THE TOP 11 DISCOVERIES IN THE HISTORY OF 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

Important advances in the history of anesthesia changed the specialty forever. Humans have inhabited the Earth for 200,000 years, yet the discovery of surgical anesthesia was a recent development in 1846. For thousands of years most surgical procedures were accompanied by severe pain. The only strategies available to blunt pain were to give patients alcohol or opium until they were stuporous.

In the 21st Century, modern anesthesiologists utilize dozens of medications and apply sophisticated high-tech medical equipment. How did our specialty advance from prescribing patients two shots of whiskey to administering modern anesthetics?

In chronologic order, my choices for the 11 most important advances in the history of anesthesia follow below. I’ve included comments to expound on the impact of each discovery.

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1846. THE DISCOVERY OF ETHER AS A GENERAL ANESTHETIC. The first public demonstration of general anesthesia occurred at Harvard’s Massachusetts General Hospital in Boston, Massachusetts. Dr. William Morton, a local dentist, utilized inhaled ether to anesthetize patient Edward Abott.  Dr. John Warren then painlessly removed a tumor from Abbott’s neck.  Comment: This was the landmark discovery. From this point forward, painless surgery became possible.

1885. THE DISCOVERY OF INJECTABLE COCAINE AND LOCAL ANESTHESIA.  Cocaine was the first local anesthetic. Dr. William Halsted of Johns Hopkins University in Baltimore first injected 4% cocaine into a patient’s forearm and concluded that cocaine blocked sensation, as the arm was numb below but not above the point of injection. The first spinal anesthetic was performed in 1885 when Dr. Leonard Corning of Germany injected cocaine between the vertebrae of a 45-year-old man and caused numbness of the patient’s legs and lower abdomen. Comment: The discovery of local anesthesia gave doctors the power to block pain in specific locations. Improved local anesthetics procaine (Novocain) and lidocaine were later discovered in 1905 and 1948, respectively.

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1896. THE DISCOVERY OF THE HYPODERMIC NEEDLE, THE SYRINGE, AND THE INJECTION OF MORPHINE. Alexander Wood of Scotland invented a hollow needle that fit on the end of a piston-style syringe, and used the syringe and needle combination to successfully treat pain by injections of morphine. Comment: The majority of anesthetic drugs today are injected intravenously. Such injections would be impossible without the invention of the syringe.

1905. DISCOVERY OF THE MEASUREMENT OF BLOOD PRESSURE BY BLOOD PRESSURE CUFF. Dr. Nikolai Korotkov of Russia described the sounds produced during auscultation with a stethoscope over a distal portion of an artery as a blood pressure cuff was deflated. These Korotkoff sounds resulted in an accurate determination of systolic and diastolic blood pressure. Comment: Anesthesiologists monitor patients repeatedly during every surgery. A patient’s vital signs are the heart rate, respiratory rate, blood pressure, and temperature. It would be impossible to administer safe anesthesia without blood pressure measurement. Low blood pressures may be evidence of anesthetic overdose, excessive bleeding, or heart dysfunction. High blood pressures may be evidence of inadequate anesthetic depth, or uncontrolled hypertensive heart disease.

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1913. DISCOVERY OF THE CUFFED ENDOTRACHEAL BREATHING TUBE. Sir Ivan Magill of England developed a technique of placing a breathing tube into the windpipe, and endotracheal anesthesia was born. Dr. Chevalier Jackson of Pennsylvania developed the first laryngoscope used to visualize the larynx and insert an endotracheal tube. Drs. Arthur Guedel and Ralph Waters at the University of Wisconsin discovered the cuffed endotracheal tube in 1928. This advance allowed the use of positive-pressure ventilation into a patient’s lungs. Comment: Surgery within the abdomen and chest would be impossible without controlling the airway and breathing with a tube in the trachea. As well, the critical care resuscitation mantra of Airway-Breathing-Circulation would be impossible without an endotracheal tube.

1934. THE DISCOVER OF THIOPENTAL AND INJECTABLE BARBITURATES. Dr. John Lundy of the Mayo Clinic in Rochester, Minnesota introduced the intravenous anesthetic sodium thiopental into anesthetic practice. Injecting Pentothal became the standard means to induce general anesthesia. Pentothal provided a more pleasant method of going to sleep than inhaling pungent ether. Comment: This was a huge breakthrough. Almost every modern anesthetic begins with the intravenous injection of an anesthetic drug. (Propofol has now replaced Pentothal)

1940. THE DISCOVERY OF CURARE AND INJECTABLE MUSCLE RELAXANTS. Dr. Harold Griffith of Montreal, Canada injected the paralyzing drug curare during general anesthesia to induce muscular relaxation requested by his surgeon. Although the existence of curare was known for many years (it was an arrow poison of the South American Indians), it was not used in surgery to deliberately cause muscle relaxation until this time. Comment: Paralyzing drugs are necessary to enable the easy insertion of endotracheal tubes into anesthetized patients, and paralysis is also essential for many abdominal and chest surgeries.

1950’s. THE DEVELOPMENT OF THE POST-ANESTHESIA CARE UNIT (PACU) AND THE INTENSIVE CARE UNIT (ICU). The shock and resuscitation units organized during World War II and the Korean War resulted in efficient care for the sick and wounded. After the wars, PACU’s and ICU’s were natural extensions of these battlefield inventions. Comment: In the PACU, a patient’s airway, breathing, and circulation are observed, monitored, and treated immediately following surgery. PACU’s decrease post-operative complications. In the ICU, Airway-Breathing-Circulation management perfected in the operating room is extended to critically ill patients who are not undergoing surgery.

1956. THE DISCOVERY OF HALOTHANE, THE FIRST MODERN INHALED ANESTHETIC. British chemist Charles Suckling synthesized the inhaled anesthetic halothane. Halothane had significant advantages over ether because of halothane’s more pleasant odor, higher potency, faster onset, nonflammability, and low toxicity. Halothane gradually replaced older anesthetic vapors, and achieved worldwide acceptance. Comment: Halothane was the forerunner of isoflurane, desflurane, and sevoflurane, our modern inhaled anesthetics. These drugs have faster onset and offset, cause less nausea, and are not explosive like ether. The discovery of halothane changed inhalation anesthesia forever.

1983. THE DISCOVERY OF PULSE OXIMETRY MONITORING. The Nellcor pulse oximeter, co-developed by Stanford anesthesiologist Dr. William New, was the first commercially available device to measure the oxygen saturation in a patient’s bloodstream. The Nellcor pulse oximeter had the unique feature of lowering the audible pitch of the pulse tone as saturation dropped, giving anesthesiologists a warning that their patient’s heart and brain were in danger of low oxygen levels. Comment: The Nellcor changed patient monitoring forever. Oxygen saturation is now monitored before, during, and after surgery. Prior to Nellcor monitoring, the first sign of low oxygen levels was often a cardiac arrest. Following the invention of the Nellcor, oxygen saturation became the fifth vital sign, along with pulse rate, respiratory rate, blood pressure, and temperature.

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1986.  END-TIDAL CO2 MONITORING. In 1986 the American Society of Anesthesiologists mandated continual end-tidal carbon dioxide analysis be performed using a quantitative method such as capnography, from the time of endotracheal tube/laryngeal mask placement until extubation/removal or initiating transfer to a postoperative care location. The detection and monitoring of carbon dioxide gave immediate feedback whenever ventilation of the lungs was failing. For example, an endotracheal breathing tube placed in the esophagus instead of the tracheal would yield zero (or close to zero) carbon dioxide. The end-tidal CO2 device alarms immediately, the anesthesiologist recognizes the problem, and fixes it at once. The development of pulse oximetry and end-tidal CO2 monitoring were concurrent, and because of these twin discoveries, anesthesia care became markedly safer after the 1980’s

These are the top 11 discoveries in the history of anesthesia as I see them. What will be the next successful invention to advance our specialty?  A superior pain-relieving drug? A better inhaled anesthetic? An improved monitor to insure patient safety? Top scientists and physicians worldwide are working this very day to join this list. Good luck to each of them.

 

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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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

CAN YOU LEAVE YOUR ANESTHETIZED PATIENT IN AN EMERGENCY?

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 of the Month:  You are in an operating room in a freestanding plastic surgery center giving general anesthesia to Patient A, and you are called by the PACU nurse because Patient B in the PACU is having stridor.  The PACU Patient B is a healthy 39-year-old female, one hour status-post liposuction, and her anesthesiologist has signed out to you.  Patient B is now cyanotic.  You are the only anesthesiologist for miles, and both Patient A and B need you.  What do you do?

Discussion:  You perch the circulating R.N. from your O.R. in front of the monitors, tell her to let you know if anything changes, and you leave the O.R. to attend to the patient in the PACU.  Is there any alternative?  Are you going to stand there with stable Patient A while Patient B dies of airway obstruction thirty feet away from you?

When you arrive in the PACU, you see a young woman sitting up in bed making loud crowing sounds with every inspiration.  Her oxygen saturation is 89% on 4 liters of nasal oxygen, and her heart rate is 110.  Her husband is standing at the bedside, and his eyes are bugging out of his head watching his wife gasp for air.  The PACU nurse is standing on the other side of the patient, and her eyes are bugging out almost as far as the husband’s.

You ask the nurse to open an Ambu bag and connect it to the oxygen source.  You ask the husband to leave the room while you evaluate and treat his wife.  A second nurse escorts him out.  You listen to the patient’s lungs, and her breath sounds are normal except for upper airway stridor.  The exam of her mouth and neck is normal.  You take additional history, and learn that she had a three hour intubation for a prone liposuction, and was extubated without complication.  She received 20 mg of meperidine 45 minutes earlier, and no other medication was given in PACU.  The stidor started two minutes earlier, when her oxygen saturation decreased from 100% to the high 80’s.

Your diagnosis is laryngospasm of unclear etiology.  You apply an anesthesia mask over her face, deliver 100% oxygen via the Ambu bag, and attempt to apply continuous positive airway pressure (CPAP) to break her laryngospasm.  You ask her to cough hard to clear secretions that may be lodged on her vocal cords.  Within a minute the stridor passes, and her oxygen saturation returns to 100%.  Her other vital signs are normal, and her skin is free of urticaria.  You review her anesthesia record, and it is unremarkable.  The patient feels significantly better, and you return to the OR to check on your patient who is still under general anesthesia.  The OR circulating nurse reassures you that Patient A is fine, and nothing changed during your absence.

Two minutes later, the PACU nurse calls in a panic again, because Patient B is having stridor again.  You run to the PACU, and repeat the assessment and therapeutic moves you made in the paragraphs above.  Your diagnosis is post-intubation laryngospasm.  You can not rule out post-intubation vocal cord paralysis.  You treat with 8 mg of IV dexamethasone.  There is no vaporized racemic epinephrine in the facility.  The patient is moving air well, but intermittently crowing with stridor.  You call 911 for an ambulance, and call the ER attending at the nearest hospital to tell him you are coming over.  You place a third call to the Respiratory Therapy service at the hospital, and tell them to meet you at the ER with a racemic epinephrine treatment for the patient.

Patient A’s surgery  ends in the next 10 minutes, as the ambulance crew arrives and prepares Patient B for transport.  You extubate Patient A and deliver her in stable condition to the PACU just in time to join the Emergency Medical Techs as they load Patient B into the ambulance.  You load your pockets with vials of propofol and succinylcholine, a laryngoscope, and two syringes, and follow her into the ambulance.  The siren blares, and the ambulance drives Code 3 to the ER.  The patient’s intermittent stidor continues, with oxygen saturation in the low 90’s on a 100% non-rebreather mask.

In the first twenty minutes in the ER, the Respiratory Therapist arrives and gives a nebulized racemic epinephrine treatment to Patient B.  Within the next twenty minutes her symptoms resolve.  Her husband arrives, and he looks a lot happier than the first time you saw him, too.

You make a phone call.  Minutes later, one of the nurses from the freestanding plastic surgery center drives up in their car to give you a ride back to where your automobile is parked back at the surgery center.

Sound impossible?  Guess again.  This entire scenario occurred three months ago, a mile or two from Stanford hospital.

The diagnosis of post-extubation stridor is more common in newborn infants after prolonged or multiple intubations, but it occurs in adults as well.  In one series of 112 extubations of adults in an ICU in France, the prevalence of post-extubation stridor was 12% (Jaber S, Intensive Care Med. 2003 Jan;29(1):69-74).  Occurrence after extubation post-surgery is less common.  When laryngospasm occurs in the OR immediately post-intubation, we are all taught to treat the patient with 100% oxygen and CPAP by face mask.  The laryngospasm usually clears as the patient awakens from anesthesia and mounts a strong cough to clear secretions from the larynx.

When stridor occurs in the PACU of a hospital, the established medical therapy is nebulized racemic epinephrine (Vaponefrin), .5 ml of a 2.25%solution q 3-4 hours given by Respiratory Therapy, and a dose of dexamethasone 4 – 8 mg IV (Miller, Anesthesia, 2005, pp 2817, 2538).   Nebulized epinephrine acts as both an alpha and beta adrenergic agonist, and has both vasoconstrictor and bronchodilator properties.

The lack of Respiratory Therapy in freestanding surgery centers is another of the issues that differentiates them from in-hospital ambulatory surgery centers.  The plastic surgery center that suffered through this episode has now purchased the equipment to deliver nebulized epinephrine post-op.  It may be years, or decades, before they get an opportunity to use it.  A more important lesson is that the perioperative care of surgical patients is multi-faceted, and no one is better prepared to diagnose or treat problems than an anesthesiologist.  If you practice anesthesia in freestanding surgery centers long enough, you too will experience a ride in an ambulance to the ER.  Hopefully your story will have a happy ending, as our Clinical Case of the Month did.

Our patient was discharged home from the ER after a stable four hour observation period, and she had no further problems at home.

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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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

CAN WE PREVENT AGITATION IN PEDIATRIC PATIENTS FOLLOWING 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

Clinical Case of the Month:  A 5-year-old boy is scheduled for general anesthesia for a cochlear implant.  On your pre-operative phone call to the mother, she tells you that after the same surgery on the other ear, the child was severely agitated in the Recovery Room.  The last anesthesiologist told her that agitation was a common side effect for the sevoflurane anesthetic that was used.  What will you do?

Discussion:  How about this plan:  You obtain the old anesthesia record, duplicate the technique exactly, and give earplugs to everyone within ten yards of the Recovery Room?  Don’t buy it?  Read on.

Before you begin, a colleague says,  “Who cares about crying?  As long as the anesthetic care is safe, crying in the PACU is no big deal.  It’s a sign of an adequate airway.”  He continues:  “Why, I went on an Interplast trip fixing cleft palates in South America, and all the kids screamed in the Recovery Room.  They all survived.”

I’ve got news for him — a screaming child in the Recovery Room is a problem for several people:  the nurse, the mother of the child (she’s freaking out herself), the attending anesthesiologist (who, by inference, looks like he doesn’t know how to finish an anesthetic), and every other PACU patient within earshot.  I’d submit that the goals of a 21st Century anesthetic go beyond safety — patients or their families feel entitled to wake up as pain-free, nausea-free, and side-effect-free as possible.

Sevoflurane was introduced in Japan in the late 1980’s and in the United States in the 1990’s (Miller’s Anesthesia, 2005, p. 18).  Because of its low solubility, sevoflurane represented a significant advance over isoflurane, which dominated the inhaled anesthetic market prior to that time.  In addition to its low solubility, sevoflurane was less pungent than isoflurane and could be used instead of halothane for inhalational induction in children.  As well, sevoflurane had a lower incidence of cardiac arrhythmias than halothane.  These properties made sevoflurane the drug of choice for inhalation induction in children (Johannesson GP, Acta Anaesthesiol Scand. 1995 May;39(4):546-50).

Soon after its introduction into clinical practice, reports of sevoflurane and post-operative agitation and delirium in preschool patients began to appear in the anesthesia literature.  The described agitation was unrelated to pain, was inversely related to age, and was most frequent in children 5 years of age or younger.  (Miller’s Anesthesia, 2005, p. 2373).   Emergence delirium with sevoflurane exceeded the rate of emergence delirium with halothane.  Aono reported a 40% incidence of delirium during recovery in preschool boys aged 3 – 5 years old who underwent urologic surgery under sevoflurane, vs. a 10% incidence of delirium for those who were anesthetized with halothane (Anesthesiology, 1997 Dec;87(6):1298-300).

A variety of remedies appeared in the peer-reviewed literature over the ensuing years.  A complete discussion of all reported techniques is beyond the scope of this short column.  I refer you to PubMed with the keywords sevoflurane, agitation, where you’ll find multiple references to support multiple techniques.  Statistical significance was obtained in controlled studies with the following techniques either before or after sevoflurane induction:  use of oral midazolam prior to induction; use of a single dose of fentanyl 1 mcg/kg ten minutes prior to emergence;  conversion to propofol infusion anesthesia after induction;  conversion to isoflurane anesthesia after induction;  conversion to desflurane anesthesia after induction;  use of IV dexmedetomidine 0.3 – 0.5 mcg/kg after induction;  use of PO clonidine premedication 4 mcg/kg before induction;  or use of IV clonidine 2 mcg/kg immediately after induction.

I polled my private practice Stanford Adjunct Clinical Faculty colleagues on their preferred methods to minimize pediatric emergence delirium, and three strategies prevailed:  1) the use of heavy midazolam premedication (up to .8 mg/kg);  2) the use of titrated doses of intravenous fentanyl or meperidine prior to emergence; and 3) discontinuance of sevoflurane after inhalation induction — instead substituting isoflurane or propofol for maintenance anesthesia.  No one used dexmedetomidine or clonidine.

Let’s return to your 5-year-old patient.  You decide to utilize all three options described in the previous paragraph.  You begin with the oral midazolam premedication 20 minutes prior to induction.  (Because the duration of this surgery is estimated to be 90 minutes, you realize that most of the effect of the midazolam premed will be dissipated at the time of emergence.)   After an uneventful sevoflurane mask induction, you place an I.V. and intubate the trachea.  At this point you turn off the sevo and switch to isoflurane.  Cochlear implant surgery involves drilling into the skull, and despite use of local anesthesia by the surgeon, you can anticipate post-operative pain.  It seems prudent to use a narcotic to treat both pain and delirium.  At the conclusion of the anesthetic, you administer doses of 5 mg of meperidine, titrated to the child’s respiratory rate.  After extubation, you supplement with additional narcotic as needed to affect comfort and tranquility.  Because both the surgery and the anesthetic technique may stimulate post-operative nausea or vomiting, you administer doses of I.V. ondansetron and metoclopramide for nausea prophylaxis.  You request the mother sit at the bedside in the PACU as soon as the child begins to reawaken, as a humane non-pharmacologic method of easing the child’s emotional discomfort .

There are no trophies given for rapid wake-ups in the pediatric PACU.  Your technique produces a gradual calm emergence characterized by safe maintenance of the airway and a relaxed, comfortable child.   The 5-year-old’s mother is thrilled with the improvement over the last anesthetic, and the PACU nurses respect that you care about the quality of your patient’s wake-up.

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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 ricknovak.com by clicking on the picture below:  

DSC04882_edited