WHAT ANESTHESIOLOGISTS DO… AN EXAMPLE ANESTHETIC

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

Most patients have no real idea what anesthesiologists do. Most college premed students have no real idea what anesthesiologists do. Most medical students have no real idea what anesthesiologists do.

Anesthesiologists are responsible for your medical care before, during, and after surgeries. At Stanford University we’re called the Department of Anesthesiology, Perioperative and Pain Medicine. “Perioperative” means “around the time of operations.” Today I’ll walk you through an example anesthetic which shows how an anesthesiologist approaches the challenges of a difficult surgical problem: emergency non-cardiac surgery in a patient with heart disease.

John Doe is a 58-year-old man with an acute inflammation of his gallbladder (acute cholecystitis), who needs to have his gallbladder removed (cholecystectomy). For the past 24 hours, Mr. Doe has suffered fever and acute right upper quadrant abdominal pain. His general surgeon advises surgery as soon as possible. Mr. Doe’s past medical history is positive for obesity (six feet tall, 240 pounds, BMI=32.5), coronary artery disease, and a history of stable angina.

PREOPERATIVE WORK: Anesthesiologist Dr. A reviews the chart and learns that Mr. Doe has had chest pain (angina) with exercise for the past two years. His cardiologist dida heart catheterization one year ago and discovered that Mr. Doe has small vessel coronary artery narrowing. His narrowed  vessels were too small to treat with coronary stents, and Mr. Doe received only medical therapy for his angina, in the form of isosorbide nitrate pills, diltiazem (calcium channel blocker pills), and nitroglycerin tablets as needed for chest pain. 

Mr. Doe takes a nitroglycerin tablet about once a week. This medical regimen has been effective in avoiding unstable angina and preventing heart attacks. Mr. Doe also takes atorvastatin (Lipitor) to control his hypercholesterolemia. Dr. A speaks with the cardiologist and asks two questions: “Are there any other diagnostic tests needed before surgery, and are there any other therapeutic measures needed before surgery?” The cardiologist answers that a preoperative echocardiogram is indicated, and he orders the test. The echocardiogram shows Mr. Doe’s heart is contracting normally (ejecting 60% of its volume with every beat). The cardiologist also measures the patient’s blood troponin level. Troponin levels are elevated when a patient is having an acute heart attack. Mr. Doe’s troponin levels are within normal limits, therefore no heart damage has occurred so far. Regarding therapeutic intervention, the cardiologist advises a continuous infusion of nitroglycerin to help prevent cardiac ischemia/heart attack damage during the anesthetic. 

An anesthesia machine, with the vital signs monitor screen on the left, and the electronic medical records computer screen on the right.

Dr. A meets Mr. Doe and interviews him. Mr. Doe is currently having moderately severe abdominal pain, nausea, fever, and chills. He has not had any chest pain for the past two weeks, and has no shortness of breath. His vital signs are heart rate = 100, BP = 150/80, respiratory rate =  20 breaths/minute, oxygen saturation 95% on room air, and temperature 100.2 degrees. Dr. A examines the patient and finds that the airway looks normal, the lungs are clear, the heart sounds are normal, and the abdomen is tender over the area of the gallbladder. Dr. A explains the general anesthetic plan to Mr. Doe, and informs the patient that his risk of heart complications for this acute surgery is higher than average because of the past cardiac history. Dr. A then records all pertinent preoperative information into the electronic medical record (EMR) via a computer keyboard and screen located just to the right of his anesthesia machine.

IN THE OPERATING ROOM: Mr. Doe will be asleep for the surgery, and Dr. A will be present the entire time. Mr. Doe has a preexisting intravenous (IV) line in his left arm. Prior to the surgery, Dr. A sedates the patient with 2 milligrams of IV midazolam (Versed) a benzodiazepine anxiety-reducing drug, and 100 micrograms of IV fentanyl, a narcotic.  

He then inserts a second catheter into the patient’s radial artery in its location at the right wrist. (I’ll use the male pronoun “he” for Dr. A in this example case, but be aware that as of 2017, 40% of anesthesiologists under the age of 36 years are female. This arterial line is connected to an electronic monitor which shows the blood pressure wave and blood pressure value continuously throughout the anesthetic. Dr. A places five ECG monitoring stickers on the patient’s chest, and a pulse oximeter on the third finger of the patient’s right hand. Dr. A notes the pre-anesthetic vital signs are heart rate = 80 beats/minute, blood pressure (BP) = 130/80, and oxygen saturation = 96% on room air, increasing to 100% on mask oxygen. This data is automatically entered into the chart of the electronic medical record.

MONITORING SCREEN with vs

After the patient breathes oxygen via a mask for two minutes, Dr. A performs a rapid sequence induction of anesthesia by injecting propofol (a hypnotic sleep drug) and succinylcholine (a muscle paralyzing drug) into the IV. The operating room nurse presses down on Mr. Doe’s cricoid cartilage in his neck, to compress the esophagus and prevent any stomach contents from regurgitating upward into the airway. 

Ten seconds after the propofol injection the patient is asleep. Forty seconds after the succinylcholine injection the patient is paralyzed. At this time Dr. A inserts a laryngoscope into the patient’s mouth and visualizes the patient’s vocal cords and the opening into the larynx or windpipe.

Under direct vision, Dr. A inserts a hollow plastic endotracheal tube (ET tube) into the patient’s windpipe, and then withdraws the laryngoscope. The cuff on the distal end of the ET tube is located just below the vocal cords, and Dr. A injects 3 milliliters of air into the cuff to inflate it and to secure the tube with a seal at the level of the windpipe. 

Dr. A then uses his anesthesia machine apparatus to squeeze breaths through the ET tube into the lungs, and listens to both sides of Mr. Doe’s chest with a stethoscope to document that breath sounds are present in both lungs. Dr. A glances at his anesthesia monitoring screen, which includes a row for the carbon dioxide detected in the exhaled breathing gas. The monitor screen traces a square wave vs. time, indicating that the ventilation of carbon dioxide (CO2) is now occurring out of the lungs with each ventilation. 

Dr. A secures the ET tube to the upper lip with adhesive tape, so the critical breathing tube cannot dislodge during the surgery. He sets the ventilator to deliver a volume of 800 milliliters into the lungs, nine times every minute. He sets the mixture of the inhaled gas as 50% oxygen and 50% air, with a resultant oxygen concentration of 60% oxygen. Dr. A turns on the sevoflurane vaporizer at this point, which releases a 1.5% concentration of sevoflurane vapor into the breathing mixture. 

Sevoflurane vaporizer (see yellow knob) on anesthesia machine

Sevoflurane, a potent inhaled general anesthetic drug, travels from the lungs via the blood stream to the patient’s brain, where sevoflurane molecules move from the bloodstream into the brain. This continuous delivery of sevoflurane molecules to the brain assures both sleep and amnesia. Dr. A injects an IV dose of 40 milligrams of rocuronium, a second paralyzing drug which will keep the patient motionless for approximately 30-40 minutes.

Dr. A prepares to start a central intravenous line into the right internal jugular vein. He preps the right side of the patient’s neck with Betadine iodine soap, and drapes the right neck with sterile towels. He places a probe on the patient’s neck from a device called an ultrasound machine. The ultrasound machine bounces soundwaves off the contents inside the neck, and generates a two-dimensional black and white image of the veins, arteries, muscles, and nerves found there. 

Dr. A inserts a needle into the right jugular vein under ultrasound visualization, and then inserts a wire through the needle into the lumen (center) of the vein. Seconds later, Dr. A slides a hollow intravenous catheter over the wire 14 centimeters into the center of the right internal jugular vein. 

Dr. A removes the wire and connects an intravenous drip to the central line catheter. He then connects a preprepared drip of nitroglycerin to a stopcock located on the central line IV, and turns on a preprogramed machine which infuses a small amount of nitroglycerin into the patient’s internal jugular vein continuously.

Dr. A steps back and surveys the patient’s vital signs. The BP is 100/50. The BP machine’s computer calculates a mean arterial blood pressure (MAP) as ((2 X diastolic BP) + systolic BP)/all divided by 3. The mean arterial pressure is thus ((2 X 100) + 50)/divided by 3 = 250/3, or 83. 

The desired range of the mean arterial pressure for this case will be from 65-90, and it will be Dr. A’s job to control the blood pressure within this range. The pulse rate is 60 beats per minute, and it will be Dr. A’s job is to keep the pulse rate from getting too high or too low (60 – 80 beats per minute is a desired goal). The oxygen saturation is 100%, and it will be Dr. A’s job is to keep the oxygen saturation, or O2sat, between 90-100%.

Dr. A administers an IV dose of an intravenous antibiotic prior to the surgical incision, and also administers two IV antinausea drugs, ondansetron (Zofran) and metoclopropamide (Reglan) prophylactically. He tapes the patient’s eyes shut so the corneas will not dry out and become scratched at any time during the surgery. 

Dr. A inserts an oral gastric tube through the mouth into the patient’s stomach, and suctions out any stomach contents. He inserts a temperature probe into the patient’s nose and connects it to a temperature monitor. He assists the nurses in positioning and padding the patient’s arms adjacent to the sides of his abdomen. He then wraps a plastic Bair Hugger blanket over the patient’s upper chest and head, and connects a Bair Hugger device which blows heated air through the bag to warm the patient if necessary during the anesthetic. 

The patient is now ready for the surgery to begin.

A nurse preps the abdomen by painting the skin with an antiseptic solution. The scrub technician and the surgeon drape sterile paper barriers over the perimeter of the abdomen, as well as a sterile paper vertical barrier (ether screen) between the anesthesiologist and the abdominal surgical site. 

The surgeon calls for a Time Out, at which time the operating room personnel review the patient’s name, the planned surgery, the patient’s allergies, and the estimated time for the surgery. Once the Time Out has been accepted, the surgeon begins the surgery. Almost all gallbladder excisions are done through a laparoscopic approach without opening the abdomen. The surgeon inserts a sharp trocar into the abdomen, removes the central core of this device, and then inflates carbon dioxide gas through the device into the interior of the abdomen. 

Once the interior of the abdomen is expanded like a balloon, an instrument with a camera on its tip is inserted into the abdomen, and the two-dimensional image of the interior of the abdomen is viewed on multiple video screens. The surgeon makes multiple small incisions and inserts additional surgical tools inside the abdomen.

The stimulus of the surgical incisions causes the blood pressure to increase. The mean arterial pressure (MAP) rises from 70 to 95. Dr. A deepens the anesthetic by injecting an additional two milliliters (100 micrograms) of IV fentanyl, which returns the MAP to 80 within two minutes. The insufflation of the abdomen with carbon dioxide is stimulating as well, because is stretches the lining of the abdomen (the peritoneum), and the MAP rises to 95 again. 

This time Dr. A increases the infusion rate of the nitroglycerin drip. Nitroglycerin dilates the venous blood vessels in the body which lowers the blood pressure, and also dilates the coronary arteries. He also begins a constant infusion of propofol via an intravenous pump to deepen the anesthetic level and lower the blood pressure further. The MAP decreases to 80 once again.

The surgeon requests the operating room table be tilted so the patient’s head is higher than the feet, and the right side of the patient’s body is higher than the left. Dr. A accomplishes this positioning by pushing buttons on the table controls. 

The purpose of this positioning is for gravity to move the intestines and abdominal contents downward toward the patient’s feet and toward the left side, thereby clearing the view of the gallbladder area in the right upper quadrant of the abdomen. 

There are hemodynamic (blood pressure and heart rate) consequences to this change in positioning. The MAP drops to 55 and the heart rate drops to 55. Dr. A treats the heart rate drop with an IV injection of atropine, an anticholinergic medication which blocks slow heart rates, and the pulse rate climbs back to 65. He chooses to treat the low MAP by injecting a small amount (5 milligrams) of a medication called ephedrine, which acts to increase both blood pressure and heart rate. The MAP returns to 70.

There is minimal bleeding during the gallbladder resection, and the experienced surgeon completes the surgery in 45 minutes. During this time Dr. A continues the maintenance anesthesia of sevoflurane and propofol, and injects further doses of the paralyzing drug rocuronium 20 milligrams (to keep the patient paralyzed ) and the narcotic fentanyl 100 micrograms (to provide ongoing pain relief).

As the surgeons close the final incisions, Dr. A removes the oral gastric tube and weans off the anesthesia drugs. The propofol infusion is discontinued. The sevoflurane is discontinued. The operating room table is returned to a level position. The rocuronium paralysis is reversed by the IV injection of a medication called sugammadex. As the anesthesia lightens, a predictable increase in blood pressure and pulse rate occurs, as the patient’s body begins to sense the stimulation of the breathing tube within the trachea and the sensation of the completed surgical repair. Once the patient is awake enough to breathe on his own, Dr. A removes the ET tube and places an oxygen mask over the patient’s nose and mouth. 

All critical care medicine is an effort to maintain Airway-Breathing-Circulation, in that order. Dr. A confirms that the patient’s airway is open in the absence of the ET tube, and that the patient is breathing adequately. 

Dr. A rechecks the vital signs and sees that the oxygen saturation is 98%, the pulse rate is 110, and the MAP is 110. The elevated pulse rate and blood pressure are dangerous in terms of this patient’s known coronary artery disease. The elevated high heart rate increases the cardiac oxygen consumption and lowers the time for the coronary arteries to fill between beats. The elevated blood pressure also increases the cardiac oxygen consumption, and puts the patient at a higher risk for heart damage or a heart attack. Dr. A treats both the elevated heart rate and blood pressure by injecting 10 milligrams of labetalol (an intravenous beta-blocker drug) which lowers the heart rate to 90 and lowers the MAP to 90 within two minutes. A second dose of IV labetalol brings the heart rate to 70 and the MAP to 80 within another two minutes. At this point Dr. A is satisfied that the patient is stable, and the staff prepares to transfer the patient to the post anesthesia care unit (PACU). A hospital bed is stationed to the side of the operating room table, and the monitors are disconnected from the patient. 

The orderlies, nurses, and doctors slide a roller device under the patient, and on the count of three they roll the patient onto the hospital bed. Dr. A secures an oxygen mask over the patient’s face, elevates the patient’s head to 30 degrees, and makes sure the IV line, the arterial line, and the internal jugular line tubings are all intact and not tangled for the transfer to the PACU. The baseline infusion of the nitroglycerin is continued throughout, as the cardiologist requested.

POSTANESTHESIA:  In the PACU, nurses reconnect the patient to the same monitoring devices worn during the anesthetic. A registered nurse personally attends to the patient in the PACU. The anesthesiologist writes all the orders for pain medications, cardiac medications, and anti-nausea medications.

The patient will stay in the PACU for approximately one hour, before he is transferred to the intensive care unit (ICU) for continued observation of his vital signs, cardiac condition, and for ongoing administration of the IV nitroglycerin. Once the patient is transferred to the ICU, Dr. A contacts both the ICU team and the cardiologist and signs off responsibility for the patient to them. In the ICU the cardiologist orders troponin levels once again, to determine whether or not the patient suffered a heart attack during surgery. The troponin levels are found to be low, indicating no heart damage occurred. The patient wakes up in a satisfactory status, with resolution of his abdominal pain. His vital signs remain normal.

Post Anesthesia Care Unit (PACU)

On the next day the patient’s nitroglycerin infusion is discontinued, his oxygen therapy is discontinued, and he’s discharged to a post-surgical ward bed. On the following day he’s discharged home.

This describes what an anesthesiologist does in performing a moderately difficult anesthetic. This model case is not unique to a university hospital—it could occur as described in any community hospital near you. Gallbladder surgery is not without risks, and not all gallbladder surgeries end well. In 5-10% of laparoscopic gallbladder surgeries, technical difficulties with the anatomy require the surgeon to switch to an open surgical method which requires a larger incision, and results in more postoperative pain. 

Open gallbladder surgery incision

As in any intraabdominal surgery, gallbladder surgery can lead to surgical complications such as:

  • Infection
  • Bleeding
  • Swelling
  • Bile leakage
  • Damage to the bile duct
  • Damage to the intestine, bowel, or blood vessels

Laparoscopic gallbladder surgery can lead to postoperative medical complications such as heart attacks, sepsis, pneumonia, pulmonary embolus (blood clot to the lungs), or rarely death. In 1987 pop icon Andy Warhol, age 58,  died just hours after gallbladder surgery in a prominent New York City hospital.  

No one ever disclosed what went wrong in Mr. Warhol’s case, but the anesthesia challenges for that surgery would have been similar to what was outlined above. 

This is what an anesthesiologist does. Your physician anesthesiologist is much more than a “sandman” or a “gas man.” Your physician anesthesiologist is your protector when you lose consciousness and go under the knife. While your surgeon attends to the surgical repair, your anesthesiologist will attend to your heart, brain, lungs, and the rest of your body . . .  before, during, and after your surgery.

Additional information on the profession of anesthesiology is available at the American Society of Anesthesiologists website.

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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.

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THE CHILD WITH AN OPEN EYE INJURY AND A FULL STOMACH

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

A 3-year-old boy is eating a McDonalds Happy Meal on the lawn of the restaurant. A lawn mower approaches, and a rock is ejected from the mower, hitting the child in the eye. The boy suffers a penetrating open eye injury, and is taken to the nearest hospital. You are on call for the repair. You’re are an experienced practitioner, but not a pediatric anesthesia specialist. What do you do?

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Discussion: There are two issues. One is how to safely perform the open-eye, full stomach anesthetic, and the other is the performance of pediatric anesthesia by non-pediatric anesthesia specialists.

Your goals for this anesthetic are to protect the airway and to avoid increases in intraocular pressure (IOP). Sudden increases in IOP in patients with an open globe injury can lead to vitreous loss and blindness. The list of things that increase IOP and risk further eye damage includes crying, coughing, the Valsalva maneuver, vomiting, firm pressure with an anesthesia face mask, laryngoscopy, and endotracheal intubation. Ketamine and succinylcholine also increase IOP. Trying to start an IV without causing crying and the attendant increase in IOP in a 3-year-old can be difficult.

True ophthalmic emergencies (e.g. central retinal artery occlusions or chemical burns) must be treated within minutes to avoid blindness or permanent vision loss. A penetrating open globe injury is usually urgent, rather than emergent. At times urgent procedures are delayed until the patient has been fasting for 6 hours, and has an appropriate NPO status.

Let’s assume your surgeon is determined to operate urgently, and doesn’t want to wait 6 hours after the patient’s meal. In his judgment delaying the surgery would increase the patient’s risk of loss of vision.

No single approach to this patient is ideal, but a proposed approach is:

  1. Apply EMLA cream with an occlusive dressing over several potential IV sites 45-60 minutes before the IV attempt. Next give the boy an oral midazolam premedication (0.67 mg/kg), and wait until he becomes sedated enough to start an intravenous line.
  2. Once the IV is in place, a modified rapid sequence induction is done with cricoid pressure, using rocuronium as the muscle relaxant. A dose of 1-1.5 mg/kg is used to speed the pace of neuromuscular blockade. With the availability of sugammadex to reverse deep rocuronium motor block, the risks of a high dose of rocuronium in this setting are minimal. A nerve stimulator is used to confirm that depth of muscled blockade is adequate, to avoid any coughing during laryngoscopy. The FDA black box warning regarding pediatric use of succinylcholine allows for its use for emergency intubation or for patients with a full stomach, but this author prefers to avoid it if alternatives exist. Succinylcholine causes a transient tonic increase (4-20 minutes) in extraocular muscle tone, which causes an increase in IOP of 10 to 20 mm Hg.
  3. If the child has chubby arms, hands, ankles and feet, and you are not able to place the IV despite adequate oral sedation, you may proceed with an inhalation induction. Utilize sevoflurane with cricoid pressure maintained throughout. Once the child is asleep, the IV can be placed, relaxant given, and the endotracheal tube inserted.
  4. An oral gastric tube is used to suction out the stomach.
  5. Controlled ventilation is recommended, to insure the field is quiet for the surgeon.
  6. At the conclusion of surgery, because of the full stomach, the patient is extubated awake. For tips on a smooth emergence, see my column on Smooth Emergence from Anesthesia.
  7. Postoperative nausea and vomiting can increase IOP. Prophylactic IV ondansetron is recommended.
  8. Postoperatively, a pain-free child will cry less and have fewer increases in IOP. The surgeon should consider a regional block of the eye to decrease the need for postoperative narcotics.

The second issue in this case is that you’re not a pediatric anesthesiologist. A children’s hospital or a university hospital will have a team of pediatric anesthesiologists with specialized training on call for emergencies. Call schedules and staffing are different in community hospitals, where a smaller team of anesthesiologists shares night call. Unless the hospital is very large, it’s uncommon to have anesthesiologists of multiple specialties on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and one for the general operating rooms. It’s common for general anesthesia practitioners to cover many or all specialties when they’re on call. If the on-call anesthesiologist is not comfortable with an individual case, he or she can seek out and call in a better-trained anesthesiologist, if one is available. The goal of producing a specialist anesthesiologist for every type of case at all hours of the night and weekend is a difficult one to staff. The decision to care for this patient at a community hospital at all is a judgment as to whether standards of care can be met with the physicians who are available. I’m double-boarded in internal medicine and anesthesiology, and have no extra post-graduate training in pediatric anesthesia, yet I have cared for children age 10 months and over for over 30 years. I consider myself expert and confident in the anesthesia care of children of these ages in a community setting.

In my opinion, neonates and younger infants need anesthesiologists with specialized pediatric training. Whether specialized training should be mandated when anesthesiologists care for older children is debatable. Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic in the future.

 

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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ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: WHY DO I HAVE TO STOP EATING AND DRINKING AT MIDNIGHT BEFORE SURGERY?

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

“Why do I have to stop eating and drinking prior to surgery?” This is a common question I hear from my patients—they’re puzzled by the connection between going to sleep and stopping eating prior to surgery.

 

It’s vital that your stomach is empty prior to elective surgery and anesthesia. Once you’re anesthetized, your cough reflex and gag reflex are abolished. These reflexes prevent food or liquids from entering your windpipe or your lungs, and are life-protecting reflexes in awake, healthy humans.

Under anesthesia these reflexes are absent. If you vomit or regurgitate stomach contents into your mouth, the material can descend into your windpipe or lungs. The complication of stomach contents entering your lungs is a dire event. The medical term for this occurrence is aspiration pneumonia. Aspiration refers to inhaling, and pneumonia refers to an inflammation of the lung tissue. In severe aspiration pneumonia, the lungs fail to exchange oxygen from the airways into the bloodstream, and brain and heart oxygen levels can drop to life-threatening lows.

The American Society of Anesthesiologists guidelines for fasting prior to elective surgery requiring general anesthesia, regional anesthesia, or conscious sedation/analgesia are as follows:

Fried or fatty foods                                                8 hours

A light meal (toast and clear liquids)                     6 hours

Non-human milk                                                    6 hours

Breast milk                                                             4 hours

Infant formula                                                         4 hours

Clear liquids                                                            2 hours

Clear liquids may be consumed up to 2 hours prior to anesthesia. Clear liquids include water, fruit juices without pulp, soda beverages, Gatorade, black coffee or clear tea. Milk and thick juices with pulp are not clear liquids.

These fasting guidelines do not apply to surgical procedures under local anesthesia, or to those with no anesthesia. You don’t have to fast for a dentist office visit, for example. The guidelines do apply for colonoscopies or upper gastrointestinal endoscopy procedures. The intravenous sedation drugs used for endoscopy procedures may sedate you to a deep enough level such that your gag and cough reflexes are absent.

In certain conditions, the stomach will be considered to be full even if the patient has not eaten or consumed fluids for eight hours. Acute pain syndromes such as appendicitis, a gall bladder attack, a broken bone, or a febrile illness are known to diminish the stomach’s emptying, and anesthesiologists treat these patients as if they had a full stomach whether they’ve fasted or not. Pregnant women and morbidly obese patients are also treated as having full stomachs for any surgery, because of delayed stomach emptying due to increased intra-abdominal pressure.

If a patient presents for emergency surgery, the anesthesiologist must proceed without waiting for the recommended fasting times. On induction of general anesthesia, the physician anesthesiologist will have a second individual (a nurse or a physician) apply downward pressure on the cricoid cartilage of the patient’s neck immediately upon loss of consciousness. The science of this is as follows: the circumferential ring of the cricoid cartilage encircles the windpipe.

Pushing downward on this ring compresses the esophagus below, to prevent passive regurgitation or vomiting of stomach contents. This pressing-down maneuver is called “giving cricoid pressure” or “the Sellick Maneuver,” named after Dr. Brian Arthur Sellick, the anesthesiologist who first described the maneuver in 1961. Inducing anesthesia using the Sellick maneuver is referred to as a Rapid Sequence Induction (RSI) of general anesthesia. In a RSI the anesthesiologist administers into the patient’s intravenous line: 1) a hypnotic drug such as propofol, followed by 2) a rapid paralyzing drug such as succinylcholine. The endotracheal breathing tube can then be placed in the windpipe within about 30 seconds after the loss of consciousness. The Sellick maneuver is held throughout those 30 seconds until medical confirmation that the tube is in the windpipe.

If stomach contents enter the upper airway at any time during an induction of anesthesia, the anesthesiologist will see vomitus in the patient’s mouth or inside the clear plastic facemask. The anesthesiologist may also detect evidence of inadequate oxygen exchange—i.e. the patient’s pulse oximeter readings will decline to less than the safe level of 90%. The anesthesiologist will then suction the upper airway and place a breathing tube into the windpipe as soon as possible. This tube is called an endotracheal tube, and it has a balloon near its tip. When inflated, the balloon protects stomach contents from descending into the lungs.

The anesthesiologist will then suction out the lungs through the inside the breathing tube. Suction catheters of varying length and diameters exist for this purpose. The surgery will likely be cancelled if it has not yet started. If the aspiration of stomach contents occurs in the middle of surgery, it’s likely the surgery will be aborted or shortened.

As I have written in multiple posts on this website, all critical care medicine resuscitation follows the A-B-C mantra of Airway—Breathing—Circulation. The regurgitation of stomach contents interferes with both A and B by blocking the airway and interfering with breathing.

The medical term for fasting prior to surgery is NPO, which stands for “nil per os,” a Latin phrase for nothing per mouth. If you hear your doctor or nurse say, “Is she NPO?” they’re asking the important question of whether you have fasted as required. Being NPO may seem inconvenient and unnecessary, but it’s critical to assure your health and well being during anesthesia.

Reference: Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters, 2011; Anesthesiology, Vol 14(3), 495-511.

 

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

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

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Will I Have a Breathing Tube During Anesthesia?

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How Safe is Anesthesia in the 21st Century?

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

10 Trends for the Future of Anesthesia

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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 ricknovak.com by clicking on the picture below:  

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