EXTUBATION IS RISKY BUSINESS. WHY THE CONCLUSION OF GENERAL ANESTHESIA CAN BE A CRITICAL EVENT

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
preparing to remove an endotracheal tube from a patient

Every general anesthetic has risk. In the immortal words of Forrest Gump, “Sh*t happens.” The conclusion of most general anesthetics requires the removal of a breathing tube. The removal of this airway tube, an event called “extubation,” is a critical and sometimes dangerous event. Extubation is risky business.

The most invasive type of airway tube used in anesthesia is called an endotracheal tube, or ET tube. At the onset of general anesthesia anesthesiologists place an ET tube through the mouth, past the larynx (voice box), and into the trachea (windpipe). The ET tube is a conduit to safely transfer oxygen and anesthesia gases into and out of the lungs.

After a surgery is finished, anesthetic gases and intravenous anesthesia drugs are discontinued, and the patient wakes up within 5 to 15 minutes. If the patient has an ET tube, it is usually removed. Anesthesiologists are vigilant during extubation. In contrast, other operating room professionals are usually relaxed and winding down at this time, because the surgical procedure is finished. Extubation is not a time to relax. The incidence of respiratory complications (e.g. low oxygen saturations or airway obstruction) occurred at a significantly higher rate following extubation than during induction of anesthesia (P < 0.01).

The Difficult Airway Society Guidelines for the Management of Tracheal Extubation state that “tracheal extubation is a high-risk phase of anesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death.”

Let’s examine five actual post-extubation scenarios that caused death, complications, or a near-miss: 

  1. During my first month of anesthesia training at a county hospital in San Jose, California, I chose to try to wake up a healthy patient without the presence of my faculty member. When I removed the endotracheal tube, the patient was unable to breathe and his oxygen level dropped acutely. I didn’t know what to do, and in a panic I paged my faculty member. He entered the operating room, elbowed me aside, assessed the diagnosis of laryngospasm, applied an anesthesia mask over the patient’s face, and began a chin-lift maneuver while forcing positive pressure oxygen into the patient via the mask. Within ten seconds the patient coughed, began breathing, and the oxygen level rose to safe levels. I was aghast with the acute deterioration I had neither predicted nor known how to remedy. The faculty member looked me in the eye and said, “Don’t take out the endotracheal tube until the patient opens his eyes.” I took that endotracheal tube out too early because I was inexperienced—still years away from finishing my anesthesia training. Laryngospasm occurs when the vocal cords clamp together following removal of the ET tube. This is usually caused by saliva or blood on the vocal cords during an intermediate phase of anesthesia. Laryngospasm is a vocal cord reflex which closes the cords to protect the trachea from aspirating fluid into the lungs. When the vocal cords remain closed, no oxygen can pass and an individual can die. The Difficult Airway Society Guidelines for the Management of Tracheal Extubation (see below), published in 2012, recommend to “wait until awake, eye opening/obeying commands,” just as my faculty member advised me in 1986.
Difficult Airway Society Guidelines “low risk” algorithm
NOTE: “Wait until awake (eye opening/obeying commands)”
  • A 40-year-old male presented for outpatient surgery on his nose. His past medical history was positive for obesity (220 pounds, 5 feet 6 inches tall) and hypertension. Anesthesia was induced with propofol, fentanyl, and rocuronium, and an ET tube was easily placed. The surgery concluded 2 hours later and the anesthetics were discontinued. The patient began to cough. The anesthesiologist decided to extubate the trachea at that time. After extubation the patient continued to make respiratory efforts, but no airflow was noted. The blood oxygen saturation dropped to a dangerous level of 78%. The anesthesiologist was unable to reintubate the trachea due to poor visibility. The oxygen saturation dropped to 50%. Seven minutes later, the anesthesiologist was finally able to replace the ET tube. Copious secretions were suctioned out of the tube, ventilation remained difficult, and the oxygen saturation level remained in the 50% range. The patient’s ECG deteriorated into a cardiac arrest. He was resuscitated, and 20 minutes later his oxygen saturation finally rose to 94%. A chest x-ray showed pulmonary edema, meaning that the lungs were full of fluid. The diagnosis was laryngospasm leading to negative pressure pulmonary edema. When a patient powerfully attempts to inhale against the obstructed vocal cords of laryngospasm, the negative pressure of each inhale moves fluid from blood vessels into the airway spaces of the lungs, a phenomenon is called negative pressure pulmonary edema. This patient was eventually declared brain dead due to prolonged his prolonged low oxygen levels.
Chest X-ray showing increased lung water in negative pressure pulmonary edema
  • A 40-year-old male presented for a routine elective upper GI endoscopy procedure. He was morbidly obese, with a weight of 380 pounds and a height of 5 feet 4 inches. The anesthesiologist induced anesthesia with propofol and paralyzed the patient with rocuronium in order to place the ET tube prior to the procedure. The procedure lasted only 15 minutes. The paralysis was reversed by the drug combination of neostigmine 5 mg and Robinul 1 mg, and patient was extubated awake. In the first minute it became clear that the patient was still partially paralyzed and unable to ventilate himself. The blood oxygen level dropped acutely to life-threatening levels. The anesthesiologist then performed an emergency reintubation to replace the ET tube to again ventilate oxygen into the patient’s lungs to save his life. (Note- this case occurred in 2015, prior to the availability of sugammadex, a new intravenous drug which rapidly and reliably reverses rocuronium paralysis in a minute or less.) 
  • An 80-year-old female presented for elective right elbow surgery. She was obese (220 pounds, 5 feet tall), had a past history of congestive heart failure, and had her aortic valve replaced two years earlier. She had a history of shortness of breath climbing one flight of stairs. The anesthesiologist induced anesthesia with propofol and rocuronium, and placed an ET tube. At the conclusion of surgery, the anesthetics were discontinued. While the ET tube remained in place, her blood pressure climbed to a high of 200/120, her heart rate climbed to 120 beats per minute, and white froth began to occlude the inside of the ET tube. This fluid was pouring out of her lungs due to acute congestive heart failure caused by marked hypertension. During extubation, 10 – 30 % increases in both heart rate and blood pressure can occur. Hypertension and increased heart rate must be monitored and treated during the extubation of patients with cardiac disease. The patient was ventilated with 100% oxygen, an arterial line was placed in the radial artery in her wrist to continually monitor her elevated blood pressure, and an emergency infusion of an ICU antihypertensive drug called nitroprusside was started. The nitroprusside decreased the blood pressure to 150/80, she was re-sedated with propofol, and she was transferred to an ICU with the ET tube still in place. A myocardial infarction was ruled out by blood tests. The ET tube was removed in the ICU the following morning. She walked out of the hospital two days later. 
  • A healthy 4-year-old female had a general anesthetic for elective surgery to reconstruct her middle ear. After a ninety-minute surgery, the anesthetics were discontinued. Five minutes later she opened her eyes. Just seconds prior to the planned extubation, the patient vomited 100 milliliters of brown solid and liquid material which overflowed from her mouth. The anesthesiologist inserted a suction catheter into her mouth to remove the vomitus. The lung examination with a stethoscope confirmed normal breath sounds. The patient’s vital signs remained normal and the ET tube was removed. The patient suffered no respiratory distress, and the lungs were free from of the stomach contents. The cuffed ET tube prevented aspiration of the vomitus into her lungs. If her ET tube had been removed at any point prior to the vomiting, it’s likely the solid and liquid stomach contents would have descended into her lungs, clogged and obstructed her lower airways, and required insertion of a new ET tube and transfer to an ICU for treatment of aspiration of stomach contents into the lungs. 

My advice to anesthesia professionals regarding extubation is to:

  • Review the Difficult Airway Society Guidelines for the Management of Tracheal Extubation. The guidelines advise awake extubation. My advice, in line with this publication, is: The ET tube is your friend. Don’t pull it out until you’re certain you don’t need it any more. Prior to extubation, many patients will struggle and move prior to the time they open their eyes or can obey commands. An onlooking surgeon will at times say, “can you take the tube out now? The patient is going to rip their sutures out or have bleeding from the surgical site.” At times anesthesiologists will comply and remove the ET tube earlier at this request. Most of the time there will be no serious complication, but there will at times be complications of airway obstruction, laryngospasm, or low oxygen levels. If a bad outcome occurs, the anesthesiologist will own the complication. No one will blame the surgeon.
  • Pass the American Board of Anesthesiologists oral board examination, and become board-certified in anesthesiology. The time spent studying for the oral boards will make you a safer and smarter anesthesiologist who is better prepared to handle emergency situations. A study in Anesthesiology showed rates for death and failure to rescue from crises were greater when anesthesia care was delivered by non-board certified midcareer anesthesiologists. In the Stanford Department of Anesthesiology, we administer mock oral board examinations to the residents and fellows twice a year. Managing a sudden hypoxic episode is a common question during the oral exam. If you can think well in a room in front of two examiners, you are more likely to think well in a true emergency when your patient’s life is at stake.
  • If you have access to anesthesia simulator sessions, enroll yourself. Like the flight simulator training that commercial pilots are required to complete, anesthesia simulators hone the emergency skills of individual anesthesiologists.

What if you’re a patient and you’re contemplating surgery? How can you optimize your chances to avoid an anesthetic complication? I offer these suggestions:

  • Choose to have your surgery at a facility that is staffed with American Board of Anesthesiology board-certified physician anesthesiologists.
  • Ask a knowledgeable medical professional to recommend a specific anesthesiologist at your facility, and request that specific anesthesiologist for your care.
  • Inquire about who would manage your crisis if you have one during or after your surgery. Will your anesthesia professional be a physician anesthesiologist, a Certified Registered Nurse Anesthetist (CRNA), or an anesthesia care team made up of both? If an anesthesia care team is attending to you, how many rooms is each physician anesthesiologist supervising? How far away or how many minutes away will your physician anesthesiologist be while you are asleep?
  • In the future, quality of care data will be available on facilities and physicians, including anesthesiologists. These metrics will allow patients to compare facilities and physicians. Do your homework with whatever data is publicized. Research the facility you are about to be anesthetized in.
  • You are a higher risk patient if you have: significant obesity, obstructive sleep apnea, heart problems, breathing problems, age > 65, if you’re having regular dialysis, emergency surgery, abdominal surgery, chest surgery, major vascular surgery, cardiac surgery, brain surgery, regular dialysis, a total joint replacement, or a surgery involving a high blood loss. Be aware you’re at a higher risk, and ask more questions of your surgeon and your anesthesia provider. 

Neither anesthesia providers nor patients want to be victims of an anesthetic emergency that leads to a bad outcome.

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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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Table

DO DOCTORS EVER RIDE IN AMBULANCES?

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

Do doctors ever ride in ambulances? Ambulances are a territory usually staffed by Emergency Medical Technician (EMT) personnel, but yes, in certain emergencies doctors do ride in ambulances.

In the process of doing 30,000 anesthetics, I’ve taken several rides in the back of an ambulance with my patients. Why? Sixty-six percent of surgeries in the United States take place as an outpatient, and many of these surgeries are performed at freestanding facilities distant from hospitals. When a patient decompensates emergently at a freestanding ambulatory surgery center or in an operating room at a doctor’s office, the facility will call for an ambulance staffed with EMT personnel. If the patient is unstable, a physician, usually an anesthesiologist, will need to accompany the patient and the EMTs to the hospital emergency room.

The following are examples of cases in which I or my colleagues have ridden in ambulances from freestanding surgery centers to the Stanford Emergency Room and Stanford Hospital in Palo Alto, California:

  1. A 3-year-old girl developed negative pressure pulmonary edema with plummeting pulse oximetry readings 10 minutes after a tonsillectomy. Her breathing tube had been removed, but she developed upper airway obstruction in the Post Anesthesia Care Unit (PACU) and needed urgent reintubation. She was extubated one hour later at the surgery center after treatment with diuretic, oxygen, and ventilation via the tube. She was then transferred to the hospital for overnight observation of her airway, pulmonary function, and oxygenation. The duty in the ambulance included monitoring her oxygenation, her airway and her breathing.  The presence of an anesthesiologist was reassuring to the stunned parents who had no expectation of a complication after a common surgery such as a tonsillectomy. The patient was discharged the following day without further complication.
  2. A 75-year-old female underwent lateral epicondylitis release surgery on her right elbow, and developed acute pulmonary edema with failing oxygen saturation levels at the conclusion of surgery. The patient had a past history of aortic stenosis, and had her aortic valve replaced with a small metal valve two years earlier. She was active, although she did experience mild shortness of breath on walking stairs. She was obese with a BMI=35. She received a general anesthetic with an endotracheal tube. The surgery was simple and the surgical duration was only 17 minutes. When the anesthetics were discontinued at the end of surgery, her blood pressure climbed to markedly high levels, and her heart failed to pump effectively against the elevated blood pressure. Pulmonary edema fluid filled her lungs and filled the hoses of the anesthesia machine. Her oxygenation returned to normal after titrating her BP down with a nitroprusside drip, and her blood pressure needed to be monitored continuously by an arterial line inserted into her radial artery at the wrist. The duty in the ambulance included ventilating the patient via the Ambu bag, keeping the patient sedated, watching the arterial line pressure continuously, and titrating the level of the vasodilating nitroprusside infusion. She remained intubated overnight in the hospital and was extubated the next day. She survived without any further complication and did not have a myocardial infarction. 
  3. A healthy 45-year-old woman developed acute hypotension 6 hours following a laparoscopic hysterectomy. The surgery was done in a small community hospital where there was no ICU, blood bank, or emergency room. The patient had multiple low-normal blood pressure readings over the first 5 hours postoperatively, and was being observed by the nursing staff. At hour 6 her blood pressure dropped to a dangerously low level and her hematocrit level on a portable device came back as 9.9%, indicative of a severe acute anemia. She was transferred urgently to the hospital. The duty in the ambulance included resuscitation with IV fluids, and observation of her airway and breathing as her level of consciousness dropped. She required repeat surgery at the hospital to control the intraabdominal bleeding, as well as preoperative transfusion to treat her anemia and hypovolemic shock.

These three cases are examples of surgical patients who became acutely ill miles from the nearest hospital. Each case illustrates how a failure of airway, breathing, or circulation can lead to an emergency. The problem in the first case was airway obstruction leading to pulmonary edema. The problem in the second case was lungs filled with fluid which made normal breathing impossible. The problem in the third case was bleeding which caused the normal circulation of blood within the body to be inadequate.

Why did an anesthesiologist travel with each patient? 

  1. Each patient was extremely sick and required acute monitoring and treatment, and medical decisions needed to be made during the trip to the hospital. EMTs are trained in resuscitation, but EMT training is only a fraction of anesthesiologist training. Having the anesthesiologist who was already resuscitating the patient continue to care for the patient en route to the hospital was the wisest course.
  2. Acute medical emergencies are defined by resuscitation of Airway-Breathing-Circulation. Anesthesiologists are the physicians with the highest level of airway skills, as well they are experts in acute resuscitation. If any physician is to travel with the patient, an anesthesiologist is the wisest choice to manage Airway-Breathing-Circulation in ongoing emergencies.
  3. Medical-legal risk is minimized if the most highly trained physician involved in the case continues to manage the case. The handoff or transfer of medical care from one practitioner to another is a high risk time for errors. The anesthesiologist  is responsible for the safety and care of his or her patient, and the highest continuity of care occurs when the anesthesiologist who managed the emergency attends to the patient during the transfer to the hospital.

I’ve been the Medical Director at a freestanding surgery center near Stanford for the past 17 years. Surgery centers strive to minimize the potential of emergencies in outpatient surgeries. Medical Directors work to limit the types of cases performed in a freestanding surgery center. This includes avoiding procedures that cause major pain, bleeding, or disruption of physiology. Typical surgeries performed in freestanding centers include:

  • Arthroscopic orthopedic surgeries
  • Simple ear nose and throat surgeries
  • GI endoscopies and colonoscopies
  • Simple general surgery procedures
  • Simple ophthalmologic surgeries
  • Plastic surgeries

Surgery centers also strive to operate on healthier patients who lack major comorbidities. Surgery centers are reluctant to approve general anesthesia in a freestanding outpatient setting to patients who have: 

  • Severe sleep apnea
  • Severe cardiac problems such as shortness of breath or ongoing chest pain
  • Severe morbid obesity or super-morbid obesity
  • Renal dialysis
  • Severe abnormal airways
  • Markedly abnormal blood pressures, heart rates, or blood oxygen levels

Regarding ambulance rides, no one is going to advocate that MDs take over EMTs roles regarding riding in ambulances. But when surgery or anesthesia leads to an acute event at a site distant from a hospital, the anesthesiologist involved in that patient’s care is responsible for that patient’s safety and for the ongoing care and resuscitation. The anesthesiologist will be riding in the ambulance and doing what anesthesiologists routinely do–managing Airway-Breathing-Circulation.

If any anesthesia professionals have stories regarding their own emergency ambulance rides resuscitating patients, I invite you to share them with my readers. 

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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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NEGATIVE PRESSURE PULMONARY EDEMA IN A FREESTANDING SURGERY CENTER

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

Clinical Case:   You are working at a freestanding surgery center.  A healthy 58-year- old man has a mask anesthetic for a shoulder manipulation.  During the procedure he coughs and bucks, and his oxygen saturation drops to 80%.  With mask continuous positive airway pressure (CPAP) the airway improves, and the oxygen saturation returns to 100%.  In the recovery room he looks well and feels great, but his oxygen saturation on room air is 90%. What do you do?

Discussion:    One key difference between academic and private practice is the number of  operating rooms in freestanding facilities, located miles from the nearest hospital.  There are marketplace incentives that induce surgeons to take their surgeries to facilities that they own themselves, or to remodel part of their office space into approved operating facilities.  This makes for additional challenges for perioperative physicians.

In this case, the preoperative oxygen saturation was 99% on room air.  The anesthetic included 200 mg of propofol,   1-2% sevoflurane, and  50% nitrous oxide.  The surgeon injected 20 cc of .5% bupivicaine into the shoulder joint.   In the recovery room, the initial oxygen saturation was 95% on 4 liters/minute of nasal oxygen.  As the patient became more awake, he received a total of 8 mg of morphine I.V. over 30 minutes for shoulder pain.  An hour later, at 1600 hours, you are called to see him because his oxygen saturation on room air does not meet discharge criteria.  You find the patient in the recovery room looking well, with no complaints of dyspnea or chest pain.  His heart rate is 95, blood pressure is 120/80, respiratory rate is 20, temperature is normal, and his oxygen saturation is 88-92%  on room air.  His physical exam is negative except for bilateral inspiratory rales at the lung bases.

What is the diagnosis?  You did not see any sign of aspiration in the operating room, although that is a possibility.  When the coughing and bucking occurred, he had an episode of laryngospasm, which you treated with mask CPAP.   It is possible  he had a mild case of negative pressure pulmonary edema.  Atelectasis is also a possibility.   You order incentive spirometry, but it does not increase his oxygen saturation.  An ECG is normal.  You continue to treat the patient with 4 liters/minute nasal oxygen while you make a plan.

The patient and his wife are pleading with you because they want to go home.   They promise to telephone you if he gets short of breath during the night.  However, there is  a new abnormal vital sign and a new finding of rales.  You are not able to do a chest radiograph at the surgery center.  Your facility is about to close for the night.  The surgeon wonders if the patient’s wife  can drive the patient to the emergency room in the family car.

You are concerned that the standard of care for a reasonably trained anesthesiologist would not include sending this patient home.  Nor would it include letting a patient drive to the hospital in the family car, without oxygen.  You telephone the patient’s family physician, and he agrees to manage the patient after transfer to the hospital.  You discuss that the differential diagnosis includes aspiration versus negative pressure pulmonary edema.  He will order a chest radiograph, and consider a dose of furosemide.  You spend an extended period of time explaining to the family the necessity of transfer, and then call for an ambulance to pick up the patient.  Your assessment is that he is stable enough that you do not need to accompany him to the hospital.

In follow up the next day, you find that the X-ray showed minimal  infiltrates at the lung bases.  The patient improved without diuretic therapy, and was discharged home at noon.  His  oxygen saturation was 97% room air, and he was taking Vicodin for shoulder pain.

At Stanford Hospital, the Ambulatory Surgery Center is in the middle of the hospital, and it is not difficult to get a chest X-ray,  a blood gas, admit a patient to the hospital, or even  transfer a patient to the ICU.  In freestanding centers, these things can be a big production.   Physicians performing or supervising a scheduled medical procedure outside of a hospital, resulting in the patient’s transfer to a hospital for medical treatment exceeding 24 hours, are required to  fill out a Patient Transfer Reporting Form and send it to the Medical Board of California within 15 days.   The Medical Board monitors freestanding facilities for patterns of frequent  transfers and complications.

This  patient did well and was discharged in less than 24 hours.  Because it was possible for worsening hypoxia or pneumonitis to develop in the first 24 hours after surgery,  you were conservative and wise to transfer the patient.  The trend toward freestanding facilities is not going away.  This case  illustrates only some of the issues of doing quality medical care in these settings.

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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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