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

Latest posts by the anesthesia consultant (see all)

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How much money does an anesthesiologist earn?

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?

 

 

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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:

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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

Latest posts by the anesthesia consultant (see all)

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GENERAL ANESTHESIA FOR PEDIATRIC PATIENTS IN 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?

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?

 

 

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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

 

 

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

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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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.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

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ANESTHESIA ERRORS AND COMPLICATIONS: 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

Latest posts by the anesthesia consultant (see all)

 

medical-malpractice-anesthesia-errors-1-638

 

If a patient suffers a bad outcome after anesthesia, did the anesthesiologist commit malpractice?

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

 

 

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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This column is directed to anesthesia professionals. 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 as part of his anesthetic?

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?

 

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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

 

 

WOULD YOU GIVE AN NFL QUARTERBACK A PERIPHERAL NERVE BLOCK?

SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER TWO

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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. “What is it, son?” I said.

“I’m screwed,” Johnny wailed. “I just got my report card for the first semester and my grades totally suck. Mom is mega-pissed. She’s going ballistic, and I’m screwed.”

My shoulders slumped. This was 911 for a 17-year-old? “How bad were the grades?”

“I got six B’s. I didn’t get one A. I just met with my counselor and he says I’m ranked #101 in my high school class. I’m so doomed. Mom is so pissed. She called me a lazy shit.”

I resisted my initial urge to scream at Johnny for scaring the hell out of me. The kid had no insight into what I did minute-to-minute in the hospital. Did he think his report card trumped my medical practice? Did he really think his report card full of B’s was an emergency?

“I’m not sure what’s worse, the grades or Mom’s screaming about the grades,” he said.

I imagined my wife having a temper tantrum about Johnny falling short of her straight-A’s standard of excellence, and I knew the answer to that question. My wife could be a total bitch. “I’m sorry Mom got mad, Johnny, but…”

“No buts, Dad. You know Mom’s idea of success is Ivy League or bust, and I’m a bust.”

“Son, four of your six classes are Advanced Placement classes, and those grades aren’t that bad.”

“Dad, almost everyone in the school takes four AP classes. Every one of my friends got better grades than me. Ray, Brent, Robby, Olivia, Jessica, Sammy, and Adrian all got straight A’s. Devon, Jackson, Pete, and Rod had all A’s and one B. Even Diego had only two B’s.”

“But you…”

Johnny cut me off. “There’s no ‘buts,’ Dad. I’m ranked in the middle of the pack in my class. I’m cooked. I’m ordinary. Forget Harvard and Princeton. I’m going to San Jose State.”

My stomach dropped. Johnny was halfway through his junior year at Palo Alto Hills High School. The competition for elite college acceptance was on my son’s mind every day, and on his mom’s mind every minute. Johnny was a bright kid, but the school stood across the street from Stanford University and was packed wall-to-wall with the sons and daughters of Stanford MBA’s, Ph.D.’s, lawyers, and doctors. Johnny’s situation wasn’t uncommon. You could be a pretty smart kid and still land somewhere in the middle of the class at P.A. Hills High.

“Everything will work out,” I said. “There are plenty of great colleges. You’ll see.”

“Lame, Dad. Don’t talk down to me. You stand there with your doctor job at Stanford and tell me that I’ll be all right. I’ll be the checkout guy at Safeway when you buy your groceries. That’s where I’m heading.”

Catastrophic thinking. Johnny Antone was holding a piece of paper in his hand—a piece of paper with some letters typed after his name—and he was translating it into an abject life of being average.

“Johnny, I can’t talk about this any more right now. My patient …”

“Whatever,” Johnny answered.

I heard a click as he hung up. I hated it when he did that. In the operating room I had authority, and respect was a given. With my family, I was a punching bag for of all sorts of verbal blows from both my kid and my wife.

I reached down and turned off my cell phone. For now, the haven of the operating room would insulate me against assaults from the outside world.

Judith Chang was the neurosurgeon that day. Dr. Chang was the finest brain surgeon in the western United States, and was arguably the most outstanding female brain surgeon on the planet. She peered into a binocular microscope hour after hour, teasing the remnants of the tumor away from the patient’s left frontal lobe. Dr. Chang always operated in silence, and her fingers moved in precise, calculated maneuvers. A 50-inch flat screen monitor on the wall of the operating room broadcast the image she saw from inside her microscope.

I paid little attention to the surgical images, which to me revealed nothing but incomprehensible blends of pink tissues. My full attention was focused on my own 42-inch monitor screen which depicted the patient’s electrocardiogram, blood pressure, and oxygen saturation, as well as the concentration of all gases moving in and out of her lungs. Everything was stable, and I was pleased.

It had been five hours since the initial skin incision. Dr. Chang pushed the microscope away and said, “We’re done. The tumor’s out.”

“A cure?” I said.

“There was no invasion of the tumor into brain tissue or bone. She’s cured.” Dr. Chang had removed a 5 X 10-centimeter piece of the patient’s skull to access the brain, and began the process of fitting the piece back into the defect in the skull—the placement not unlike finishing the last piece in a jigsaw puzzle. As Dr. Chang wired the bony plate into place, she said, “How’s your family, Nico?”

She hadn’t said a word to me in five hours, but once she was finished with the critical parts of surgery, Judith Chang had a reputation as a world-class chatterer. Some surgeons liked to listen to loud rock n’ roll “closing music” as they sewed up a patient. Some surgeons preferred to tell raunchy jokes. Judith Chang enjoyed the sound of her own voice. We hadn’t worked together for months, so we had a lot to catch up on.

“They’re good,” I said. “Johnny’s in 11th grade. He’s going to concerts, playing video games with friends, and sleeping until noon on weekends. Alexandra is working a lot, as usual. She just sold a house on your street.”

“I heard about that property,” Judith said. “You’re a lucky guy. That house sold for close to $5 million. Her commission is more than some doctors earn in a year. In my next lifetime I’ll be a big-time realtor like Alexandra. Does she give you half her income to spend?”

“In theory half that money is mine, but she invests the dough as soon as it hits her checking account.”

“Smart. Is Johnny looking at colleges yet?”

Her question had eerie relevance, because I’d been ruminating over Johnny’s phone call all morning. “That’s a sensitive point. Johnny just got his mid-year report card, and he’s freaking out.”

“How bad was it?”

“Six B’s. No A’s. He’s ranked #101 in a class of 480 students.” I spilled out the whole story while Dr. Chang twisted the wires together to affix the bony plate into the patient’s skull. I left out the “lazy shit” label from Johnny’s mom.

Dr. Chang had no immediate answer, and I interpreted her silence as tacit damning of Johnny’s fate. She opened her mouth and a flood of words began pouring out. “You know my twin daughters Meredith and Melody, who are sophomores at Stanford? They worked their butts off in high school. They were both straight-A students. Meredith captained the varsity water polo team, played saxophone in the jazz band, and started a non-profit charity foundation for an orphanage in Costa Rica. Melody was on the debate team and the varsity tennis team, and for three years she worked with Alzheimer patients at a nursing home in Palo Alto. Meredith and Melody were sweating bullets waiting to hear if Stanford would accept them, even though they were both legacies since I went to undergrad and med school here.

“The college admission game is a bitch, Nico. It’s not like when we were kids. It’s almost impossible to get into a great school without some kind of massive gimmick. It’s a fact that Harvard rejects 75% of the high school valedictorians that apply. Can you believe that?”

I could believe it. And I didn’t really care, since my only kid was at this moment freaking out because his grades qualified him for San Jose State, not the Ivy League. I didn’t care to hear any more about the Chang daughters right now, either. To listen to Judith Chang, her daughters were the second and third coming of Judith Chang, destined for world domination. I was envious of the Chang sisters’ academic successes—what parent wouldn’t be? But I didn’t want to compare them to my own son.

“What are Johnny’s test scores like?” Dr. Chang said.

Ah, a bright spot, I thought. “He’s always excelled at taking standardized tests. His SAT reading, math, and writing scores are all at the 98th percentile or better. His grade point average and class rank don’t match his test scores.”

“Does he have many extracurricular activities?”

“Johnny’s extracurricular activities consist mostly of watching TV and playing games on his laptop. At the same time,” I said, as if the combination of the two pastimes signaled a superior intellect.

Dr. Chang grew quiet again. More silent condemnation of my son’s prospects. “Listen to me,” she said. “My brother is a pharmacist in Sioux Falls, South Dakota. His son got accepted to Princeton, and let me tell you, my nephew isn’t that bright. His test scores aren’t anywhere near as high as Johnny’s. But he just happens to live in South Dakota. He just happens to be a straight-A student in a rural state. He just happens to be one of the best students in South Dakota.”

“How much do you think that matters?”

“It matters big time. The top schools want geographic variety in their student body. Stanford wants diversity. The Ivy League wants diversity. Princeton can find fifty kids from Palo Alto who meet their admission requirements. They want kids from all walks of life. They want … the son of a pharmacist from Podunk, South Dakota. If Johnny lived in South Dakota, with those test scores he’d be a shoo-in with the Ivy League admissions committees.”

Judith Chang turned her back on the operating room table, and peeled off her surgical gloves. The bony plate was back in place, and her patient’s skull was intact again. The surgical resident would conclude the task of sewing the skin closed. Dr. Chang paused for a moment, turned her palms upward, and said, “Just move to the Dakotas, Nico.”

I stroked my chin. She made it sound so easy.

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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

 

 

INEXPERIENCED DOCTORS, OVERCONFIDENT DOCTORS, AND YOU

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

THE JULY EFFECT AND THE NOVEMBER EFFECT

In American teaching hospitals, newly minted doctors begin internships each July. The term “July Effect” was coined to describe this shift change in academic hospitals each July, when the arrival of inexperienced doctors may increase the risks of medical care. In the United Kingdom, newly minted doctors begin their internships each August. In Britain, August has been referred to as the “Killing Season,” because of a perceived increased risk of medical complications, morbidity, and mortality with new doctors during their first month on duty.

Phillips found medication errors increased 10% during the month of July at American teaching hospitals, but not at neighboring community hospitals (1). In England, an Imperial College London study of records for 300,000 patients at 170 hospitals from 2000 and 2008 found death rates were 6% higher on the first Wednesday in August than on the previous Wednesday (2).

Multiple other studies have shown no change in mortality in American teaching hospitals in July, but the July Effect has real elements. There’s no way the competence of an academic hospital’s physician staff on July 1st can compare with that same hospital’s staff on June 30th. In the specialty of internal medicine, a residency is three years long (the first year of residency is also referred to as an internship). Each July 1st, third-year residents graduate and new medical school graduates replace one-third of the internal medicine team.

Imagine if a corporation like Google, Apple, Facebook, or General Electric dismissed one-third of their workforce once a year. There ‘s no way a company could be as productive after the change.

An anesthesia residency is three years long, preceded by one year of internship. One year after medical school, the same graduate who just completed twelve months of internship now reaches perhaps an even more difficult transition—the first months of anesthesia residency. Instead of writing histories, examining patients, making diagnoses, and prescribing medications as interns and internal medicine doctors do, anesthesia residents are rendering their patients unconscious, applying acute pharmacology, and inserting tubes and needles into patients in operating rooms at all hours of the day and night.

On July 1st of the first day of my anesthesia residency I reported at 0630 hours to the San Jose, California county hospital where I was assigned. I walked into the operating room and stared at the collection of anesthesia apparatus with complete bewilderment. I had no idea how the patient would even be connected to the anesthesia machine. As it turned out, the hoses that exited the machine weren’t installed yet, because I’d arrived before the anesthesia technicians who stocked the operating rooms. When it was time to begin the first anesthetic, the attending faculty anesthesiologist said to me, “I don’t think the operating room is a good place to learn in the beginning.” He injected sodium pentothal into the patient’s IV, placed the breathing tube into the patient’s windpipe, and hooked the patient up to the anesthesia machine. After ten minutes, he left to pursue other duties. I was alone, under-informed, and full of dread. I was on call that same night, and spent twenty-four hours in the hospital enduring case after case until six the next morning. When I left the hospital I had some rudimentary knowledge of how an anesthetic was done, but I’d failed to successfully place a breathing tube into any patient’s windpipe myself—a faculty member had to do every procedure for me. At the conclusion of the last anesthetic, I turned off the isoflurane (the predominant gas anesthetic at the time), switched off the ventilator, and waited, wondering why the patient wasn’t waking up. Many days later I learned that the isoflurane had no way to escape the patient’s lungs or brain unless I kept the ventilator on and continued ventilation of the patient’s lungs.

Anesthesia education today has improved since the 1980’s when I was a first-year resident, but the same themes persist. First-month trainees are very inexperienced. A supervising attending must teach them, mentor them, and lecture them—case by case—until each resident learns the basic skills.

Every month during anesthesia residency, the calendar turns to a new page and a new set of challenges. New rotations include specialty services in obstetrical anesthesia, pediatric anesthesia, trauma anesthesia, cardiac anesthesia, or regional block anesthesia. The most complex cases are saved for the second and third years of residency, but first-year residents will rotate through perhaps 80% of the array of cases during their first twelve months. During the earliest months of training, first-year anesthesia residents gain skills in the basic tasks of placing breathing tubes, intravenous lines, spinal blocks, epidural blocks, and arterial lines. They begin to feel confidence, and the anxiety of July fades.

It’s best if the jitters never fade away completely.

In my fifth year as an anesthesiologist, I was an attending at Stanford University, and I greeted one of my senior colleagues outside the locker room one morning. I asked him how he was doing, and he said, “I’m OK except for the customary pre-anesthesia anxiety.”

“What do you mean?” I said.

“Every morning I have to cope with the reality of what I do. I’m taking patients’ lives into my hands, and I can’t screw up.”

Think about that. Those workers at Google, Apple, Facebook, or General Electric have work pressures, but none of them has anxiety that they could harm a patient’s life forever.

Beyond the July Effect is the “November Effect.” The November Effect is the time when a physician feels confidence—even cockiness—and senses that they are well trained, experienced, in control, and can handle almost anything. The path to the November Effect is circuitous and the timing is variable. When I was an anesthesia resident, several of my colleagues never got there. One colleague succumbed to the stress of late night emergency anesthesia induction. He described to me the ordeal of trying to place a breathing tube urgently into a surgical patient who had a belly full of pizza and beer. I still remember the anesthesiologist’s face as he told the story. His eyes bugged out, his cheeks were pale, and he said, “I underestimated this specialty. I can’t do this for a whole career.” He quit. A second colleague had a near-disaster during the induction of anesthesia for an emergency Cesarean section. His anesthesia machine had no oxygen flow, so he blew into the mother’s breathing tube with his own mouth to keep the patient oxygenated. The patient and her baby survived, but his assessment was, “I can’t do this as a career. I need something less stressful.” He quit, too.

In November of my second year as an anesthesia resident I had 16 months of anesthesia training under my belt. I’d gained the swagger that comes with accomplishment, and lost some of the respect for the dangers of my specialty. I was on call in the hospital for obstetrics one night, and I tried to handle an emergency Cesarean section surgery at 1 a.m. by myself before my anesthesia faculty member arrived to assist me. I’ve chronicled the tale in a previous column (http://theanesthesiaconsultant.com/2012/07/15/an-anesthesia-anecdote-an-inept-anesthesia-provider-can-kill-a-patient-in-less-than-two-minutes). I was unable to place the patient’s breathing tube, she ran out of oxygen, and I thought I’d killed both her and her baby. My attending arrived in the nick of time, entered the operating room donned in his street clothes, and saved the day for all of us.

It was November, not July. I didn’t think I was a novice, but I was. It takes years, maybe a lifetime, to become an expert at anesthesia. Per Malcolm Gladwell’s book Outliers it takes 10,000 hours to become an expert at anything. For the specialty of anesthesia, even if one works 60 hours a week—which translates to about 3000 hours a year—it will take more than three years time to become an expert.

Even after those 10,000 hours, every patient presents a unique opportunity for events to stray from routine. Any case could go awry—there could be an unanticipated allergic reaction, an unexpected surgical bleed, an airway emergency or a mistaken diagnosis. Safe anesthesia practice demands a respectful level of anxiety at all times. Like a Boy Scout, an anesthesiologist needs to be prepared at all times.

Physician overconfidence is a current area of study. Meyer looked at 118 physicians who were each given 4 cases to diagnose (3). Two cases were easy and two were difficult, and the physicians were also asked how confident they were that they’d made the correct diagnosis. The physicians got 55% of the diagnoses correct for the two easier cases, and only 5% of the diagnoses correct for the more difficult cases. On a scale of 0-10, physicians rated their confidence as 7.2 on average for the easier cases, but as 6.4 on average for the more difficult cases. Physicians still had a very high level of confidence, even though their diagnostic accuracy dropped to a mere 5%. This was a striking statistic. Even physicians who are fully trained can be overconfident and can make misdiagnoses. Further data regarding physician overconfidence and how to correct it are welcomed.

An anesthesiologist’s work requires rapid, complex decisions that can be very susceptible to decision errors. Anesthesiologists work in a complex environment in the operating room, a setting where there is little room for mistakes. In acute care medicine, be it in the operating room, the emergency room, a battlefield, or an intensive care unit, the correct management of Airway-Breathing-Circulation is imperative to keep patients alive and well. Errors, be they caused by inexperience or overconfidence, can result in dire complications.

What does this mean for you?

If you’re a patient be wary of inexperienced doctors at a teaching hospital, especially in July and August. You might bring a friend or family member as a patient advocate to assure that more senior and experienced attending physicians are involved in your case. If you’re a patient and dealing with a confident doctor, be aware that confidence is not always well founded. Be skeptical of overconfidence and ask questions.

If you’re an anesthesiologist, look inward and assess whether you’re inexperienced or whether you tend toward overconfidence. Know yourself and better yourself. If you are inexperienced, then gain experience. If you tend to be overconfident, then humble yourself before the practice of medicine humbles you.

References:

(1) Phillips DP et al, A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents; J Gen Intern Med, May 2010;25(8): 774–779.

(2) Will patients really die this week because of new NHS hospital doctors? The Guardian. Retrieved 28 September 2013.

(3) Meyer ND et al, Physician’s Diagnostic Accuracy, Confidence, and Resource Requests, JAMA Intern Med. 2013;173(21):152-58.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

IS ANESTHESIA AN ART OR A SCIENCE?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Is the practice of anesthesia an art or a science? Is the practice of medicine an art or a science?

Over one hundred years ago the father of modern medicine, Dr. William Osler of Johns Hopkins Medical Center, made the following statements:

“Medicine is a science of uncertainty and an art of probability,” and “The practice of medicine is an art, based on science.”

In my career I’ve practiced three specialties at Stanford: internal medicine, emergency medicine, and anesthesiology. My career has bridged clinics, operating rooms, intensive care units, emergency rooms, and helicopter trauma medicine. I’ve practiced in four different decades.

With all respect to Dr. Osler’s legacy, what I’m witnessing in the clinical arena today tells me 21st century medical practice will be very much about science and very little about art.

A Merriam-Webster dictionary definition of science reads “knowledge about or study of the natural world based on facts learned through experiments and observation.”

An Oxford English dictionary definition of art reads “the various branches of creative activity, such as painting, music, literature, and dance.”

Which of these definitions best fits your medical practice?

To me, the answer is clearly “science.”

I searched through all the secondary definitions of “art” in multiple dictionaries, and found very few definitions of “art” that apply to the practice of medicine. The closest fits were: art is a skill or special ability e.g. a skill at doing a specified thing, typically one acquired through practice, from the Oxford English Dictionary; or art is skill acquired by experience, study, or observation e.g. the art of making friends, from the Merriam-Webster dictionary.

Medical school training consists of four years of intensive study of anatomy, physiology, biochemistry, pharmacology, microbiology, pathology, diseases, and the treatment for diseases. Core classes require extensive memorization and comprehension of complex scientific facts. In the last two years of medical school, clinical classes require the student to apply this complex science while evaluating individual human patients. New skills acquired at this clinical stage are those of interviewing, history taking, physical examination, interpretation of medical test results, differential diagnosis, and application of appropriate therapies. Mastering the doctor-patient interaction requires an education in empathy, effective listening, respect, and conversation about complex medical topics using parlance non-medical laypersons can comprehend.

Creative activities such as painting, music, literature, and dance are absent from the preceding paragraph. There is an “art” to making the correct diagnosis, and there is an “art” to applying empathy, effective listening, respect, and conversing about complex medical topics in language non-medical laypersons can comprehend. In this context, “art” connotes those secondary definitions, as in “a skill at doing a specified thing, typically one acquired through practice.” A talented doctor with years of experience is a skilled artist of medical practice, just as World Series hero Madison Baumgartner is a skilled artist of pitching baseballs. A student entering a career in medicine in the 21st century must prepare herself or himself for the scientific rigors of the job. The opportunity to create is largely absent.

Painters, musicians, authors, and dancers create original art, some of it fantastic and some mundane. In medicine this type of creativity is rare, but it does exist. The medical laboratory researchers who cured smallpox and polio changed the world by creating their discoveries. The medical researchers seeking cures for Alzheimer’s disease, Ebola, or HIV are in a constant quest for the discovery of original ideas. Physician authors such as the Bay Area’s Abraham Verghese (Cutting for Stone) and Khaled Hosseini, (The Kite Runner) wrote outstanding literary works and are very creative. Many physicians express creative skills in their hobbies as musicians, artists, sculptors, actors, dancers, and writers. These physicians earn their living with their primary jobs in medicine, and expend their creative energies in these secondary outlets in their spare time.

A generation ago the ideal physician may have been depicted in the persona of Dr. Marcus Welby, a fictional television doctor. Dr. Welby was the Atticus Finch of medicine, a kind, smiling, gray-haired physician who spent each week’s sixty-minute show working on healing and treating one patient’s problems. His heroic skills were wisdom, intelligence, empathy, and a steadfast dedication to that one patient for the entire TV show each week. Although he was portrayed as a savvy, highly-schooled professional, Dr. Welby thrived by an almost god-like ability to feel his way through a difficult case and create a workable diagnosis and solution. In Dr. Welby’s office practice each patient posed a dilemma he had to solve during an hour-long television episode. In today’s office practice each patient’s complaints must be addressed in a twenty-minute period of time, after which the physician must enter all the information into a cumbersome version of a computerized Electronic Medical Record (EMR) before meeting the next patient for the next twenty-minute encounter.

In the 21st century operating room practice of anesthesiology, we typically have ten minutes to talk to a patient prior to rendering them unconscious. After anesthetic induction the patient is changed into a sleeping human who carries objective values for blood pressure, heart rate, oxygen saturation, respiratory rate, temperature, and exhaled gas concentrations. The practice of anesthesiology becomes very much like a physiology experiment with the twin goals for the patient of a) guaranteeing sleep, while b) striving to maintain perfect vital signs. Where is the art? Is there art in varying techniques to accomplish these goals? Is it an “art” to anesthetize shoulder arthroscopy patient #1 with propofol and sevoflurane, and then to anesthetize shoulder arthroscopy patient #2 with propofol and an interscalene block? Rather than “art,” I’d call this using clinical judgment based on experience and scientific information.

Let me point out several current trends which are moving physician jobs further away from any creativity:

1) The organization of medicine into large corporate practices, with the variability of practice minimized. I recently attended a clinical lecture Stanford Medical Center in which the topic was “Variation is the Enemy of Good.”

2) The goal of organizing patient management into detailed and specific algorithms for physicians to follow, to insure they’re all treating the same medical problems the same way. In the Forbes article Medicine Is An Art, Not A Science: Medical Myth Or Reality?(July 12, 2014), author Robert Pearl MD, the CEO of the Permanente Medical Group, describes the value of protocols for the operating room, for treatment of stroke, and for prevention of heart attack, and concludes “We can predict that doctors who today refuse to follow the national recommendations for treating patients with strokes, heart attacks and a variety of other medical problems will be hard to convert. But we must change their behavior. The health of their patients and our nation depends on it.” Examples of such protocols in anesthesia practice are algorithms introduced for the management of total knee and hip replacement anesthesia, using a combination of neuroaxial block, regional nerve block such as adductor canal block, plus multimodal pain medication regimens (Gandhi and Viscusi, Multimodal Pain Management Techniques in Hip and Knee Arthroplasty, The New York School of Regional Anesthesia (www.nysora.com) Volume 13, J u l y 2009, pages 1-10).

3) A move to a “shift work” mentality in modern medical practice. A generation ago an MD would follow up on his patients until all the work was done for a given day, in addition to being night on-call for patients of his partners or colleagues once a week. In the past I worked for the largest HMO in California. The HMO culture promoted a 40-hour-per-week shift work mentality for physicians. When three p.m. arrived, many doctors signed off to the next doctor coming on duty to take over their job.

4) The promotion of non-physicians into the workforce to perform roles previously handled by MDs. Due to an inadequate supply of primary care doctors, the future of clinic medicine in large corporate medical practices will likely be legions of nurse practitioners and/or physician assistants supplying much of primary care.

5) Pursuit of artificial intelligence in medicine (AIM) as a goal. A recent Wall Street Journal article, IBM Crafts a Role for Artificial Intelligence in Medicine: Deal for Merge Healthcare is step toward training IBM’s Watson software to identify cancer, heart disease (August 11, 2015) described a significant advance in AIM technology. It’s not hard to imagine artificial intelligence computers making diagnoses and treatment decisions in the future.

Are these trends bad? Time will tell. The trends are driven by economics, and don’t expect to see them reverse. Variability will decrease and so will the feeling that medicine is an art.

Let’s hope future generations of physicians will still quote Osler’s claim that “the practice of medicine is an art, based on science.” May empathy, effective listening, respect, and conversation always be critical skills envied and mastered by all 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?

 

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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

 

 

ROBOT ANESTHESA II

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

THE iCONTROL-RP ANESTHESIA ROBOT

On May 15, 2015, the Washington Post published a story titled, “We Are Convinced the Machine Can Do Better Than Human Anesthesiologists.”

Is this true? Are anesthesiologists on the verge of being replaced by a new robot?

In a word, “No.”

The new device being discussed is the iControl-RP anesthesia robot.

In recent years there have been significant advances in the automated delivery of the intravenous anesthetic drugs propofol and remifentanil. (Orliaguet GA, Feasibility of closed-loop titration of propofol and remifentanil guided by the bispectral monitor in pediatric and adolescent patients: a prospective randomized study, 2015 Apr;122(4):759-67). Propofol is an ultra-short-acting hypnotic drug that causes sleep. Remifentanil is an ultra-short-acting narcotic that relieves pain. Administered together, these drugs induce what is referred to as Total Intravenous Anesthesia, or TIVA. Total Intravenous Anesthesia is a technique anesthesiologists use when they choose to avoid using inhaled gases such as sevoflurane and nitrous oxide. Anesthesiologists administer TIVA by adjusting the flow rates on two separate infusion pumps, one infusion pump containing each drug.

A closed-loop system is a machine that infuses these drugs automatically. These systems include several essential items: The first is a processed electroencephalogram (EEG) such as a bi-spectral monitor (BIS monitor) attached to the patient’s forehead which records a neurologic measure of how asleep the patient is. The BIS monitor calculates a score between 0 and 100 for the patient’s level of unconsciousness, with a score of 100 corresponding to wide awake and 0 corresponding to a flat EEG. A score of 40 – 60 is considered an optimal amount of anesthesia depth. The second and third essential items of a closed-loop automated system are two automated infusion pumps containing propofol and remifentanil. A computer controls the infusion rate of a higher or lower amount of these drugs, depending on whether the measured BIS score is higher or lower than the 40- 60 range.

Researchers in Canada have expanded this technology into a device they call the iControl-RP, which is in clinical trials at the University of British Columbia. The iControl-RP is a closed-loop system which makes its own decisions. The initials RP stand for the two drugs being titrated: remifentanil and propofol. In addition to monitoring the patient’s EEG level of consciousness (via a BIS monitor device called NeuroSENSE), this new device monitors traditional vital signs such as blood oxygen levels, heart rate, respiratory rate, and blood pressure, to determine how much anesthesia to deliver.

Per published information on their research protocol, the iControl-RP allows either remifentanil or propofol to be operated in any of three modes: (1) closed-loop control based on feedback from the EEG as measured by the NeuroSENSE; (2) target-controlled infusion (TCI), based on previously-described pharmacokinetic and pharmacodynamic models; and (3) conventional manual infusion, which requires a weight-based dose setting. (Reference: Closed-loop Control of Anesthesia: Controlled Delivery of Remifentanil and Propofol Dates, Status, Enrollment Verified by: Fraser Health, August 2014, First Received: January 15, 2013, Last Updated: March 5, 2015, Phase: N/A, Start Date: February 2013, Overall Status: Recruiting, Estimated Enrollment: 150).

In Phase 1 of the iControl-RP testing involving 50 study subjects, propofol will be administered in closed-loop mode and a remifentanil infusion will be administered based on a target-controlled infusion. In phase 2 involving 100 study subjects, both propofol and remifentanil will be administered in closed-loop mode. The investigators aim to demonstrate that closed-loop control of anesthesia and analgesia based on EEG feedback is clinically feasible.

In both phases, an anesthesiologist will monitor the patient as per routine practice and have the ability to modify the anesthetic or analgesic drugs being administered. That is, he or she will be able to adjust the target depth of hypnosis, adjust the target effect site concentration for remifentanil, immediately switch to manual control of either infusion, administer a bolus dose, or immediately stop the infusion of either drug. iControl-RP is connected to the NeuroSENSE EEG monitor, the two infusion pumps for separately controlled propofol and remifentanil administration, and the operating room patient vital signs monitor. A user interface allows the anesthesiologist to set the target EEG depth level, switch between modes of operation (manual, target-controlled infusion, or closed-loop), and set manual infusion rates or target effect-site concentrations for either drug as required.

Per the article in the Washington Post. (Todd C. Frankel, Washington Post, May 15, 2015), one of the machine’s co-developers Mark Ansermino, MD said, “We are convinced the machine can do better than human anesthesiologists.” The iControl-RP has been used to induce deep sedation in adults and children undergoing general surgery. The device had been used on 250 patients so far.

Why is this robotic device only a small step toward replacing anesthesiologists?

A critical realization is that anesthetizing patients requires far more skill than merely titrating two drug levels. Every patient requires (1) preoperative assessment of all medical problems from the history, physical exam, and laboratory evaluation of each individual patient, so that the anesthesiologist can plan and prescribe the appropriate anesthesia type; (2) placement of an intravenous line through which the TIVA drugs may be administered; (3) mask ventilation of an unconscious patient (in most cases), followed by placement of an airway tube to control the delivery of oxygen and ventilation in and out of the patient’s lungs; (4) observation of all vital monitors during surgery, with the aim of directing the diagnosis and treatment of any complication that occurs as a result of anesthesia or the surgical procedure; (5) removal of the airway tube at the conclusion of most surgeries, and (6) the diagnosis and treatment of any complication in the newly awake patient following the anesthetic.

In the future, closed-loop titration of drugs may lessen an anesthesiologist’s workload and free him or her for other activities. In the distant future, closed-loop titration of drugs may free a solitary anesthesiologist to initiate and monitor multiple anesthetics simultaneously from a control booth via multiple video screens and interface displays. But the handling of all tasks (1) – (6) by an automated robotic device is still the stuff of science fiction. The Washington Post article said an early role for the machine could be in war zones or remote areas where an anesthesiologist is unavailable. One could conjecture that a closed-loop anesthesia system may be used to facilitate surgery in outer space some day as well.

In either case, an anesthesiologist or some other highly-trained medical professional will still be required on site to achieve tasks (1) – (6).

The iControl-RP has not been approved by the U.S. Food and Drug Administration.

The iControl-RP team has struggled to find a corporate backer for its project. Dr. Ansermino, the anesthesiologist inventor in Vancouver, told the Washington Post, “Most big companies view this as too risky,” but he believed a device like this was inevitable. “I think eventually this will happen,” Ansermino told the Washington Post, “whether we like it or not.”

That may be, but I suspect companies are risk averse regarding the iControl-RP because investment is guided by analysts and physicians who must consider the practical applications and risks of any new medical device. The issues of leaving (1) – (6) up to a robotic device are impractical at best, and dangerous to the patient at worse.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

HYPOTENSION OF 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

Latest posts by the anesthesia consultant (see all)

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?

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?

 

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*
*
*

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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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

Latest posts by the anesthesia consultant (see all)

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.”

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:

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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

Latest posts by the anesthesia consultant (see all)


Is anesthesiology one of America’s most stressful careers? Not according to prominent Internet media sources.

Careercast.com listed the Top 10 Most Stressful Jobs in America in 2015 (http://www.careercast.com/jobs-rated/most-stressful-jobs-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 (http://abcnews.go.com/GMA/be_your_best/page/top-10-stressful-jobs-america-14355387), 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, (http://www.salary.com/the-top-10-most-stressful-jobs) 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

 

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

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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

Latest posts by the anesthesia consultant (see all)

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.”

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?

 

 

 

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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

 

 

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

Latest posts by the anesthesia consultant (see all)

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?

 

 

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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

 

 

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

Latest posts by the anesthesia consultant (see all)

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.” (http://www.asahq.org/psh)

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

Latest posts by the anesthesia consultant (see all)

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:

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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

Latest posts by the anesthesia consultant (see all)

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. How do you prepare to induce general anesthesia in two minutes?

Discussion: 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:

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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

Latest posts by the anesthesia consultant (see all)

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

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. See:

https://www.asahq.org/For-Members/Clinical-Information/Ebola-Information/Ebola-Guidelines-from-COH.aspx

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 complete American Society of America Ebola Workgroup Recommendations at:

https://www.asahq.org/For-Members/Clinical-Information/Ebola-Information/Ebola-Guidelines-from-COH.aspx

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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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

Latest posts by the anesthesia consultant (see all)

 

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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. 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. (Matsusaki T, The role of Certified Registered Nurse Anesthetists in the United States, J Anesth. 2011 Oct;25(5):734-40. doi: 10.1007/s00540-011-1193-5. Epub 2011 Jun 30)

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. (Gunn IP, Rural health care and the nurse anesthetist, CRNA 2000 May;11(2):77-86).
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. (MacIntyre P, Cost of education and earning potential for non-physician anesthesia providers. AANA J. 2014 Feb;82(1):25-31)
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. (MacIntyre P, Cost of education and earning potential for non-physician anesthesia providers. AANA J. 2014 Feb;82(1):25-31)
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 (Anesthesiologist direction and patient outcomes, Anesthesiology. 2000 Jul;93(1):152-63) 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?” (Anesthesiology: April 2001 – Volume 94 – Issue 4 – p 713)

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?

 

 

 

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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

 

 

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

Latest posts by the anesthesia consultant (see all)

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.”

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

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?

 

 

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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

 

 

SHOULD PHYSICIANS BE TESTED FOR DRUGS AND ALCOHOL?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)


An 60-year-old man has a heart attack in the middle of an emergency abdominal surgery at 11:00 pm and dies two hours later. Should the anesthesiologist be made to submit to a drug test to seek out alcohol or drug ingestion that could have made her performance impaired?

Discussion: In the 2012 movie Flight, Denzel Washington stars as a commercial airline pilot addicted to alcohol and cocaine, who crashes his airplane while he is intoxicated. Analogies between aviation and anesthesia are commonplace. Both involve takeoffs, landings, and varying cruising times between the two. Both are generally quite safe, but on occasion disastrous accidents occur.

Pilots are required to submit to random drug testing and to testing following accidents. The Federal Aviation Administration (FAA) mandated drug and alcohol testing of safety-sensitive aviation employees in the Omnibus Transportation Employees Testing Act of 1991 to help protect the public and keep the skies safe.

Proposition 46 was a 2014 California legal initiative that proposed similar random drug testing of physicians and drug testing following critical sentinel events. Prop 46 was on the ballot for the November 2014 general election, and was soundly defeated. This proposition was noteworthy for bundling the drug-testing proposal with an additional proposal that would increase the maximum pain and suffering malpractice reward from $250,000 per case to $1,100,000 per case. Prop 46 was funded and supported by trial lawyers who sought to raise the ceiling on pain and suffering awards they could win in medical malpractice suits in California.

This malpractice award increase proposed by trial lawyers was viewed as a money grab, and was unpopular with voters. Because of concerns with increasing malpractice costs and health care costs, Prop 46 was defeated.

But what if Prop 46 had solely been about drug-testing physicians? Would it have a better chance of passing? I have no crystal ball, but my guess is that yes, it would have had a better chance of passing. According to the September 13, 2014 edition of the Los Angeles Times, the component of Prop 46 that required random drug and alcohol testing of doctors was popular among those surveyed: 68% of likely voters were in favor of it, while 25% were opposed.

In the August 1, 2014 issue of the New York Times, Adam Nagourney wrote “At a time when random drug testing is part of the job for pilots, train operators, police officers and firefighters—to name a few—one high-profile line of work has managed to remain exempt: doctors. That may be about to change. California would become the first state to require doctors to submit to random drug and alcohol tests under a measure to appear on the ballot this November. The proposal, which drew approval in early focus groups, was inserted as a sweetener in a broad initiative pushed by trial lawyers that also includes an unrelated measure to raise the state’s financial cap on medical malpractice awards for the first time since 1975, to $1.1 million from $250,000.”

The same New York Times article states, “Backers of Proposition 46 have begun putting out a steady stream of news releases about cases involving doctors with a history of drug and alcohol abuse…. ‘It’s crucial: I can’t believe we haven’t done this already,’ said Arthur L. Caplan, a medical ethicist at New York University. ‘But the idea that we wouldn’t be screening our surgeon, our anesthesiologist or our oncologist when we are going to screen our bus drivers and our airline pilots strikes me as ethically indefensible.’” In the same article, Daniel R. Levinson, the inspector general for the Department of Health and Human Services, opines that there should be random drug testing across the medical profession, given the access in hospitals to controlled substances. “I don’t think that a carve-out when it comes to the medical field is sensible public policy,” he said. “No one should be above suspicion or below suspicion. I think we all need to play by similar rules.”

In a recent commentary published in the Journal of the American Medical Association (JAMA), Dr. Julius Pham of Johns Hopkins wrote, “Patients and their family members have a right to be protected from impaired physicians…. Why is there such a difference among high-risk industries, which all pledge to keep the public safe? First, medicine is underregulated compared with other industries. The fiduciary patient-physician relationship is generally considered to be governed by the profession, not to be tampered with by regulatory bodies. While some state and individual health system regulations exist, they tend to be weak. Second, self-monitoring is the essence of medical professionalism. Peer review is the accepted modality to identify physicians with impaired performance. Most states now have a designated physician health program to detect and assist potentially impaired physicians before those physicians cause patients harm. However, these programs vary in their mandate, authority, reporting requirements, and activities. For instance, California has the largest number of US physicians, but its physician health program was recently discontinued. In states without proactive programs, it seems, by default, that patient harm has to occur before a review process occurs. In many cases, an overwhelming amount of data (i.e., harmed patients) must be available before a hospital or state initiates an investigation.”

Dr. Pham goes on to say, “What might a model of physician impairment regulation look like? First, mandatory physical examination, drug testing, or both may be considered before a medical staff appointment. This already occurs in some hospitals and has been successful in other industries. Second, a program of random alcohol-drug testing could be implemented. Random testing is required for most federal employees and has been successfully implemented in several medical settings. Random testing in the military has resulted in a decrease in illicit drug use. Third, a policy for routine drug-alcohol testing could be initiated for all physicians involved with a sentinel event leading to patient death. Fourth, a national hospital regulatory/accrediting body could establish these standards to maintain consistency across states.” (Pham JC et al, Identification of Physician Impairment, JAMA. 2013;309(20):2101-2102)

It’s estimated that approximately 10% to 15% of all healthcare professionals misuse drugs or alcohol at some time during their career. Although rates of substance abuse and dependence are no different than those in the general population, the stakes are higher because healthcare professionals are caregivers responsible for the general health and well-being of our population. It’s known that specialties such as anesthesiology, emergency medicine, and psychiatry have higher rates of drug abuse, possible due to the stress level associated with these specialties, the baseline personalities of these healthcare providers, and easy access to drugs in these specialties. (Baldisseri, MR, Impaired Healthcare Professional, Crit Care Med 2007 Feb;35(2 Suppl):S106-16)

As physicians, do we have any compelling arguments to deflect the notion of MD’s being drug tested? Physicians decry the intrusion into their privacy. There is the ethical question whether the risk of patient injury by the 10% of physicians who use drugs and/or alcohol merits that the other 90% of physicians should be subjected to drug testing. There is also the specter of false-positive tests, which could wreak havoc with a doctor’s reputation. The details of any proposed drug and alcohol screening programs will be crucial, and any screening program will require careful consideration of a physician’s rights and privacy.

Two prominent hospitals—Massachusetts General Hospital in Boston and the Cleveland Clinic in Ohio—implemented random urine drug testing in their anesthesia residency teaching departments. A 2005 survey by the Cleveland Clinic estimated that 80 percent of anesthesiology residency training programs reported problems with drug-impaired doctors, and an additional 19 percent reported a death from overdose. “The problem is that we are exposed to, and we have the use of, very highly addictive and potent medications,” said Dr. Michael G. Fitzsimons, administrator for the substance abuse program of the department of anesthesia and critical care at Massachusetts General Hospital in Boston. Dr. Gregory B. Collins, section head of the Alcohol and Drug Recovery Center, at the Cleveland Clinic Foundation, said, “The first thing you often realize in these cases, it’s a kid dead in the bathroom with a needle in his arm.” Dr. Arnold Berry, an anesthesiologist and a member of the Committee on Occupational Health of the American Society of Anesthesiologists, said estimates of anesthesiologists who are addicted to medication range from only 1 to 2 percent. “The most recent study in training programs suggests the (addiction) rate has stayed the same for 20 years,” he said. Dr. Berry said the American Society of Anesthesiologists (ASA) has decided to use other tactics to stave off addiction, rather than recommending urine testing. The ASA is implemented a “wellness initiative” to help anesthesiologists deal with stressors in their lives. (Urine Drug Tests for Doctors? Nov. 12, 2008, By Lauren Cox, ABC News Medical Unit)

While doctors and organized medicine may delay the notion of drug testing for themselves, public opinion and lawmakers may lead the way toward making physicians “pee in the cup.” Citizens don’t want their airline pilots, firemen, and police officers under the influence of alcohol or drugs, and patients don’t want their doctors under the influence of alcohol or drugs either.

Our patients always come first. It will be an arduous task for MD’s to forever oppose a mandate for clean and sober physicians. Hugh Laurie was a fascinating character as the opiate-popping junkie doctor in “House,” but what patient wants the TV persona of Dr. Gregory House at their bedside?

 

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

 

 

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

Latest posts by the anesthesia consultant (see all)

Do you need an anesthesiologist for an 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

Latest posts by the anesthesia consultant (see all)

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 herbs, 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?

 

 

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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

 

 

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

Latest posts by the anesthesia consultant (see all)

succinylcholine_chloride_10_med-21

A vial of succinylcholine

The muscle relaxant 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.

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.

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 neostigmine/glycopyrrolate:

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 wears off in 9 – 13 minutes was not considered any safer in “cannot intubate, cannot ventilate” situations, because waiting 9 minutes for a return to spontaneous respirations would still 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

 

 

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

Latest posts by the anesthesia consultant (see all)

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, 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 12 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?

 

 

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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

 

 

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

Latest posts by the anesthesia consultant (see all)

IMG_0825I’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. As the Deputy Chief at Stanford, I’m an elected officer who leads the private practice/community section of the anesthesia department.

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?

 

 

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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

 

 

AVOIDING AIRWAY DISASTERS IN ANESTHESIA

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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

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

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

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

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

A simplified approach has been touted.

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

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

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

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

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

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

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

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

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

“in life-threatening airway obstruction, … an emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. It should be deleted from the ASA Difficult Airway Algorithm. I have participated in seven cricothyrotomies in emergency airway situations, and all of the patients left the hospital without any

neurological injury or complications from the cricothyrotomy. The risk-benefit ratio is markedly in favor the knife technique…. With a knife, or scissors, one cuts quickly either vertically or horizontally below the thyroid cartilage and there is the cricothyroid membrane or tracheal rings. The knife is inserted into the trachea and turned 90 degrees, and an airway is established. At that point, a small tube of any type can be inserted next to the knife. The knife technique is much safer because there is virtually nothing that one can harm by making an incision within two inches or less in the midline of the neck, and it can be performed in less than 30 seconds. In contrast, the needle is fraught with complications, including identifying the trachea, making certain that the needle is entirely in the trachea and does not move ( to avoid subcutaneous emphysema when an oxygen source is established), establishing a pressurized oxygen delivery system (which will take more than five minutes even in the most experienced circumstances), and avoiding causing a tension pneumothorax… I know of multiple cases of acute airway obstruction where the needle technique was attempted, and in all cases the patients died. I know of no such cases when a cricothyrotomy was used as the primary treatment of acute airway obstruction.”

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

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

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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*
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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

 

 

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

Latest posts by the anesthesia consultant (see all)

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?

 

 

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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

 

 

HOW DOES A HEROIN OVERDOSE KILL? AN ANESTHESIOLOGIST’S VIEW

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)


On February 2, 2014, Academy Award-winning actor Phillip Seymour Hoffmann was found dead with a needle in his arm and syringes and packets of heroin in his room.

How does a heroin overdose kill a person?

Anesthesiologists are uniquely qualified to answer this question. Anesthesiologists administer intravenous narcotics every day, because narcotics are important pain-relieving drugs in anesthetic care. If an anesthesiologist is attending to you while narcotics are injected into your bloodstream, you are safe. If an addicts chooses to inject narcotics into his or her bloodstream while they are alone in their apartment, they can die.

Heroin (diacetylmorphine or morphine diacetate) is in the same category of drugs as morphine, Demerol, and fentanyl. Heroin is prescribed as a controlled drug in the United Kingdom for use as a potent analgesic or pain reliever, but the drug is not approved for any medical use in the United States.

Within minutes, injected heroin crosses from the bloodstream to the brain. Once inside the brain, heroin is metabolized to the active drug 6-monoacetylmorphine (6-MAM), and then to morphine. Each of these chemicals binds to opioid receptors in the brain, which results in heroin’s euphoric, pain relieving, and anxiety-relieving effects. The duration of a single dose of heroin is 3-4 hours.

In addition to sensations of euphoria, calmness, sleepiness, pain relief, and blunting of anxiety, narcotics cause significant decrease in both the rate of breathing and the depth of each breath. This respiratory depression can be lethal, especially at higher doses.

In all acute care medicine, whether in the operating room, the intensive care unit, the emergency room, or the battlefield, physicians follow the mantra of “Airway-Breathing-Circulation.” A doctor’s first priority to keep the upper airway open, using a variety of techniques including jaw thrusts, extending the neck, inserting an oral airway, or placement of a breathing tube.  A doctor’s second priority is to assure that breathing, or ventilation, is ongoing. The doctor may assist breathing by delivering breaths of oxygen into the patient’s lungs via a ventilation bag (e.g. an Ambu bag). A doctor’s third priority is to assure that adequate circulation, or heart function, is ongoing.

If a large dose of narcotic is administered, breathing may cease or become so obstructed by the tongue and soft palate that no air moves in and out through the lungs. If an addict injects heroin while alone in their home, and they lose consciousness, their airway may become obstructed and breathing may cease. Oxygen levels to the brain and heart will plummet. After only minutes of inadequate oxygen, their heart will arrest and the addict will die.

Simultaneous usage of additional central nervous system depressant drugs, such as alcohol, benzodiazepines (Xanax, Valium, Librium, Ativan), or narcotic pills (oxycodone, Vicodin, Percocet) along with heroin can intensify the respiratory depression, and place the addict at even higher risk of ineffective breathing and resultant cardiac arrest.

Tolerance to heroin develops quickly, and users require more of the drug to achieve the same effects. This prompts addicts to inject increasing doses to achieve the desired “high,” with the attendant risk that each increased dose will be excessive, and lead to airway obstruction, inadequate breathing, and cardiac arrest.

Intravenous heroin usage carries additional risks, including viral infection (hepatitis or AIDS) from contaminated needles, bacterial infection of the heart valves (bacterial endocarditis), reactions to contaminants (e.g. starch, talc, or other drugs) in the heroin preparation, localized infections (abscesses) at the site of injection, and powerful withdrawal symptoms on cessation of heroin use.

But cardiac arrest from respiratory depression looms as the most frequent cause of sudden death in heroin addicts.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

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

Latest posts by the anesthesia consultant (see all)

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.

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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.

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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.

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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.

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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?

 

 

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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

 

 

HOW RISKY IS A TONSILLECTOMY?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

tonsillectomy-recovery-day-by-day-12

13-year-old Jahi McMath of Oakland, California suffered sudden bleeding from her nose and mouth and cardiac arrest following a December 9th 2013 tonsillectomy, a surgery intended to help treat her obstructive sleep apnea. After the bleeding she lapsed into a coma. Three days later she was declared brain-dead.

How could this happen?

Behind circumcision and ear tubes, tonsillectomy is the third most common surgical procedure performed on children in the United States. 530,000 tonsillectomies are performed children under the age of 15 each year. Tonsillectomy is not a minor procedure. It involves airway surgery, often in a small child, and often in a child with obstructive sleep apnea. The surgery involves a risk of bleeding into the airway. The published mortality associated with tonsillectomy ranges from 1:12,000 to 1:40,000. (American Academy of Otolaryngology-Head and Neck Surgery Guidelines for Tonsillectomy in Children and Adolescents, Am Family Physician. 2011 Sep 1;84(5):566-573).

Between 1915 and the 1960’s, tonsillectomy was the most common surgery in the United States, done largely to treat chronic throat infections. After the 1970’s, the incidence of tonsillectomies dropped, as pediatricians realized the procedure had limited success in treating chronic throat infections. The number of tonsillectomies has increased again in the last thirty years, as a treatment for obstructive sleep apnea (OSA). Currently 90 percent of tonsillectomies are performed to treat OSA. Only 1 – 4 % of children have OSA, but many of these children exhibit behavioral problems such as growth retardation, poor school performance, or daytime fatigue. The American Academy of Otolaryngology concluded that “a growing body of evidence indicates that tonsillectomy is an effective treatment for sleep apnea.” (AAO–HNS Guidelines for Tonsillectomy in Children and Adolescents, Am Family Physician. 2011 Sep 1;84(5):566-573).

Tonsillar and adenoid hypertrophy are the most common causes of sleep-disordered breathing in children. Obstructive sleep apnea is defined as a “disorder of breathing during sleep characterized by prolonged upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep.” (Miller’s Anesthesia, 7th edition, 2009, Chapter 82).

In OSA patients, enlarged tonsils can exacerbate loud snoring, decrease oxygen levels, and cause obstruction to breathing. Removal of the tonsils can improve the diameter of the breathing passageway. Specific diagnosis of OSA can be made with an overnight sleep study (polysomnography), but applying this test to large populations of children is a significant expense. Currently only about 10 percent of otolaryngologists request a sleep study in children with sleep-disordered breathing prior to surgery (Laryngoscope 2006;116(6):956-958). In our surgical practice in Northern California, most pediatricians and otolaryngologists forego the preoperative overnight sleep study if the patient has symptoms of obstructed sleep, confirmed by a physical exam that reveals markedly enlarged tonsils.

Every tonsillectomy requires general anesthesia, and anesthesiologists become experts in the care of tonsillectomy patients. Prior to surgery the anesthesiologist will review the chart, interview the parent(s), and examine the child’s airway. Most children under the age of 10 will be anesthetized by breathing sevoflurane via an anesthesia mask, which is held by the anesthesiologist. Following the child’s loss of consciousness, the anesthesiologist will place an intravenous (IV) catheter in the child’s arm. The anesthesiologist then inserts a breathing tube into the child’s windpipe, and turns the operating table 90 degrees away so the surgeon has access to operate on the throat. The surgeon will move the breathing tube to the left and right sides of the mouth while he or she removes the right and left tonsils. (note: children older than the age of 10 will usually accept an awake placement of an IV by the anesthesiologist, and anesthetic induction is accomplished by the IV injection of sleep drugs including midazolam and propofol, rather than by breathing sevoflurane via an anesthesia mask).

The child remains asleep until the tonsils are removed, and all bleeding from the surgical site is controlled. The anesthesiologist then discontinues general anesthetic drugs and removes the breathing tube when the child awakens. Care is taken to assure that the airway is open and that breathing is adequate. Oxygen is administered until the child is alert. Tonsillectomy is painful, and intravenous opioid drugs such as fentanyl or morphine are commonly administered to relieve pain. The opioids depress respiration, and monitoring of oxygen levels and breathing is routinely done until the child leaves the surgical facility.

Most tonsillectomy patients have surgery as an outpatient and are discharged home within hours after surgery. Prior to the 1960’s patients were hospitalized overnight routinely post-tonsillectomy. In 1968 a case series of 40,000 outpatient tonsillectomies with no deaths was reported, and performance of tonsillectomy on an outpatient basis became routine after that time. (Miller’s Anesthesia, 7th edition, 2009, Chapter 33).

Published risk factors for postoperative complications after tonsillectomy include: (1) age younger than 3 years; (2) evidence of OSA; (3) other systemic disorders of the heart and lungs); (4) presence of airway abnormalities; (5) bleeding abnormities; and (6) living a long distance from an adequate health care facility, adverse weather conditions, or home conditions not consistent with close observation, cooperativeness, and ability to return quickly to the hospital. (Miller’s Anesthesia, 7th edition, 2009, Chapter 82).

The incidence of post-tonsillectomy bleeding increases with age. In a national audit of more than 33,000 tonsillectomies, hemorrhage rates were 1.9% in children younger than 5 years old, 3% in children 5 to 15 years old, and 4.9% in individuals older than 16. The return to the operating room rate was 0.8% in children younger than 5 years old, 0.8% in children 5 to 15 years old, and 1.2% in individuals older than 16. (Miller’s Anesthesia, 7th edition, 2009, Chapter 75).

Primary bleeds usually occur within 6 hours of surgery. Hemorrhage is usually from a venous or capillary bleed, rather than from an artery. Complications occur because of hypovolemia (massive blood loss), the risk of blood aspiration into the lungs, or difficulty with replacing the breathing tube should emergency resuscitation be necessary. Early blood loss can be difficult to diagnose, as the blood is swallowed and not seen. Signs suggesting hemorrhage are an unexplained increasing heart rate, excessive swallowing, pale skin color, restlessness, sweating, and swelling of the airway causing obstruction. Low blood pressure is a late feature. (Miller’s Anesthesia, 7th edition, 2009, Chapter 75).

What happened to 13-year-old Jahi McMath in Oakland following her tonsillectomy? We have no access to her medical records, and all we know is what was reported to the press. The following text was published in the 12/21/2013 Huffington Post:

After her daughter underwent a supposedly routine tonsillectomy and was moved to a recovery room, Nailah Winkfield began to fear something was going horribly wrong.

Jahi was sitting up in bed, her hospital gown bloody, and holding a pink cup full of blood.

“Is this normal?” Winkfield repeatedly asked nurses.

With her family and hospital staff trying to help and comfort her, Jahi kept bleeding profusely for the next few hours then went into cardiac arrest, her mother said.

Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.

“Ms. McMath is dead and cannot be brought back to life,” the hospital said in the memo, adding: “Children’s is under no legal obligation to provide medical or other intervention for a deceased person.”

In an interview at Children’s Hospital Oakland on Thursday night, Winkfield described the nightmarish turn of events after her daughter underwent tonsil removal surgery to help with her sleep apnea.

She said that even before the surgery, her daughter had expressed fears that she wouldn’t wake up after the operation. To everyone’s relief, she appeared alert, was talking and even ate a Popsicle afterward.

But about a half-hour later, shortly after the girl was taken to the intensive care unit, she began bleeding from her mouth and nose despite efforts by hospital staff and her family.

While the bleeding continued, Jahi wrote her mother notes. In one, the girl asked to have her nose wiped because she felt it running. Her mother said she didn’t want to scare her daughter by saying it was blood.

Family members said there were containers of Jahi’s blood in the room, and hospital staff members were providing transfusions to counteract the blood loss.

“I don’t know what a tonsillectomy is supposed to look like after you have it, but that blood was un-normal for anything,” Winkfield said.

The family said hospital officials told them in a meeting Thursday that they want to take the girl off life support quickly.

“I just looked at the doctor to his face and I told him you better not touch her,” Winkfield recalled.

Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.

 

Despite the precaution of hospitalizing Jahi McMath post-tonsillectomy, when her bleeding developed it seems the management of her Airway-Breathing-Circulation did not go well. I’ve attended to bleeding post-tonsillectomy patients, and it can be a harrowing experience. It can be an extreme challenge to see through the blood, past the swollen throat tissues post-surgery, and locate the opening to the windpipe so that one can insert the breathing tube needed to supply oxygen to the lungs. Assistance from a second anesthesiologist is often needed. The surgeon will be unable to treat or control severe bleeding until an airway tube is in place.  Difficult intubation and airway management can lead to decreased oxygen levels and ventilation, jeopardizing oxygen delivery to the brain and heart. If severe bleeding is unchecked and transfusion of blood cannot be applied swiftly, the resulting low blood pressure and shock can contribute to the lack of oxygen to a patient’s brain.

A bleeding tonsillectomy patient can be an anesthesiologist’s nightmare.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

 

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*

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

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

Latest posts by the anesthesia consultant (see all)

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 reading and tapping on the screen of his iPad. 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 (Slagle JM, Weinger MB, Anesthesiology 2009 Feb;110(2):275-83, effects of intraoperative reading on vigilance and workload during anesthesia care in an academic medical center) 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 (Jorm CM, Anaesthesia Intensive Care. 2012 Jan;40(1):71-8, laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?) 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

Latest posts by the anesthesia consultant (see all)

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.

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

 

 

ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: YOU’RE HAVING SURGERY. 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

Latest posts by the anesthesia consultant (see all)

How is your anesthesia bill calculated?

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?

 

 

 

 

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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

 

 

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

Latest posts by the anesthesia consultant (see all)

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?

 

 

 

 

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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

 

 

ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: ANESTHESIA FOR SPECIALTY SURGERIES

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

I.  CHILDBIRTH (OBSTETRIC ANESTHESIA):

Most obstetric anesthesia is for either vaginal delivery or for Cesarean sections.

Anesthesia for Vaginal Delivery:  Anesthesia for vaginal delivery is utilized to diminish the pain of labor contractions, while leaving the mother as alert as possible, with as muscle strength as possible, to be able to push the baby out at the time of delivery.  Anesthesia for labor and vaginal delivery is usually accomplished by epidural injection of the local anesthetics bupivicaine (brand name Marcaine) or ropivicaine.

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 after childbirth.

Anesthesia for Cesarean Section: Cesarean section is a surgical procedure in which the obstetrician makes an incision through the skin of the lower abdomen, and through the wall of the uterus, or womb, to extract the baby without the child requiring a vaginal delivery.  Anesthesia for Cesarean section is usually a spinal or an epidural anesthetic, which leaves the mother as alert as possible, while rendering surgical anesthesia to her abdomen and pelvis.  Spinal or epidural anesthesia is accomplished by injection of local anesthetics, with or without a narcotic medication, into the low back into the subarachnoid or the epidural space. The anesthesiologist remains present for the entire surgical procedure, to assure that the mother is comfortable and that all vital signs are maintained as close to normal limits as possible.

In a minority of cases, the anesthesia provider will administer a general anesthetic for Cesarean section surgery.  The most common indications for general anesthesia are (1) emergency Cesarean, when there is no time for a spinal or epidural block;  and (2) significant bleeding by the mother, leading to a low blood volume, which is an unsafe circumstance to administer a spinal or epidural block.  General anesthetics for Cesarean section carry an increased risk over spinal/epidural anesthesia, primarily because the mother is no longer able to breath on her own and maintain her own airway.

II.  CARDIAC SURGERY/OPEN HEART SURGERY:

Open heart surgery requires specialized equipment.  Anesthesia for cardiac surgery is complex, and the following is a brief summary:  Prior to the surgery, the anesthesiologist inserts a catheter into the radial artery at the wrist, to monitor the patient’s blood pressure continuously, rather than relying on a blood pressure cuff.  This enables the anesthesiologist to fine-tune the blood pressure, never allowing it to be too high or too low for an extended period of time.  The anesthesiologist also inserts a catheter (a central venous catheter, or CVP catheter) into a large vein in the patient’s neck.  The anesthesiologist uses this catheter to monitor the pressure inside the heart, and also to administer infusions of potent medications into the central circulation to raise or lower the blood pressure, or to increase the heart’s pumping function.

After the patient is anesthetized, the anesthesiologist often inserts a Transesophageal Echocardiogram (TEE) probe into the patient’s mouth, down the esophagus, and into the stomach.  The TEE gives the anesthesiologist a two-dimensional image of the beating heart and the heart valves in real time, and enables him or her to adjust medications and fluid administration as needed to keep the patient stable.

For open heart surgery, once the chest is open, the cardiac surgeon inserts additional tubes into the veins and arteries around the heart, diverting the patient’s blood from the heart and lungs into a heart-lung machine located alongside the operating table.  During the time the patient is connected to the heart-lung machine, the patient’s heart can be stopped so that the surgeon can operate on a motionless heart.

When the surgeon has completed the cardiac repair, the heart is restarted, and the heart-lung machine is disconnected from the patient.

As the heart resumes beating, the anesthesiologist manages the drug therapy and intravenous fluid therapy to optimize the cardiac function.

III.  ANESTHESIA FOR NEUROSURGERY (BRAIN SURGERY):

Intracranial (brain) surgery requires exacting maintenance of blood pressure, heart rate, and respiratory control.  Prior to the surgery, the anesthesiologist inserts a catheter into the radial artery at the wrist, to monitor the patient’s blood pressure continuously, rather than relying on a blood pressure cuff.  This enables the anesthesiologist to fine-tune the blood pressure, never allowing it to be too high or too low for an extended period of time.  The anesthesiologist also inserts a catheter (a central venous catheter, or CVP catheter) into a large vein in the patient’s neck.  The anesthesiologist uses this catheter to monitor the pressure inside the heart, and also to administer infusions of potent medications into the central circulation to raise or lower the blood pressure.

The anesthetic technique is designed to provide a motionless operating field for the surgeon.  After the anesthesiologist anesthetizes the patient, he or she inserts the endotracheal tube into the windpipe.  The patient is often hyperventilated, because hyperventilation causes the blood vessels in the brain to constrict, and makes the volume of the the brain decrease.  The relaxed brain affords the surgeon more room to dissect and expose brain tumors or aneurysms.

An important goal of the anesthetic is a quick wake-up at the conclusion of surgery, so that (1) normal neurological recovery of the patient can be confirmed, and (2) the patient is alert enough to  maintain their own airway and breathe on their own.  Most brain surgery patients spend at least one night in the intensive care unit (ICU) after surgery.

 

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: HOW DOES THE ANESTHESIOLOGIST DECIDE WHAT DOSE OF ANESTHETIC TO GIVE A PATIENT?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

You are a 100-pound, 70-year-old woman.

Your son is a 200-pound, 35-year-old man.

Do you both require the same doses of general anesthetic if you each need to have your gall bladder removed?

No, you do not.

Anesthesiologists use several criteria to choose the correct dose for your anesthetic.

  • Your weight.      All intravenous anesthetic drugs, such as hypnotics (propofol, sodium pentothal), narcotics (morphine, Demerol, fentanyl), anxiolytics (Versed, Ativan), or muscle paralyzing drugs (rocuronium, vecuronium, succinylcholine) are dosed on a milligram-per-kilogram basis. If you weigh half as much as your neighbor, if all other factors are equal, then you will receive approximately half as many milligrams of the injectable medication as she will.
  • Your age.        Abundant research has demonstrated the relationship between age and anesthetic effect. Youthful patients require more milligrams-per-kilogram of body weight. A teenager may require twice the dose of an 80-year-old patient.
  • How stimulating the surgery is, and how much pain there will be postoperatively.          A non-painful surgery, such as the repair of a small tendon in a finger, will not require large doses of narcotics or pain relievers post-operatively. A painful surgery, such as on open abdominal procedure to remove a pancreatic or liver tumor, will require more narcotics and increased doses of anesthetics. If postoperative pain is blocked by local anesthetic injection in the surgical site or by a nerve block, a patient will require less general anesthetic medications.
  • The duration of the surgery.      An 8-hour surgery will require a longer exposure to more anesthetic drugs than a 1-hour surgery.
  • Your preoperative exposure to central nervous system depressants.      All else being equal, a patient who drinks 12 beers every day will require more anesthesia than a teetotaler who never drinks. A patient who is addicted to chronic prescription painkillers will require more anesthesia than a non-addict.

Inhaled anesthetics, such as sevoflurane, desflurane, isoflurane, or nitrous oxide, are administered in standard concentrations, independent of all the above factors except the patient’s age.  Inhaled anesthetics are mixed into vapor by an anesthesia machine which is connected to the your breathing system during the surgery. The anesthesia machine will usually be set to deliver either sevoflurane 1-2 %, desflurane 3 – 6 %, or isoflurane 0.8 – 1.5 %. The required concentration of these potent inhaled anesthetic decreases with age. The dose for teenager is approximately twice the dose required for a 90-year-old patient.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: LETHAL INJECTION AND THE ANESTHESIOLOGIST

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

In the 2011 movie The Lincoln Lawyer, Matthew McConaughey’s character, a criminal defense lawyer working in Los Angeles, taunts his client who is on trial for murder to tell the truth in order to “avoid the needle.”  The needle he is talking about is the specter of execution by lethal injection.

Since 2006, there have been no death penalty executions by lethal injection in the state of California.  In February 2006, U.S. District Court Judge Jeremy D. Fogel blocked the execution of convicted murderer Michael Morales because of concerns that if the three-drug lethal injection combination was administered incorrectly, it could lead to suffering for the condemned, and potential cruel and unusual punishment.  The ruling arose from an injunction made by the U.S. 9th Circuit Court of Appeals, which stated that an execution could only be carried out by a medical technician legally authorized to administer intravenous medications.  This led to a moratorium of capital punishment in California, as the state was unable to obtain the services of a licensed medical professional to carry out an execution.

The three intravenous drugs involved in lethal injection are (1) sodium thiopental, a barbiturate drug that induces sleep, (2) pancuronium, a drug that paralyzes all muscles, making movement and breathing impossible, and (3) potassium chloride, a drug that induces ventricular fibrillation of the heart, causing cardiac arrest.  The potential of cruel and unusual punishment can occur if the sodium thiopental does not reliably induce sleep, so that the individual to be executed is awake and aware when the paralyzing drug freezes all muscular activity.

How could sodium thiopental fail to induce sleep?  The lethal injection administered dose of sodium thiopental is always a massive dose, up to 3000 mg.  To compare, the usual dose of sodium thiopental administered by an anesthesiologist to begin a general anesthetic is 200 mg.  The 15-fold increase in the dose should insure lack of awareness, right?

Not necessarily.  What if the intravenous catheter or needle is incorrectly positioned, so that the drug does not enter the vein in a reliable fashion?  Is this a possibility?  It is.  If the catheter is not inserted by a trained medical professional, it’s possible that the catheter will be outside of the vein, and the intended medications will spill into the soft tissues of the arm.  The intended site of action of sodium thiopental is the brain.  To reach the brain, the drug must be correctly delivered into a vein.

Cases in which failure to establish or maintain intravenous access have led to executions lasting up to 90 minutes before the execution was complete.Thus, the role of a medical professional to insert the intravenous catheter and administer the lethal injection is critical.  The dilemma is that medical professionals are trained to save lives, not to execute people.  The Hippocratic Oath clearly states that physicians must “do no harm” to their patients.

The American Medical Association states, “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

The American Society of Anesthesiologists states, “Although lethal injection mimics certain technical aspects of the practice of anesthesia, capital punishment in any form is not the practice of medicine … The American Society of Anesthesiologists continues to agree with the position of the American Medical Association on physician involvement in capital punishment. The American Society of Anesthesiologists strongly discourages participation by anesthesiologists in executions.”

The American Nurses Association states, “The American Nurses Association is strongly opposed to nurse participation in capital punishment. Participation in executions is viewed as contrary to the fundamental goals and ethical traditions of the profession.”

Without a trained medical professional to administer the intravenous catheter and inject the drugs in a reliable fashion, the practice of lethal injection has stalled in the State of California.  The last prisoner executed by lethal injection in California was Clarence Ray Allen on January 17, 2006.

In 2010, a Riverside County judge scheduled the execution of Albert Greenwood Brown, after a California court lifted an injunction against capital punishment with the certification of new procedures.  The new procedures included the option of increasing the sodium thiopental dose to 5000 mg, and administering the drug alone without the pancuronium and potassium chloride.  (In this scenario, death would occur because the large dose of sodium thiopental would by itself induce both general anesthesia and the cessation of breathing, leading to death by lack of sufficient oxygen levels to the brain and heart.)  However, prior to the execution, the same Judge Jeremy D. Fogel halted the execution to permit time to determine whether the new injection procedures addressed defense arguments of cruel and unusual punishment.

An additional barrier to lethal injection arose in January 2011, as Hospira Corporation, the sole manufacturer of sodium thiopental, announced that they would stop making the anesthetic sodium thiopental, the key component in the drug cocktails used by 35 states for chemical executions.

Hospira had planned to shift production of thiopental from the U.S. to Italy, but Italian officials wanted assurances that the drug would not be used for lethal injections.  Hospira’s response was that while they “never condoned” the use of thiopental in executions, the company determined that it could not prevent corrections departments in the United States from obtaining the drug. “Based on this understanding, we cannot take the risk that we will be held liable by the Italian authorities if the product is diverted for use in capital punishment,” Hospira said in a statement.

The American Society of Anesthesiologists released a statement on January 21, 2011 condemning Hospira’s decision to cease manufacturing sodium thiopental. The American Society of Anesthesiologists “certainly does not condone the use of sodium thiopental for capital punishment, but we also do not condone using the issue as the basis to place undue burdens on the distribution of this critical drug to the United States. It is an unfortunate irony that many more lives will be lost or put in jeopardy as a result of not having the drug available for its legitimate medical use.”  According to the American Society of Anesthesiologists, thiopental is an important alternative for geriatric, neurologic, cardiovascular and obstetric patients “for whom the side effects of other medications could lead to serious complications.”

In current anesthetic practice in the U.S. and around the world, sodium thiopental is occasionally but rarely utilized in anesthetic or intensive care unit practice.  Propofol replaced sodium thiopental, as propofol is a shorter-acting drug with fewer side effects of post-operative sleepiness and nausea.

Propofol or other sedative drugs such as midazolam, Valium, etomidate, or methohexital could be used to replace sodium thiopental to carry out lethal injection, but the key issue of obtaining a trained medical professional to administer the drug still looms as a roadblock.

I recommend The Lincoln Lawyer as riveting entertainment, but when Matthew McConaughey urges the defendant to “avoid the needle” of lethal injection, you have to understand … it’s unlikely any anesthesiologist is ever going to assist in that execution.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: IS YOUR GRANDMOTHER TOO OLD FOR 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

Latest posts by the anesthesia consultant (see all)

Your 85-year-old grandmother had two gallstone attacks in the past 6 months. Is she too old for surgery? Is it safe for her to have her gallbladder removed?

 

It depends. A general surgeon would serve as the consultant as to the natural history of the gallbladder disease. He may opine that future gallstone attacks are likely, and that the severe pain and fever of acute cholelithiasis is possible.

If your grandmother was 50 years old, you’d expect the surgical team to operate on her. For an 85-year-old patient, the surgical prognosis depends on her medical condition. She needs preoperative assessment from a specialist, and that specialist would be an anesthesiologist.

At Stanford University the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word perioperative refers to medical practice before, during, and after surgical operations. Preoperative assessment refers to the medical work-up before a surgical procedure—the work-up which establishes that all necessary diagnostic and therapeutic measures have been taken prior to proceeding to the operating room.

Age alone should not be a deterrent to surgery. Increased life expectancy, safer anesthesia, and less invasive surgical techniques such as laparoscopy have made it possible for a greater number of geriatric patients to undergo surgical intervention. The decision to operate should not be based on age alone, but should be based on an assessment of the risk-to-benefit ratio of each individual case. Surgical risk and outcome in patients 65 years old and older depend primarily on four factors: (1) age, (2) whether the surgery is elective or urgent, (3) the type of procedure, and (4) the patient’s physiologic status and coexisting disease. (reference: Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7th Edition, 2009).

Let’s look at each of these four factors:

1)   Age. Data support that increasing age increases risk.  Complication rates and mortality rates are higher for patients in their 80’s than for patients in their 60’s.

2)   Emergency surgery. Patients presenting for emergency surgery are often sicker than patients for elective surgery, and have increased risk.  There may be insufficient time for a full preoperative medical workup or tune-up prior to anesthesia.

3)   Type of procedure. A trivial procedure such as finger or toe surgery carries significantly less risk than open heart surgery or intra-abdominal surgery.

4)   Coexisting disease. The American Society of Anesthesiologists has a classification system for patients which categorizes how healthy or sick a patient is (see the American Society of Anesthesiologists Physical Status Class categories below). A patient with severe heart or lung disease is at higher risk than a rigorous patient who hikes, bikes or swims daily without heart or lung pathology.

Let’s examine these four factors in your 85-year-old grandmother. Regarding factor (1), she is old, and therefore she carries increased risk solely because of her advanced age. Regarding factor (2), her surgery is non-emergent, and this is in her favor. Regarding factor (3), her procedure requires intra-abdominal surgery, which is more invasive and carries more cardiac and respiratory risk than a trivial hand or foot or cataract surgery. She’ll have to cope with post-operative abdominal pain and pain on deep breathing, each of which can affect her lung function after anesthesia. Factor (4), her pre-existing medical history and physical condition, is the key element in her pre-operative consult.

The American Society of Anesthesiologists Physical Status Class categorizes patients as follows:

Class I   – A normal healthy patient. Almost no one over the age of 65 is an ASA I.

Class II  – A patient with mild systemic disease.

Class II  – A patient with severe systemic disease.

Class IV – A patient with severe systemic disease that is a constant threat to life.

Let’s say your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity. She is reasonably active without limiting heart or lung disease symptoms, and she can climb two flights of stairs without shortness of breath.

She is an ASA Class II.

What if your grandmother had a past heart attack which left her short of breath walking up two flights of stairs, or she has kidney failure and is on dialysis, or she has severe emphysema that leaves her short of breath walking up two flights of stairs? These problems make her an ASA Class III, and she is at higher risk than a Class II patient.

If your 85-year-old grandmother is short of breath at rest or has angina at rest, due to either heart failure or chronic lung disease, she is an ASA Class IV patient, and she is at very high risk for surgery and anesthesia.

Laypersons can access an online surgical risk calculator, sponsored by the American College of Surgeons, at www.riskcalculator.facs.org, and enter the specific data for any surgical patient, to estimate surgical risk.

If your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity as described above, then her operative risk is moderate and most anesthesiologists will be comfortable giving her a general anesthetic. The American College of Surgeons risk calculator estimates her risk of death, pneumonia, cardiac complications, surgical site infection, or blood clots as < 1%. Her risk of serious complication is estimated at 2%.

How will the anesthesiologist proceed?

For an 85-year-old patient, most anesthesiologists will require a written consultation note from an internal medicine primary care doctor or a cardiologist prior to proceeding with anesthesia. The anesthesiologist will then confirm that all necessary diagnostic and therapeutic measures have been done prior to surgery. Routine lab testing is not be ordered because of age alone, but rather pertinent lab tests are done as indicated for the particular medical problems of each patient.

The anesthesiologist then explains the risks of anesthesia and obtains informed consent prior to the surgery. He or she will explain that an 85-year-old patient with treated hypertension, asthma, hyperlipidemia, and obesity has a higher chance of heart, lung, or brain complications than a young, healthy patient. Your grandmother will have to accept the risks as described by the anesthesiologist.

What do anesthesiologists do differently for geriatric anesthetics, in contrast to anesthesia practice on young patients?

(1) Anesthesiologists use smaller doses of drugs on elderly patients than they do on younger patients. Geriatric patients are more sensitive to anesthetic drugs, and the effect of the drugs will be more prolonged.

(2) Geriatric patients have progressive loss of functional reserve in their heart, lungs, kidney, and liver systems. The extent of these changes varies from patient to patient, and each patient’s response to surgery and anesthesia is monitored carefully. (Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7th Edition, 2009). The anesthesiologist’s routine monitors will include pulse oximetry, electrocardiogram, automated blood pressure readings, temperature monitoring, and monitoring of all inspired gases and anesthetic concentrations. Because most anesthetic drugs cause decreases in blood pressure, anesthesiologists slowly titrate additional anesthetic doses as needed, and remain vigilant for blood pressure drops that are excessive or unsafe.

What about mental decline following geriatric surgery?

Postoperative short-term decrease in intellect (decrease in cognitive test performance) during the first days after surgery is well documented, and typically involves decreases in attention, memory, and fine motor coordination. Early cognitive decline after surgery is largely reversible by 3 months. The reported incidence of cognitive dysfunction after major noncardiac surgery in patients older than 65 years is 26% at 1 week and 10% at 3 months. (reference: Johnson T, Monk T, Rasmussen LS, et al: Postoperative cognitive dysfunction in middle-aged patients. Anesthesiology 2002; 96:1351-1357).

In conclusion, the decision to proceed with your grandmother’s surgery and anesthesia requires an informed assessment of the benefit of the surgery versus the risks involved. Well-trained anesthesiologists anesthetize 85-year-old patients every day, with successful outcomes. My advice is to choose a medical center with fine physician anesthesia providers, and heed their consultation regarding whether your grandmother poses any unacceptable risk for surgery and 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?

 

 

 

*
*
*
*

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

 

 

LANDING THE ANESTHESIA PLANE: WHEN SHOULD YOU EXTUBATE THE TRACHEA?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Clinical Case for Discussion: You’re anesthetizing a 60-year-old woman for a thyroidectomy. The surgeon tells you, “If this woman bucks on the endotracheal tube on awakening it could cause a neck hematoma and damage my surgical closure. Can you extubate her deep?”

Discussion: The patient has a normal airway, and she is healthy and slender. You decide to comply with the surgeon’s request and remove the endotracheal tube (ET tube) at the end of surgery while the patient is still fully anesthetized. You turn off the nitrous oxide, allow the patient to breath 100% oxygen and 3% sevoflurane, and suction the patient’s throat. You deflate the cuff on the ET tube and remove the tube. Once the tube is withdrawn, you turn off all anesthetics. At this point the patient coughs and her mouth fills with yellow gastric contents. You suction the mouth again, but the patient develops upper airway obstruction. The oxygen saturation drops to 80%. Your diagnosis is laryngospasm. You attempt to apply continuous positive airway pressure with an anesthesia mask, but her oxygen saturation falls to 70%. Panicked, you inject 100 mg of IV succinylcholine to re-paralyze the patient, and you perform laryngoscopy and reintubate her. After the ET tube is replaced, the oxygen saturation returns to 100%. You suction through the lumen of the ET tube, and you find yellow gastric material inside the lungs. You diagnose aspiration.

After a 10½ hour flight from Seoul, Korea, an Asiana airplane crashed on landing at San Francisco Airport on July 6, 2013. Aviation and anesthesia have similarities. The takeoff and landing of an airplane, just as induction and emergence from anesthesia, are more complex events than piloting the middle of a plane flight or managing the maintenance phase of a long anesthetic.

The timing of the removal of the endotracheal tube at the end of an anesthetic requires skill and judgment. Does deep extubation ever make sense? During my first year after residency training, a gray-haired anesthesia attending at my new medical center told me, “Richard, in private practice you never extubate anyone deep.” Twenty-seven years later, I’m writing to convince you he was right.

Let’s define “deep extubation.” Per Miller’s Anesthesia, 7th Edition, 2009, Chapter 50, “Extubation may be performed at different depths of anesthesia, with the terms ‘awake,’ ‘light,’ and ‘deep’ often being used. ‘Light’ implies recovery of protective respiratory reflexes and ‘deep’ implies their absence. ‘Awake’ implies appropriate response to verbal stimuli. ‘Deep’ extubation is performed to avoid adverse reflexes caused by the presence of the tracheal tube and its removal, at the price of a higher risk of hypoventilation and upper airway obstruction. Straining, which could disrupt the surgical repair, is less likely with ‘deep’ extubation. Upper airway obstruction and hypoventilation are less likely during ‘light’ extubation, at the price of adverse hemodynamic and respiratory reflexes.”

The medical literature describes deep extubation as extubating a patient who is still breathing 1.5 times the minimal alveolar concentration (MAC) of inhaled anesthetic. A 2004 study examined 48 children tracheally extubated while deeply anesthetized with 1.5 times the MAC of desflurane (Group D) or sevoflurane (Group S). No serious complications occurred in either group, and the time to discharge was not significantly different between groups. The study concluded that deep extubation of children can be performed safely with desflurane or sevoflurane. (Valley RD, Anesth Analg. 2003 May;96(5):1320-4, Tracheal extubation of deeply anesthetized pediatric patients: a comparison of desflurane and sevoflurane.)

In a prospective trial, 100 children age<16 years, each with at least one risk factor for perioperative respiratory adverse events (e.g. current or recent upper respiratory tract infection or asthma) were randomized to extubation under deep anesthesia or extubation when fully awake after tonsillectomy. There were no differences in respiratory adverse events (laryngospasm, bronchospasm, persistent coughing, airway obstruction, or desaturation <95%). Tracheal extubation in fully awake children was associated with a greater incidence of persistent coughing (60 vs. 35%, P = 0.028), however the incidence of airway obstruction relieved by simple airway maneuvers in children extubated while deeply anaesthetized was greater (26 vs. 8%, P = 0.03).

Seventy healthy patients between 2 and 8 yr of age who had elective strabismus surgery or tonsillectomy were randomly assigned to group 1 (awake extubation) or group 2 (anesthetized extubation). The incidence of airway-related complications such as laryngospasm, croup, sore throat, excessive coughing, and arrhythmias was not different between the two groups. The authors concluded that the anesthesiologist’s preference or surgical requirements may dictate the choice of extubation technique in otherwise healthy children undergoing elective surgery. (Patel RI, Anesth Analg. 1991 Sep;73(3):266-70. Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients).

In an informal poll of the private practice anesthesiologists at Stanford University, the incidence of deep extubation (i.e. patient extubated asleep while breathing >1.5 MAC of inhaled anesthetic) approached zero. Why do I and my colleagues avoid deep extubation? If you have a life-saving and life-preserving device such as an endotracheal tube safely in place in your patient, and your goal is to maintain the values of Airway, Breathing, and Circulation, why remove that life-preserving device prematurely without any evidence that such a removal is beneficial? Why leave your anesthetized patient with an unprotected airway?

I cannot cite you outcome data that shows awake extubation provides superior outcomes to deep extubation, but with modern short-acting anesthetics such as propofol, sevoflurane, and desflurane, a well-trained anesthesiologist can decrease anesthetic depth quickly and have their patient very awake within minutes after the conclusion of surgery. Per Miller’s Aesthesia, “Rapid recovery of consciousness shortens the at-risk time during extubation and may reduce morbidity, particularly in obese patients. … Nitrous oxide, sevoflurane, and desflurane all contribute to rapid recovery, particularly after prolonged procedures.”

If your patient vomits on emergence and the ET tube is still in situ, the cuff on the ET tube will protect their lower airway. And if you choose to extubate your patient awake, the occurrence of laryngospasm will be, in this author’s experience, rare.

It’s true that coughing on an ET tube can disrupt surgical repairs, increase intracranial pressure, increase intraocular pressure, or cause hypertension and tachycardia, but per Miller’s Anesthesia, “Marked increases in arterial blood pressure and heart rate occur frequently at the time of ‘light’ extubation. These effects are alarming but normally transient, and there is little evidence of adverse consequences.”

My advice: Use light levels of general anesthetics on your intubated patients, and learn how to wake your patients from general anesthesia quickly at the conclusion of surgery. Don’t suction the patient until you are ready to remove the ET tube, because the suction catheter stimulates early coughing.

The ET tube is your friend. I’d recommend you don’t pull it out until you’re certain you don’t need it any more.

The definitive reference from the medical literature on this topic is Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the management of tracheal extubation, Anaesthesia 2012, 67, 318-340.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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WHY DOES ANYONE DECIDE THEY WANT TO BECOME AN 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

Latest posts by the anesthesia consultant (see all)

A question anesthesiologists are commonly asked is, “Why did you decide on a career in anesthesiology?

Let’s assume a young man or woman has the discipline and intellect to attend medical school. Once that individual gains their M.D. degree, they will choose a specialty from a long line-up that includes multiple surgical specialties (general surgery, orthopedics, urology, neurosurgery, cardiac surgery, ophthalmology, plastic surgery, ear-nose-and-throat surgery), internal medicine, pediatrics, family practice, dermatology, radiology, invasive radiology, radiation oncology, allergy-immunology, emergency medicine, and anesthesiology.

Why choose anesthesiology? I offer up a list of the reasons individuals like myself chose this specialty:

  1. Anesthesiologists do acute care rather than clinic care or chronic care. Some doctors enjoy sitting in a clinic 40+ hours a week, talking to and listening to patients. Other doctors prefer acute care, where more exciting things happen moment to moment. It’s true that surgeons do acute care in the operating room, but most surgeons spend an equal amount of time in clinic, seeing patients before and after scheduled surgical procedures. Chronic care in clinics can be emotionally taxing. Ordering diagnostic studies and prescribing a variety of pills suits certain M.D.’s, but acute care in operating rooms and intensive care units is more stimulating. It’s exciting controlling a patient’s airway, breathing, and circulation. It’s exciting having a patient’s life in your hands. Time flies.
  2. Patients like and respect their anesthesiologist, and that feels good. Maybe it’s because we are about to take each patient’s life into our hands, but during those minutes prior to surgery, patients treat anesthesiologists very well. I tend to learn more about my patients’ personal lives, hobbies, and social history in those 10 minutes of conversation prior to surgery than I ever did in my internal medicine clinic.
  3. An anesthesiologist’s patients are unconscious the majority of time. Some anesthesiologists are attracted the this aspect. An unconscious patient is not complaining. In contrast, try to imagine a 50-hour-a-week clinic practice as an internal medicine doctor, in which every one of your patients has a list of medical problems they are eager to tell you about.
  4. There is tremendous variety in anesthesia practice. We take care of patients ranging in ages from newborns to 100-year-olds. We anesthetize patients for heart surgery, brain surgery, abdominal or chest surgeries, bone and joint surgeries, cosmetic surgery, eye surgery, urological surgery, trauma surgery, and organ transplantation surgery. Every mother for Cesarean section has an anesthetist, as do mothers for many vaginal deliveries for childbirth. Anesthesiologists run intensive care units and anesthesiologists are medical directors of operating rooms as well as pain clinics.
  5. Anesthesiologists work with a lot of cool gadgets and advanced technology. The modern anesthesia workstation is full of computers and computerized devices we use to monitor patients. The modern anesthesia workstation has parallels to a commercial aircraft cockpit.
  6. Lifestyle. We work hard, but if an anesthesiologist chooses to take a month off, he or she can be easily replaced during the absence. It’s very hard for an office doctor to take extended time away from their patients. Many patients will find a alternate doctor during a one month absence if the original physician is unavailable. This aspect of anesthesia is particularly attractive to some female physicians who have dual roles as mother and physician, and choose to work less than full-time as an anesthesiologist so they can attend to their children and family.
  7. Anesthesia is a procedural specialty. We work with our hands inserting IV’s, breathing tubes, central venous IV catheters, arterial catheters, spinal blocks, epidural blocks, and peripheral nerve blocks as needed. It’s fun to do these procedures. Historically, procedural specialties have been higher paid than non=procedural specialties.

What about problematic issues with a career in anesthesia? There are a few:

  1. We work hard. Surgical schedules commonly begin at 7:30 a.m., and anesthesiologists have to arrive well before that time to prepare equipment, evaluate the first patient, and get that patient asleep before any surgery can commence. After years of this, my internal alarm clock tends to wake me at 6:00 a.m. even on weekends.
  2. Crazy hours. Every emergency surgery—every automobile accident, gunshot wound, heart transplant, or urgent Cesarean section at 3 a.m. needs an anesthetist. Working around the clock can wear you out.
  3. The stakes are high if you make a serious mistake. In a clinic setting, an M.D. may commit malpractice by failing to recognize that a patient’s vague chest pain is really a heart attack, or an M.D. may fail to order or to check on an important lab test, leading to a missed diagnosis. But in an operating room, the malpractice risks to an anesthesiologist are dire. A failure in properly insert a breathing tube can lead to brain death in minutes. This level of tension isn’t for everyone. Some doctors are not emotionally suited for anesthesia practice.
  4. In the future, anesthesia doctors may gradually lose market share of their practice to nurse anesthetists. You can peruse other columns in this blog where I’ve discussed this issue.
  5. Anesthesiologists don’t bring any patients to a medical center. In medical politics, this can be problematic. Anesthesiologists have limited power in some negotiations, because we can be seen as service providers rather than as a source of new patient referrals for a hospital. Some hospital administrators see an anesthetist as easily replaced by the next anesthetist who walks through the door, or who offers to work for a lower wage.

The positive aspects of anesthesiology far outweigh these negatives.

Akin to the Dos Equis commercial that describes “The Most Interesting Man in the World,” I’d describe the profession of anesthesiology as “The Most Interesting Job in the World.”

And when you love your job, you’ll never work a day in your life.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

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