FREE SOLO

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Every anesthesia provider must learn to free-solo anesthesia early in his or her career. The 2018 movie Free Solo showcases Alex Honnold as he became the first person to free solo climb the 3000-feet high El Capitan wall of granite in Yosemite National Park without ropes or safety gear. This has been called the greatest feat in rock climbing history, and the movie is nominated for a 2019 Academy Award in the Feature Documentary category.

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FREE SOLO movie poster 2018

Believe it or not, but Free Solo could have been an anesthesiologist’s movie. How can that be? “Free-soloing” describes the most anxiety–producing event in every anesthesiologist’s life: the transition from anesthesia training when your faculty member is backing up your every move and every mistake, to the real world of anesthesia when you have to do scary cases alone without assistance.

During the dayshift, working alone is seldom an issue for any anesthesiologist. A typical hospital will have dozens of other anesthesia providers working in the same building. Within seconds or minutes, any anesthesiologist can be assisted or bailed out by a colleague.

Unlike Alex Honnold, the anesthesiologist is not putting their own life at risk—rather it is their patient who is at risk. The degree of risk is variable. For healthy patients undergoing elective surgery the anesthetic risks are minimal, and are similar to the risks of driving on a freeway in an automobile. For emergency surgeries, cardiac surgeries, chest surgeries, brain surgeries, or for anesthetics on patients with significant heart, lung, blood pressure, or airway problems, the risks of anesthesia are higher. The patient is totally dependent on their anesthesiologist to return them to consciousness safely.

Commercial aviation is sometimes compared to anesthesia practice. When commercial pilots take off in airliners, their passengers are totally dependent on the pilot to return them to the ground safely. But in commercial aviation there is one important difference: by law there must be a second pilot in the cockpit.

In anesthesia there is no guaranteed second anesthesiologist. There are multiple different models of anesthesia care. In an anesthesia care team, a physician anesthesiologist supervises up to four operating rooms and each operating room is staffed with a certified registered nurse anesthetist (CRNA). In a university hospital, a faculty member may supervise two operating rooms each with a resident anesthesiologist-in-training in attendance. In many hospital operating rooms, a solitary physician anesthesiologist attends to his or her patient alone. In seventeen “opt-out” states in America a solitary CRNA can attend to a patient without any physician anesthesiologist backup. Working alone may be less safe. A 2019 study from Europe reported an outcome advantage for anesthesiologist working in teams: The study showed that anesthesia given by teams of anesthesiologists and anesthesia nurses was associated with decreased 30-day postoperative mortality and a shorter length of stay when compared with solo anesthesiologists. There was no evidence for the specific cause of the decreased mortality.

Because of manpower necessities, there will never be a law mandating a second anesthesiologist for every surgery as there is in commercial aviation. There will always be emergencies at 2 a.m. or on weekend afternoons when all other anesthesiologists are elsewhere. As well, there are tens of thousands of freestanding surgery centers and office operating rooms where only one anesthesia professional is present.

Is there any data in the medical literature documenting that inexperienced anesthesia professionals have a greater incidence of adverse outcomes? Per Pubmed, there is no such publication. But there is no publication that denies the truth of this correlation. There is a paucity of data on the topic. The issue has not been rigorously studied in a scientific basis.

I review malpractice legal cases, and I can attest that inexperienced anesthesia personnel (who are less than board-certified physician anesthesiologists) are involved in many cases. I believe recent graduates are at particular risk when they work alone. In most cases with severe complications, the anesthesia professional (an MD or a CRNA) was managing the anesthetic alone until it was too late to save the patient.

During physician anesthesia training, a faculty member teaches, supervises, advises, and bails out each resident should there be a mishap. Following their three years of residency, a graduate is free to take a job as an attending anesthesiologist in any hospital system, multi-specialty clinic, or anesthesia group who will hire him or her. This is when the free-soloing begins.

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Let me cite some examples of anesthesia free-soloing:

  1. The new graduate is on duty at 2 a.m., and a three-hundred-pound man arrives at the emergency room with the abdominal emergency of a dying, obstructed intestine. The surgeon decides the case is an emergency and cannot wait until morning. The typical anesthetic for this surgery is a rapid-sequence induction of intravenous general anesthesia, followed by the placement of a hollow breathing tube through the mouth into the patient’s windpipe. This sounds easy enough, except when it isn’t. Morbidly obese patients can be very difficult to intubate, and without a properly placed breathing tube these patients can be difficult to keep oxygenated. Five minutes without oxygen causes irreversible brain death. Sound scary? It is.
  2. The new graduate is on duty at 3 p.m. at a community hospital. A two-year-old girl arrives at the emergency room gasping for breath, crowing with each inspiration, febrile, drooling, and barely conscious. Both the emergency room physician and the anesthesiologist quickly make the diagnosis of acute epiglottitis, a rare bacterial infection which causes the epiglottis (the flap which covers the windpipe when you swallow) to become inflamed and swollen. This causes a severe obstruction during each inhaled breath. The patient needs a breathing tube within minutes, before the swollen epiglottis cuts off all passage for air inflow into the lungs. I had this very case during my first year in private practice. I’d read about the proper management, but I’d never seen acute epiglottitis myself. The appropriate treatment is to bring the patient to the operating room urgently, and to staff an experienced head and neck surgeon at the bedside. The anesthesiologist’s job is to induce sleep with an inhaled anesthetic (sevoflurane) via a mask, while carefully supporting the airway and facilitating the passage of oxygen and anesthesia gas in and out of the lungs until the patient falls asleep. Once the patient is asleep, a physician or nurse must place an IV catheter in the patient’s arm, and then the anesthesiologist must insert a lighted scope into the patient’s mouth, locate the swollen epiglottis and the opening to the windpipe below it, and insert a tiny hollow plastic breathing tube into the windpipe. If anything goes wrong and the breathing tube cannot be inserted before the child turns blue, the surgeon must immediately slice into the child’s neck and insert a breathing tube through the skin. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
  3. The new graduate is on duty alone at a dental office, anesthetizing a 17-year-old male for wisdom teeth removal. After the induction of general anesthesia but before the beginning of surgery, the anesthesiologist administers a requested dose of intravenous antibiotic. Minutes later, the patient’s blood pressure drops from 120/80 to 60/30, the heart rate climbs from 80 to 160 beats per minute, and the normal lung sounds convert to tight wheezes. Hopefully the anesthesiologist will make the correct diagnosis of an anaphylactic allergic reaction—most likely due to the antibiotic. The effective treatment requires perfect management of the patient’s airway, breathing, and circulation. The specific treatment for anaphylaxis requires intravenous injection of epinephrine (adrenaline). A misdiagnosis leading to the omission of epinephrine can be fatal. If the blood pressure remains low and the lungs continue to deteriorate, there will be a lack of oxygen delivery to the brain. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.

What can be done to make free-soloing safer for patients? In my opinion, the best safety ropes are these:

  1. Most hospitals have an emergency room physician on duty at all hours. These MDs are multi-talented and have the acute care skills necessary to assist an anesthesiologist in an emergency. Rather than waiting until a patient has a cardiac arrest or until an airway is lost and the patient’s brain is losing oxygen, an anesthesia professional can consult the ER doctor in advance, e.g. requesting them to assist with a difficult induction of anesthesia on a morbidly obese adult or with a child with a difficult airway.
  2. Even if no experienced anesthesiologist is present in the hospital, there is always an experienced physician anesthesiologist colleague available on the other end of a phone call. Young or inexperienced anesthesia professionals can telephone senior anesthesiologists prior to the anesthetic, whenever a situation arises in which they are doubtful, insecure, or uncomfortable. It’s difficult to admit a lack of confidence, but it’s better to do this than to review a terrible complication with the senior anesthesiologist the next day, like two firefighters gazing over the burned basement remains of a previously preserved house.
  3. Most American anesthesia training programs are now utilizing simulation training facilities to prepare residents for severe acute care scenarios. A simulator lab has a surrogate patient and a full battery of vital sign monitors under the control of a teacher. The teacher can dial in a variety of emergencies and observe the pupil’s response to the emergencies. Feedback is given afterward regarding observed errors and any needed improvements in management. If a young physician anesthesiologist has faced emergencies in the simulator, we believe the anesthesiologist will be better prepared to free-solo following their training.
  4. The Stanford Anesthesiology department authored the Stanford Cognitive Aid Emergency Manual, a booklet of itemized recipes and checklists for all common dire emergencies one might see in an operating room. A PDF of this booklet is available for free of charge download here. Using the Stanford Cognitive Aid Emergency Manual in the operating room will help prevent medical errors, even by inexperienced anesthesia professionals.
  5. Whenever possible, solo anesthesiologists should have already passed the American Board of Anesthesiologists written and oral examinations, and therefore be board-certified. It’s a fact that one can practice anesthesiology in the United States without being board certified, but the ABA oral examination forces graduates to answer difficult questions in the pressure cooker of an oral exam room. Board-certified anesthesiologists will be better prepared for the pressure cooker of an operating room emergency as well.

If you’re a patient, should you worry about your anesthetist free-soloing during your surgery?

Let me reassure you. If you’re having an elective surgery in a hospital in the daytime, there are usually multiple backup anesthesia providers to assist with any problems. But for emergencies in the middle of the night, on weekends, or at freestanding surgical facilities with only one anesthesiologist present, your anesthesia care and outcome will be solely dependent on the skills, training, and experience of the solitary individual who is attending to you.

I’ve stood at the bottom of El Capitan in Yosemite National Park and looked upward at the vertical granite face with awe. I could never climb El Capitan, with or without ropes. I respect what Alex Honnold did at the highest level. He is brave beyond measure and he was willing to put his life on the line. Anesthesiologists, particularly junior anesthesiologists, must free-solo as well. No Hollywood cameras will be rolling, but the adrenaline will be pumping through their veins just as if they themselves were climbing El Capitan.

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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:

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ARE OLDER ANESTHESIOLOGISTS LESS SAFE? 

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Do you want an older anesthesiologist only months from retirement? Do you want a young and inexperienced anesthesiologist? Is there any data to help answer these questions?

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You’re boarding a commercial aircraft. It’s raining hard outside, and visibility is limited. You catch a glimpse of the pilots in the cockpit. To your relief, both of them are gray-haired. You’re nervous, and you don’t want a young and inexperienced pilot.

How do you feel when you meet your anesthesia provider prior to a surgical procedure? Do you want a young and inexperienced anesthesiologist? Do you want a geriatric anesthesiologist only months from retirement? Is there any data to help answer these questions? This topic was reviewed in a recent issue of Anesthesiology News (December 2015, Volume 41:12).

In an abstract presented at the 2015 American Society of Anesthesiologists annual meeting, data from the 2014 National Anesthesia Clinical Outcomes Registry was compiled for every anesthesiologist of known age who performed at least 100 cases. (Chen LC, et al, Abstract A1012). The anesthesiologists were divided into three age groups: less than 45 years (36%), 45 – 54 years (31.5%) and 55 years and older (32.4%). There were nearly 4 million cases from 5,334 providers. The overall mortality rate was 3.6 per 10,000 cases.

There was no mortality difference related to the anesthesia provider’s age. Higher ASA physical status (i.e. sicker patients) was associated with poorer outcomes. ASA Physical status 4 and 5 patients were more likely to die compared to ASA status 1 – 3 patients.

The study also examined practice patterns, and significant differences were discovered. Older anesthesiologists were:

  1. More likely to perform anesthetics under monitored anesthesia care, and less likely to perform regional, spinal, or epidural anesthesia.
  2. Less likely to work evenings, weekends and holidays.
  3. More likely to work part-time, and with a nurse anesthetist care-team delivery system.
  4. More likely to do outpatient cases and nonsurgical obstetrical/gynecology cases.
  5. More likely to perform shorter surgical cases and be involved in simpler surgeries with lower base units.

Major complications occurred at a rate of 18.4 per 10,000 cases. The middle-aged group (provider ages between 45 and 54) had more major complications compared with older anesthesiologists. The authors believed that elevated ASA physical status played a part in this statistic, because the middle-aged anesthesiologists took care of sicker patients. The middle-aged anesthesiologists were also more likely to care for inpatients under general anesthesia for longer cases, and these longer cases resulted in more major complications.

In a separate study on the topic of aging anesthesiologists in Canada, a survey found 7% of Canadian anesthesiologists were aged 65-74 years, and 3% were older than 74 years old. Anesthesiologists older than 65 years in the provinces of Ontario, Quebec, and British Columbia had 50% more cases involving litigation and almost twice the number of cases involving severe patient injury, compared with anesthesiologists younger than 51 years of age. The authors of this paper proposed regulations to include: no further on-call duties for those aged 60 and older, no further high-acuity cases for those aged 65 and older, and retirement from operating room clinical practice at age 70. (Baxter AD, The aging anesthesiologist: a narrative review and suggested strategies. Can J Anaesth. 2014 Sep;61(9):865-75.)

A 2006 United States survey of physicians aged 50-79 years showed that the work week of anesthesiologists decreased with advancing age, and part-time work increased. (Orkin FK, et al. United States anesthesiologists over 50: retirement decision making and workforce implications. Anesthesiology 2012 Nov;117(5):953-63.)

I’m currently in the higher of the three age groups (age 55 years and older). In my years as an anesthesiologist, I’ve watched colleagues of my generation change their clinical workload in a pattern consistent with the data presented above. As anesthesiologists age, most of us do not desire to be working at 3 a.m. resuscitating trauma patients, or doing anesthesia for 24-hour liver transplantation cases. These are surgeries for younger anesthesiologists. The overwhelming majority of aging anesthesiologists migrate toward administrative roles, daytime work, patients who are less sick, and simpler surgeries that minimally alter a patient’s physiology.

In the United States the mandatory retirement age is 65 for commercial pilots. There are no rules or regulations that prohibit an anesthesiologist from working at any particular advanced age. Could an 80-year-old anesthesiologist give you a safe anesthetic? It depends. If the 80-year-old has a valid medical license, a valid certificate from the DEA (Drug Enforcement Agency), and medical staff privileges at the facility your surgery is scheduled for, then he or she could work there. You can expect the 80-year-old will fare much better on simple outpatient anesthetics, and will never be doing open heart surgery or brain surgery anesthetics.

The hospital I work in at Stanford University confronted this issue in 2012 by enacting a Late Career Practitioner Policy. Physicians aged 75 and older are required to undergo a physical examination, cognitive screening, and a peer assessment of their clinical performance. These evaluations must be completed every two years to retain hospital privileges. Stanford is one of very few academic medical centers to require this scrutiny regarding older practitioners, and the policy met significant resistance from medical staff members prior to the policy being passed and enacted.

It is my impression, based on my clinical career, my peer review work, and my expert witness work on medical malpractice cases, that newly trained and inexperienced anesthesiologists present an increased risk for patient complications and poor outcomes. During anesthesia residency there is always a faculty member nearby to save an inexperienced anesthesiologist when he or she gets into a clinical problem. After that inexperienced anesthesiologist graduates and transitions into a community clinical practice, they may have to care for a sick patient at 3 a.m. as the solo on-call anesthetist, or they may have to manage an emergency airway disaster by themselves. Will they think clearly under pressure and make correct decisions to prevent their patients from dying? Every new graduate has these fears regarding their transition to post-residency practice. There’s nothing like having a couple of years of practice experience and 1500 solo cases under your belt to make you a safer anesthesiologist.

Expect to see further research on the topic of an anesthesiologist’s age in the years to come. Older physicians have a wealth of experience, but may have geriatric limitations on their ability to safely care for patients. Younger anesthesiologists have limited experience, and may be at increased risk for complications and mortality. Further Big Data from the National Anesthesia Clinical Outcomes Registry will help answer these questions in the future. As of now, there is no convincing data that practitioners at either extreme of age present a risk factor.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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INEXPERIENCED DOCTORS, OVERCONFIDENT DOCTORS, AND YOU

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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

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

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

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

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

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

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

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

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

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

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

“What do you mean?” I said.

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

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

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

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

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

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

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

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

What does this mean for you?

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

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

References:

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

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

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

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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