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

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10 TRENDS FOR THE FUTURE OF ANESTHESIOLOGY

 

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What can we expect in the next 10 years of anesthesiology? I’m writing this in January 2016. God willing, we’ll all be alive and well to reread this in 2026, and find out how many of these predictions came true.

I’m writing this from the perspective of a busy clinician who has worked as an anesthesiologist in California in both private practice and at a major university hospital for over 30 years. I see 10 trends for the future of anesthesiology as:

  1. Lower income (as adjusted for inflation). There will be multiple causes for this: a) An aging population, with the significantly lower pay for attending to Medicare patients, b) Obamacare and other governmental payment cuts, c) Bundled insurance payments to hospitals, requiring anesthesiologists to negotiate for every nickel of that payment due to them, and d) Corporate anesthesia (see #9 below).
  2. More care team anesthesia and more Certified Nurse Anesthetists (CRNAs). Hospital systems will have increased incentives to perform anesthetics with cheaper labor. Rather than physician anesthesiologists personally performing anesthesia, expect to see CRNAs supervised by physician anesthesiologists in an anesthesia care team, or in some states, CRNAs working alone.
  3. There will be a paucity of new drugs to change the practice of operating room anesthesia. A few years ago I had a conversation with Don Stanski, MD, PhD, former Chairman of Anesthesiology at Stanford and now a leading pharmaceutical company executive, regarding new anesthetic drugs in the pipeline. Dr. Stanski’s reply was something along the line of, “There are almost no new anesthetic drugs in development. The ones we currently have work very well, and the research and development cost in bring an additional idea to market is high. Don’t expect much change in the coming years.” Consider sugammadex, a new drug for the reversal of neuromuscular blockade, recently approved by the Food and Drug Administration. The drug is more effective in reversing a rocuronium or vecuronium block than is neostigmine, but the cost is high. The acquisition cost of the smallest available vial of sugammadex is over $90, far exceeding the cost of neostigmine. In certain instances, faster reversal by sugammadex will be critically important, but for routine cases the cost is prohibitive. This trend of fewer new anesthesia drugs isn’t only a futuristic phenomenon. In my current private practice, I see my colleagues using the same medications that they used 25 years ago: propofol, sevoflurane, rocuronium, fentanyl, and ondansetron.
  4. An aging population, an increased volume of surgery, and an increased demand for anesthesia personnel. As the baby boomers age, there will be an increased number of surgeries on older, sicker patients. Anesthesia personnel will be in great demand.
  5. Anesthesiology will become more and more a shift-work job. A generation ago an anesthesiologist started a case and finished that case. An on-call anesthesiologist came to work at 7 a.m., took 24-hour call, and finished their last case as the sun came up the next morning. Certain instances of this model may persist, but as more anesthesiologist become corporate employees, expect more anesthesia practitioners working 8-hour or 12-hour shifts, just like employees in other jobs.
  6. Increased interest in the specialty of anesthesiology amongst medical students. Although several items on my list may seem discouraging, take heart, because the career of anesthesiology will remain extremely popular. Why? Because the other fields of medicine have problems, too. Bigger problems. Many future doctors will shun the primary care fields of family practice, internal medicine, and pediatrics. The primary care fields offer long days in clinics, dealing with a new patient every 10 – 15 minutes, and they suffer from low pay. Because of the higher reimbursement in procedural specialties, careers in surgery, anesthesia, cardiology, and invasive radiology will always be popular.
  7. Expect improved safety statistics regarding anesthesia mortality and morbidity. Anesthesia has never been safer. See “How Safe is Anesthesia in the 21st Century?” Expect further improvements in monitors, protocols, education, and the analysis of Big Data that will make anesthesia safer than ever.
  8. There will still be a non-zero incidence of anesthesia-related fatalities. There will still be disasters, particularly airway disasters. Some anesthesia clinical situations will always remain extremely difficult and challenging, and human error will not be eradicated.
  9. Large national corporations will continue buying up private anesthesia practices, perhaps eliminating the current model in which groups cover one hospital or one city alone. In the last three months, Sheridan, the physician services division of AmSurg, Corp has purchased the 60-physician, 140-anesthetist Northside Anesthesiology Consultants in Atlanta, and the 240-physician Valley Anesthesiologists & Pain Consultants in Phoenix. In these purchases, senior board members and partners receive seven-digit checks to sell their practice, then all physicians in the practice’s future labor for a discounted wage, perhaps as low as 50% of the prior income. If this trend becomes widespread, this subset of the anesthesia workforce will become low paid practitioners, while the purchasing corporations will make significant profits for their stockholders.
  10. Continued fascination with anesthesia practice, a discipline which makes all surgical treatments and cures feasible. Without anesthesia, there can be no major surgical procedures. Medical care without major surgical procedures is unthinkable. Whether as anesthesia providers, as patients requiring surgery, or just as observers of the process, we will all continue to value and marvel at the field of anesthesia.

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

ZDoggMD MUSIC VIDEO TRASHES ELECTRONIC MEDICAL RECORDS IN A TRUTHFUL, PERTINENT, AND HILARIOUS VISION

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I’m not a fan of the current state of Electronic Health Records (EHR), also known as Electronic Medical Records (EMR). Particularly in acute care, the computer keyboard and screen have no place between an anesthesiologist and his patient, an emergency room physician and his patient, an ICU doctor and his patient, or an ICU nurse and her patient.

In a past column I identified the EHR as the most overrated advance affecting anesthesia practice in the past 25 years.

ZDoggMD expresses similar sentiment in his powerful and humorous You Tube video An EHR State of Mind, in which he raps about Electronic Health Records to the tune of Jay Z’s and Alicia Key’s hit single An Empire State of Mind.

 ZDoggMD is a former Stanford physician known for his music videos, parodies, and comedy sketches regarding contemporary medical issues and work in the medical field. ZDoggMD is played by Dr. Zubin Damania, CEO and Founder of Las Vegas-based Turntable Health. Dr. Damania attended UC Berkeley in the early 1990s, followed by medical school at UCSF and residency at the Stanford University School of Medicine.

Check out his website at http://zdoggmd.com. Links exist to multiple equally funny satiric videos. You’re sure to be entertained.

I agree with him that the current cumbersome EHRs come between doctors and patients during hospital care. My criticisms include:

  1. Different EHRs at different hospitals are unable to communicate with each other.
  2. If you work at different hospitals with different EHRs, you have to be trained and retrained in multiple EHR platforms.
  3. With an EHR it takes at least 5 clicks to chart “atropine 0.4 mg.” In the past with a paper record you would merely write “0.4” on the atropine line.
  4. Nurses consistently have their backs to patients as they type, type, type data into computer terminals. In an operating room, the circulating nurse’s job is analogous to that of a court reporter/stenographer. Florence Nightingale would have had a stroke.
  5. As ZDoggMD points out in his video, the current EHR is a “glorified billing platform with some patient stuff tacked on.” Hospitals spend hundreds of millions of dollars to install the EHR, and then tell us that the EHR will help them bill and collect money at a superior rate. The economics don’t add up, and have nothing to do with patient care.
  6. With an EHR, instead of writing a pertinent note at each patient encounter, health care providers copy and paste previous notes, altering the minimal differences at each encounter. This habit makes it difficult to ferret out the pertinent information in, for example, a six-page copied template.

ZDoggMD challenges us as healthcare providers. On his website he writes, “We on the front lines of healthcare need to stand up and demand that our organizations, government, and tech vendors stop letting the unintended consequences of legislation and technology wreck our sacred relationship with patients while destroying our ability to do what we do without having to tell our kids to stay as far away from medicine as they can. Great technology [insert Steve Jobs fanboy comments here] can be the glue that connects us…”

Indeed, I wish Apple Computers would create an EHR which was as intuitive and easy as their iPad software.

Perhaps in the future the state of mind of an EHR will be superior. As of now, as ZDoggMD points out, it is not.

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

AN ANESTHESIA PATIENT QUESTION: “WHY DID IT TAKE ME SO LONG TO WAKE UP AFTER ANESTHESIA?”

I often hear this question from patients. A previous anesthetic left them somnolent all day after surgery, and/or they felt sleepy or ill for days after a previous surgery. They wonder if they are at increased risk for anesthesia, if something went wrong in their past anesthetics, and whether they can do about it.

Whenever a patient tells me they’ve been very sensitive to anesthesia in the past, they’re always right. The good news for patients is: you probably can do something to help yourself in the future.

The most valuable thing you can do is obtain a copy of your previous anesthetic record and Post Anesthesia Recovery Room records from a surgery in which you had a perceived prolonged wake up. Save these documents and present them to future anesthesiologists. Inform future anesthesiologists regarding your history of prolonged sedation, and they can make adjustments in their drug delivery and techniques to attempt to avoid the same problems. Future anesthesiologists can administer lower doses of medications or fewer medications as they deem advisable.

The world’s foremost anesthesia textbook, Miller’s Anesthesia, does not have a specific section or chapter on the topic of avoiding prolonged wake ups. If you search the Internet or the PubMed website for a discussion of the topic “prolonged awakening from anesthesia,” you’ll find a shortage of useful information. Few papers have been published on the topic.

But every case of prolonged wake-up has its own story. General anesthetics and sedative drugs work by anesthetizing the brain and central nervous system. Based on thirty years as an anesthesiologist, the personal administration of 25,000+ anesthetics, and information from medical textbooks, what follows are lists of the primary factors which cause prolonged sedation after anesthesia.

Patient characteristics that correlate with prolonged awakening after anesthesia:

  1. Patients with a past history of slow awakening from anesthesia.
  2. Patients who are naïve to central nervous system depressants in their weekly life. That is, they never or very rarely drink alcohol, and never take sedating medications of any kind. Chronic alcohol consumption increases the dose of propofol required to induce loss of consciousness (Fassoulaki, A et al. Chronic alcoholism increases the induction dose of propofol in humans.Anesthesia and Analgesia. 1993;77(3):553-556). Conversely, patients who have zero or modest exposure to drugs like alcohol can require lower doses of anesthetic drugs.
  3. Patients who claim they are “sensitive to all medicines.”
  4. Elderly patients. As you age your ability to metabolize medications decreases. Older persons, especially those over the age of 70-80 years, require lower doses.
  5. Obese patients. Intravenous doses of medications are calculated according to a patient’s weight, but this number should be their lean body weight, not their weight including excess fat. Imagine two patients who are the same age and height, but one weighs 150 pounds and the second weighs 300 pounds. The second patient will need higher doses than the first, but will not require twice the dose. Markedly increasing the weight of fat cells does not mean the brain needs twice the dose of medications.
  6. Petite patients. What if an anesthesia provider administers his or her standard recipe for anesthesia without noticing that their current patient only weighs 88 pounds? Standard doses for a 150-pound person will be excessive in an 88-pound patient.
  7. Patients with decreased function of one or more of the major organ systems, that is the heart, lungs, liver, or kidney. Depending on the medication, one or more of these organ systems are required to clear the drug from the body. A patient with heart failure or decreased cardiac output will not be able to pump the drug efficiently throughout the body to the lungs, liver, or kidneys to clear the drug. A patient with decreased lung function/ventilation will not be able to exhale vapor anesthetics promptly. A patient with decreased liver function will not be able to clear certain drugs like narcotics from the body promptly. A patient with decreased kidney function will not be able to clear paralyzing drugs such as the muscle relaxant rocuronium from the body promptly.
  8. Patients with an abnormal brain. For example, patients with dementia, delirium, congenital developmental delay, or any organic brain syndrome may experience increased post-operative sedation due to exaggerated effects of the anesthetic medications on their brains.

Medical circumstances that contribute to prolonged patient awakening after anesthesia:

  1. The longer the surgery and anesthetic duration, the longer the wake up time. This is because the longer exposure to anesthetic drugs requires a longer time to exhale the vapor drugs or to clear and metabolize the intravenous drugs.
  2. The more complex the surgery, the longer the wake up time. Certain surgeries, for example a liver transplant, are so complex that an anesthesiologist often plans to keep the patient asleep in the intensive care unit after the surgery until the first post-operative day.
  3. An inexperienced anesthetist may resort to a standard recipe for every patient, and administer a more heavy-handed concoction of anesthetic drugs than are necessary for patients in our first list above.
  4. Painful surgery. Any surgery which hurts a great deal will require increased pain-relieving medications in the Post Anesthesia Recovery Room. Pain-relieving medications include narcotics such as morphine or fentanyl, which are sedating and sometimes nauseating. The less of these medicines you require, the more alert you’ll feel. Local anesthetic injections by the surgeon or a regional anesthesia nerve block by the anesthesiologist can decrease your need for narcotics, decrease post-operative pain, and decrease your risk of prolonged sedation after surgery.

You have little control over the drugs you’ll be given during surgery, but please inform and remind your anesthesiologist regarding any characteristics from the first list above. An honest discussion of your previous bad anesthetic experience(s), together with obtaining a copy of a previous anesthetic record(s), may grant you some control regarding how sedated you feel after future anesthetic experiences.

YOU are your own best advocate. Don’t be afraid to inform your anesthesiologist.

I refer you to a related column, HOW LONG WILL IT TAKE ME TO WAKE UP FROM GENERAL ANESTHESIA?

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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HOW COMMON ARE CARDIAC ARRESTS DURING SURGERY AND ANESTHESIA?


How common are cardiac arrests during surgery?

Uncommon, but the incidence is not zero and the outcome is usually dire.

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.

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

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SERIALIZATION OF THE DOCTOR AND MR. DYLAN … CHAPTER THREE

3) QUEEN ALEXANDRA APPROXIMATELY

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

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

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

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

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

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

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

“How are you?” she said.

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

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

“How much is the Jorgensen house listed for?”

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

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

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

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

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

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

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

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

“He said you called him a lazy shit.”

“I did. He is a lazy shit.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Great plan?” Contempt turned to suspicion.

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

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

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

“Duh. Of course, Mom.”

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

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

“No weed.”

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

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

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

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

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

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

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

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

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

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

“Whoa. Harvard?”

“Yes, Harvard.”

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

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

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

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

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

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

“That’s not true.”

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

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

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

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

“Yep. The Chinese food hit the spot.”

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

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

“Amanda’s history,” Johnny said.

“History?”

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

“What happened?”

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

“She was cute.”

“Yep.”

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

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

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

“Yeah, like what?”

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

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

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

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

“Even if you can’t get one A.”

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

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

“That’s insane.”

“It ain’t California.”

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

“Good night, son. I love you.”

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

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

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

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

Again.

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

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

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

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

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

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

“I don’t believe you.”

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

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

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

“What are you talking about?”

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

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

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

“Are you having an affair?” I screamed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

He had my attention.

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

“It was.”

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

“Do it?”

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

“You mean it?”

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

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

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

“Can’t wait, Daddy-O,” Johnny said.

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

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

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

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ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: WHY DO I HAVE TO STOP EATING AND DRINKING AT MIDNIGHT BEFORE SURGERY?

“Why do I have to stop eating and drinking prior to surgery?” This is a common question I hear from my patients—they’re puzzled by the connection between going to sleep and avoiding eating after midnight the day prior to surgery.

It’s vital that your stomach is empty prior to elective surgery and anesthesia. Once you’re anesthetized, your cough reflex and gag reflex are abolished. These reflexes prevent food or liquids from entering your windpipe or your lungs, and are life-protecting reflexes in awake, healthy humans.

Under anesthesia these reflexes are absent. If you vomit or regurgitate stomach contents into your mouth, the material can descend into your windpipe or lungs. The complication of stomach contents entering your lungs is a dire event. The medical term for this occurrence is aspiration pneumonia. Aspiration refers to inhaling, and pneumonia refers to an inflammation of the lung tissue. In severe aspiration pneumonia, the lungs fail to exchange oxygen from the airways into the bloodstream, and brain and heart oxygen levels can drop to life-threatening lows.

The American Society of Anesthesiologists guidelines for fasting prior to elective surgery requiring general anesthesia, regional anesthesia, or conscious sedation/analgesia are as follows:

Fried or fatty foods                                                8 hours

A light meal (toast and clear liquids)                     6 hours

Non-human milk                                                    6 hours

Breast milk                                                             4 hours

Infant formula                                                         4 hours

Clear liquids                                                            2 hours

Clear liquids may be consumed up to 2 hours prior to anesthesia. Clear liquids include water, fruit juices without pulp, soda beverages, Gatorade, black coffee or clear tea. Milk and thick juices with pulp are not clear liquids.

These fasting guidelines do not apply to surgical procedures under local anesthesia, or to those with no anesthesia. You don’t have to fast for a dentist office visit, for example. The guidelines do apply for colonoscopies or upper gastrointestinal endoscopy procedures. The intravenous sedation drugs used for endoscopy procedures may sedate you to a deep enough level such that your gag and cough reflexes are absent.

In certain conditions, the stomach will be considered to be full even if the patient has not eaten or consumed fluids for eight hours. Acute pain syndromes such as appendicitis, a gall bladder attack, a broken bone, or a febrile illness are known to diminish the stomach’s emptying, and anesthesiologists treat these patients as if they had a full stomach whether they’ve fasted or not. Pregnant women and morbidly obese patients are also treated as having full stomachs for any surgery, because of delayed stomach emptying due to increased intra-abdominal pressure.

If a patient presents for emergency surgery, the anesthesiologist must proceed without waiting for the recommended fasting times. On induction of general anesthesia, the physician anesthesiologist will have a second individual (a nurse or a physician) apply downward pressure on the cricoid cartilage of the patient’s neck immediately upon loss of consciousness. The science of this is as follows: the circumferential ring of the cricoid cartilage encircles the windpipe.

Pushing downward on this ring compresses the esophagus below, to prevent passive regurgitation or vomiting of stomach contents. This pressing-down maneuver is called “giving cricoid pressure” or “the Sellick Maneuver,” named after Dr. Brian Arthur Sellick, the anesthesiologist who first described the maneuver in 1961. Inducing anesthesia using the Sellick maneuver is referred to as a Rapid Sequence Induction (RSI) of general anesthesia. In a RSI the anesthesiologist administers into the patient’s intravenous line: 1) a hypnotic drug such as propofol, followed by 2) a rapid paralyzing drug such as succinylcholine. The endotracheal breathing tube can then be placed in the windpipe within about 30 seconds after the loss of consciousness. The Sellick maneuver is held throughout those 30 seconds until medical confirmation that the tube is in the windpipe.

If stomach contents enter the upper airway at any time during an induction of anesthesia, the anesthesiologist will see vomitus in the patient’s mouth or inside the clear plastic facemask. The anesthesiologist may also detect evidence of inadequate oxygen exchange—i.e. the patient’s pulse oximeter readings will decline to less than the safe level of 90%. The anesthesiologist will then suction the upper airway and place a breathing tube into the windpipe as soon as possible. This tube is called an endotracheal tube, and it has a balloon near its tip. When inflated, the balloon protects stomach contents from descending into the lungs.

The anesthesiologist will then suction out the lungs through the inside the breathing tube. Suction catheters of varying length and diameters exist for this purpose. The surgery will likely be cancelled if it has not yet started. If the aspiration of stomach contents occurs in the middle of surgery, it’s likely the surgery will be aborted or shortened.

As I have written in multiple posts on this website, all critical care medicine resuscitation follows the A-B-C mantra of Airway—Breathing—Circulation. The regurgitation of stomach contents interferes with both A and B by blocking the airway and interfering with breathing.

The medical term for fasting prior to surgery is NPO, which stands for “nil per os,” a Latin phrase for nothing per mouth. If you hear your doctor or nurse say, “Is she NPO?” they’re asking the important question of whether you have fasted as required. Being NPO may seem inconvenient and unnecessary, but it’s critical to assure your health and well being during anesthesia.

Reference: Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters, 2011; Anesthesiology, Vol 14(3), 495-511.

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*
*
*

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited