AUTISM AND ANESTHESIA

the anesthesia consultant

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

Anesthetizing uncooperative patients is difficult. The combination of autism and anesthesia requires careful planning.

autism and anesthesia

Children or adults with psychological, developmental, or behavioral disorders such as autism may be combative or aggressive, and may require extra measures of preanesthetic sedation or restraint. The parents/guardians and the anesthesia team need to be actively involved with forming the preoperative plan for uncooperative patients.

The incidence of autism in the United States is high—the Autism and Developmental Disabilities Monitoring (ADDM) Network of the Center for Disease Control estimates about 1 in 59 children has autism spectrum disorder (ASD).

Characteristics of autism include developmental delays of behavioral and social skills, and an inability to communicate. The symptoms of ASD stretch across a broad range from mild to incapacitating.

It’s not infrequent that autistic patients need surgery and anesthesia. Patients with autism commonly need to be sedated for routine procedures that a normal child or adult would cooperate with. Dental cases are common, and are frequently referred to a hospital because the typical care systems at an outpatient surgery center or a dental office are inadequate to complete a successful anesthetic.

The most common anesthesia induction technique in children and toddlers is an inhalation induction with sevoflurane. The routine practice of performing an inhalational sevoflurane induction on a child with autism may be impossible.

The most common anesthesia induction technique in adults involves the intravenous injection of propofol. The routine practice of starting a preoperative IV to begin anesthesia care on an adolescent or adult with autism may also be impossible.

Let’s look at an example case of an uncooperative adolescent who is adult-sized and who requires an anesthetic:

A 16-year-old, 70-kilogram male with Autistic Spectrum Disorder is scheduled for dental surgery and teeth cleaning. He is verbal with his mother, but refuses to interact with the anesthesia or nursing personnel. He refuses to change into a hospital gown, or to remove his long-sleeved sweater. He refuses to drink or swallow any premedication, he refuses an IV, and he refuses inhalation induction. The mother, who is the patient’s legal guardian, consents to surgery and anesthesia, but she is unable to convince her son to cooperate with the medical team.

What do you do?

The surgical and anesthetic team spent significant time explaining, reassuring, and coddling the patient, to no avail. They told the mother she had the choice of going home without any surgical procedure or anesthesia at all. The mother was adamant that the procedure needed to be performed. To this end, all parties agreed to the following plan:

  1. Two hospital security guards were called to the bedside in the preoperative area.
  2. The two hospital guards and the mother donned white operating room coveralls.
  3. At the mother’s consent, the guards laid the patient down on the hospital gurney, held him there, and the surgical team and the guards pushed the gurney down the hallway to the operating room (a significant distance of approximately 100 yards).
  4. Upon arrival in the operating room, one of the security guards uncovered the sweater from the patient’s arm, and the anesthesiologist injected an intramuscular mixture of 2 mg/kg ketamine, 0.2 mg/kg midazolam, and .02 mg/kg atropine into the patient’s deltoid muscle. The patient protested, and the mother reassured him.
  5. The oximeter and routine monitors were placed.
  6. Once the patient became sedated (2-4 minutes later), the mother was escorted from the room and the anesthesiologist started an IV in the patient’s arm. The patient was then preoxygenated via mask in the standard fashion, propofol 1 mg/kg and rocuronium 0.5 mg/kg were injected IV, and the trachea was intubated.
  7. The surgery proceeded as scheduled, with sevoflurane as maintenance anesthesia.
  8. At the conclusion of surgery, the patient was extubated awake and taken to the Post Anesthesia Care Unit (PACU) in stable condition. The mother was reunited with the patient there. The patient was sedate, calm, comfortable, and tolerated the PACU care well.
  9. The patient was discharged home without complications after 90 minutes in the PACU. The mother was happy with the perioperative care.

Perhaps this practice of intramuscular induction of anesthesia sounds brutal to you.

The intramuscular (IM) ketamine/midazolam/atropine induction of anesthesia as described in the case study above is effective. In our practice, the recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine.

The ketamine concentration is 100 mg/ml. The midazolam concentration is 5 mg/ml. The total volume of the intramuscular injection in our case study patient was 140 mg ketamine (1.4 ml), 14 gm midazolam (2.8 ml), and 1.4 mg atropine (1.4 ml), for a total injectate volume of 5.6 ml. More dilute concentrations of these three drugs will necessitate too large a volume for intramuscular injection. This IM induction technique is effective in safely inducing general anesthesia without an IV within 2-4 minutes, and has been described in a previous article on dental office anesthesia.

There are more gentle approaches to an uncooperative patient—approaches which this patient would not agree to. The literature lists these options for premedication or induction of anesthesia in uncooperative patients:

  1. Intranasal premedication sedation with either 0.5 mg/kg of midazolam, or 1 microgram/kg of dexmedetomidine were found to be equally effective in sedating 20 uncooperativechildren aged 2-6 years for dental treatment visits. 0.25 mg/kg of atropine, in combination with 0.5 mg/kg of midazolam, and 1-2
  2. Oral premedication sedation with 5 mg/kg oral midazolam. Oral sedation is considered as the oldest, easiest way of administrating sedative drugs to pediatric patients. Midazolam is a well-known sedative, and we use this often in our practice if the patient will accept it. The effect initiates within 20–30 minutes of oral administration.
  3. Oral premedication with dexmedetomidine 5 mcg/kg.
  4. Oral midazolam, ibuprofen, and 6 mg/kg of ketamine. Oral ketamine of  up to 8 mg/kg has shown to effective in improving compliance during induction of anesthesia. Compared with oral midazolam, oral ketamine causes less respiratory depression. Ketamine does cause nystagmus, increased salivation, hallucinations and emergence delirium. When used alone as a premedicant ketamine has not been found to be effective. There is no significant difference between oral ketamine and oral midazolam in the postoperative recovery or hospital discharge.

Uncooperative children or adults with ASD will each have individualized needs. Patients with significant ASD may have severe objections to the doctor-patient relationship, and it can take a prolonged time to gain their trust. It’s important to discuss the perioperative anesthetic issues and the preoperative plan with a parent or guardian well in advance of the surgical date if possible. The anesthesia team can determine the simplest means of preoperative sedation/anesthesia to complete the case successfully, and the family can give input regarding previous anesthesia successes or failures. It’s optimal if the family and the MDs can agree to an appropriate approach to the anesthetic, days prior to the actual surgery.

Parents often ask about the risk of general anesthesia to the brain of their child. At present there is no documented connection between exposures to general anesthesia and the development or worsening of autistic symptoms. In a study of a birth cohort of 114,435 children from Taiwan from 2001 to 2010, 5197 children under the age of 2 years were exposed to general anesthesia and surgery. The 1 : 4 matched control group comprised 20,788 children. The results showed that neither exposure to general anesthesia and surgery before the age of 2 years age, nor the number of exposures, were associated with the development of autistic disorder. 

Do autistic patients suffer more complications from anesthesia and surgery than non-autistic patients? In a review by Arnold published in Pediatric Anesthesia in 2015, other than a significant difference in the premedication type and route (per the discussion above), children with ASD had similar perioperative experiences as non‐ASD subjects.

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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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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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For questions, contact:  rjnov@yahoo.com

 

DENTAL ANESTHESIA DEATHS . . . GENERAL ANESTHESIA FOR PEDIATRIC PATIENTS IN DENTAL OFFICES

the anesthesia consultant

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

GENERAL ANESTHESIA FOR DENTAL OFFICES CASE PRESENTATION: A 5-year-old developmentally delayed autistic boy has multiple dental cavities. The dentist consults you, a physician anesthesiologist, to do sedation or anesthesia for dental restoration. What do you do?

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DISCUSSION:  Children periodically die in dental offices due to complications of general anesthesia or intravenous sedation. Links to recent reports include the following:

3-year-old girl dies in San Ramon, CA after a dental procedure in July 2016.

A 14-month-old child, scheduled to have 2 cavities filled, dies in an Austin, TX dental office. The dentist and an anesthesiologist were both present.

A 6-year-old boy, scheduled to have teeth capped at a dental clinic, has anesthesia and dies after the breathing tube is removed.

Another 6-year-old boy, scheduled to have a tooth extracted by an oral surgeon, dies after the oral surgeon administers general anesthesia.

Pediatric dentists use a variety of tactics to keep a typical child calm during dental care. The child is encouraged to view a movie or cartoon while the dental hygienist or dentist works. The parent or parents are encouraged to sit alongside their child to provide emotional support. If a typical child requires a filling for a cavity, the dentist can utilize nitrous oxide via a nasal mask with or without local anesthesia inside the mouth.

These simple methods are not effective if the child has a developmental delay, autism, behavioral problems, or if the child is very young. Such cases sometimes present to a pediatric hospital for anesthetic care, but at times the child will be treated in a dental office. Possible anesthesia professionals include a physician anesthesiologist, a dental anesthesiologist, or an oral surgeon (who is trained in both surgery and anesthesia).

 

HOW WOULD A PHYSICIAN ANESTHESIOLOGIST ANESTHETIZE A CHILD IN A DENTAL OFFICE?

There are a variety of techniques an anesthesiologist might use to sedate or anesthetize a young child. The correct choice is usually the simplest technique that works. Alternative methods include intramuscular sedation, intravenous sedation, or potent inhaled anesthetics.

 

ANESTHESIA INDUCTION:

The first decision is how to begin the anesthetic on an uncooperative child. Options for anesthesia induction include:

  1. Intramuscular sedation. A typical recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine. These three medications are drawn up in a single syringe and injected into either the deltoid muscle at the shoulder or into the muscle of the anterior thigh. Ketamine is a general anesthetic drug that induces unconsciousness and relieves pain. Midazolam is a benzodiazepine which induces sleepiness and decreases anxiety. Ketamine can cause intense dreams which may be frightening. Midazolam is given because it minimizes ketamine dreams. Atropine offsets the increased oral secretions induced by ketamine. Within minutes after the injection of these three drugs, the child will become sleepy and unresponsive, and the anesthesiologist can take the child from the parent’s arms and bring the patient into the operating room. Most anesthesiologists will insert an intravenous catheter into the patient’s arm at this point, so any further doses of ketamine, midazolam, or propofol can be administered through the IV.
  2. Oral sedation with a dose of 0.5-0.75 mg/kg of oral midazolam syrup (maximum dose 20 mg). If the child will tolerate drinking the oral medication, the child will become sleepy within 15- 20 minutes. At this point, the anesthesiologist can take the patient away from the parent and proceed into the operating room, where either an intravenous anesthetic or an inhaled sevoflurane anesthetic can be initiated.

 

MONITORING THE PATIENT:

  1. The patient should have all the same monitors an anesthesiologist would use in a hospital or a surgery center. This includes a pulse oximeter, an ECG, a blood pressure cuff, a monitor of the exhaled end-tidal carbon dioxide, and the ability to monitor temperature.
  2. The anesthesiologist is the main monitor. He or she will be vigilant to all vital signs, and to the Airway-Breathing-Circulation of the patient.

 

MAINTENANCE OF ANESTHESIA:

  1. Regardless of which anesthetic regimen is used, oxygen will be administered. Room air includes only 21% oxygen. The anesthesiologist will administer 30-50% oxygen or more as needed to keep the patient’s oxygen saturation >90%.
  2. Intravenous sedation: This may include any combination of IV midazolam, ketamine, propofol, or a narcotic such as fentanyl.
  3. Local blocks by the dentist. The dentist may inject local anesthesia at the base of the involved tooth, near the superior alveolar nerve to block all sensation to the upper teeth, or near the inferior alveolar nerve to anesthetize all sensation to the lower jaw.
  4. Inhaled nitrous oxide. The simplest inhaled agent is nitrous oxide, which is inexpensive and rapid acting. Used alone, nitrous oxide is not potent enough to make a patient fall asleep. Nitrous oxide can be used as an adjunct to any of the other anesthetic drugs listed in this column.
  5. Potent inhalation anesthesia (sevoflurane). Most dental offices will not have a machine to administer sevoflurane. (Every hospital operating room has an anesthesia machine which delivers sevoflurane vapor.) Portable anesthesia machines fitted with a sevoflurane vaporizer are available. A colleague of mine who worked full time as a roving physician anesthesiologist to multiple pediatric dental offices leased such a machine and used it for years. The advantages of sevoflurane are: i) few intravenous drugs will be necessary if the anesthesiologist uses sevo, and ii) the onset and offset of sevo is very fast—as fast as nitrous oxide. The administration of sevoflurane usually requires the use of a breathing tube, inserted into the patient’s windpipe.
  6. The anesthesiologist will be present during the entire anesthetic, and will not leave.

 

AWAKENING FROM ANESTHESIA:

  1. With intramuscular and/or intravenous drugs, the wake-up is dependent on the time it takes for the administered drugs to wear off or redistribute out of the blood stream. This may take 30-60 minutes or more following the conclusion of the anesthetic.
  2. With inhaled agents such as sevoflurane and nitrous oxide, the wake-up is dependent on the patient exhaling the anesthetic gas. The majority of the inhaled anesthetic effect is gone within 20-30 minutes after the anesthetic is discontinued.
  3. The patient must be observed and monitored until he or she is alert enough to be discharged from the medical facility. This can be challenging if a series of patients are to be anesthetized in a dentist’s office. The medical staff must monitor the post-operative patient and also attend to the next patient’s anesthetic care. It’s imperative that the earlier patient is awake before the anesthesiologist turns his full attention to the next patient.

 

THE ANESTHETIC FOR OUR CASE PRESENTATION ABOVE:

  1. The anesthesiologist meets the parents and the patient, and explains the anesthetic options and procedures to the parent. The parent then consents.
  2. The anesthesiologist prepares the dental operating room with all the necessary equipment in the mnemonic M-A-I-D-S, which stands for Monitors and Machine, Airway equipment, Intravenous line, Drugs, and Suction.
  3. The anesthesiologist injects the syringe of ketamine, midazolam, and atropine into the child’s deltoid muscle. The child becomes sleepy and limp within one minute, and the anesthesiologist carries the child into the operating room.
  4. All the vital sign monitors are placed, and oxygen is administered via a nasal cannula.
  5. An IV is started in the patient’s arm.
  6. The dentist begins the surgery. He or she may inject local anesthesia as needed to block pain.
  7. Additional IV sedation is administered with propofol, ketamine, midazolam, or fentanyl as deemed necessary.
  8. When the surgery is nearing conclusion, the anesthesiologist will stop the administration of any further anesthesia. When the surgery ends, the anesthesiologist remains with the patient until the patient is awake. The patient may be taken to a separate recovery room, but that second room must have an oxygen saturation monitor and a health care professional to monitor the patient until discharge.

CHALLENGES OF DENTAL OFFICE ANESTHESIA:

  1. You’re do all the anesthesia work alone. If you have an airway problem or an acute emergency, you’ll have no other anesthesia professional to assist you. Your only helpers are the dentist and the dental assistant.
  2. The cases are difficult, otherwise you wouldn’t be there at all. Every one of the patients will have some challenging medical issue(s).
  3. You have no preop clinic, so you don’t know what you’re getting into until you meet the patient. I’d recommend you telephone the parents the evening before, so you can glean the past medical and surgical histories, and so you can explain the anesthetic procedure. Nonetheless, you can’t evaluate an airway over the phone, and on the day of surgery you may encounter more challenge than you are willing to undertake.
  4. It’s OK to cancel a case and recommend it be done in a hospital setting if you aren’t comfortable proceeding.
  5. The anesthesiologist usually has to bring his or her own drugs. The narcotics and controlled substances need to be purchased and accounted for by the anesthesiologist with strict narcotic logs to prove no narcotics are being diverted for personal use. All emergency resuscitation drugs need to be on site in the dental office or brought in by the anesthesiologist.
  6. If a sevoflurane vaporizer is utilized, dantrolene treatment for Malignant Hyperthermia must be immediately available.

 

BENEFITS OF DENTAL OFFICE SEDATION AND GENERAL ANESTHESIA:

  1. The parents of the patients are grateful. The parents know how difficult dental care on their awake child has been, and they’re thankful to have the procedures facilitated in a dental office.
  2. The dentist and their staff are grateful. They don’t have a method to safely sedate such patients, and are thankful that you do.
  3. Most cases are not paid for by health insurance, rather they are cash pay in advance.

 

HOW SAFE IS ANESTHESIA AND SEDATION IN A DENTAL OFFICE?

No database can answer the question at present. In 2013 the journal Paediatric Anesthesia published a paper entitled Trends in death associated with pediatric dental sedation and general anesthesia. (1) The paper reported on children who had died in the United States following receiving anesthesia for a dental procedure between1980-2011. Most deaths occurred among 2-5 year-olds, in an office setting, and with a general or pediatric dentist (not a physician anesthesiologist or dental anesthesiologist) as the anesthesia provider. In this latter group, 17 of 25 deaths were linked with a sedation anesthetic.

Another study analyzed closed claims databases of 17 malpractice claims of adverse anesthesia events in pediatric patients in dental offices from 1992 – 2007. (2) Thirteen cases involved sedation, 3 involved local anesthesia alone, and 1 involved general anesthesia. 53% of the claims involved patient death or permanent brain damage. In these claims the average patient age was 3.6 years. Six cases involved general dentists as the anesthesia provider, and 2 involved local anesthesia alone. The adverse event occurred in the dental office in 71% of the claims. Of the 13 claims involving sedation, only 1 claim involved the use of vital sign monitoring. The study concluded that very young patients (≤ 3-years-old) were at greatest risk during administration of sedative and/or local anesthetic agents. The study concluded that some practitioners were inadequately monitoring patients during sedation procedures. Adverse events had a high chance of occurring at the dental office where care is being provided.

If general anesthesia or deep sedation are performed in a dental office, the anesthetist must practice with the same vigilance and standards of care as they would in a hospital or surgery center. Either a physician anesthesiologist, an oral surgeon (acting as both the dental surgeon and the anesthetist), or a dental anesthesiologist may perform the anesthesia. There are no data at this time to affirm that a physician anesthesiologist is the safest practitioner in this setting.

Note: This column addressed the office practice of pediatric dental anesthesia as seen from a physician anesthesiologist’s point of view.

References:

(1) Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6.

(2) Chicka MC et al, Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent.2012 May-Jun;34(3):231-8.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited