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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.
emailrjnov@yahoo.com

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I.  CHILDBIRTH (OBSTETRIC ANESTHESIA):

Most obstetric anesthesia is for either vaginal delivery or for Cesarean sections.

Anesthesia for Vaginal Delivery:  Anesthesia for vaginal delivery is utilized to diminish the pain of labor contractions, while leaving the mother as alert as possible, with as muscle strength as possible, to be able to push the baby out at the time of delivery.  Anesthesia for labor and vaginal delivery is usually accomplished by epidural injection of the local anesthetics bupivicaine (brand name Marcaine) or ropivicaine.

is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood.

The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.   Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given.  The catheter is removed after childbirth.

Anesthesia for Cesarean Section: Cesarean section is a surgical procedure in which the obstetrician makes an incision through the skin of the lower abdomen, and through the wall of the uterus, or womb, to extract the baby without the child requiring a vaginal delivery.  Anesthesia for Cesarean section is usually a spinal or an epidural anesthetic, which leaves the mother as alert as possible, while rendering surgical anesthesia to her abdomen and pelvis.  Spinal or epidural anesthesia is accomplished by injection of local anesthetics, with or without a narcotic medication, into the low back into the subarachnoid or the epidural space. The anesthesiologist remains present for the entire surgical procedure, to assure that the mother is comfortable and that all vital signs are maintained as close to normal limits as possible.

In a minority of cases, the anesthesia provider will administer a general anesthetic for Cesarean section surgery.  The most common indications for general anesthesia are (1) emergency Cesarean, when there is no time for a spinal or epidural block;  and (2) significant bleeding by the mother, leading to a low blood volume, which is an unsafe circumstance to administer a spinal or epidural block.  General anesthetics for Cesarean section carry an increased risk over spinal/epidural anesthesia, primarily because the mother is no longer able to breath on her own and maintain her own airway.

II.  CARDIAC SURGERY/OPEN HEART SURGERY:

Open heart surgery requires specialized equipment.  Anesthesia for cardiac surgery is complex, and the following is a brief summary:  Prior to the surgery, the anesthesiologist inserts a catheter into the radial artery at the wrist, to monitor the patient’s blood pressure continuously, rather than relying on a blood pressure cuff.  This enables the anesthesiologist to fine-tune the blood pressure, never allowing it to be too high or too low for an extended period of time.  The anesthesiologist also inserts a catheter (a central venous catheter, or CVP catheter) into a large vein in the patient’s neck.  The anesthesiologist uses this catheter to monitor the pressure inside the heart, and also to administer infusions of potent medications into the central circulation to raise or lower the blood pressure, or to increase the heart’s pumping function.

After the patient is anesthetized, the anesthesiologist often inserts a Transesophageal Echocardiogram (TEE) probe into the patient’s mouth, down the esophagus, and into the stomach.  The TEE gives the anesthesiologist a two-dimensional image of the beating heart and the heart valves in real time, and enables him or her to adjust medications and fluid administration as needed to keep the patient stable.

For open heart surgery, once the chest is open, the cardiac surgeon inserts additional tubes into the veins and arteries around the heart, diverting the patient’s blood from the heart and lungs into a heart-lung machine located alongside the operating table.  During the time the patient is connected to the heart-lung machine, the patient’s heart can be stopped so that the surgeon can operate on a motionless heart.

When the surgeon has completed the cardiac repair, the heart is restarted, and the heart-lung machine is disconnected from the patient.

As the heart resumes beating, the anesthesiologist manages the drug therapy and intravenous fluid therapy to optimize the cardiac function.

III.  ANESTHESIA FOR NEUROSURGERY (BRAIN SURGERY):

Intracranial (brain) surgery requires exacting maintenance of blood pressure, heart rate, and respiratory control.  Prior to the surgery, the anesthesiologist inserts a catheter into the radial artery at the wrist, to monitor the patient’s blood pressure continuously, rather than relying on a blood pressure cuff.  This enables the anesthesiologist to fine-tune the blood pressure, never allowing it to be too high or too low for an extended period of time.  The anesthesiologist also inserts a catheter (a central venous catheter, or CVP catheter) into a large vein in the patient’s neck.  The anesthesiologist uses this catheter to monitor the pressure inside the heart, and also to administer infusions of potent medications into the central circulation to raise or lower the blood pressure.

The anesthetic technique is designed to provide a motionless operating field for the surgeon.  After the anesthesiologist anesthetizes the patient, he or she inserts the endotracheal tube into the windpipe.  The patient is often hyperventilated, because hyperventilation causes the blood vessels in the brain to constrict, and makes the volume of the the brain decrease.  The relaxed brain affords the surgeon more room to dissect and expose brain tumors or aneurysms.

An important goal of the anesthetic is a quick wake-up at the conclusion of surgery, so that (1) normal neurological recovery of the patient can be confirmed, and (2) the patient is alert enough to  maintain their own airway and breathe on their own.  Most brain surgery patients spend at least one night in the intensive care unit (ICU) after surgery.

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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: