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.
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What’s the most critical technical skill for an anesthesiologist? I ask this question when I’m teaching anesthesia residents and medical students. Their most frequent answer is . . . the ability to place an endotracheal tube. This is the wrong answer. The most critical technical skill for an anesthesiologist is . . . facemask ventilation. Why?


All acute medical care follows the sequence of A-B-C, or Airway, Breathing, Circulation. Control of the airway is the most important clinical priority in anesthesia care. Placement of an endotracheal tube to establish an airway is an essential skill, but at times it’s difficult or near impossible to intubate the trachea on the first attempt.

The American Society of Anesthesiologists  Difficult Airway Algorithm addresses this issue. The Algorithm recommends, “Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management. Opportunities for supplemental oxygen administration include (but are not limited to) oxygen delivery by nasal cannulae, facemask, or LMA, insufflation; and oxygen delivery by facemask, blow-by, or nasal cannulae after extubation of the trachea.”

In emergency situations, maintenance of oxygen delivery by facemask can be critical.

The INTUBATION AFTER INDUCTION OF GENERAL ANESTHESIA section of the Difficult Airway Algorithm is bifurcated into two pathways. The left side is labeled FACE MASK VENTILATION ADEQUATE. The right side is labeled FACE MASK VENTILATION NOT ADEQUATE.


The left side FACE MASK VENTILATION ADEQUATE leads to a NONEMERGENCY PATHWAY algorithm. The right side FACE MASK VENTILATION NOT ADEQUATE begins with CONSIDER/ATTEMPT SGA (Supraglottic Airway), but if SGA placement is unsuccessful, the right side FACE MASK VENTILATION NOT ADEQUATE pathway leads directly to an EMERGENCY PATHWAY algorithm subtitled “Ventilation not adequate, intubation unsuccessful.”

“Ventilation not adequate, intubation unsuccessful” is a circumstance every anesthesiologist dreads, and every anesthesiologist hopes to avoid. Failure to keep a patient oxygenated can lead to hypoxia and brain death in as short a time as three minutes.

One way to spend less time on the right side of the ASA Difficult Airway Algorithm is to be expert and proficient in facemask ventilation.

In my practice, I’d estimate 1 – 2 patients out of every 100 patients, or 7 – 10 patients per year, present an unexpected difficult intubation. In my preoperative assessment I believe their intubation will be routine or only moderately difficult. After I induce general anesthesia and paralyze the patient, I find their larynx is anterior and difficult to visualize by direct laryngoscopy. In these patients in which my initial attempt(s) are unsuccessful, repeat laryngoscopies are required, and facemask ventilation between laryngoscopies to maintain oxygenation and ventilation is critical.

A second intubation attempt may involve a change in head and neck positioning, oropharangeal suctioning, or a different laryngoscope. If these modifications are unsuccessful, video laryngoscopy is indicated. A recent study in Anesthesiology showed video laryngoscopy to be the most successful technique to achieve successful tracheal intubation after failed direct laryngoscopy, with a 92% rescue rate. Video laryngoscopy is known to be associated with improved visualization of the larynx , although placement of the tube into the trachea may still require repeated attempts, requiring alteration in curve of the stylet or repositioning of the laryngoscope.

Some might argue that the use of video laryngoscopy for the first attempt at endotracheal intubation will eliminate this problem. But as described above, for difficult airways or obese patients, even video laryngoscopy can require repeated attempts because of difficulty advancing the tube into the trachea. No data exists to support that initial video laryngoscopy is safer or more effective than direct laryngoscopy when used by anesthesiologists in operating rooms.

Airway and Breathing must be maintained by facemask ventilation until an endotracheal airway or supraglottic airway is established. The manual skill of maintaining a seal between the mask and the patient’s face requires strength. The four fingers hold the caudal aspect of the mask firmly against the chin, and also serve to extend the patient’s neck. The thumb presses down on the cephalad aspect of the mask against the bridge of the nose. The right hand squeezes the ventilation bag on the anesthesia machine.

An anesthesiologist with an injured or impaired left hand is unable to safely ventilate a patient via facemask, especially an overweight patient or a patient with a beard or abnormal facial anatomy. Because of this, an anesthesiologist with an injured or impaired left hand should not be administering general anesthesia. Anesthesiologists would be wise to avoid hand or wrist injuries which could make them unemployable. Anesthesiologists would be wise to avoid falling on their outstretched hands. The pastimes of bicycle riding, skateboarding, rollerblading, climbing ladders, and rock climbing are all fraught with hand-injury danger. Should anesthesiologists avoid these activities? At the very least, anesthesiologists need to be overly careful with these activities.

Operating room practice requires anesthesiologists to perform multiple additional technical procedures, including the placement of IVs, arterial lines, central venous catheters, spinal blocks, epidural blocks, and ultrasound-guided regional nerve blocks. Each of these skills is important, but none of them are as critical as the ability to keep a patient oxygenated, first with a facemask, and second by placing an airway tube.

In a previous column, I described a case in which an anesthesiologist lost the airway on a pregnant woman following induction of general anesthesia for Cesarean section. The acute situation led to the anesthesiologist’s unrelenting focus on repeat laryngoscopies, at the expense of the facemask ventilation needed to return the oxygen saturation to a level greater than 90%. Failure to keep the patient oxygenated through repeated intubation attempts can lead to hypoxia and brain death.

The full list of the intellectual, technical, and personal qualities necessary to succeed in the profession of anesthesiology are summarized in my column On Becoming an Anesthesiologist – What Personal Characteristics are Essential.


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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?


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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?



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


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

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

Nuanced characterization and crafty details help this debut soar.

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