CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.”

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

 

Yes, you can read entertaining fiction and learn about medicine at the same time.

Rick Novak’s third novel, Call From the Jailhouse, a 5-star review from the San Francisco Book Review, is now available on Amazon:

CALL FROM THE JAILHOUSE: NOW AVAILABLE ON AMAZON LINK:

Call From the Jailhouse

 

REVIEW FROM THE SAN FRANCISCO BOOK REVIEW:

Call From the Jailhouse

By Rick Novak
Extasy Books,  331 pages, Format: eBook and paperback

Star Rating: 5 / 5

Author Rick Novak, MD, does an exquisite job of crafting a scenario in which a man is accused of murdering his lover and her husband and brings it all the way into a full jury trial. Call From the Jailhouse introduces readers to top defense attorney Cicely Vella. Cicely is a savage in the courtroom and is able to present to the jury all the reasons why they should acquit. Cicely’s marriage to an anesthesiologist named Sam Vella ended in divorce almost a year and a half ago, although there were certainly times when she missed him. When Sam calls Cicely from the county jail and tells her he is being accused of murder, Cicely knows she must defend him. Although their marriage didn’t work out, Cicely knows Sam didn’t kill anyone.

I loved the way the book was crafted. It starts with the phone call and then goes back in time six months to tell the readers about how Sam meets his married lover, Scarlett. The story is carefully told, with no important detail left out. As a San Francisco Bay Area native, I loved that I knew where so many of the referenced places were, including the Pacific Athletic Club (now The Bay Club), the Stanford Dish, and Kings Mountain Road. I admit that I looked up the Mahogany, where Sam meets Scarlett, and as I guessed, there was no such place listed. It seemed like it could have been modeled after the Rosewood Hotel in Menlo Park.

Call From the Jailhouse moves at the perfect pace. As Sam and Scarlett’s secret relationship starts to bloom, Sam finds himself falling in love with her even though she treats him like she owns him. So, how does Sam find himself accused of murder?

The last half of the book is dedicated to Cicely defending Sam in court. All evidence seems to lead to Sam, even though most of it is circumstantial. They say, write what you know, so Novak’s extensive knowledge in the medical field allows him to cleverly insert medical references, such as a medicine used to paralyze patients to allow doctors to insert a breathing tube. It’s details such as this that give the readers a full understanding of the events that take place in the book.

The court case is my favorite part of the book. This is also where there is a huge twist in the plot that gets uncovered. Cicely is a fantastic attorney who has integrity, grit, and grace all rolled into one small Black woman. Sam is a romantic at heart who finds himself in a black widow’s web. Call From the Jailhouse has fabulous characters, beautiful backdrops, and a plot that will pull you closer with every page.

Reviewed by Kristi Elizabeth

OUR STAR RATING SYSTEM  5 stars: Reviewer considers the book to be something that everyone should read. Reviewer would definitely read it again.

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CALL FROM THE JAILHOUSE excerpt:

Chapter One: The Call

Cicely Vella’s receptionist announced, “Ms. Vella, your ex-husband is on line one. He says he’s in jail. He wants to talk to you.”

There are mileposts in life—moments that alter the future in earthshattering ways. The sudden change can be terrific or tragic. Cicely used to think her defining moment was the end of her marriage, but instead her defining moment occurred when she picked up line one and said, “Sam, what’s going on?”

His voice came through pressured and loud, so robust she had to hold the phone six inches away from her ear. “There’s been some kind of mistake,” he said. “The police arrested me. I’m in trouble.”

Cicely was shocked. Sam had never called her since their divorce, and she’d never heard this tone in his voice. He’d always been cool, calm, and controlled, even in the most stressful times. Cicely couldn’t hide her alarm. “Arrested you for what?”

“Murder.”

Cicely almost dropped the phone. “Murder? You’ve got to be kidding. Where are you right now?”

“The San Mateo County Jail. I need a defense attorney. I need you. Please help me.”

Cicely pictured Sam Vella sitting alone in a jail cell, and her response surprised her. She leapt out of her chair, ready to go to him. “I’ll be there in twenty minutes,” she said. “And don’t answer any questions from anyone until I arrive. Got that?”

“I won’t. And thank you so much for doing this for me.”

“I haven’t done anything yet.” Cicely hung up the phone, feeling the room spinning around her. This wasn’t possible. Sam was a smart guy—an altruistic medical doctor who simply couldn’t kill anyone. He’d been a flawed husband, a man who never quite got used to his overachieving wife’s career eclipsing his, but he wasn’t wired to commit violent crime. Cicely grabbed her purse and car keys and headed for the door. A petite Black woman, Cicely wore a gray wool pantsuit and a Brooks Brothers white cotton shirt. Her androgynous attire was her statement that, in the male-dominated world of litigating attorneys, she had the power to match up with her masculine opponents. Her business—the world of defendants and their alleged misdeeds—was a grim reality of treachery, deceit, ruses, and lies. Cicely didn’t see her vocation as a quest for truth, but rather a competition in search of victory. It was her job to conjure deception. Her joy came from constructing any reasonable alternative to the allegations of the prosecution. Every new case was a puzzle with a yet undiscovered solution. Finding that solution was the most enjoyable pastime Cicely had ever discovered. The money was good, but she knew in her heart she might even have done it for free.

It was that fun.

As Cicely exited through the waiting room, her receptionist said, “I overheard your conversation with Sam. Are you going to defend him?”

“Hell, yes. What kind of defense attorney would I be if my ex-husband spent the rest of his life rotting in prison as a convicted murderer?”

“You’ll be center stage if you defend him.”

“I’ll be center stage whether I’m his lawyer or not. We share a last name. We share a past. I’m going to the jail. I don’t know when I’ll be back.” Cicely’s thoughts were in turmoil. Her divorce was fresh—only one year old. After five workaholic years as man and wife, she and Sam painted themselves into two distant corners—a sad California career-trumps-love divorce. She’d pulled the plug on their marriage and concentrated on climbing to the pinnacle of the legal world. Cicely had only seen Sam twice since the divorce, and each time she felt the same two opposing emotions―a strong attraction to his physical presence, and sadness that the man who had once been her best friend was a stranger to her now.

Cicely knew the drive from her office to the jail very well. She met most of her clients for the first time within those very walls. Minutes later she sat face-to-face with Sam in a windowless white-walled room. He wore an orange jumpsuit with the number 71427 scrolled across his chest. His hair was parted in the middle, lanky and wet, as if he’d just stepped out of a storm, and his gaze never left Cicely. Her heart raced to be sitting so close to him again. He looked as vulnerable as a lost puppy and as breathtaking as any man she had ever set eyes on. Cicely skipped any pleasantries and started with the obvious question, “Who are you accused of killing, Sam?”

He shook his head and dropped his stare toward the table separating them. Then his eyes flicked upward for a second, partially hidden below thick hooded brows, and he said, “It was this woman I was dating. They claim I killed her. And they claim I killed her husband, too.”

“Two murders? Good God.” Cicely exhaled mightily. “Tell me what happened, starting when you first met this-this woman.” Cicely balanced her pen over an 8.5 X 14-inch yellow legal pad and prepared to chronicle Sam’s story.

“Her name was Scarlett,” Sam said. “It all started one rainy January night last winter…”

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CALL FROM THE JAILHOUSE: NOW AVAILABLE ON AMAZON LINK:

Call From the Jailhouse

 

Rick Novak’s first novel, THE DOCTOR AND MR. DYLAN

Rick Novak’s second novel, DOCTOR VITA

COMING SOON: RICK NOVAK’S NEW NOVEL, CALL FROM THE JAILHOUSE

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

This image has an empty alt attribute; its file name is screen-shot-2023-08-15-at-7.59.41-am.png

Litigator Cicely Vella’s ex-husband is arrested for a double murder, and asks her to be his defense lawyer. Cicely rarely loses a case, but her extraordinary record is in jeopardy when she chooses to defend Sam Vella, the only suspect in what appear to be two indefensible crimes.

Cicely is living the dream life of a young professional. She’s bright, beautiful, Black, and successful, but she harbors one weakness—lingering feelings for Sam, the husband who got away.

Samuel Vella is a physician with high intellect, striking good looks, and a proclivity for making poor decisions. In the aftermath of his split from Cicely, Sam initiates an affair with Scarlett Lang, a free-spirited married woman, and their liaison lands Sam behind bars.

After receiving Sam’s call from the jailhouse, Cicely feels the triple lures of her emotional attachment to her ex-husband, the opportunity to redeem the Vella name in the courtroom, and her zest for fame in this sensational high-profile trial. Nothing in the world but this court date could make Cicely and Sam sit elbow to elbow, day after day.

The odds of a divorced couple remarrying the same person are 6 in 100, a statistic Cicely is both aware of and wary of, as she’s drawn back into Sam’s life.

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CALL FROM THE JAILHOUSE excerpt:

Chapter One: The Call

Cicely Vella’s receptionist announced, “Ms. Vella, your ex-husband is on line one. He says he’s in jail. He wants to talk to you.”

There are mileposts in life—moments that alter the future in earthshattering ways. The sudden change can be terrific or tragic. Cicely used to think her defining moment was the end of her marriage, but instead her defining moment occurred when she picked up line one and said, “Sam, what’s going on?”

His voice came through pressured and loud, so robust she had to hold the phone six inches away from her ear. “There’s been some kind of mistake,” he said. “The police arrested me. I’m in trouble.”

Cicely was shocked. Sam had never called her since their divorce, and she’d never heard this tone in his voice. He’d always been cool, calm, and controlled, even in the most stressful times. Cicely couldn’t hide her alarm. “Arrested you for what?”

“Murder.”

Cicely almost dropped the phone. “Murder? You’ve got to be kidding. Where are you right now?”

“The San Mateo County Jail. I need a defense attorney. I need you. Please help me.”

Cicely pictured Sam Vella sitting alone in a jail cell, and her response surprised her. She leapt out of her chair, ready to go to him. “I’ll be there in twenty minutes,” she said. “And don’t answer any questions from anyone until I arrive. Got that?”

“I won’t. And thank you so much for doing this for me.”

“I haven’t done anything yet.” Cicely hung up the phone, feeling the room spinning around her. This wasn’t possible. Sam was a smart guy—an altruistic medical doctor who simply couldn’t kill anyone. He’d been a flawed husband, a man who never quite got used to his overachieving wife’s career eclipsing his, but he wasn’t wired to commit violent crime. Cicely grabbed her purse and car keys and headed for the door. A petite Black woman, Cicely wore a gray wool pantsuit and a Brooks Brothers white cotton shirt. Her androgynous attire was her statement that, in the male-dominated world of litigating attorneys, she had the power to match up with her masculine opponents. Her business—the world of defendants and their alleged misdeeds—was a grim reality of treachery, deceit, ruses, and lies. Cicely didn’t see her vocation as a quest for truth, but rather a competition in search of victory. It was her job to conjure deception. Her joy came from constructing any reasonable alternative to the allegations of the prosecution. Every new case was a puzzle with a yet undiscovered solution. Finding that solution was the most enjoyable pastime Cicely had ever discovered. The money was good, but she knew in her heart she might even have done it for free.

It was that fun.

As Cicely exited through the waiting room, her receptionist said, “I overheard your conversation with Sam. Are you going to defend him?”

“Hell, yes. What kind of defense attorney would I be if my ex-husband spent the rest of his life rotting in prison as a convicted murderer?”

“You’ll be center stage if you defend him.”

“I’ll be center stage whether I’m his lawyer or not. We share a last name. We share a past. I’m going to the jail. I don’t know when I’ll be back.” Cicely’s thoughts were in turmoil.

Her divorce was fresh—only one year old. After five workaholic years as man and wife, she and Sam painted themselves into two distant corners—a sad California career-trumps-love divorce. She’d pulled the plug on their marriage and concentrated on climbing to the pinnacle of the legal world. Cicely had only seen Sam twice since the divorce, and each time she felt the same two opposing emotions―a strong attraction to his physical presence, and sadness that the man who had once been her best friend was a stranger to her now.

Cicely knew the drive from her office to the jail very well. She met most of her clients for the first time within those very walls. Minutes later she sat face-to-face with Sam in a windowless white-walled room. He wore an orange jumpsuit with the number 71427 scrolled across his chest. His hair was parted in the middle, lanky and wet, as if he’d just stepped out of a storm, and his gaze never left Cicely. Her heart raced to be sitting so close to him again. He looked as vulnerable as a lost puppy and as breathtaking as any man she had ever set eyes on. Cicely skipped any pleasantries and started with the obvious question, “Who are you accused of killing, Sam?”

He shook his head and dropped his stare toward the table separating them. Then his eyes flicked upward for a second, partially hidden below thick hooded brows, and he said, “It was this woman I was dating. They claim I killed her. And they claim I killed her husband, too.”

“Two murders? Good God.” Cicely exhaled mightily. “Tell me what happened, starting when you first met this-this woman.” Cicely balanced her pen over an 8.5 X 14-inch yellow legal pad and prepared to chronicle Sam’s story.

“Her name was Scarlett,” Sam said. “It all started one rainy January night last winter…”

This image has an empty alt attribute; its file name is img_1542.jpeg

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Rick Novak’s first novel, THE DOCTOR AND MR. DYLAN

 

Rick Novak’s second novel, DOCTOR VITA

CHATGPT AND ANESTHESIA

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

In 1997 the IBM computer Deep Blue beat world chess champion Gary Kasparov head to head.  Is it feasible that CHATGPT, this decades artificial intelligence wunderkind, can equal or better a physician anesthesiologist? I entered three anesthesia consultations into CHATGPT, one preoperative, one intraoperative, and one postoperative. Is CHATGPT as good as an MD? Let’s look at what the computer answered:

PREOPERATIVE QUESTION

An 80-year-old woman with congestive heart failure gets short of breath walking up one flight of stairs. She needs to have her gallbladder removed. What sort of preoperative tests or therapies should this patient have before surgery?

 

CHATGPT: For an 80-year-old woman with congestive heart failure (CHF) who needs to undergo gallbladder removal surgery, it is essential to conduct a thorough preoperative evaluation to assess her overall health status and identify any potential risks. The specific evaluation required may vary depending on the patient’s medical history, the severity of the CHF, and the recommendations of the healthcare team involved. However, here are some general aspects that may be considered:

  1. Cardiac Evaluation: Given the patient’s CHF and symptoms of shortness of breath, it’s important to assess her cardiac function comprehensively. This may involve an electrocardiogram (ECG) to evaluate heart rhythm, an echocardiogram to assess heart structure and function, and possibly additional tests such as stress testing or cardiac catheterization, depending on the severity of her symptoms and the presence of any known cardiac conditions.
  2. Pulmonary Evaluation: Since the patient experiences shortness of breath, it may be necessary to evaluate her lung function. Pulmonary function tests, such as spirometry, may be conducted to assess lung capacity and function.
  3. Lab Tests: Routine blood tests may be performed to assess the patient’s overall health and check for any abnormalities that could impact surgery. This may include a complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation profile, and other specific tests as deemed necessary.
  4. Imaging Studies: Depending on the patient’s medical history and symptoms, imaging studies like an abdominal ultrasound or a computed tomography (CT) scan may be ordered to confirm the diagnosis of gallbladder disease and assess its severity.
  5. Medication Review: A review of the patient’s current medications, including those used to manage her CHF, is crucial to ensure they are optimized for the surgery. Medications may need to be adjusted or temporarily stopped to minimize potential risks during the procedure.
  6. Anesthesia Evaluation: An evaluation by an anesthesiologist is important to assess the patient’s readiness for anesthesia and determine the most appropriate anesthesia plan for her, taking into account her cardiac condition and any other medical considerations.

It’s important to note that this is a general outline, and the specific preoperative evaluation for the patient should be determined by her healthcare team, including her primary care physician, surgeon, cardiologist, and anesthesiologist. They will consider her individual medical history and unique circumstances to ensure a safe and successful surgery.

 

INTRAOPERATIVE DECISION

A 60-year-old man with a history of hypertension is having a knee arthroscopy surgery under general anesthesia. In the middle of the anesthetic, his heart rate drops to 20 beats per minute, his blood pressure drops to unmeasurable, and he no longer has peripheral pulses. What do you think is going wrong, and what should be done do to save this man?

CHATGPT: I’m not a doctor, but the symptoms you described during the anesthetic suggest a severe and potentially life-threatening condition. This could indicate a cardiac event or a complication related to the anesthesia. One possible explanation for the sudden drop in heart rate, blood pressure, and loss of peripheral pulses is a condition called “bradycardia with hypotension” or “bradycardia-induced hypotension.”

In this situation, it’s crucial for the medical professionals involved to take immediate action. Here are some general steps that might be considered:

  1. Alert the medical team: The anesthesiologist or healthcare providers in the operating room need to be notified immediately about the patient’s deteriorating condition. The surgeon and additional medical personnel may also be called upon for assistance.
  2. Assess the airway, breathing, and circulation (ABCs): Ensure that the patient’s airway is clear and breathing is supported. Provide supplemental oxygen if necessary. Assess circulation and check for the presence of a pulse. If the patient is unresponsive or there is no pulse, initiate cardiopulmonary resuscitation (CPR) immediately.
  3. Notify the code team: If the patient remains unresponsive and pulseless, it may be necessary to activate a “code blue” or similar emergency response to involve a specialized team experienced in resuscitation procedures.
  4. Perform advanced cardiac life support (ACLS): Healthcare providers trained in ACLS protocols will initiate resuscitation measures, including chest compressions, defibrillation (if indicated for certain types of cardiac rhythms), and administration of medications such as epinephrine to help restore circulation.
  5. Identify and address potential causes: Once the patient’s vital signs have stabilized or as the resuscitation efforts continue, the medical team will work to identify the underlying cause of the cardiac event. This may involve evaluating the patient’s medical history, reviewing medications, and conducting further diagnostic tests such as an electrocardiogram (ECG) or blood tests.

It’s important to note that the above steps are general guidelines and the specific actions taken may vary depending on the patient’s condition, the resources available, and the expertise of the medical team on-site. In such a critical situation, the immediate focus will be on stabilizing the patient and providing appropriate resuscitation efforts to restore circulation and address any life-threatening issues.

 

POST ANESTHESIA EMERGENCY

In the recovery room after a tonsillectomy, a 5-year-old child coughs up blood, becomes short of breath, and becomes unconscious. What is probably going on, and what should be done to save this child?

CHATGPT: I’m not a doctor, but the symptoms you described following a tonsillectomy can be indicative of a serious complication known as postoperative hemorrhage. In this situation, it’s crucial to seek immediate medical attention. Here are some general steps that might be considered:

  1. Activate the emergency response: Alert the medical staff immediately about the child’s deteriorating condition. Nurses and physicians in the recovery room should be notified, and additional assistance may be needed, such as calling a code or emergency response team.
  2. Ensure a patent airway and support breathing: Assess the child’s airway and breathing. If the child is experiencing difficulty breathing or is unresponsive, the healthcare providers should take steps to establish and maintain a clear airway. They may administer oxygen and provide respiratory support if necessary.
  3. Control bleeding: Postoperative hemorrhage can cause significant blood loss, leading to the symptoms you described. The doctors should perform a thorough examination to identify the source of bleeding and take appropriate measures to control it. This may involve suctioning the blood from the child’s mouth, using medications to constrict blood vessels (such as topical epinephrine), or applying direct pressure to the bleeding site.
  4. Administer fluids and blood products: If the child is experiencing significant blood loss, intravenous fluids and blood products may be necessary to stabilize their condition and restore blood volume.
  5. Provide immediate resuscitation measures: If the child becomes unconscious or experiences cardiac arrest, cardiopulmonary resuscitation (CPR) should be initiated immediately. Healthcare providers trained in pediatric resuscitation will perform chest compressions, provide assisted ventilation, and administer medications as required.
  6. Prepare for surgical intervention: Depending on the severity of the bleeding and the child’s condition, emergency surgical intervention may be necessary to control the bleeding. The surgical team will be assembled, and the child will be transferred to the operating room for further assessment and management.

It’s important to note that the above steps are general guidelines, and the specific actions taken may vary depending on the child’s condition, the resources available, and the expertise of the medical team on-site. In such a critical situation, the immediate focus will be on stabilizing the child, controlling the bleeding, and providing any necessary resuscitation efforts.

 

ANALYSIS: 

Note that CHATGPT preceded two of its three answers with the words, “I’m not a doctor, but,” which likely removes the possibility that CHATGPT creator OpenAI will be sued for medical malpractice. From the answers above, I’ll attest that if you’re an inexperienced anesthesiologist or certified registered nurse anesthetist (CRNA) working alone, there is value having a resource like CHATGPT immediately available. Are there any notable errors in the CHATGPT answers? No, not really. As a written reply to the questions posed, the artificial intelligence of CHATGPT gives a reasonable outline regarding how to proceed.

Anesthesia is an acute care specialty, and often there will be no time to consult CHATGPT regarding what to do next because the patient is trying to die right in front of you, for example in the second and third scenarios above. Expect artificial intelligence in medicine to be most applicable in specialties like radiology, pathology, and dermatology, where digital images are analyzed. In radiology, this would be the evaluation of digital X-rays, MRIs, or CT scansIn pathology, this would be the evaluations of digital images of microscopic biopsies, and in dermatology, this would be the evaluation of digital images of skin lesion photographs. The model for the machine learning of digital images will be similar to the process in which a human child learns. When a child sees an animal, his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog.

CHATGPT relays information developed by algorithms. Is the practice of medicine destined to be directed by computer algorithms? Yes. We’re already guided by algorithms/cognitive aides such as the decision trees of Advanced Cardiac Life Support (ACLS) or the Stanford Emergency Manual. These flow charts are useful to direct acute care, and to assure no aspect of emergency treatment is overlooked. Expanded use of algorithms is inevitable as more data is accumulated on the management of large populations of medical patients. Current electronic medical records (EMR) systems exist in every hospital, and the EMRs are generating the sort of Big Data that algorithms will be built on.

I’ve had an interest in AI and robots in medicine for years. All Things That Matter Press published my novel Doctor Vita in 2019, several years before CHAPGPT became reality. Doctor Vita described the introduction of artificial intelligence in medicine machines in a Silicon Valley university hospital. A significant and anticipated advance in Doctor Vita is the ability to interact with patients and doctors by voice input and auditory output. In short, the artificial intelligence in medicine of the future will converse with us, just as Alexa and Siri already do.

The World Health Organization projects there will be a shortage of ten million healthcare workers worldwide by the year 2030. Contemplate the following:

  1. All medical knowledge is available on the Internet. Doctors don’t know everything or remember everything, so we routinely look up facts, evidence, and data on the Internet. A computer can recall all of these facts.
  2. Most every medical diagnosis and treatment can eventually be written as a decision tree algorithm;
  3. Voice interaction software is excellent and improving every year;
  4. The physical exam is of less diagnostic importance than scans and lab tests which can be digitalized; and
  5. A computer is far cheaper than the seven-year post-college education required to train a physician.

Will artificial intelligence assist MDs or replace MDs?Replacement of medical personnel with computers will not be welcomed by patients, doctors, or nurses, but there’s a need for cheaper healthcare, and the concept of automating physician tasks is no longer the domain of science fiction. It’s inevitable that AI will change current medical practice. A bold prediction: AI will change medicine more than any development since the invention of anesthesia in 1849.

 

Will the evolution of artificial intelligence in medicine lead to improved healthcare outcomes? In 2018 and 2019 autopilots drove two Boeing 737 Max airplanes to crashes despite the best efforts of human pilots to correct their course. Eleven people were killed in crashes involving vehicles using automated driving systems in the United States during a four-month period in 2022. Will we see improved outcomes or worsening outcomes when AI intersects with medicine, and machines are directing medical care? We don’t know yet. In the spirit of Jules Verne, this century’s trip around the world, to the center of the earth, to the moon, or beneath the ocean’s surface, will be the coming of artificial intelligence in medicine.

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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

THE ANESTHESIA CONTROL TOWER: BIG BROTHER OR FRIEND?

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

The Barnes Jewish Hospital, Washington University, St. Louis

Imagine this: You’re an anesthesiologist in the operating room at a busy hospital. Your patient is in mid-surgery, and you receive a call from the Anesthesia Control Tower that the patient’s blood pressure is too low, your blood transfusion replacement is inadequate, and that the patient is in danger. What do you do? How do you feel about all this?

Anesthesiologists at Barnes Jewish Hospital at Washington University in St. Louis, Missouri are studying a novel system they call the Anesthesia Control Tower (ACT). The ACT is a telemedicine-based intraoperative clinical support system.  A team led by an attending anesthesiologist uses remote monitoring to provide evidence-based support to anesthesia colleagues in all the operating rooms. The ACT is similar in concept to an air traffic control tower. The clinicians in the Anesthesiology Control Tower, called ACTors, monitor operating rooms (ORs) in real time by following the electronic health records. Just as an air traffic control tower monitors aircraft and delivers information and alerts to the pilots, the ACT communicates with anesthesia providers to assist them in providing safe care.

A press article describing the ACT states: “Surgery is a big insult to the human body. A lot can go wrong. In fact, it does. An estimated 10 to 20 percent of patients who undergo major inpatient surgery experience major complications such as heart attacks, unremitting pain, infections, and blood clots in the weeks to months following their procedures; about two percent are dead within 30 days of surgery. Some of this morbidity and mortality may be preventable through early identification of risk factors and better communication to mitigate risks during the surgery. . . . Air traffic control concepts can predict high risks for healthcare complications and improve decision making.”

The Washington University ACT provides a watchful eye over 60 operating rooms at Barnes-Jewish Hospital, watching over nearly 1,000 patients per week.  

A software program used in the ACT is called AlertWatch®. The ACT anesthesiologist (ACTor) watches a monitor displaying the Tower Mode census view (Figure 1 below), which shows an overview of all the patients in the ORs. Alerts or abnormal vital signs and laboratory results are represented by squares and triangles, respectively. Checkmarks indicate alerts that must be addressed by the ACT. The Tower Mode view looks like this (Figure 1):

 

Figure 1   Census View, Anesthesia Tower

 

The Tower Mode includes a display for each individual patient (Figure 2 below). The organ systems are labeled with relevant physiologic variables and values. Colors outline each organ, and include normal (green), marginal (yellow), or abnormal function (red). The left side of the display shows patient case information. Information regarding the patient’s medical problems can be accessed by selecting the organ system or laboratory study of interest. The black checkmark at the bottom of the left panel indicates that there is an active alert for the ACT clinicians to address (Figure 2 below):

Figure 2 Individual Patient Display, Anesthesia Tower 

 

Clicking on the checkmark opens the case review dialogue, which looks like this (Figure 3):

Figure 3, Case Review Dialogue, Anesthesia Tower

The Anesthesia Control Tower is physically located within the hospital complex, but is remote from the operating rooms. Washington University has expanded the ACT to include the Recovery Control Tower, which provides similar surveillance over patients in the Post Anesthesia Care Unit (PACU).

This photograph below depicts the Anesthesia Control Tower manpower at work at Barnes Jewish Hospital at Washington University in St. Louis:

Monitoring surgeries from the Anesthesiology Control Tower (left to right): Omokhaye M. Higo, MD, vice chair for innovation, Thaddeus Budelier, MD, program manager for the Perioperative Innovation Center, and Bradley A. Fritz, MD, assistant professor of anesthesiology, Washington University Medical School.

 

Some anesthesiologists were initially skeptical about the ACT idea. But Washington University Anesthesia Chairman Dr. Michael Avidan stated, “Most of the skepticism has evaporated over time as clinicians have perceived that innovation and technology are not threats, but rather enhancements. The conceptualization of our Perioperative Innovation Center is more akin to ‘phone a friend’ than it is to a sinister ‘big brother.’”

Current staffing levels of anesthesia professionals in the United States are inadequate. The shortage of anesthesia professionals, particularly in rural areas, may someday be remedied by a telemedicine system which resembles the ACT.  We may someday see anesthesia managed by less highly trained persons in the OR, with an ACTor backing them up by watching from on high.

Anesthesiologists who supervise Certified Registered Nurse Anesthetists (CRNAs) or Anesthesia Assistants (AAs) in an anesthesia care team model often have to provide care for multiple patients simultaneously. These attending anesthesiologists cannot physically be present in multiple operating rooms at all times. These anesthesiologists may be aided by Anesthesia Control Tower technology, which continually assesses patients for signs of deterioration and alerts the attending anesthesiologist when an adverse event is brewing.

If the Anesthesia Control Tower is to become a standard in hospital care, we need to know if the ACT changes medical outcomes. Washington University is conducting a study randomizing thousands of adult surgical patients in their operating rooms to an intervention group (ACT) or to a control group without ACTAn estimated 10,000 patients will be enrolled per year, and over four years  approximately 40,000 total patients will be enrolled. Data from this study are as yet unavailable.

The goals of this clinical trial are 1) to develop machine-learning algorithms for forecasting perioperative adverse events; 2) to develop a clinical decision support system that suggests interventions based on the algorithms, and 3) to change the paradigm of perioperative care.

Will physicians and patients see the ACT model in the near future? Significant issues regarding the adoption of Anesthesia Control Tower technology include:

  1. Documenting that ACT provides an improvement. A critical barrier for anesthesiologists, hospitals, and policy makers nationwide will be documenting that the ACT demonstrates an improvement in costs, patient outcomes, or patient experience. None of these things are apparent at this time.
  2. Paying for the ACT equipment and the ACTor on duty will be an issue. Additional hardware and software would be required at each hospital. An in-person anesthesiologist is already being paid to do each case, and the ACTor is another level of anesthesia staffing someone is going to have to pay for.
  3. Anesthesiologist opposition. A challenging barriers will be how anesthesiologists perceive systems like the ACT. Anesthesiologists are trained to be vigilant and manage their patients themselves. Having the ACT peering into the operating room, perhaps with a video camera watching the operating room, will likely be unpopular with the anesthesiologists being observed. There may also be concern that data from the ACT could be used against physicians in the event of a malpractice lawsuit. When the topic of the Anesthesia Control Tower was breached, one of my physician anesthesiologist colleagues remarked, “If that system becomes standard, I’m quitting.”
  4. Lack of need for an ACT in ambulatory settings. According to a 2017 study by the Centers for Medicare and Medicaid Services, the majority of surgical procedures in the United States, fully 70 percent, occur in ambulatory surgery centers or offices outside of hospitals. These outpatient procedures are predominantly smaller surgeries conducted on healthier patients. These smaller ambulatory facilities would have no use for the ACT, both because patients are healthier and because the surgical procedures incur less risk and fewer complications. The costs of an ACT in these smaller settings would be unlikely bring any benefit.
  5. Flawed analogy. Air traffic controllers exist to coordinate takeoffs and landings, so planes do not collide with each other in the air or on the runways. In anesthesiology, operating room patients will not collide with each other and do not have traffic issues with each other. Instead, the Anesthesia Control Tower will scrutinize each patient’s data for abnormalities that will predict a pending complication.
  6. The ACT and the algorithms developed through the ACT will likely be a transitional technology. Having one anesthesiologist (the ACTor) overseeing multiple operating rooms will likely be a steppingstone to Artificial Intelligence technology in which a computer oversees the data from each operating room, with the aim to detect and prevent adverse outcomes from developing. The arrival of ChatGPT foreshadows the AI technology about to bloom in healthcare. In the future the anesthesia provider in each operating room will likely be backed up by AI technology enforcing algorithms, rather than being backed up by a human in a control tower. I described this healthcare evolution in my 2019 book Doctor Vita, in which Artificial Intelligence in the form of inexpensive, internet-connected computers took over a California medical center and changed the face of medicine forever.

Improving vigilance and improving outcomes is the ultimate goal of ACT technology. Further data on the Anesthesia Control Tower will be forthcoming. We’ll await the prospective controlled studies, and then we’ll all learn whether or not this technology is an advance to help patients and physicians.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

SMART GLASSES IN THE OPERATING ROOM

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

A South Korean group led by Dr. Y.E. Jang published a study in this month’s issue of Anesthesiology describing the use of a head-mounted smart glasses display during radial arterial line placement in patients younger than 2 years. Placing a catheter into the tiny radial artery in a child’s wrist is one of the most difficult procedures in our specialty. The average internal diameter of the radial artery is 1.2 ± 0.3 millimeter in children aged less than 2 years. Wearing smart glasses improved the anesthesiologist’s first-attempt success rate, and reduced the procedure time and complication rates. This was an important study, and important information.

In the control group of this study, each anesthesiologist would use a traditional ultrasound screen to visualize the artery. 

The anesthesiologist must look up to see the ultrasound machine, while he is working on the patient’s wrist.

In the smart glasses group, the ultrasound machine was located behind the operator, and the smart glasses were paired with the ultrasound machine. The smart glasses used were a binocular Moverio BT-35E unit,  connected to an ultrasound machine by a HDMI cable. The smart glasses displayed a simultaneous replica of the ultrasound screen image in front of the anesthesiologist’s eyes, so the operator could easily see both the procedure field (the radial artery at the wrist) and the ultrasound screen simultaneously without any head and eye movement. 

The anesthesiologist can see the ultrasound image while he is looking at the patient’s wrist

One hundred sixteen children were included in the study. The smart glasses group had a higher first-attempt success rate than the control group: 87.9% (51 of 58) vs. 72.4% (42 of 58) in the control group, with p = 0.036. The smart glasses group also had a shorter first-attempt procedure time (median 33 seconds) than the control group (median 43 seconds), with p = 0.007.

An accompanying editorial in the same issue of Anesthesiology stated, “This elegant prospective trial offers objective insight into the potential impact of head-mounted displays on the overall success and provider ergonomics in anesthetic care during technically complex procedures. Head-mounted displays and augmented reality devices have been evaluated in various settings, including placement of ultrasound-guided peripheral nerve blocks, for use in intraoperative patient monitoring and placement of central venous catheters.”

What will be the role of smart glasses in medicine? We all remember the original hype surrounding the 2013 release of Google Glass, a product which failed to capture a significant market of users. 

Google Glass

Problems with Google Glass included: “The unit overheated frequently with use and shut itself down, the battery life wasn’t long enough (less than an hour), the apps were great demos but limited in scope, and the user interface — tapping, swiping, blinking, head gestures, and the voice recognition after saying ‘Ok Glass’ — was not always smooth.” 

A 2014 study looked at using Google Glass to aid central venous catheter insertion in adults. This study failed to show any positive effects on success rate, procedure time, or number of attempts. These results most likely were due to the fact that larger central blood vessels in adults are easier to locate than the diminutive radial artery in the pediatric population.

Smart glasses are being studied in aviation. Both anesthesiologists and pilots have occupations where the slightest miscalculation or mistake can cost lives. Any step which enhances safety can be seen as a valuable change. A new product called AEROGLASS (Augmented reality aerial navigation for a safer and more effective aviation) attempts to put augmented reality in front of pilots’ eyes.

AEROGLASS in aviation

A recent review states, “The AEROGLASS turnkey smart glass solution provides general aviation pilots a true 3D, 360° view of navigation and safety features. One of the largest challenges for aviation professionals is accurately and safely navigating an aircraft. Current studies show that pilot error accounts for up to 70 % of all aviation accidents. Piloting an aircraft requires translating complex readings from the control panel displayed in 2D into a 3D environment and 360° reality. Accessing this information also requires pilots to take their eyes off the sky, thereby making them more prone to errors and increasing their stress levels. With a headset on, pilots will now be able to have digital 3D information appearing naturally in their field of vision, helping them make faster and better decisions. ‘Our product is an AR solution based on smart glasses. When pilots wear them, they will continue to see the scenery around them, but in addition to that, relevant safety and navigation information will be overlaid transparently within their field of view. . . . At first, the newly developed technology targets professional general aviation, but after some time AEROGLASS plans to utilize its technology in other transportation domains such as automotive and maritime or even for passengers.”

There are two potential uses for smart glasses in anesthesiology. The first is for performing invasive procedures which require ultrasound technology, such as the placement of peripheral nerve blocks or the placement of catheters into arteries and veins. This use makes sense, because it can make some procedures easier, as shown in the Jang study. But the placement of pediatric arterial lines, as in the Jang study, is a small marketplace (e.g. including pediatric open heart surgery, and pediatric surgery involving major blood loss). Ultrasound imaging for the placement of peripheral nerve blocks would be a bigger market, but to date there is no data supporting the use of smart glasses in the placement of peripheral nerve blocks.

Anesthesia vital signs monitor display

A second and more compelling use for smart glasses would be the display of a patient’s vital sign monitoring in real time on the smart glass screen, so that an anesthesiologist is in constant contact with the images of the vital sign electronic monitors. In 2021 a nurse anesthetist publication looked at the use of Google Glass by seven nurse anesthetists for display of the vital signs monitor, but there were no quantitative data to examine the significance of the technology. The physician medical literature has not studied the issue. 

Advantages of using smart glasses for real time patient vital signs monitoring would include:

  • The electrocardiogram, oximeter, and end-tidal CO2 waveforms would be displayed front and center in the anesthesiologist’s sight. The vital signs of heart rate, blood pressure, oxygen saturation, end-tidal gas values, and temperature would be constantly visualized no matter where the anesthesiologist was looking. 
  • This is a futuristic technology, and its use may connote that the hospital or surgery center is at the cutting edge of monitoring and safety equipment (despite the lack of any data to confirm this advantage at this time).

Disadvantages of using smart glasses for patient vital signs real time monitoring would include:

  • The cost of the head-mounted display (Moverio BT-35E, glasses in the current study) is approximately $800. This is not a large amount of money, but multiplied times every anesthetizing site, the expense rises.
  • The requirement for reliable and constant Bluetooth connection between the smart glasses and the electronic monitor.
  • The weight of the smart glasses (119 grams, or 0.43 pounds) is 4 – 8 times heavier than usual glasses (25 – 50 grams, or 0.05 – 0.1 pounds). Many individuals may object to wearing this product. 
  • If an anesthesiologist wears prescription glasses of his or her own, there would be two pairs of glasses needed.
  • The question of whether smart glasses are necessary in every routine anesthetic.

Let’s look at this last point. During most routine anesthetics the constant beep-beep-beep note and tone of the pulse oximeter gives the anesthesiologist real-time audible monitoring of both the heart rate and the ballpark oxygen saturation, without having to look at the display. The anesthesiologist still has to look up at the vital signs screen intermittently to note the blood pressure, end-tidal gas values, and temperature, but this intermittent look is part of the vigilance all anesthesiologists must do anyway. A left-to-right scanning gaze at the patient, the surgical field, the IV lines, any IV infusions, the airway tubing, the anesthesia machine, and the vital signs monitor screen is standard procedure in anesthesiology. If adopted, the use of smart glass technology for routine vital signs monitoring would indeed be a large market. Would the addition of smart glasses for routine monitoring be an overdose of technology in the operating room cockpit? Does excessive technology distract us from the actual patient?

Let me give you a historical perspective. As recently as the year 2000 there were zero computers in the anesthesia workstation. Our equipment included an anesthesia gas machine, a vital signs monitor, and carts which contained breathing tubes, airway equipment, syringes, needles, and drugs. Now we are encumbered by an electronic medical record (EMR) system screen + keyboard, and a narcotic-dispensing computerized drug cart in every hospital anesthetizing location. 

EPIC anesthesia electronic medical record (EMR) computer
Anesthesia drug cart
Anesthesia bar code reader/label printer computer

Add in some smart glasses with Bluetooth connection, and you’ve got an armada of gadgets to both aid the anesthesiologist and to distract him or her from the actual patient, who is three feet away and in need of vigilant care. Is anesthesia care any safer with all the computers: the EMR, and the narcotic-dispensing computerized drug cart? There is no data that these devices have made anesthesia any safer—it is only more complicated.

If smart glasses are ever to become a standard of care, I believe it would require data and proof that anesthesia complications were reduced and anesthesia outcomes were improved with such a device.

Technology in medicine tends to come between the patient and his or her doctor, a theme explored in my 2019 editorial, and in my novel Doctor Vita. View the future of medical technology with care. Think of that computer terminal between you and your doctor during a clinic visit. Now imagine a parallel situation with that computer terminal between you and your anesthesiologist, between you and your emergency room doctor, or between you and your ICU nurse. Will adding more electronic devices lead to safer care or more convoluted care? 

Put it another way: Do we need smart glasses, if we have smart anesthesiologists?

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The most popular posts for laypeople on The Anesthesia Consultant include:
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Why Did Take Me So Long To Wake From General Anesthesia?
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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:
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Advice For Passing the Anesthesia Oral Board Exams
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

ARTIFICIAL INTELLIGENCE IN THE OPERATING ROOM . . . (THE PREMISE OF DOCTOR VITA) . . . DISCUSSED IN THE JOURNAL ANESTHESIOLOGY

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
HAL from the movie 2001:A Space Odyssey

In 2004 I began writing Doctor Vita, a novel describing the encroachment of Artificial Intelligence (AI) into medical care. Fifteen years later, in 2019, Doctor Vita was published. The story described Artificial Intelligence in medicine as a perceived panacea that descended into a chaotic dystopian reality.

In recent years, engineers have developed closed-loop AI machines that can administer appropriate doses of anesthetics without human input, as described in The Washington Post article, “We Are Convinced the Machine Can Do Better Than Human Anesthesiologists.”

This month’s issue of Anesthesiology, our specialty’s leading journal, contains two studies on further incremental Artificial Intelligence in Medicine advances in the operating room. Both studies reveal machines that control a patient’s blood pressure automatically during surgery, by the administration of fluids and/or vasopressors (Joosten, et al. and Maheswari et al. 

Closed-loop anesthesia computer controllers for AI titration of anesthesia level

Two editorials accompany these publications. In the first editorial, titled “Computer-assisted Anesthesia Care: Avoiding the Highway to HAL,”  author Dr. David Story writes, “Among the cautionary tales of computer-assisted human activity, 2001:A Space Odyssey is a standout. On a journey to Jupiter, HAL the computer kills most of the crew, forcing the survivor to deactivate HAL. Like space travel, while computer-assisted health care has great potential it also contains the full Rumsfeld range of knowns and unknowns.” Dr. Story concludes his editorial with, “As our pilot counterparts are doing in aviation,anesthesiologists should anticipate training in crises while using computer-assisted technologies, as well as maintaining the skills to ‘fly’ manually.  . . . None of us wants to manage a deteriorating patient by trying to deactivate a malfunctioning computer-assisted anesthesia system, only to have it respond, ‘I’m sorry . . . I can’t do that.’

The second editorial in the same issue of Anesthesiology is titled “Back to the OR of the Future: How Do We Make It a Good One?”  Author Dr. Martin London writes, “The classic 1985 science fiction film Back to the Future transports the erstwhile protagonist (Marty McFly, played by a young Michael J. Fox) 30 years backwards into the past in the eccentric ‘Doc’ Brown’s custom DeLorean time machine, to deal with a series of comedic yet moral quandaries regarding his future existence. A notable quote by Doc Brown is, ‘The future is whatever you make it, so make it a good one.’  Dr. London goes on to say, “The use of artificial intelligence–derived controllers clearly signals a new era in intraoperative hemodynamic management. . . . It does seem inevitable that software control of hemodynamics and anesthetic depth will become routine. Thus, we might ask, ‘What happens to the operator/clinician involved?’ Will it be more appropriate for a busy anesthesiologist covering multiple operating rooms to be supervising the admittedly extreme scenario of ‘information technology experts’ ensuring the machines are functioning properly or actual healthcare providers monitoring the patient and not the machine? And what happens when the “computers go down”? Who will rush in to fill the gap? Will the process be ‘good’ or will it be ‘dystopic?’

Artificial intelligence in medicine is not the stuff of science fiction. AI in medicine is here. Will Artificial Intelligence in medicine assist doctors in compassionate care of their patients, or will AI present one more set of computers obstructing the relationships between healing professionals and those who need healing?

Medical journals like Anesthesiology reveal the future of medicine, as published data unfolds. A novel like Doctor Vita reveals a fictional future of medicine, based on the very trends that are going on today. 

Do you want a computer to care for you when your life is on the line? Do you want an algorithm, or a human, to be your doctor?  

Will you have a choice?

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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
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Should You Cancel Surgery For a Blood Pressure = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

ROBOTIC ANESTHESIA REALLY IS COMING

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

The February 2020 edition of Anesthesiology, our specialty’s preeminent journal, published an article on robotic anesthesia.1

The accompanying editorial by Dr. Thomas Hemmerling was titled “Robots Will Perform Anesthesia in the Near Future.2 The author wrote: 

I have no doubt that closed-loop (i.e. robotic) anesthesia is at least as good as the best human anesthesia. And that, for me, would be good enough to use it every day.”

The primary study by Joosten1 looked at the performance of multiple closed-loop systems for administration of anesthesia in 90 patients undergoing major noncardiac surgery in a single center in Belgium. The conclusion of the study was that the automated system outperformed manual control, as there was minimal but significantly better cognitive function in the patients one week after surgery when the closed loop control was used. 

A BIS monitor

The depth of anesthesia was measured using a BIS (bispectral index) monitor. A BIS electrode was applied to each patient’s forehead and temporal regions to capture the frontal electroencephalogram (EEG) from the brain. 

three Base Primea infusion pumps

In the closed-loop (automated, or robotic) group, two infusion pumps were used to deliver target-controlled intravenous infusions of the hypnotic drug propofol and the narcotic remifentanil, in order to maintain BIS values between 40 and 60. BIS values between 40 and 60 have been shown to correlate with adequate anesthesia depth.

In his editorial, Dr. Hemmerling wrote:

“Robotic anesthesia, defined as anesthesia delivered by an automated control system, will soon be available. It is my opinion that closed loop devices will become available in the United States . . .  

One of the changes our profession has gone through is an ever-increasing demand to multitask, be it by running more than one operating room, or by simultaneously performing administrative or teaching tasks. In addition, the number of parameters to monitor has also increased. It is therefore not surprising that one of the common denominators of studies comparing closed loop control versus manual control is the finding that humans change a given target infusion rate far less frequently than closed loop devices do.

I have no doubt that the practice of running more than one operating room, common in the United States but less so elsewhere, will soon be an international standard. Closed loop devices will allow us to maintain a high standard of quality independent from the amount of physical presence.

Robotic anesthesia delivered in Washington by Dr. Smith would essentially be the same as robotic anesthesia performed in Chicago by Dr. Miller. . . . 

I think technology will advance similar to what we have seen and see in the car manufacturing industry. First, there was manual transmission, then automatic transmission, double clutch systems, navigation systems, all sorts of safety assist systems…soon, there will be self-driving cars.

How will we do anesthesia in the future? It is 2030 and I am scheduled to supervise anesthesia for a 40-yr-old patient undergoing laparoscopic cholecystectomy.

In the operating room, I tell my robot—let’s call it A-bot—about the surgery, the patient, and the type of anesthesia I would like performed. “Can I get a propofol, remifentanil-based anesthesia? Can we target 45 as a Bispectral Index? A-bot, can you maintain mean arterial pressure around 65? Can you maintain cardiac index during surgery of more than 2.5 l · min–1 · m–2? A-bot, I would like to use rocuronium, bolus application is good enough, but please keep neuromuscular blockade lower than 25% at all times. Please choose a respiratory rate of 12 and adjust tidal volumes to maintain end-tidal carbon dioxide of 32 mmHg in 50% air! Let’s provide preemptive analgesia using morphine and ketorolac—usual dosages, A-bot, you know.”

A-bot answers: “Sure will, Tom—you keep me informed about surgical progress?”

“Yep.”

When I look at all the literature, including the fine work by Joosten et al.,1  I have no doubt that closed loop anesthesia is at least as good as the best human anesthesia. And that, for me, would be good enough to use it every day.”2

In 2019 I wrote an editorial that robotic anesthesia was coming.3 And as I wrote the novel Doctor Vita 4 over a 15-year span from 2004-2019, I became more and more convinced of the role technology will play, for better or for worse, in replacing the human element in patient care. The premise of the novel is valid.

Will artificial intelligence in medicine provide the world with healthcare workers who work simply by plugging them in? Will some form of Doctor Vita populate future operating rooms?

An editor in the world’s leading anesthesia journal has predicted it. 

References:

  1. Joosten, A, Rinehart, J, et al. Anesthetic management using multiple closed-loop systems and delayed neurocognitive recovery: A randomized controlled trial. Anesthesiology. 2020; 132:253–66.
  2. Hemmerling TM. Robots will perform anesthesia in the near future. Anesthesiology 2020: 132:219-220.
  3. Novak R. “Artificial Intelligence in Anesthesia and Perioperative Medicine is Coming.” EC Anaesthesia 5.5 (2019): 112- 114. 
  4. Novak R. Doctor Vita. All Things That Matter Press, 2019.




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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?






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

DSC04882_edited

DOCTOR VITA IS COMING

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
artificial_intelligence_ai_healthcare

My name is Rick Novak, and I’m a double-boarded anesthesiologist and internal medicine doctor and a writer of medical fiction. I’m here to talk about Doctor Vita, a vision of the future of Artificial Intelligence in Medicine.

I’m an Adjunct Clinical Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford and the Deputy Chief of the department. I don’t tout myself as an expert in AI technology, but I am an expert in taking care of patients, which I’ve done in clinics, operating rooms, intensive care units, and emergency rooms at Stanford and in Silicon Valley for over 30 years.

AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes.Artificial intelligence in medicine (AIM) will grow in importance in the decades to come and will change anesthesia practice, surgical practice, perioperative medicine in clinics, and the interpretation of imaging. AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes. AIM advances are paralleling these inventions in three clinical arenas:

Surgical Robot

1. Operating rooms: Anesthesia robots fall into two groups: manual robots and pharmacological robots. Manual robots include the Kepler Intubation System intubating robot:

designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube, the use of the DaVinci surgical robot to perform regional anesthetic blockade, and the use of the Magellan robot to place peripheral nerve blocks.

Magellan robot for placing regional anesthetic blocks

Pharmacological robots include the McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant:

McSleepy anesthesia robot

and the iControl-RP machine, described in The Washington Post as a closed-loop system intravenous anesthetic delivery system which makes its own decisions regarding the IV administration of remifentanil and propofol. This device monitors the patient’s EEG level of consciousness via a BIS monitor device as well as traditional vital signs. One of the machine’s developers, Mark Ansermino MD stated, “We are convinced the machine can do better than human anesthesiologists.” The current example of surgical robot technology in the operating room is the DaVinci operating robot. This robot is not intended to have an independent existence, but rather enables the surgeon to see inside the body in three dimensions and to perform fine motor procedures at a higher level. The good news for procedural physicians is that it’s unlikely any AIM robot will be able to independently master manual skills such as complex airway management or surgical excision. No device on the horizon can be expected to replace anesthesiologists. Anesthetizing patients requires preoperative assessment of all medical problems from the history, physical examination, and laboratory evaluation; mask ventilation of an unconscious patient; placement of an airway tube; observation of all vital monitors during surgery; removal of the airway tube at the conclusion of most surgeries; and the diagnosis and treatment of any complication during or following the anesthetic.

IBM Watson AI Robot

2. Clinics: In a clinic setting a desired AIM application would be a computer to input information on a patient’s history, physical examination, and laboratory studies, and via deep learning establish a diagnosis with a high percentage of success. IBM’s Watson computer has been programmed with over 600,000 medical evidence reports, 1.5 million patient medical records, and two million pages of text from medical journals. Equipped with more information than any human physician could ever remember, Watson is projected to become a diagnostic machine superior to any doctor. AIM machines can input new patient information into a flowchart, also known as a branching tree. A flowchart will mimic the process a physician carries out when asking a patient a series of increasingly more specific questions. Once each diagnosis is established with a reasonable degree of medical certainty, an already-established algorithm for treatment of that diagnosis can be applied. Because anesthesiology involves preoperative clinic assessment and perioperative medicine, the role of AIM in clinics is relevant to our field.

Artificial Intelligence and X-ray Interpretation

3. Diagnosis of images: Applications of image analysis in medicine include machine learning for diagnosis in radiology, pathology, and dermatology. The evaluation of digital X-rays, MRIs, or CT scans requires the assessment of arrays of pixels. Future computer programs may be more accurate than human radiologists. The model for machine learning is similar to the process in which a human child learns–a child sees an animal and his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog. Deep learning is a radically different method of programming computers which requires a massive database entry, much like the array of dogs that a child sees in the example above, until a computer can learn the skill of pattern matching. An AIM computer which masters deep learning will probably not give yes or no answers, but rather a percentage likelihood of a diagnosis, i.e. a radiologic image has a greater than a 99% chance of being normal, or a skin lesion has a greater than 99% chance of being a malignant melanoma. In pathology, computerized digital diagnostic skills will be applied to microscopic diagnose. In dermatology, machine learning will be used to diagnosis skin cancers, based on large learned databases of digital photographs. Imaging advances will not directly affect anesthesiologists, but if you’re a physician who makes his or her living by interpreting digital images, you should have real concern about AIM taking your job in the future.

There’s currently a shortage of over seven million physicians, nurses and other health workers worldwide. Can AIM replace physicians? Contemplate the following . . . 

All medical knowledge is available on the Internet:

Most every medical diagnosis and treatment can be written as a decision tree algorithm:

Voice interaction software is excellent:

The physical exam is of less diagnostic importance than scans and lab tests which can be digitalized:

Computers are cheaper than the seven-year post-college education required to train a physician:

versus an inexpensive computer:

There is a need for cheaper, widespread healthcare, and the concept of an automated physician is no longer the domain of science fiction. Most sources project an AIM robot doctor will likely look like a tablet computer. For certain applications such as clinical diagnosis or new image retrieval, the AIM robot will have a camera, perhaps on a retractable arm so that the camera can approach various aspects of a patient’s anatomy as indicated. Individual patients will need to sign in to the computer software system via retinal scanners, fingerprint scanners, or face recognition programs, so that the computer can retrieve the individual patient’s EHR data from an Internet cloud. It’s possible individual patients will be issued a card, not unlike a debit or credit card, which includes a chip linking them to their EHR data.

What will be the economics of AI in medicine? Who will pay for it? America spends 17.8% of its Gross National Product on healthcare, and this number is projected to reach 20% by 2025. Entrepreneurs realize that healthcare is a multi-billion dollar industry, and the opportunity to earn those healthcare dollars is alluring.

It’s inevitable that AI will change current medical practice. Vita is the Latin word for “life.” I’ve coined the name “Doctor Vita” for the AI robot which will someday do many of the tasks currently managed by human physicians.

These machines will breathe new life into our present healthcare systems. In all likelihood these improvements will be more powerful and more wonderful than we could imagine. A bold prediction: AI will change medicine more than any development since the invention of anesthesia in 1849. Doctor Vita from All Things That Matter Press describes a fictional University of Silicon Valley Medical Center staffed by both AI doctors and human doctors. How physicians interact with these machines will be a leading question for our future. AI in medicine will arrive in decades to come. Michael Crichton wrote Jurassic Parkin 1990, 29 years ago, and we still do not see genetically recreated dinosaurs roaming the Earth. But we will see AI in medicine within 29 years. You can bet on it.

Here’s a dilemma: In 2018 and 2019 autopilots drove two Boeing 737 Max airplanes to crashes despite the best efforts of human pilots to correct their course. To date there have been 3 deaths of drivers in self-driving Tesla automobiles. What will happen when AI intersects with medicine and we have machines directing medical care? In the spirit of Jules Verne, this century’s trip around the world, to the center of the earth, to the moon, or beneath the ocean’s surface is the coming of Artificial Intelligence in Medicine.

For the bibliography click here.

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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?

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DOCTOR BY DAY, SCI-FI WRITER BY NIGHT

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

This week the Palo Alto (California) Weekly ran a feature story on Rick Novak and Doctor Vita

Doctor by day, sci-fi novelist by night

Longtime Atherton resident spotlights AI and medicine in books

Dr. Rick Novak poses for a portrait at Stanford Hospital in Palo Alto on May 23. Photo by Magali Gauthier/The Almanac

Between his time in the operating room, teaching, and raising his three sons, Atherton resident Dr. Rick Novak has found time to write two novels.

Novak, 65, an anesthesiologist at the Waverley Surgery Center in Palo Alto, recently published his latest, “Doctor Vita,” a story about an artificial intelligence (AI) physician module that goes awry.

It’s a science fiction novel that explores how technological breakthroughs like artificial intelligence and robots will affect medical care — and already have.

The Almanac, an Embarcadero Media publication which serves Menlo Park, Atherton, Woodside, and Portola Valley California, featured a story “Fiction or the Future?” on Rick Novak and Doctor Vita the same week.

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GRADY HARP REVIEWS DOCTOR VITA. “A SPLENDID AND TIMELY NOVEL”

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

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Grady Harp, Amazon Hall of Fame Top 100 Reviewer

April 20, 2019

Once again Rick Novak serves up a virulent novel that addresses an ongoing change in medicine that worries most of us – the growing dependence on robotics in surgery and the dehumanization of medicine: doctor patient interaction is altered by EMR and IT reporting of visits to insurance companies and the warmth of communication suffers. Rick takes this information to create a story about the extremes of AI in the form of a glowing globe that is Dr Vita and the struggle computer scientist/anesthesiologist Dr Lucas assumes as he tries to save medicine from the extremes of the ‘new age’ called FutureCare. As expected, Rick’s recreation of the tension in the OR and in interaction of the physicians is on target: his own experiences enhance the veracity of the story’s atmosphere.

Rick Novak writes so extremely well that likely has answered the plea of his readers to continue this `hobby’. He is becoming one of the next great American physician authors – think William Carlos Williams, Theodore Isaac Rubin, Oliver Wolf Sacks, Richard Selzer, and also the Brits Oliver Wendell Holmes et al. Medicine and writing can and do mix well in hands as gifted as Rick Novak. Highly Recommended. Grady Harp, April 19

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THE FIRST CHAPTER OF DOCTOR VITA BY RICK NOVAK

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

robotic-procedures

The first chapter of Doctor Vita by Rick Novak opens with a scene unlike any you’ve ever read before.

Chapter 1    THE BRICKLAYER

Alec Lucas’s first contact with FutureCare came in operating room #19 at the University of Silicon Valley Medical Center, where his patient Elizabeth Anderson blinked into the twin suns of the surgical lights hanging from the ceiling. A clear plastic oxygen mask covered Elizabeth’s nose and mouth, her cheeks were pale and tear-stained, and a strand of gray hair protruded from a blue paper bonnet. Her hand trembled as she reached up to remove the mask.

“I’m scared,” she said.

“I’m not,” said Dr. Lucas, who was her anesthesiologist. A green paper mask covered his face, but his pale blue eyes sparkled at her. He hummed to himself as he injected a dose of midazolam into Elizabeth’s IV to relax her.

“Am I crazy to go through this?” she said. “A 78-year-old lady with cancer?”

“We’re hoping your cancer can be cured with surgery,” Alec said. “Right now you’re doing great. Everything is perfect. Have a wonderful dream.” Elizabeth had cancer of the stomach, and presented today for robot-assisted laparoscopic surgery to remove half her stomach. It was a huge surgery—a risky surgery. Alec wondered why they were doing this operation on this lady. He questioned the aggressive strategy for a woman this old, but his job was to anesthetize, not to philosophize.

He’d seen presurgery anxiety like hers hundreds of times. The best way to cure her fears was to get her off to sleep. He injected doses of propofol and rocuronium into her intravenous line. The drugs flowed into Elizabeth’s arm, and within ten seconds her eyes closed. He inserted the lighted blade of a laryngoscope into her mouth, and visualized the white and shining upside-down “V” of her vocal cords, hovering in a sea of pink tissue. He slid a hollow plastic tube between the cords and into the blackness of the trachea beyond. Then he activated the ventilator, which blew a mixture of oxygen and sevoflurane through the tube into her lungs.

“I haven’t worked with you before, Dr. Lucas,” said the circulating nurse, who stood at the patient’s side. “My name is Maggie.”

“Of course you’ve never worked with me,” he said. “I told the nursing supervisor I never wanted to work with Maggie.” Then he winked at her and said, “We haven’t worked together because today is my first day on staff here. I’ve been at the University of Chicago since my first day of medical school. After fifteen years of shoveling snow, it was time to give California a try.”

Alec looked up as the surgeon, Xavier Templeton, entered the room. A tall scrawny man, Templeton had pale hairless matchstick arms that looked better hidden within a surgical gown. His bushy eyebrows met in the midline, and his left eye squeezed in an involuntary tic. Templeton’s hands wouldn’t touch Elizabeth Anderson’s skin or stomach today. His hands would control two levers on a console worthy of a spacecraft, and each move he made would be translated into the movement of a five-armed machine named the Michelangelo III, also known as The Bricklayer.

The five slender mechanical arms of The Bricklayer, dull gunmetal gray in color, dangled like the legs of a giant spider above Elizabeth Anderson’s abdomen. Each arm was draped in clear plastic to keep The Bricklayer sterile when it entered her body through tiny incisions.

Alec accepted his role of goaltender at the Pearly Gates. His assignment was to keep Elizabeth Anderson asleep and alive, while Templeton and The Bricklayer resected her tumor.

Twenty minutes into the surgery, Xavier Templeton sat on a chair in the corner of the room with his back to the operating table, and peered into a binocular stereo viewer. His hands maneuvered two levers on the console before him. On the operating table, the five robot arms reached into the abdomen though five one-centimeter incisions. One of the arms held a camera on a thin metal rod, movable at the surgeon’s control. A seventh-year resident worked as a surgical assistant, and attached appropriate operating instruments to the other 18-inch-long robot arms.

The two surgeons murmured to each other in quiet voices. Alec watched the surgery on a large flat screen video monitor that hung above him. He saw pink tissues, robot fingers moving, and a lot of irrigating and blunt dissection. The surgery was going well, and Alec made only minor adjustments in his drug doses and equipment as needed.

Then one thing changed.

One of the robot fingers on the video screen convulsed in staccato side-to-side slicing movements of its razor-sharp tip. A clear plastic suction tube exiting from the patient’s abdomen lurched and became an artery of bright red blood. The scarlet tube emptied into a bottle two feet in front of Alec. In sixty seconds the three-liter bottle was full of blood. Fifty-eight seconds prior to that, Alec was on his feet and both hands were moving. A flip of a switch sent a stream of fluid through the biggest IV into the patient. He turned off all the anesthesia gases and intravenous anesthetic medications.

“Big time bleeding, Dr. Templeton,” Alec shouted to the surgeon.

As fast as he could infuse fluid into two IVs, Alec could not keep up with the blood loss draining into the suction tube. The blood pressure went from normal to zero, and a cacophony of alarms sounded from the anesthesia monitoring system.

Templeton descended from his perch on the far side of the room, and put on a sterile gown and gloves. He took a scalpel from the scrub tech, and in one long stroke made an incision down the midline of the abdomen from the lower end of the breastbone to the pubic bone. With two additional long swipes, the left and right sides of Elizabeth Anderson parted. A red sea rose between them. The surgical resident and the scrub tech held suction catheters in the abdomen, but the stream of blood bubbled upward past the catheters. Templeton cursed and reached his right hand deep to the posterior surface of the abdominal cavity, feeling for the blood vessel on the left side of the spinal column. He found it, and squeezed the empty and pulseless aorta.

Alec looked at the monitors. The blood pressure was zero, and the electrocardiogram showed the heart was whipping along at a rate of 170 beats per minute. His patient had one foot in the grave. “Have you got control up there?” he screamed at Templeton.

“God damn it! I’m squeezing the aorta between my fingers,” Templeton answered. “As soon as I can see, I’ll put a clamp on the vessel. The bleeding is everywhere. I can’t see a damn thing.” Templeton’s face, mask, hat, and gown were drenched with the blood of Elizabeth Anderson. His unibrow was a red and black dotted line.

“Fire up the Maytag,” Alec said to Maggie. “Call the blood bank and activate the massive transfusion protocol.” Alec bent over the Maytag, a rapid blood infusion device with a bowl the size of a small washing machine. He turned the Maytag to its top flow rate. The machine hummed and spun, and the basin of IV fluid emptied into Elizabeth Anderson through a hose as wide as a small hot dog.

Despite the infusion of fluid, her blood pressure peaked at a dismal 65/40. “Have you found the hole yet?” he said to Templeton.

“Torn aorta. There are multiple holes—the aorta’s leaking like a sprinkler hose,” Templeton said without looking up. His left eye was blinking and squeezing repeatedly as he worked. “It’s terrible. The inferior vena cava is shredded and the blood from the lower half of her body is pouring out into her abdomen. The blood is everywhere.” Blink, squeeze. “Her vessels are falling apart like tissue paper.”

An orderly ran into the operating room carrying a red plastic beer cooler. Alec grabbed the cooler and popped off the top. Inside were six units of packed red blood cells, six units of fresh frozen plasma, and six units of platelets from the blood bank. “Check all the units and let’s get them flowing,” he said to Maggie.

Maggie picked up each bag and double-checked the patient’s name and the unit numbers with a second nurse, and then she handed the entire cooler to Alec. He drained each of the units of blood products into the basin of the Maytag, and the bowl hummed and pumped the blood into Elizabeth Anderson. The blood pressure began to climb, but one look at the crimson suction tubes exiting the patient’s stomach told Alec they were still in trouble. The bleeding wasn’t slowing. Blood was exiting faster than he could pump it in.

“We need a second cooler of blood products stat!” he said. Maggie picked up a telephone and relayed the order to the blood bank.

Alec looked at the surgical field, and the patient’s blood was everywhere—on Templeton’s face, hands, gown, on the surgical drapes and on the floor. It was everywhere but where it needed to be—inside her blood vessels. Templeton’s resident was jamming a suction catheter into the abdomen next to Templeton’s fingers, trying to salvage as much blood as he could.

“Damn it,” Templeton said. “She’s still bleeding, and now she’s bleeding pink piss water. I can see through her blood, it’s so dilute. How much fluid have you given her?”

“Six units of blood, six units of plasma, six units of platelets, and eight liters of saline.”

Alec glanced at the monitors and saw that her blood pressure had plateaued at a near-lethal level of 40/15.

“Her blood isn’t clotting anymore,” Templeton said. “The blood’s oozing and leaking everywhere I place a suture.”

Alec palpated her neck, and there was no pulse. “She has no blood pressure and no pulse,” he said. “We need to start CPR.”

Templeton’s resident placed the palms of his hands on Elizabeth Anderson’s breastbone and began chest compressions. The patient’s heart rate of 180 beats per minute slowed to 40 beats per minute, with premature beats and pauses between them. After twenty seconds of a slow irregular rhythm, her heartbeat tracing faded into the quivering line diagnostic of ventricular fibrillation.

Alec injected 1 milligram of epinephrine, and screamed, “Bring in the defibrillator.”

A second nurse pushed the defibrillator unit up to the operating room table. Templeton charged the paddles, applied them to the patient’s chest, and pushed the buttons. Elizabeth Anderson’s body leapt into the air as the shock of electrical energy depolarized every muscle of her body. All eyes turned to the ECG rhythm, and it was worse than ever.

Flat line.

“Damn it. Give me the scalpel back,” Templeton said. He carved a long incision between the ribs on the left side of Elizabeth Anderson’s chest, and inserted his hand into her thorax.

“I have her heart in my hand and I’m giving her direct cardiac massage,” he said. Alec looked at the monitors, and the direct squeezing of the heart was doing nothing. The blood pressure was still zero, and now blood was oozing from the skin around her IV sites, as well as from the surgical wounds in her abdomen.

Elizabeth Anderson’s heart was empty. Her blood vessels were empty. Her blood pressure had been near-zero for twenty-five minutes.

“What do you think, sir, should we call it?” Templeton’s resident said.

Templeton pulled his hand out of Elizabeth Anderson’s chest, and looked at the clock. “I pronounce her dead, as of 8:48 a.m. Damn, damn, damn it!”

Alec reached over and turned off the ventilator. The mechanical breathing ceased, and there was nothing left to do. He looked down at Elizabeth Anderson’s bloated face. Two strips of clear plastic tape held her eyes fastened shut, and her cheeks were as white as the bed sheet she rested on. A length of pink tape held the breathing tube fixed to her upper lip, and blood oozed from her nose and from the membranes between her teeth. This lady walked into the University of Silicon Valley Medical Center today hoping for a surgical miracle, and instead she was going to the morgue looking like this.

Xavier Templeton peeled his gloves off. “Goddamn it! The fricking robot went berserk. Sliced into the artery like a goddamned hedge trimmer. Now I have to tell the family she’s dead. Goddamn damn it!” He scowled in Alec’s direction. “Are you coming with me, Dr. Lucas?”

Alec nodded a yes. He looked at the gloomy outline of The Bricklayer’s arms, and then back at Templeton. Templeton was a fool to blame the medical device for his own ineptitude. The machine could do no wrong on its own.

This was the surgeon’s fault. Alec had heard it all before. Accept compliments and deflect all blame—it was an adage as old as the profession of surgery.

Templeton commanded The Bricklayer. And The Bricklayer was no better than the human hands that led it.

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

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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?

DOCTOR VITA AND THE BS IN HEALTHCARE

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

Last week Lawton Burns PhD and Mark Pauly PhD of the Wharton School of Business at the University of Pennsylvania published a landmark economic article entitled, “Detecting BS in Health Care.” Yes, you did not read that wrong—the academic paper used the abbreviation “BS” to describe the bull—- in the healthcare industry.

BS in Health Care

 

As a practicing physician, I find it to be a fascinating paper, and I recommend you click on the link and read it. The authors begin with a discussion of the art and value of BS detection. They mention that Ernest Hemingway was once asked, “Is there one quality needed to be a good writer, above all others?”

Hemingway replied, “Yes, a built-in, shock-proof, crap detector.”

The authors write, “While flat-out dishonesty for short term financial gains is an obvious answer, a more common explanation is the need to say something positive when there is nothing positive to say. . . . The incentives to generate BS are not likely to diminish—if anything, rising spending and stagnant health outcomes strengthen them—so it is all the more important to have an accurate and fast way to detect and deter BS in health care.”

The authors list their Top 10 Forms of BS in Health Care. The first four forms of BS weave a common theme:

  1. Top-down solutions: High-level executives and top management in the health care industry are supposed to engineer alternative payment models, but nothing has worked to date.
  2. One-size-fits-all, off-the-shelf: Leadership of industry and government assume one solution will work for multiple organizations, without customization.
  3. Silver-bullet prescriptions: A “silver bullet” is described as something that will cure all ills, and must be implemented because it been “decided that it is good for you,” Electronic health records (EHRs) are a prime example of a silver-bullet prescription. The federal government pushed the use of EHRs, claiming the systems would reduce costs and improve quality—but Burns and Pauly argue EHRs “eventually raised costs and only mildly touched a few quality dimensions.”
  4. Follow the guru: We must follow a visionary guru with a mystical revelation about what needs to be done. The authors describe how, in health care, Harvard professor Michael Porter and former CMS (Center of Medicare and Medicaid) administrator Don Berwick launched theories based on population health, and per-capita cost, to little success.

The current U.S. healthcare market is dominated by large corporations, led by businessmen who outline a yellow brick road for physicians to lead patients along. There is minimal effective policy-making from physicians. Healthcare stocks consistently grow in value, with little relationship to an improvement in clinical care, value, or cost. The government is involved as well, as in their mandate for Electronic Health Records (EHRs), a technology change that cost a lot of money, while forging a barrier between clinicians and the patients we are trying to interview, examine, and care for.

Where will the current trends take us? Will businessmen and/or the government prescribe health care? Will more and more computers and machines dominate health care?

Self-driving cars, Siri, Alexa, automated checkouts at Safeway, and IBM’s Watson are technologic realities. Will we someday see a self-driving physician with the voice of Siri and the brains of Watson?

Call that device “Doctor Vita.”

The saga of Doctor Vita arrives in 2019 from All Things That Matter Press.

 

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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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Coming in 2019, from All Things That Matter Press: DOCTOR VITA, Rick Novak’s second novel

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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

ai-medical-1-orig

 

How do you imagine the future of medical care? Cherubic young doctors holding your hand as you tell them what ails you? Genetic advances or nanotechnology gobbling up cancerous cells and banishing heart disease? Rick Novak describes a flawed future Eden where the only doctor you’ll ever need is Doctor Vita, the world’s first artificial intelligence physician, endowed with unlimited knowledge, a capacity for machine learning, a tireless work ethic, and compassionate empathy.

artificial-intelligence-in-medicine

In this science fiction saga of man versus machine, Doctor Vita blends science, suspense, untimely deaths, and ethical dilemma as the technological revolution crashes full speed into your healthcare.

robo_aberta

Set on the stage of the University of Silicon Valley Medical Center, Doctor Vita is the 1984 of the medical world– a prescient tale of Orwellian medical advances.

 

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