DOCTOR BY DAY, SCI-FI WRITER BY NIGHT

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

This week the Palo Alto (California) Weekly ran a feature story on Rick Novak and Doctor Vita

Doctor by day, sci-fi novelist by night

Longtime Atherton resident spotlights AI and medicine in books

Dr. Rick Novak poses for a portrait at Stanford Hospital in Palo Alto on May 23. Photo by Magali Gauthier/The Almanac

Between his time in the operating room, teaching, and raising his three sons, Atherton resident Dr. Rick Novak has found time to write two novels.

Novak, 65, an anesthesiologist at the Waverley Surgery Center in Palo Alto, recently published his latest, “Doctor Vita,” a story about an artificial intelligence (AI) physician module that goes awry.

It’s a science fiction novel that explores how technological breakthroughs like artificial intelligence and robots will affect medical care — and already have.

The Almanac, an Embarcadero Media publication which serves Menlo Park, Atherton, Woodside, and Portola Valley California, featured a story “Fiction or the Future?” on Rick Novak and Doctor Vita the same week.

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ZDoggMD MUSIC VIDEO TRASHES ELECTRONIC MEDICAL RECORDS

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

I’m not a fan of the current state of Electronic Health Records (EHR), also known as Electronic Medical Records (EMR). Particularly in acute care, the computer keyboard and screen have no place between an anesthesiologist and his patient, an emergency room physician and his patient, an ICU doctor and his patient, or an ICU nurse and her patient. In a past column I identified the EHR as the most overrated advance affecting anesthesia practice in the past 25 years. ZDoggMD trashes EHR in his powerful and humorous You Tube video An EHR State of Mind, in which he raps about Electronic Health Records to the tune of Jay Z’s and Alicia Key’s hit single An Empire State of Mind.

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ZDoggMD is a former Stanford physician known for his music videos, parodies, and comedy sketches regarding contemporary medical issues and work in the medical field. ZDoggMD is played by Dr. Zubin Damania, CEO and Founder of Las Vegas-based Turntable Health. Dr. Damania attended UC Berkeley in the early 1990s, followed by medical school at UCSF and residency at the Stanford University School of Medicine.

Check out his website at http://zdoggmd.com. Links exist to multiple equally funny satiric videos. You’re sure to be entertained.

I agree with him that the current cumbersome EHRs come between doctors and patients during hospital care. My criticisms include:

  1. Different EHRs at different hospitals are unable to communicate with each other.
  2. If you work at different hospitals with different EHRs, you have to be trained and retrained in multiple EHR platforms.
  3. With an EHR it takes at least 5 clicks to chart “atropine 0.4 mg.” In the past with a paper record you would merely write “0.4” on the atropine line.
  4. Nurses consistently have their backs to patients as they type, type, type data into computer terminals. In an operating room, the circulating nurse’s job is analogous to that of a court reporter/stenographer. Florence Nightingale would have had a stroke.
  5. As ZDoggMD points out in his video, the current EHR is a “glorified billing platform with some patient stuff tacked on.” Hospitals spend hundreds of millions of dollars to install the EHR, and then tell us that the EHR will help them bill and collect money at a superior rate. The economics don’t add up, and have nothing to do with patient care.
  6. With an EHR, instead of writing a pertinent note at each patient encounter, health care providers copy and paste previous notes, altering the minimal differences at each encounter. This habit makes it difficult to ferret out the pertinent information in, for example, a six-page copied template.

ZDoggMD challenges us as healthcare providers. On his website he writes, “We on the front lines of healthcare need to stand up and demand that our organizations, government, and tech vendors stop letting the unintended consequences of legislation and technology wreck our sacred relationship with patients while destroying our ability to do what we do without having to tell our kids to stay as far away from medicine as they can. Great technology [insert Steve Jobs fanboy comments here] can be the glue that connects us…”

Indeed, I wish Apple Computers would create an EHR which was as intuitive and easy as their iPad software.

Perhaps in the future the state of mind of an EHR will be superior. As of now, as ZDoggMD points out, it is not.

 

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 ricknovak.com by clicking on the picture below:  

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SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER SIX

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

6) MR. DYLAN’S BLUES

Johnny and I ate breakfast together at 6:30 a.m. It was a complex meal—we split a six-pack of powdered sugar donuts from the Seven-Eleven and washed them down with two glasses of orange juice. The talc-like sugar dusted Johnny’s upper lip and the collar of his San Francisco Giants T-shirt. The kitchen was quiet as a library. The only sounds were our glasses clacking against the tabletop. It was Johnny’s first day of school and my first day to report to the local hospital. We were each journeying into the unknown, and the tension connected us.

I broke the silence. “Nervous?” I said.

“Nope.”

I didn’t believe it. Johnny’s eyebrows cast dark shadows, shielding his sunken eyes in blackness. I waited a minute for a sequel to his monosyllabic teenage offering, but no conversation followed.

“Want me to walk over there with you?” I said. “Make sure the paperwork is all OK for your transfer?”

Johnny scoffed. “Are you kidding? I’m 17 years old, Dad, not 7. I’ll figure it out.” He pushed away from the table and left the kitchen. I watched him pace back and forth across the living room floor like a skydiver awaiting his turn to jump out of the plane. Then he grabbed the front door knob and said, “I hope this school doesn’t suck, for both of our sakes.” The door slammed shut, and I looked out the front window to see Johnny hopping through last night’s frozen footprint holes in the snow. Steam rose from his wet hair. He wore a fleece turtleneck over a pair of cotton sweat pants, and no gloves, hat, or boots. I watched him bound two stairs at a time up the entryway of Hibbing High School.

I needed to be at Hibbing General Hospital before 7:30. I’d filled out all the necessary paperwork online. I’d already secured my medical staff privileges and my appointment to the anesthesia service. I wanted to arrive early to check out the facilities and meet the people I’d be working with in the coming months.

I dressed myself in a pair of Sorel boots, a North Face jacket, and one of Dom’s Minnesota Vikings knit caps. A puff of wind from the north scorched my face as I headed out into the winter morning. The stark chill woke me up faster than two espressos. The hospital was a three-block hike from Dom’s house, so it made sense to leave the battered BMW on the curb and walk to Hibbing General.

The hospital was an aging three-story building made of yellowed stone. The front doors were tall brown slabs flanked by two white Doric columns. I smiled at the polished surface of the brown wooden doors. I’d worked summers as a maintenance helper at the General during my college years. One day my foreman gave me a can of red paint and told me to paint these very doors. The next day the hospital administrator chewed our heads off for painting the hospital front doors the color of blood. He dispatched me to the front of the building with a paintbrush and a gallon of brown paint. The doors were still brown this very day.

I found the surgical locker room, a small space one-tenth the size of the men’s locker room at Stanford. I selected a set of scrubs off the shelf and changed out of my street clothes. At Stanford the scrubs were bright royal blue. In Hibbing the scrubs were faded green and looked like they’d been in use since the day I was born in this very building.

I was edgy, even though I was overqualified to work at this little community hospital. At Stanford every nurse, doctor, and janitor knew my name. Here I’d have to earn the respect of dozens of people who’d never heard of me. Medical careers don’t travel as well as business careers. A businessman in California could be promoted to a CEO job in Minneapolis, but doctors who moved from one state to another started at the bottom of the ladder, behind physicians who had reputations and referral patterns already established in the new community.

I entered the hallway of the operating room complex. Hibbing General had only six operating rooms, compared to the 40 rooms at Stanford. The schedule for the day was posted on a white board across from the central desk. My old med school classmate, Michael Perpich, the Chief of Staff at Hibbing General, was the surgeon working in operating room #1. Dr. Perpich was repairing an inguinal hernia on a 43-year-old man—a routine case. I could pop in and say hello without distracting Perp from his task.

I put on a surgical hat and mask and pushed open the door into O.R. #1. The operating room was small, a compact 30 feet by 30 feet. The linoleum floor showed brown stains from old iodine spills. The faded turquoise tile on the walls had witnessed thousands of hernia surgeries. Michael Perpich was bent over the patient’s abdomen. He saw me walk through the door, and said, “Nico Antone. The Tone. Get your ass over here.” A surgical mask covered his face, but I knew my friend was grinning.

“They said you needed some help to fix this hernia,” I said.

“You’re a God damned gas-passer. You couldn’t fix this hernia if I held the book open for you.”

“I’m here to see if your hands shake as much as they used to, Perp.”

“I came here straight from the card room at the Corner Bar at dawn. Never felt better.”

“You’re so full of shit.”

“Did you guys get situated over at Dom’s?”

“We did. Johnny wasn’t thrilled about waking up at 6 a.m., but he ran up the high school steps two at a time this morning.”

“So he’s a gunner. Just like his dad.”

“I got by.”

“You opened a textbook once a week in med school, and you still finished number one in our class. I can’t believe you came back. When you left for California you said never wanted to see a snowflake again.’”

“Things change, Perp. My kid needs an upper-Midwest high school diploma.”

“California kid comes to the wilderness to go to the head of the class, eh? I’ll tell you one thing: the Hibbing teachers will shape him up. I had sergeants in the Army who were more mellow than the Hibbing faculty.”

The scrub tech, a blonde woman wearing too many layers of blue eye shadow, said, “My son is a sophomore. He studies four hours every night.”

“Nico, meet Heidi, my right-hand woman,” Perpich said. “She’s my assistant, my psychotherapist, and the encyclopedia of all gossip great and small in the village of Hibbing.”

“Nice to meet you,” I said.

“Heidi, this is Dr. Nicolai Antone, a welcome addition to the anesthesia staff. Dr. Antone and I went to med school together. He was an anesthesiologist in California, but now he’s one of us, the slightly-better-than-average staff of Hibbing General. So you left Alexandra behind?”

“I did.”

“Good move. Not much up here for princesses.”

“You’re married, Dr. Antone?” Heidi said.

“I am. My wife is back in California.”

She fluttered mascara-laden eyelashes at me and said, “Welcome to Hibbing General. I look forward to working with you.”

Perpich looked up toward the head of the operating room table and said, “Bobby, did he get his antibiotic?”

A wisp of a man—narrow and bony—stood at the head of the operating room table in the anesthesia cockpit of machines, monitors, intravenous drips, and drug cabinets. The man said, “She did. One gram of Kefzol at 7:45.”

“Nico, I want you to meet Bobby Dylan, our Director of Nurse Anesthesia,” Perpich said.

My head snapped back. I wondered if I trusted my ears. Bobby Dylan? The same name as the legendary musician? Here in Hibbing?

The nurse anesthetist ignored Perpich’s cordial introduction and said nothing to me. I was miffed. Who did this guy think he was? He was only a nurse anesthetist. Why the ingratiating attitude toward me, a board-certified anesthesiologist physician?

It was a small hospital, and despite my negative first impression I felt compelled to meet my fellow anesthesia colleague. I walked around the operating room table and entered the anesthesia station. A blue paper hat and mask covered Dylan’s face. His sole facial features were the recessed caves that housed his glossy fish eyes, and the speckled black and gray eyebrows that floated above them.

I extended my hand and said, “Greetings. I guess we’ll be working together.”

Dylan turned his back on me. The beep, beep, beep of the patient’s pulse rate hung between us. He reached over and turned the knob on the anesthesia machine that titrated the oxygen flow. He coughed twice—loud, harsh, barking sounds, and said, “We opted out here, Mac.”

“What?” I said. I wasn’t sure what I had just heard.

“We opted out,” Dylan repeated. He still wasn’t looking at me. He picked up his clipboard and made some notations on the patient’s chart with a pen.

I was getting more and more pissed off. My first impressions were confirmed. This guy was a dick. I didn’t care if this was Dylan’s anesthetic, his operating room, and his hospital. I was unaccustomed to this degree of condescension within two feet of an anesthesia machine. He turned up the intravenous propofol infusion and continued to ignore me, even though I was close enough to smell the staleness of his body odor.

I checked the settings on the anesthesia machine and monitors, looking for some sign that Dylan was as incompetent as an anesthetist as he was as a conversationalist. He was using routine concentrations of standard anesthetic drugs. The ECG, blood pressure, and oxygen saturation numbers all showed normal values. Dylan wasn’t a doctor, but at the moment he was delivering a routine anesthetic in a safe fashion.

I thought to myself, Fuck you, you dirtball. If this Bobby Dylan character wanted to be left alone, I was going to leave him alone. I said, “Hey Perp, I’ll catch you when your case is done, OK?”

“Will do. I’ll meet you in the lounge. Give me 30 minutes.”

“See you there.” My feathers were ruffled. It was great to see Michael Perpich again, but if my initial contact with this nurse anesthetist was any indication, my welcome in the Hibbing medical community was going to be as chilly as a January dawn. I made my way to the operating room lounge, a stark room with four walls of undecorated peach-colored wallboard. The sole furnishings were two long tables and a dozen chairs. All the chairs were empty. Sections of the Duluth News Tribune and the Hibbing Daily Tribune were strewn over the tabletops. The aroma of fresh brewed coffee filled the air. I poured myself a cup and selected a glazed doughnut from a platter.

I felt like a midcareer misfit, stuck in somebody else’s workplace. I missed Stanford. On a professional level, this move to Minnesota looked to be a near-death experience for me.

Michael Perpich’s clogs hammered the floor when he walked in. He pinched the back of my neck, snatched two doughnuts for himself, and plopped down in a chair across from me. “It’s great to see you, Tone,” he said. “I still can’t believe it.”

I hadn’t sat eye to eye with Perp for years. With his surgical cloaking removed, he looked ten years older than me. The top of his head had more dandruff than hair, and the creases around his nose and mouth were deep and long. His smile was genuine, and I chose to disregard the ancient appearance of the only acquaintance I had within a thousand miles.

“Glad you’re here,” I said. “I’m counting on you to be my lifeline at this place.” I waved my hand at the desolate room. “Does anybody else work here?”

“Of course. We have a full staff, like any other community hospital, but we’re light on anesthesiologists. Your timing is perfect. Our last two anesthesiologists retired and moved to the Sun Belt in November. We have six nurse anesthetists, but for tough cases we need an M.D. anesthesiologist in town. Now we’ve got you.”

“So the rest of the anesthesia staff is all nurses?”

“Yep. Six nurse anesthetists. They’re a solid group. I haven’t had too many problems with them.”

I was unconvinced. Nurse anesthetists were registered nurses with a year or more of intensive care unit experience, followed by two or three years of training in a nurse anesthesia program. They learned how to anesthetize patients, but they weren’t medical doctors. In some hospitals, anesthesiologists worked with nurse anesthetists in anesthesia care teams, a team model in which one M.D. anesthesiologist might supervise four nurse anesthetists working in four separate operating rooms. Because this hospital had no anesthesia doctors, the nurse anesthetists were working unsupervised.

“What’s the deal with the Bobby Dylan guy?” I asked. “He stopped one step short of open hostility. Is he a prick, or what?”

“Sometimes he is.”

“He didn’t give me the time of day.”

“It’s a turf thing. This is his hospital. You’re an outsider. The guy doesn’t want you here.”

“He’s a nurse. How does he get off giving me a hard time?”

“Minnesota is an opt-out state, Nico. The Minnesota governor opted out of the requirement for a medical doctor to supervise nurse anesthetists. Bobby Dylan can give anesthesia here, just the same as you can, even though he’s not a doctor.”

We opted out here, Mac. The words Dylan had uttered to me. Opted out.

“So it’s legal here for a nurse anesthetist to give an anesthetic without being supervised by a physician?”

“That’s right.”

“That’s substandard care, if you ask me, and it still doesn’t make this Bobby Dylan guy a doctor. If you had enough physician anesthesiologists in town, would you still let jokers like him give anesthetics alone, or would you replace him with a doctor?”

Perpich threw up his hands. “That’s never going to happen, so who cares? Dylan has been here a long time. He hasn’t had any deaths, he’s kept his nose clean, and he’s not going anywhere.”

“Why is he named Bobby Dylan? That can’t be for real.”

Perpich shrugged again. “I don’t know what his real name is, and I don’t care. He showed up in Hibbing 8 or 10 years ago, and his license and paperwork all identified him as Bobby Dylan. I asked him if that was his real name or if he’d changed his name.”

“And he said?”

“He said his name was Bobby Dylan. Period. He dodged any questions about his past. He was a nurse anesthetist in the Afghanistan War. He’s got a wife and a daughter. He plays guitar and sings at a bar downtown. Plays all the original Dylan songs. People tell me he’s pretty talented. Maybe he was a huge Bob Dylan fan and he just wanted to move to Dylan’s hometown, take Dylan’s name, and get a job here. If so, he’s done all three.”

I shook my head. “That’s pretty weird stuff.”

“It gets more weird. He bought the old Zimmerman house.”

“You’re kidding.”

“Nope.”

“He’s a psycho,” I said.

Perpich’s eyes twinkled. “Up here, there are a lot of characters. Get used to it. He’ll grow on you, once you accept the fact that he’s your peer.”

“My peer? I’ll never accept that.”

As if summoned by their conversation, Bobby Dylan came in through the doorway, poured himself a cup of coffee, and sat in the opposite corner of the room. He peeled off his surgical hat to reveal a fuzzball of curled black and gray hair. He took out a pen and started filling out a crossword puzzle from the morning paper. His mouth stretched into a long yawn. It was just another day for him. My presence was of no consequence.

“I’m going to make rounds on my patients upstairs on the surgical wards,” Perpich said. “Will you be home tonight?”

“Where else would I be?”

“I’ll drop by. I’ve got some housewarming presents for you.”

“I hope it’s a digital video recorder. Dom doesn’t have one.”

“No DVR. Just make sure you’re hungry.”

“Sounds good. See you later.”

Right after Perpich left, I heard a rumbling voice behind me say, “Doctor Antone?”

I turned. It was Mr. Dylan. His facial expression was a cross between a smirk and an all-knowing smile.

“Yes?” I said, puzzled at the encounter.

“I dissed you back there in the operating room. Sorry about that. I was concentrating on my patient, and no one told me you were coming to town. I expect this place is big enough for both of us. No hard feelings?”

I was suspicious. The curl of Dylan’s upper lip seemed to say, I don’t like you one bit, but I’ll pretend that I do just to fuck with you. Before I could answer, he sat on the tabletop in front of me and asked, “Why does a California guy like you move to the Iron Range?”

“I grew up here. I missed the ice fishing and deer hunting.”

“Bullshit.”

“My son transferred into the 11th grade. We want him to graduate from Hibbing High.”

“Let me guess. You think he’ll be the smartest kid in town.”

“I have no idea. We just got here.”

Dylan twirled a wisp of his moustache between his fingers and thumb. “I’ll bet $1000 you and your kid are gone by next January. This ain’t no place for boys from Californ-eye-aye. No place at all.”

“We’ll adjust.”

“You OK working here, where nurse anesthetists are your equals?”

I bit the inside of my cheek. “I’m not sure nurses and doctors are equal. I expect I’ll get used to the fact that nurses can give their own anesthetics here.”

“Of course you will. Just remember, you’ve got no power over me here. No power at all.” Dylan winked and said, “Now, if you’ll pardon me, I’ve got to go make me some money.”

He walked away, and his words echoed in my ears: No power over me at all. My first impression was reconfirmed. This Bobby Dylan was trouble.

It was break time, and the lounge was filling up. An attractive woman sat down at the adjacent table. She had the palest of green eyes that precisely matched the color of her scrub shirt. She had flawless skin and adorable dimples, and the knack of smiling nonstop as she chatted.

I smiled to myself, and forgot about the onerous Mr. Dylan. The sight of a beautiful woman trumped all of life’s ills.

It really did.

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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

 

 

AN ANESTHESIA PATIENT QUESTION: “WHY DID IT TAKE ME SO LONG TO WAKE UP AFTER 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

Patients sometimes say, “Why did it take me so long to wake up after anesthesia?” when they discussed their previous anesthetic history. They are fearful that something is wrong with them, and they will always have delayed awakenings.

 

Certain patients have consistent bad experiences from a past general anesthetic. A previous anesthetic left them somnolent all day after surgery, and/or they felt sleepy or ill for days after a previous surgery. They wonder if they are at increased risk for anesthesia, if something went wrong in their past anesthetics, and whether they can do about it.

Whenever a patient tells me they’ve been very sensitive to anesthesia in the past, they’re always right. The good news for patients is: you probably can do something to help yourself in the future.

The most valuable thing you can do is obtain a copy of your previous anesthetic record and Post Anesthesia Recovery Room records from a surgery in which you had a perceived prolonged wake up. Save these documents and present them to future anesthesiologists. Inform future anesthesiologists regarding your history of prolonged sedation, and they can make adjustments in their drug delivery and techniques to attempt to avoid the same problems. Future anesthesiologists can administer lower doses of medications or fewer medications as they deem advisable.

The world’s foremost anesthesia textbook, Miller’s Anesthesia, does not have a specific section or chapter on the topic of avoiding prolonged wake ups. If you search the Internet or the PubMed website for a discussion of the topic “prolonged awakening from anesthesia,” you’ll find a shortage of useful information. Few papers have been published on the topic.

But every case of prolonged wake-up has its own story. General anesthetics and sedative drugs work by anesthetizing the brain and central nervous system. Based on thirty years as an anesthesiologist, the personal administration of 25,000+ anesthetics, and information from medical textbooks, what follows are lists of the primary factors which cause prolonged sedation after anesthesia.

Patient characteristics that correlate with prolonged awakening after anesthesia:

  1. Patients with a past history of slow awakening from anesthesia.
  2. Patients who are naïve to central nervous system depressants in their weekly life. That is, they never or very rarely drink alcohol, and never take sedating medications of any kind. Chronic alcohol consumption increases the dose of propofol required to induce loss of consciousness (Fassoulaki, A et al. Chronic alcoholism increases the induction dose of propofol in humans.Anesthesia and Analgesia. 1993;77(3):553-556). Conversely, patients who have zero or modest exposure to drugs like alcohol can require lower doses of anesthetic drugs.
  3. Patients who claim they are “sensitive to all medicines.”
  4. Elderly patients. As you age your ability to metabolize medications decreases. Older persons, especially those over the age of 70-80 years, require lower doses.
  5. Obese patients. Intravenous doses of medications are calculated according to a patient’s weight, but this number should be their lean body weight, not their weight including excess fat. Imagine two patients who are the same age and height, but one weighs 150 pounds and the second weighs 300 pounds. The second patient will need higher doses than the first, but will not require twice the dose. Markedly increasing the weight of fat cells does not mean the brain needs twice the dose of medications.
  6. Petite patients. What if an anesthesia provider administers his or her standard recipe for anesthesia without noticing that their current patient only weighs 88 pounds? Standard doses for a 150-pound person will be excessive in an 88-pound patient.
  7. Patients with decreased function of one or more of the major organ systems, that is the heart, lungs, liver, or kidney. Depending on the medication, one or more of these organ systems are required to clear the drug from the body. A patient with heart failure or decreased cardiac output will not be able to pump the drug efficiently throughout the body to the lungs, liver, or kidneys to clear the drug. A patient with decreased lung function/ventilation will not be able to exhale vapor anesthetics promptly. A patient with decreased liver function will not be able to clear certain drugs like narcotics from the body promptly. A patient with decreased kidney function will not be able to clear paralyzing drugs such as the muscle relaxant rocuronium from the body promptly.
  8. Patients with an abnormal brain. For example, patients with dementia, delirium, congenital developmental delay, or any organic brain syndrome may experience increased post-operative sedation due to exaggerated effects of the anesthetic medications on their brains.

Medical circumstances that contribute to prolonged patient awakening after anesthesia:

  1. The longer the surgery and anesthetic duration, the longer the wake up time. This is because the longer exposure to anesthetic drugs requires a longer time to exhale the vapor drugs or to clear and metabolize the intravenous drugs.
  2. The more complex the surgery, the longer the wake up time. Certain surgeries, for example a liver transplant, are so complex that an anesthesiologist often plans to keep the patient asleep in the intensive care unit after the surgery until the first post-operative day.
  3. An inexperienced anesthetist may resort to a standard recipe for every patient, and administer a more heavy-handed concoction of anesthetic drugs than are necessary for patients in our first list above.
  4. Painful surgery. Any surgery which hurts a great deal will require increased pain-relieving medications in the Post Anesthesia Recovery Room. Pain-relieving medications include narcotics such as morphine or fentanyl, which are sedating and sometimes nauseating. The less of these medicines you require, the more alert you’ll feel. Local anesthetic injections by the surgeon or a regional anesthesia nerve block by the anesthesiologist can decrease your need for narcotics, decrease post-operative pain, and decrease your risk of prolonged sedation after surgery.

You have little control over the drugs you’ll be given during surgery, but please inform and remind your anesthesiologist regarding any characteristics from the first list above. An honest discussion of your previous bad anesthetic experience(s), together with obtaining a copy of a previous anesthetic record(s), may grant you some control regarding how sedated you feel after future anesthetic experiences.

YOU are your own best advocate. Don’t be afraid to inform your anesthesiologist.

I refer you to a related column, HOW LONG WILL IT TAKE ME TO WAKE UP FROM GENERAL ANESTHESIA?

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

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SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER FIVE

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

5) BOB DYLAN DRIVE

In Northern Minnesota, a “Ranger” is an inhabitant of the mining towns along the Mesabi, Vermillion, and Cuyuna Iron Ranges. Unlike a mountain range, a Minnesota iron range has no elevated topography, no grand vistas and no snow-capped peaks. An iron range is a geological phenomenon, named for the deposits of rich iron-laden minerals just beneath the earth’s surface. Rangers take great pride in their iron mines. They’ll tell you the American ships, tanks, and planes which won World Wars I and II were constructed from steel that originated in these Minnesota mines. No tunnels are required to mine Minnesota ore—a mere scraping of the top layer of trees and topsoil is all that’s needed to expose the largest deposits of iron-containing rock in the United States.

Johnny and I passed the open pit of the Pillsbury Mine, five miles outside of Hibbing. Deep in the concavity of mines like this one, electric shovels the size of small office buildings excavated the iron-containing taconite rock, while the largest dump trucks on Earth carried 240-ton loads of rock to the mining factories on the edges of pit.

Johnny pointed to a solitary billboard standing in the woods on the left side of the highway, and said, “Whoa, check that out.” The billboard depicted a giant fetus in utero. The caption read, Hello world. My heart was beating 18 days after conception.

“Hmm. Disturbing,” Johnny said. “What’s the point of that?”

“Some folks up here don’t believe in abortion. They believe life begins in the womb. I guess they pay for billboards to try to sway people to their way of thinking.”

Two more curves up the road, the town of Hibbing spread out before us. A row of boxy stucco homes stood shoulder to shoulder, their canted roofs covered with fresh snow. A silver water tower bearing the stenciled name HIBBING crested a hilltop behind them. Our journey was at an end.

Bob Dylan once wrote, “Hibbing’s a good ol’ town… I ran away from it when I was 10, 12, 13, 15, 15 ½, 17 an’ 18. I been caught an’ brought back all but once.” I followed a similar path. I blew out of this town years ago, and clawed my way to a better life in California. I vowed never to return. That was before I had a son, a son who needed Hibbing.

I turned onto Howard Street, the main thoroughfare, and drove along the downtown strip of commercial buildings. Neon lights flashed the names of two banks, three restaurants, three taverns, and a liquor store. Six inches of new-fallen snow covered the surface of the two-laned street. Our tires made a scrunching sound as we drove. Mounds of ice and snow lined the perimeter of the road like levees isolating the street from the storefronts.

The vista was familiar, and it saddened me. Hibbing was unchanged from the Januarys of my youth. A woman dressed in a bulky goose-down parka crossed Howard Street in front of us, her scarf trailing in the wind behind her. I slowed to let her pass. She tested the snow-covered surface with exacting steps. Johnny followed the parka-clad woman’s progress in wordless wonder.

I drove the 12-block length of Howard Street and made a left turn onto 1st Avenue, the second of Hibbing’s two main business routes. Similar to Howard Street, 1st Avenue was home to three gas stations, four more bars, and two liquor stores.

“What do you think?” I said.

“There’s not much here,” Johnny said. “It looks like a ghost town. Black and white. Dark buildings and white snow. Lots of bars and liquor stores.”

“Alcohol is a tonic against the tedium. It’s a long winter up here.”

“Iron miners drink a lot?”

“As long as there have been mining towns, there have been mining towns with taverns. But Hibbing is different. There are a lot of educated people here. Remember, this is the biggest urban area between Duluth and Winnipeg.”

Johnny laughed. “That’s not saying much, Daddy-O.”

I turned off 1st Avenue and drove through six blocks of humble residential neighborhoods until I reached 7th Avenue, a narrow tunnel between rows of stark leafless trees. Stocky two-story homes lined up behind the trees like chess pieces behind pawns. Windows were miniscule. Walls were thick. The buildings were efficient barricades for holding in heat against brutal conditions. Hibbing houses weren’t built for style; they were built to protect people from bitter cold.

After five or six blocks, the 7th Avenue street signs changed, and read Bob Dylan Drive. I parked the car when we reached the corner of 24th Street and Bob Dylan Drive. The corner house was a two-story grey cube lacking a single gable. Foot-long icicles hung from the roofline. No sign or placard designated the structure as a famous building.

“Why are we stopped here?” Johnny said.

“This was Bob Dylan’s house.”

“This was where he was born?”

“No. He was born in Duluth, 75 miles south of here. His parents moved to this house when Dylan was a boy. His real name was Robert Zimmerman, and this was his home back in 1959 when he graduated from Hibbing High School.”

“So it’s not a museum or anything.” Johnny craned his neck to take in the particulars of the scene.

“No. It’s someone’s residence. I don’t know who lives here now, but it’s just a regular house.”

As I spoke, a man came out of the front door. He tightened the hood of his parka against the wind and aimed a shovel at the snow on the walkway. After his second shovelful, he stopped and looked up at us in our bashed-in BMW. A $120,000 German sports car with a smashed-in front end and California license plates couldn’t be commonplace in Hibbing in January. On the other hand, I suspect an out-of-town vehicle perusing the old Zimmerman home was not unusual. Muslims made pilgrimages to Mecca. Dylan fans made pilgrimages to Hibbing.

The shoveler wore his hood pulled down over his eyebrows and a brown scarf wrapped snug over his mouth. Only his eyes were exposed to the frigid air. He continued to stare at Johnny and me.

Behind my windshield, I felt like a goldfish inside an aquarium. To ease the awkwardness of the moment, I waved at the man. The resident of 2425 Bob Dylan Drive only exhaled steam into the frigid Minnesota air. He did not wave back.

“Friendly guy,” Johnny said.

“Cut him some slack. I’ll bet every day some dude from New York, Pennsylvania, Illinois, England or Italy knocks on this guy’s door and asks him if they can take a tour of the house. It must get old.”

“Let’s get out of here,” Johnny said.

I put the car in gear and drove thirty seconds down the road to the intersection of Bob Dylan Drive and 21st Street. To our right, an imposing three-story red brick fortress sprawled over four square blocks. It was easily the largest building in town.

Johnny craned his neck up at the structure, and said, “What’s this?”

“This is your new school.”

“It looks like a castle. How can they have such a monster school in such a little town?”

“A hundred years ago the town of Hibbing was located two miles north of here. When the mining companies discovered the richest supply of iron ore in the United States in the soil below the existing town, they cut a deal. The mining companies agreed to move the entire village and build Hibbing this wonderful high school in the new location as a reward for being relocated. C’mon, let’s go take a look.”

We walked up the front steps of the high school. I touched the brass railing with my bare hand, just like I had when I was 17 years old. At that moment, I was proud of my roots and proud of my alma mater. The front door was unlocked, and we stepped inside. The entryway was adorned with a tiled mosaic floor, a majestic marble staircase, and original oil paintings and murals on the walls depicting the history of the Iron Range.

“It looks like a museum,” Johnny said.

“See that plaque? This building is on the National Register of Historic Places. Wait until you see the auditorium.”

We walked to the end of the main hallway and passed through a set of double doors into the auditorium, an Art Deco wonder adorned by cut-glass chandeliers built in Czechoslovakia, and modeled after the ornate Capitol Theater in New York City. With a capacity of 1,800, the auditorium could seat every student in the school at once.

“This is where I received my high school diploma. And this is where Bob Dylan first performed and sang in public. They say he banged on the piano like a Little Richard clone.”

Johnny said nothing. He was biting the nails of his right hand, and he looked nervous.

“You OK?” I said.

“I don’t know. Now that I see this place, I’m getting worried. What if it doesn’t work out for me here? I mean, wherever I go, I’m still Johnny Antone. What if I’m in the middle of the pack here, just like I was in Palo Alto? What if we moved here for nothing?”

“You’ve got what it takes, Johnny. You’ll do great here. Let’s go. I’ve got something else to show you.” I led him out the front entrance of the school, and pointed across the street to a white colonial mansion on the corner of Bob Dylan Drive and 21st Street. It was twice the size of any house we’d seen in town. The front lawn was an expansive half-acre of drifted snow.

“That’s Uncle Dom’s house,” I said.

“Nice.”

“It’s one of the most impressive homes in town. When I was a schoolboy, doctors were the wealthiest people, and Dr. Dominic Scipioni was the top surgeon in Hibbing.”

We crossed the street together. Dom’s front walk was covered by a foot of crusted snow, unbroken by a single footprint. Johnny tip-toed up the path, his Nike Air Jordans sinking in and filling with snow on every step. “Dom isn’t doing a great job of keeping the snow off his walk,” he said.

“He doesn’t live here anymore, that’s why we got the place. Dom has homes in Arizona and Montana. He keeps this family house for the nostalgia of the old homestead.”

“What’s the deal with this Uncle Dom, anyway?” Johnny said. “Is he your uncle, or is he my uncle?”

“He’s nobody’s uncle. Dom’s not related to any of us, but he’s always treated me like family. Dr. Dom was my role model and mentor ever since I was a teenager.”

I bent over and peeled back the corner of the welcome mat. A shiny steel key lay underneath. “This is a sweet deal for us. We get one of the best houses in town, two blocks from the hospital and across the street from the high school, no questions asked. It’ll be our Minnesota man-cave.”

Johnny followed me into the house. The interior was meat-locker cold. We could see the water vapor of our breath. A lifelong ectomorph, I loathed hypothermia. I turned the thermostat up to 72 degrees and switched on the lights in the living room. “I recommend you proceed at once to the den in the basement. Dom has three big screen televisions, side by side by side. You can watch the NBA, the NHL, and the PGA Tour at the same time, by the mere effort of swiveling your neck a few degrees. And you want to know the best thing about Dom’s house?”

“What’s that?”

“There’s no one here to yell at you.”

“I’m with you there, Dad.” Johnny descended the stairs into the basement.

I toured the living room. Dom’s house lacked the towering ceilings of our glassed-in California home. The space felt claustrophobic with its tiny square windows, dark paneled walls, and smoke-stained brown-bricked fireplace. I knew every knot-hole in this room from my previous lifetime here, when Dom’s family was my family. Once upon a time, this room represented the height of luxury to me.

I walked over to the framed black-and-white photograph I knew would be standing on the fireplace mantle. The photo portrayed a young man and a young woman dressed in formal attire. The dark-haired girl wore a square-necked white dress, and held a broad bouquet of flowers. Her lips were closed, and she had a solemn, far-away look in her eyes. The man wore a tuxedo and a goofy smile that was incongruous with the woman’s apparent gloom.

A flood of grief overcame me. I’d traveled all day, and this picture was the tortured endpoint to my journey. It was Dom’s house, and Dom could decorate the place as he pleased. Some people preferred to put their memories on their fireplace mantles. Some memories were better left hidden.

The boy in the picture was Nico Antone. And the girl? She was from another lifetime. I’d shoveled dirt over this unsmiling girl years ago. She was dead, and I needed her to stay dead.

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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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SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER FOUR

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

4) HIGHWAY 61 VISITED

I drove the black bullet of my BMW up Minnesota Highway 61, one hour north of Duluth and two hours short of the Canadian border. Johnny and I flew in from San Francisco to the Twin Cities that morning, and picked up the car from an interstate driving service in Minneapolis.

Our send-off in California was bitter. Alexandra dropped us off at the curb at San Francisco International Airport. She gave Johnny a big hug and said, “I love you, John-John. Call me every night.”

“Love you too, Mom,” he said. I watched their exchange with intrigue. Although he was eager to move thousands of miles away from her, Johnny still loved his mother. What can you say? She was the best mom he’d ever had.

As for me, I wasn’t going to profess any love this morning. Alexandra faced me, her eyes vacant and cold. “Are you going to be OK without us?” I said.

“I’ll be better than OK without you,” she said, her voice dripping with its customary arrogance. “If I’m lucky, you’ll never come back.” She grabbed the door handle of her Aston Martin, jutted her chin toward the sky and said, “Go.”

That’s the way it ended. I watched her drive off, and I was jolted by an unexpected surge of glee. I felt an unfamiliar sense of freedom, like a captive hawk unhooded and released from its tether. I had no idea when I would see her again, and I wasn’t in a hurry to find out.

Ten hours later, Johnny and I were driving north on a spectacular Minnesota winter day, with the blue expanse of Lake Superior sprawling ocean-like on our right and the setting sun disappearing behind the infinite expanse of pines on our left. I detoured up Highway 61 for the novelty of the famous road, so my son could witness the world’s largest freshwater lake. The scenery was world class, but for me the highlight was spending time with Johnny uninterrupted by the distractions of a television, an Xbox, or cell phone calls. Exiled from California, Johnny had no friends except me, and I liked it that way.

He slumped in the passenger seat and stared out the side window. Despite the winter temperatures, he’d rolled down his window and the icy breeze from Highway 61 fluttered through his hair. I was in control of the music. For this occasion, it had to be Bob Dylan. I cued up “Highway 61 Revisited,” and blasted the title song though the speakers. I belted out the lyrics in a nasal twang: “Well Abe says, ‘Where do you want this killin’ done,’ God says, ‘Out on Highway 61.’” My “61” came out as a screeching “sexty-waawn,” mimicking Dylan to the best of my ability.

“Bob Dylan wrote that song about this highway?” Johnny said.

“He did.”

“It’s a pretty creepy lyric. And you’re screaming it out like it’s an anthem. He’s singing about killing a son?”

“It’s from the Old Testament. God told Abraham to sacrifice his only son.”

“So? Did he kill his son?”

“No. He was prepared to do it, to obey God, but at the last minute God sent an angel to stop him. Instead of killing his son, Abraham sacrificed a ram.”

Johnny shook his head. “What kind of song is that? Sorry, Dad. I can’t get into the Dylan thing. It’s so hard to listen to the guy’s voice. That screeching is pretty awful.”

“Bob Dylan is one of the most imitated vocalists of the last hundred years. He gave every singer with a less-than-perfect voice a blueprint of how to sneer and twist off syllables.”

“He’s all mumbles to me.”

“Try to get past the sound of his voice, and listen to the words. Dylan was the first songwriter to turn poetry into popular music.”

“Who cares about poetry?”

“What is rap and hip-hop music but poetry? What do Jay Z or Kanye West do but chant some simple rhymes over a drum beat?”

Johnny looked unconvinced.

“Bob Dylan changed music forever. Before Dylan, the top singers were crooners like Frank Sinatra and Elvis Presley, guys with silky voices who performed songs written by unknown people. Then along came Dylan, coughing out “Blowin’ in the Wind” with a voice like sandpaper on wood. He jammed his songs into your ears with that raspy nasal twang, and crossed you up with changes in inflection no one ever heard before.”

“Why would anyone ever listen to that?”

“Great songs. ‘The Times They Are A-Changin’,’ ‘Mr. Tambourine Man,’ ‘Like a Rolling Stone.’ Songs that influenced every writer that followed after him.”

“It doesn’t make sense to me. How can a guy who changed the world come out of all this?” Johnny said, waving his hands at the endless forests. “From up here in the sticks?”

“God only knows where genius is born, but education had something to do with it. Hibbing High School. The same classrooms and hallways you’ll be in tomorrow.”

I spun the steering wheel to the left as we departed Highway 61 and veered west toward the heart of the Superior National Forest. Lake County Highway 15 was a curving two-lane highway that slalomed over gentle hills and carved through wilderness untouched by 21st-Century development. It connected the two metropolises of Silver Bay and Hoyt Lakes, each with a population of about 2,000. The road was smooth and the setting was desolate. We hadn’t seen another car in ten minutes. I compressed the accelerator pedal and watched the speedometer climb. “Hang on, son. We’re going for triple digits.”

When our speed hit 100 miles per hour, I looked over at Johnny. There was no trace of fear—he was loving it.

A sudden blaze of brown fur streaked across the road as the deer jumped out of the forest 100 yards in front of our car. “Shit!” I yelled, and stomped on the brakes so hard I thought my foot would break through the floorboard. Our car fishtailed counterclockwise. The rear wheels made a skid into the dirty snow on the side of the road, and our front fender slammed into the deer’s flank. I heard the crunch of crumbling steel, and saw the deer’s white tail slide up the windshield and over the top of the car. The airbags deployed, and twin balloons of white fabric blotted out the sun. The rear of the car wracked into something solid and stopped with a resounding thump.

I reached down and turned off the ignition. My hands were shaking. We’d hit the deer broadside at 100 mph. Highway 15 was now graced with one dead deer, one smashed-up BMW, and two happy-to-be-alive Antones. I took census of my four limbs and my vital functions. I didn’t seem to be injured. I feared for Johnny. I elbowed my air bag aside, and looked over at the passenger seat. There was movement behind Johnny’s air bag. I pushed the fabric aside, and saw my son crouched forward with his head between his knees.

“Are you all right?” I said.

Johnny was hyperventilating—a violent wind entered and exited his gaping mouth. Blood dripped from the right side of his chin. “Are you nuts, Dad?” he screamed. “You almost killed me. That was the scariest thing I’ve ever seen.”

I was reeling. What kind of father was I? I’d almost offed us both. “I’m sorry,” I said. “I didn’t think…”

You didn’t think? Do you ever think? Oh, what the hell am I doing up here?” Johnny buried his face in his hands and wailed, “Everybody I know is in California. My mother is thousands of miles away. I’m up here in the woods with you, stuck in a ditch in outer Mongolia. We’re going to freeze to death and die right here. I should never have left home.”

I didn’t know what to say. I started to reach out toward my son to comfort him, but Johnny grew more agitated, turned away, and wrestled with the airbag until he found the door latch. He pushed the door ajar, and burst out into the sub-freezing air outside.

I opened my own door and twisted my way out of the car. The right front quarter of the vehicle was buckled like an accordion. The deer lay mangled on the roadside at the rear of the car, its glassy eyes staring skyward into the void. Blood seeped from its ears, nose, and mouth. Its thorax was buckled, concave and deformed.

What a waste.

Behind me, Johnny said. “Dead deer. Totaled car. Stranded in the middle of nowhere. Great job, Dad.”

“It all happened so fast…”

“No. You were driving like a maniac, and now we’re stuck. We’re so stuck. There’s no people in these woods but lumberjacks. Lumberjacks who would be hunting this deer if you hadn’t killed it.” Johnny shook his head. He stuck out his jaw, square and resolute. “I’m done. I changed my mind. I want to go home.”

I’d heard enough. “No. We’re going to Hibbing,” I barked. “It’s what you and I decided to do. Together, that’s what you and I decided.”

“I’m un-deciding.”

“It’s too late for that. I’m pulling rank on you. We’re in Minnesota, and we’re staying in Minnesota.” I walked back to the driver’s door, unsheathed a small Swiss Army knife from my key chain, stabbed the point of the blade into the airbag, and slashed a 10-inch gouge in the material. I squeezed the remainder of the air out, compressed the bag into a dense lump the size of a basketball, and stuffed it back into its housing inside the steering wheel. I repeated the same treatment on the passenger airbag, and pushed the deflated fabric back into the dashboard.

“Get in,” I commanded.

“You don’t understand, Dad. What’s the point of getting into this wreck of a car, marooned ass-end first in a snow bank?”

I ignored his sky-is-falling attitude, and pushed the ignition button. The engine sprang to life. I floored the accelerator pedal, and listened to the roar of the motor echo off the virgin pines around us.

“Get in,” I repeated.

Johnny looked both ways on the deserted highway, and his shoulders slumped. He climbed into the passenger seat, with a look of hopeless resignation etched on his face. We were miles from the nearest town, and the deformed car was our only hope to limp out of the wilderness. I shifted the transmission into Drive and wondered if the right front tire would move within the mangled fender. With a lurch, the BMW rolled forward out of the snow bank. Lucky us. I whistled through my teeth and turned the automobile back onto Highway 15 for the last leg of our trip toward Hibbing.

I vowed that the next time I saw God, I’d run a little slower. Abraham sacrificed a ram instead of killing his son.

I settled for a deer.

*
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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

 

 

HOW COMMON ARE CARDIAC ARRESTS DURING SURGERY AND ANESTHESIA?

the anesthesia consultant

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

 

How common are cardiac arrests during surgery? Uncommon, but the incidence is not zero and the outcome is usually dire.

ventricular fibrillation

In 2004 the Japanese Society of Anesthesiologists reported 2,443 cardiac arrests (6.34 per 10,000 anesthetics) and 2,638 deaths (6.85 per 10,000 anesthetics) among 3,855,384 anesthetics. The majority of deaths were due to preoperative health complications (64.7%) and surgical problems (23.9%). The main preoperative problem leading to death was hemorrhagic shock, and the main surgical problem leading to death was excessive surgical bleeding. The incidence of cardiac arrest totally attributable to anesthesia mismanagement was low (0.47 per 10,000 anesthetics), and anesthesia mismanagement was responsible for only 1.5% of deaths. (1)

The American College of Surgeons National Surgical Quality Improvement database from 2005 to 2007 documented the incidence of intraoperative cardiac arrest in non-cardiac surgery as 7.22 per 10,000 cases. Intraoperative blood loss, represented by the amount of blood transfused, was the most important risk factor. Patients receiving over 10 units of blood had greater than 10 times the risk of those receiving 1-3 units of blood. Two other significant risk factors were emergency surgery and the patient’s preoperative health as assessed by the American Society of Anesthesiologists (ASA) physical status ranking. Of the 262 patients with intraoperative cardiac arrests, 44% died within 24 hours and 62% died within 30 days. (2)

From 2010 to 2013 the National Anesthesia Clinical Outcomes Registry reported the risk of intraoperative cardiac arrest as 5.6 per 10,000 cases. Fifty-eight percent of these patients died. The incidence of cardiac arrest increased with age and ASA physical status ranking, with the majority occurring in patients with an ASA physical status of 3-5. (3)

Physicians from a Thai teaching hospital reviewed 44,339 emergency surgery patients from 2003 to 2011, and found the incidence of perioperative cardiac arrest in emergency surgery was 163 per 10,000 cases. Risk factors were age 2 years or younger, an ASA physical status of 3-4, risky anatomic sites of surgery (upper abdomen, intracranial, intrathoracic, cardiac, or major vascular), cardiac or respiratory comorbidities, and shock prior to anesthesia. (4)

A Brazilian study documented a higher incidence of perioperative cardiac arrest in children than in adults. From 1996 to 2004, 15,253 anesthetics were performed in children. There were 35 cardiac arrests (22.9 per 10,000) and 15 deaths (9.8 per 10,000). Risk factors for cardiac arrest were children under one year of age, emergency surgery, ASA physical status 3-5, and general anesthesia. There were 11 cardiac arrests related to anesthesia care. Seventy-one per cent of these were caused by airway management/respiratory events, and 28% were caused by medication-related events. There were zero deaths attributed to anesthesia. (5).

What does all this mean?

If you’re an anesthesia provider, know that that the risk of cardiac arrest during surgery and anesthesia is low. The average reported incidence is in the ballpark of 6 to 7 per 10,000 cases, higher in children (22.9 per 10,000), and highest in emergency surgeries (163 per 10,000).

A busy anesthesiologist doing his or her own cases performs 1000 anesthetics per year. A predicted experience would be one cardiac arrest every 6-7 years, or 4-5 cardiac arrests in a 30-year career. A physician anesthesiologist supervising four CRNAs in four operating rooms could do four times as many cases per year, so a predicted incidence would be 16-20 cardiac arrests in a 30-year career.
Anesthesiologists should be prepared to promptly manage cardiac arrests in the patients at highest risk, which include: those with extensive bleeding and transfusion requirements; patients in shock; emergency surgeries; particularly emergency surgeries involving the upper abdomen, craniotomies, cardiac, intrathoracic, and major vascular vessels; patients with preoperative physical status limitations (ASA physical status 3-5); and children under one year of age.

In 30+ years of administering approximately 25,000 anesthetics I’ve seen cardiac arrests in three cases, for a personal anecdotal incidence of 1.2 per 10,000. All were in the high-risk categories above. One patient was in hemorrhagic shock prior to surgery because of an acute bleed from a ruptured aortic aneurysm, one patient was undergoing aortic artery bypass surgery, and one patient was a sick end-stage renal disease dialysis patient undergoing vascular surgery.

If you’re a patient, realize that your risk of having a cardiac arrest under anesthesia is low. If you have any of the risk factors described above, your risks are higher. Trust that the surgeon and physician anesthesiologist who take care of you will be well prepared, aware of this data, and will take excellent care of you while you are asleep.

In the future, physician anesthesiologists will have an abundance of “Big Data” on clinical issues such as this one. The ASA and its affiliate, the Anesthesia Quality Institute (AQI), are compiling the National Anesthesia Clinical Outcomes Registry (NACOR), which has been designated as a Qualified Clinical Data Registry (QCDR) by the Centers for Medicare & Medicaid Services for Physician Quality Reporting System (PQRS).

Can we lower the incidence of perioperative cardiac arrest? Perhaps, as we gain more understanding of risk factors. But as the Baby Boomer population in the United States ages, there will be more old patients, more patients with multiple medical problems, and more emergency surgeries on older, sicker patients.
Anesthesiologists will continue to be challenged.

References:
1. Irita K, et al. Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review. Masui. 2004 Mar;53(3):320-335.

2. Goswami S, Brady JE, Jordan DA, Li G. Intraoperative cardiac arrests in adults undergoing noncardiac surgery: incidence, risk factors, and survival outcome. Anesthesiology. 2012 Nov;117(5):1018-26.

3. Nunnally ME, O’Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth Analg. 2015 Feb;120(2):364-70.

4. Siriphuwanun V, et al. Incidence of and factors associated with perioperative cardiac arrest within 24 hours of anesthesia for emergency surgery. Risk Manag Healthc Policy. 2014 Sep 4;7:155-62. doi: 10.2147/RMHP.S67935. eCollection 2014.

5. Gobbo Braz L, et al. Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital. Paediatr Anaesth. 2006 Aug;16(8):860-6.

 

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?

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Will I Be Nauseated After General Anesthesia?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

SERIALIZATION OF THE DOCTOR AND MR. DYLAN … CHAPTER THREE

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

3) QUEEN ALEXANDRA APPROXIMATELY

I drove my black BMW M6 convertible up the semicircular driveway to our Palo Alto home after work, and parked behind my wife’s silver Aston Martin One-77. Together, the value of the two cars approximated the gross national products of some third world nations. Our home was a 7,000-square-foot Tuscan villa built on a hilltop west of the Stanford University campus. The Antone estate encompassed three acres of tranquility, and towered above an urban area of seven million Californians, most of whom were mired in less-than-tranquil rush hour traffic at that very moment.

Our living room featured thirty-foot-high ceiling-to-floor windows overlooking San Francisco Bay. The décor included opulent white Baker couches no one ever sat on and a Steinway grand piano no one ever played. I sped through the formal room at flank speed. I couldn’t remember ever spending more than five minutes hanging out in this museum piece of showroom design.

I carried a large bag of Chinese take-out food from Chef Chu’s, and set it down on the stainless steel countertop of our spotless, never-used kitchen. I made a beeline for the refrigerator, popped the top off a Corona, and chugged half the bottle. I was still vibrating from my day in the operating room. I looked out the French doors toward the back patio.

Alexandra was lying on a lounge chair and sipping a tall drink through a straw. A broad-brimmed Panama hat graced her swirling mane of black hair. She wore a white one-piece swimming suit. It was an unseasonably warm day for January, and my wife never missed an opportunity to bronze her lanky limbs.

I walked up behind Alexandra, wrapped my arms around her neck, and kissed her left cheek. She held a cell phone against her right ear, and she pushed me away while she continued her conversation. I frowned and said nothing. Was it so hard for Alexandra to pretend she loved me? I sank into a second chaise lounge beside her, closed my eyes and listened.

“That property is overpriced at $6.5 million,” she said. “I know we can get it for 6.2. Put in the bid tonight and tell the seller they need to decide by tomorrow morning or the deal’s off. Got it? Call me back when they cave. Ciao.”

Alexandra set her phone down and lit a Marlboro Light 100. She inhaled with a violent effort, exhaled the smoke through her nostrils, dragon-like, and turned toward me. She wore broad Ray-Ban sunglasses. I couldn’t tell if she was looking at me or if she was looking out over San Francisco Bay, a vista Alexandra may well have considered far more interesting.

“How are you?” she said.

“I had a busy day. Today I was in the neuro room…”

Her phone rang again, and she waved me off while she took the call. My heart sank anew. She listened for an extended time and then she said, “I’ll be there at 5. No problem. Thanks.” She hung up and thrust her fist into the air. “Got a whale on the line,” she said. “There’s a couple from Taiwan who want to see the Jorgensen house tonight. Their agent drove them by the property this morning. They are very, very interested, and very, very wealthy. It’s an all-cash deal. A blank check.” She took a second long drag on her cigarette, and leaned toward me. At this angle, I could see my own reflection dwarfed in the lenses of her sunglasses. “This is big, Nico.”

“How much is the Jorgensen house listed for?”

“Just under 8 mill. That’s a quarter of a million dollar commission for yours truly.”

Her monomaniacal pursuit of money baffled me. Alexandra Regina Antone was one of America’s top real estate agents. Because of her explosive earning power, we lived in one of the nation’s most expensive residential neighborhoods, a zip code where Silicon Valley’s multimillionaire CEO’s and venture capitalists lorded in their castles. The residential properties Alexandra bought and sold for her clients were in the $3 million to $10 million range, and she earned a 3% commission on each sale. She sold one or two houses each month, and her income for the past year topped $9 million.

Alexandra’s salary dwarfed mine. None of my medical peers lived in this kind of luxury. To Alexandra, another $240,000 commission was headline news. It wasn’t about the cash—this was about the glory of Alexandra and her talent. It was about the Queen of Palo Alto rising higher and higher on the pedestal she’d erected for herself.

“So, you were telling me about your day,” Alexandra said, as she stretched her arms toward the sky and stifled a yawn.

“I did a craniotomy with Judith Chang. One case. It took all day.”

She took a final drag on her Marlboro, shivered in disgust, and said, “Judith Chang is such a stiff. Always bragging about her robotic daughters. I don’t know how you can do that job, locked in a windowless room with her hour after hour.” Alexandra had zero interest in listening to medical stories. She changed the topic at once. “Did you hear about Johnny’s report card?”

“I did. He’s pretty upset. Johnny wishes his grades were better. I wish his grades were better. He said you yelled at him.”

“Johnny’s a slacker. God knows I tried to light a fire under him years ago, but you taught him how to watch ESPN instead of pushing academics.”

“He said you called him a lazy shit.”

“I did. He is a lazy shit.”

“He’s your son, for God’s sakes. Johnny loves you and looks up to you. How do you think he feels when his mother says that?”

“I don’t give a fuck how he feels. Johnny needs to hear it, and he needs to change. Clue in! You don’t seem to get it, either. You think he’s fine just the way he is. Well he isn’t, Nico. Johnny’s a spoiled brat, living in luxury on top of this hill. He has no incentive to work hard. He thinks he can live off my money forever.”

Alexandra was dogmatic about the pathway to success. She was an unabashed academic snob—a graduate of Dartmouth College and Harvard Business School—and she’d have tattooed her Ivy League diplomas across her cleavage if she hadn’t been too vain to disfigure her silicone orbs. I wasn’t going to fight with her—I never won.

I shifted gears. “Dr. Chang had an interesting take on Johnny’s grades. She said Johnny could get into any college he wanted to if we lived in South Dakota.” I explained how Dr. Chang’s nephew from Sioux Falls was accepted to Princeton.

Alexandra removed her hat, shook out her hair, and took off her sunglasses to reveal flashing brown eyes. “For a change, Judith Chang is right. Johnny’s chances for success are slim on his current path. He has no chance at the Ivy League coming out of Palo Alto with his B average.” She chewed on the earpiece of her Ray-Bans as she contemplated. “Why don’t we send him to Minnesota to live with Dominic?”

“You’re kidding,” I said. My Uncle Dominic had a home near the Canadian border, in Hibbing, Minnesota, where I graduated from high school. Hibbing was a great place if you wanted to hunt partridge or ice fish for walleye pike, but the tiny village was a subarctic outpost light-years removed from the opulence Johnny grew up with in California.

“I’m not kidding. Johnny needs a gimmick for college admissions, and he has none. Hibbing could be his ticket.”

“He can’t just move up there with Dominic. Johnny’s 17 years old. And Dominic moved to Arizona. His house is empty.”

“Then take a year off. Go up there with him. Get your ass out of that windowless tomb of an operating room and take your son back to your childhood home.”
I frowned. “What about you?”

“Are you kidding? I’m not going anywhere. My friends are here, my job is here. But you go right ahead, Nico.”

Now it was my turn to stare off at the blue expanse of San Francisco Bay. Move back to the Iron Range of Northern Minnesota, to the land of rusted-out Fords and beer-swilling Vikings fans? What had my marriage come to? Before Johnny was born, Alexandra and I used to sit in these same chairs and drink margaritas together. Naked dips in this same pool led to nights of laughter and hot sex. Our current sex life had declined to hall sex, when I murmured “fuck you” under my breath after Alexandra walked past me in the hallway on her way to the second bedroom where she slept alone.

Alexandra was unrelenting. “Don’t give Johnny an option. Tell him you’re taking him to Minnesota to turn his life around, get some A’s, and graduate number one in his class from Hibbing High School. Call Dominic tonight and make the arrangements. It’ll be the best decision you’ve ever made. Trust me.”

Trust me. Alexandra could sell bikinis to Eskimos. “You’re OK with your husband and son moving 2,000 miles away?” I said.

She wrapped her arms around herself in an absurd parody of self-love and said, “Of course I’ll miss you.” Then she laid back onto the chaise lounge, the top third of her breasts busting out of her swimsuit top. She knit her hands behind her head, pushed her cleavage out into the January sunshine, and grinned in silence.

I watched the spectacle of her arching self-absorption and winced. Move 2,000 miles away? I was 2,000 miles away from this woman already.

“Hey guys,” came a voice from behind us. Johnny was home from school. He walked onto the patio and stood between us. My mood improved at once. Our son was tall and muscular with perfect skin, dark wavy hair, and striking blue eyes. He wore his usual uniform of gym shorts and an oversized T-shirt. My love for Johnny was unlike any emotion I’d ever felt. Romantic love for a woman was a wonderful abyss—the subject matter of a million songs, books, movies, and television shows. I’d watched romantic love drift off into the ozone as years passed, but with my son I was in love forever. If Alexandra and I ever divorced, I’d carry on. If my son ever shut me out, I’d need electroshock therapy.

Johnny wasn’t smiling. His shoulders drooped, his chin scraped his chest, and his gaze was locked onto the slate tiles under his well-worn Nike athletic shoes.

“How’s the Boy with the B’s doing?” Alexandra said.

Johnny regarded her through hooded eyes—James Dean with a cause. His upper lip curled skyward in a look of contempt. He was already smoldering from a bad day, and she was throwing kerosene on his fire.

She forged on, hawking optimism now. “Dad and I have a great plan for you that should make your report card problem of no consequence.”

“Great plan?” Contempt turned to suspicion.

“Johnny, are you happy that your grades rank you in the middle of the pack at your school?” she said.

“You know I’m not,” he sneered. I didn’t have a 42-inch monitor displaying Johnny’s vital signs, but I knew my son’s blood pressure was escalating.

“Would you like to be accepted into a top college?”

“Duh. Of course, Mom.”

“What if we told you there was a way for you to graduate at the top of your class and go on to one of America’s best colleges?”

“I’d say you were smoking too much weed.”

“No weed.”

“How am I going to jump to the head of my class at Palo Alto Hills High?”

“Not Palo Alto Hills High School, Johnny. Hibbing High School.”

Johnny looked from me to his mother and back again. “You two are messed up. Hibbing? Where the hell is that?”

“Hibbing is in Northern Minnesota. It’s where your dad grew up. It could be worse. We’re not sending you off to some military school in the badlands of Utah where you don’t know anyone. Your dad will move to Minnesota with you.”

“That’s ridiculous… Dad?” he said, panic in his voice.

I opened my mouth, but Alexandra didn’t give me a chance to weigh in. “There are consequences for your lack of effort in school, Johnny,” she said. “We want you to get out of Palo Alto and compete for grades with the sons and daughters of some iron ore miners. Right, Nico?” She turned to me for affirmation.

Johnny’s jaw sagged. “Dad?” he said again.

“I’m overdue for my sabbatical at the University,” I said. “My Uncle Dominic has a house in Hibbing. With your brains, your test scores, and a lot of hard work, you could be a top student up there. Instead of being a middle-of-the-pack Palo Alto student, you could be….” At this point I decided to gamble and appeal to my son’s ego and vanity, “You could be the valedictorian.”

“Can the best students from a school like that get into a top college?”

“They can. When I was a senior at Hibbing High, two kids were accepted to Harvard. It’s got to be the best high school in the northern half of Minnesota.”

“Whoa. Harvard?”

“Yes, Harvard.”

Johnny looked over at his mother. She smirked, as if she’d single-handedly masterminded a strategic maneuver worthy of Machiavelli.

“I’ll have to think about this,” Johnny said.

“I’ve got to shower and get ready for my meeting,” Alexandra said. “Nico, you guys are on your own for dinner. Johnny, I’m sure you’ll love Minnesota.” She rolled off her lounge chair as Johnny covered his eyes and pressed his thumbs into his temples.

She walked away, and I admired the swagger of her slender hips and the bounce of her long tresses. I never got tired of looking at Alexandra, but it wasn’t much fun living with a woman whose best friend was her mirror.

I turned to Johnny. “Want some Chinese food?” I said.

“I’ll eat it in my room, Dad. I have a ton of homework. I’m really pissed off about everything and I don’t want to talk anymore. First I get the crappy report card, and now you guys want to ship me off to the Yukon. All you guys care about is grades. You don’t give two shits about whether I’m happy or not.”

“That’s not true.”

“It is true. Just leave me alone. I’m going to my room. This B-student has a date with Hamlet.” Johnny walked away, and I let him go. My B-student son needed more dates with the Danish prince.

I dished out a plate of Szechwan prawns and General’s Tso’s chicken, and popped the top off a second Corona. The Golden State Warriors were playing the Miami Heat at 6 p.m. A second Corona, some Schezwan prawns, and the basketball game sounded like a decent evening.

After halftime, Johnny came shuffling down the hallway. He stretched out on the couch opposite me, and opened his laptop. He was humming to himself, and his fingers were flying.

I was happy to see he’d cheered up. “Feeling better?” I said.

“Yep. The Chinese food hit the spot.”

I waited for more conversation, but none was forthcoming. The Warriors connected on an alley-oop and an outrageous dunk. Johnny didn’t look up.

“How’s Amanda?” I said, trying to stoke up a dialogue. Amanda Feld was Johnny’s girlfriend, a petite cross-country runner who gazed at Johnny like he was a Greek god. She hadn’t been over for a couple of weeks, and Johnny hadn’t brought up her name for longer than that.

“Amanda’s history,” Johnny said.

“History?”

“I broke up with her a month ago, Dad.”

“What happened?”

“Nothing happened. It didn’t work out.”

“She was cute.”

“Yep.”

I waited for more of an explanation, but none came. Amanda’s fate paralleled all the other breakups of the past year, when Johnny ended relationships with Samantha the cheerleader, Emily the debate star, and Jenna the girl across the street. Johnny seemed to attract girls by repelling them. The less interest he showed, the more the women orbited him. I was envious.

Johnny said, “The report card and class rank bullshit really wore me down today. Why should my whole future revolve around some alphabet letters on a page?”

“It doesn’t. Your life is much more than your grades.”

“Yeah, like what?”

I pointed my two forefingers at my son just like I had a thousand times in his life, and said, “You’re a great kid. Don’t ever forget it.”

“Why do you always have to say that to me, Dad?”

“Because it’s true. I want you to imprint it in your brain and never doubt it.”

“Even if I can’t get an A in one class?”

“Even if you can’t get one A.”

“I want to get A’s. All A’s. But transferring to Minnesota?” Johnny tapped the screen of his laptop and said, “I’m looking at the Weather Channel website. It’s minus five degrees and snowing in Hibbing right now.”

“Yep. That’s why I left. In the winter the sun sets at 3:30 in the afternoon.”

“That’s insane.”

“It ain’t California.”

He shook his head. “I’m going to sleep.”

“Good night, son. I love you.”

“Love you, too,” Johnny said, and then he headed off toward his room.

I welcomed the tranquility from the two beers. My eyelids grew heavy, and I faded toward unconsciousness. My cell phone rang and woke me. I didn’t recognize the number. I answered the call, and a male voice said, “Alexandra?”

“No, this is her husband’s number. Who’s calling?”

There was a click as the line went dead. The heaviness in my eyelids was gone. I found myself mistrusting my wife.

Again.

I woke in the middle of the night. I’d dozed off in my chair in front of the flickering television. A Seinfeld rerun was playing. I turned off the TV, tried my best to stay asleep, and stumbled down the hallway toward my bedroom. The door to Alexandra’s bedroom was open, and her bed was untouched. I looked at my watch. It was 2:07 a.m.

A surge of annoyance ran through me. Where the devil was she at 2 o’clock in the morning on a Thursday night? My hopes for a quick return to slumber were dashed. I was full of adrenaline, and I wasn’t going back to sleep anytime soon. I walked into her room and laid down on her bed. The familiar smell of her hair from the pillows jolted me. It had been a long time since we’d touched the same sheets together.

I heard a car door slam outside. A minute later, Alexandra stood in the bedroom doorway. She carried her high heel shoes in one hand and wore a black spaghetti strap cocktail dress. Those spectacular legs were glistening from mid-thigh on down.

She was startled to see me. “What are you doing in my room?” she said.

“Waiting up. Where were you?” My voice quivered with resentment.

“Oh, Jesus, Nico. I’m not a sixteen-year-old girl, and you’re not my dad. I went out with the girls and had a couple of drinks and some laughs. It was fun. You should try it sometime.”

“I don’t believe you.”

“Believe whatever you want. Can you get out of my room now so I can go to sleep?”

I turned on the overhead lights, and examined the illuminated spectacle of Alexandra Antone. Her arms were crossed, and she was smirking down at me. A streak of red lipstick stretched from her upper lip across her right cheek. Was she was playing kissy-face with the girls?

I lost it. “Are you playing me?” I said.

“What are you talking about?”

“Are you playing me for a fool? Who were you with?”

She turned her back on me and walked into her closet. “You are such a buzzkill,” she called out. “You always hate it when I have fun. I have a life. I’m sorry you’re jealous.”

I ran to her like a wild bull. I grabbed her by the arm and swung her around to face me.

“Are you having an affair?” I screamed.

Dull eyes stared back at me. Alexandra blinked twice, shook her head in disgust, and said, “No, I’m not. And get your hands off of me, Nico. You’re still the same small-town hick you’ve always been.”

Her defiance infuriated me further. “I’m sick of you, and I’m sick of our bogus marriage.”

She laughed at me and said, “You need to find somebody else. Someone who likes listening to your boring medical stories. Someone who wants to cook meat and potatoes for you. Someone who enjoys staying home and watching TV with you.”

“I’m married to you. I’m not finding anybody else while I’m your husband.”

“Are you my husband, Nico? Or my dependent?”

I saw flames. I picked up her six-foot-tall cast iron coat rack and rammed the shaft through the closet wall. The metal hung there, cleaving the room between us.

“Are you crazy?” Her shriek was ear-splitting.

“At least I’m not a whore.” With those words, I’d crossed the line. As of that moment, I knew I could no longer live with the woman. “If you want to stay out half the night like a tramp, don’t bother to come home at all.”

“I’m not going anywhere,” she screeched. “You’re the one who needs to move out. I paid for this damn house.”

The hardwood floor creaked behind me, and a voice bellowed, “Shut the fuck up! Both of you!” It was Johnny, standing in the doorway in his undershorts. My world stopped. Alex and I stared at our son, and no words were offered.

Alexandra spoke at last. She said, “Whatever. Can you two get out of my bedroom now?”
Johnny shook his head and disappeared into the darkness of his own room. I was so embarrassed and furious I found it hard to breathe. The two most important relationships in my life were imploding before my eyes. I left Alexandra’s room, and she shut her door behind me. I leaned against the closed door of Johnny’s bedroom and said, “I’m sorry, son. I’m sorry you had to hear that.”

“Then stop talking about it,” he said. I waited there for five minutes. He made no further sound. I walked away, back to my isolation in the master bedroom.
I lay in the dark with a pillow over my eyes and replayed what had just gone down. My life was ridiculous. My separate-evening, separate-bedroom, give-your-husband-shit-whenever-possible marriage was ridiculous. How could Johnny have a healthy adolescence under these circumstances?

I had no answers. I was angry, depressed, and reeling. I reached into the drawer of my bedside table, pulled out my bottle of Ambien, popped two, and chased them with a swallow of water from last night’s glass. I was an expert at anesthesia, even when I was the patient.

The next day I dragged myself through five routine surgeries although I was so angry it took all my will to concentrate on my craft. When I returned to my house that evening, Johnny was stretched out in my lounge chair. He was watching TV and typing into his laptop. He’d been asleep when I left for work that morning, so I hadn’t seen him since the screaming session in the hallway. Alexandra was nowhere to be seen.

“Hey, Dad,” Johnny said without looking up.

“Hello, son. Did you get some sleep after that whole episode last night?”

“I did. Mom gave me a ton of crap this morning for swearing at her and being disrespectful.” His face soured. If there was more to say, he wasn’t going there. He closed the laptop and said, “Other than that, it was a good day. I’ve been researching a lot of stuff about Hibbing on the Internet.”

He had my attention.

“That was excellent Chinese food last night, wouldn’t you agree?” he said.

“It was.”

“It’ll be our last decent Chinese food for awhile, Dad. I don’t think there’ll be any outstanding Chinese restaurants up there in Hibbing. I want to do it.”

“Do it?”

“I want to get away from Palo Alto Hills High, away from Amanda Feld, and away from Mom.
I want to go to Minnesota. Will you take me?” He held out his hand toward me. I stared at it and contemplated the implications of the gesture. Johnny was an impulsive kid, capable of making radical and irrational decisions in a heartbeat, but he’d never made a decision that impacted his life to this degree.

“You mean it?”

“I do. Can you walk away from your anesthesia job?”

“Well…” My thoughts were jumbled as I pondered the coin spinning through the air. Heads, I honored my love for my son and joined him in this adventure. Tails, I maintained my love for the warmth of California and my stable university job.

The tipping point was Alexandra. She was a toxic presence in my life. More than a marital separation, I needed an exorcism. It wasn’t a question of love. I didn’t even like her.
The coin landed on heads. I clasped Johnny’s outstretched hand and said, “Let’s do this, son. Let’s move.”

“Can’t wait, Daddy-O,” Johnny said.

“I’ll call Uncle Dominic in the morning and set things up.”

Johnny smiled and repeated again, “Can’t wait.”

*
*
*
*

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

 

 

DSC04882_edited

SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER TWO

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

2) A PHARMACIST’S SON IN SOUTH DAKOTA

Eight months earlier

My cell phone pinged with a text message from my son Johnny. The text read:

911 call me

I was administering an anesthetic to a 41-year-old woman in an operating room at Stanford University, while a neurosurgeon worked to remove a meningioma tumor from her brain. I stood near my patient’s feet in an anesthesia cockpit surrounded by two ventilator hoses, three intravenous lines, and four computer monitor screens. Ten syringes loaded with ten different drugs lay on the table before me. My job was to control my patient’s breathing, blood pressure, and level of unconsciousness, but at that moment I could only stare at my cell phone as my heart rate climbed.

                                                                       911 call me

911? My son was in trouble, and I was stuck in surgery, unable to leave. I wanted to contact Johnny as soon as possible, but my patient was asleep, paralyzed, and helpless. Her life was my responsibility. I scanned the operating room monitors and confirmed that her vital signs were perfect. I had to make a decision: should I call him now, or attend to my anesthetic and call after the surgery was over? My patient was stable, and my son was in danger. I pulled out my cell phone and dialed his number. He picked up after the first ring. “What is it, son?” I said.

“I’m screwed,” Johnny wailed. “I just got my report card for the first semester and my grades totally suck. Mom is mega-pissed. She’s going ballistic, and I’m screwed.”

My shoulders slumped. This was 911 for a 17-year-old? “How bad were the grades?”

“I got six B’s. I didn’t get one A. I just met with my counselor and he says I’m ranked #101 in my high school class. I’m so doomed. Mom is so pissed. She called me a lazy shit.”

I resisted my initial urge to scream at Johnny for scaring the hell out of me. The kid had no insight into what I did minute-to-minute in the hospital. Did he think his report card trumped my medical practice? Did he really think his report card full of B’s was an emergency?

“I’m not sure what’s worse, the grades or Mom’s screaming about the grades,” he said.

I imagined my wife having a temper tantrum about Johnny falling short of her straight-A’s standard of excellence, and I knew the answer to that question. My wife could be a total bitch. “I’m sorry Mom got mad, Johnny, but…”

“No buts, Dad. You know Mom’s idea of success is Ivy League or bust, and I’m a bust.”

“Son, four of your six classes are Advanced Placement classes, and those grades aren’t that bad.”

“Dad, almost everyone in the school takes four AP classes. Every one of my friends got better grades than me. Ray, Brent, Robby, Olivia, Jessica, Sammy, and Adrian all got straight A’s. Devon, Jackson, Pete, and Rod had all A’s and one B. Even Diego had only two B’s.”

“But you…”

Johnny cut me off. “There’s no ‘buts,’ Dad. I’m ranked in the middle of the pack in my class. I’m cooked. I’m ordinary. Forget Harvard and Princeton. I’m going to San Jose State.”

My stomach dropped. Johnny was halfway through his junior year at Palo Alto Hills High School. The competition for elite college acceptance was on my son’s mind every day, and on his mom’s mind every minute. Johnny was a bright kid, but the school stood across the street from Stanford University and was packed wall-to-wall with the sons and daughters of Stanford MBA’s, Ph.D.’s, lawyers, and doctors. Johnny’s situation wasn’t uncommon. You could be a pretty smart kid and still land somewhere in the middle of the class at P.A. Hills High.

“Everything will work out,” I said. “There are plenty of great colleges. You’ll see.”

“Lame, Dad. Don’t talk down to me. You stand there with your doctor job at Stanford and tell me that I’ll be all right. I’ll be the checkout guy at Safeway when you buy your groceries. That’s where I’m heading.”

Catastrophic thinking. Johnny Antone was holding a piece of paper in his hand—a piece of paper with some letters typed after his name—and he was translating it into an abject life of being average.

“Johnny, I can’t talk about this any more right now. My patient …”

“Whatever,” Johnny answered.

I heard a click as he hung up. I hated it when he did that. In the operating room I had authority, and respect was a given. With my family, I was a punching bag for of all sorts of verbal blows from both my kid and my wife.

I reached down and turned off my cell phone. For now, the haven of the operating room would insulate me against assaults from the outside world.

Judith Chang was the neurosurgeon that day. Dr. Chang was the finest brain surgeon in the western United States, and was arguably the most outstanding female brain surgeon on the planet. She peered into a binocular microscope hour after hour, teasing the remnants of the tumor away from the patient’s left frontal lobe. Dr. Chang always operated in silence, and her fingers moved in precise, calculated maneuvers. A 50-inch flat screen monitor on the wall of the operating room broadcast the image she saw from inside her microscope.

I paid little attention to the surgical images, which to me revealed nothing but incomprehensible blends of pink tissues. My full attention was focused on my own 42-inch monitor screen which depicted the patient’s electrocardiogram, blood pressure, and oxygen saturation, as well as the concentration of all gases moving in and out of her lungs. Everything was stable, and I was pleased.

It had been five hours since the initial skin incision. Dr. Chang pushed the microscope away and said, “We’re done. The tumor’s out.”

“A cure?” I said.

“There was no invasion of the tumor into brain tissue or bone. She’s cured.” Dr. Chang had removed a 5 X 10-centimeter piece of the patient’s skull to access the brain, and began the process of fitting the piece back into the defect in the skull—the placement not unlike finishing the last piece in a jigsaw puzzle. As Dr. Chang wired the bony plate into place, she said, “How’s your family, Nico?”

She hadn’t said a word to me in five hours, but once she was finished with the critical parts of surgery, Judith Chang had a reputation as a world-class chatterer. Some surgeons liked to listen to loud rock n’ roll “closing music” as they sewed up a patient. Some surgeons preferred to tell raunchy jokes. Judith Chang enjoyed the sound of her own voice. We hadn’t worked together for months, so we had a lot to catch up on.

“They’re good,” I said. “Johnny’s in 11th grade. He’s going to concerts, playing video games with friends, and sleeping until noon on weekends. Alexandra is working a lot, as usual. She just sold a house on your street.”

“I heard about that property,” Judith said. “You’re a lucky guy. That house sold for close to $5 million. Her commission is more than some doctors earn in a year. In my next lifetime I’ll be a big-time realtor like Alexandra. Does she give you half her income to spend?”

“In theory half that money is mine, but she invests the dough as soon as it hits her checking account.”

“Smart. Is Johnny looking at colleges yet?”

Her question had eerie relevance, because I’d been ruminating over Johnny’s phone call all morning. “That’s a sensitive point. Johnny just got his mid-year report card, and he’s freaking out.”

“How bad was it?”

“Six B’s. No A’s. He’s ranked #101 in a class of 480 students.” I spilled out the whole story while Dr. Chang twisted the wires together to affix the bony plate into the patient’s skull. I left out the “lazy shit” label from Johnny’s mom.

Dr. Chang had no immediate answer, and I interpreted her silence as tacit damning of Johnny’s fate. She opened her mouth and a flood of words began pouring out. “You know my twin daughters Meredith and Melody, who are sophomores at Stanford? They worked their butts off in high school. They were both straight-A students. Meredith captained the varsity water polo team, played saxophone in the jazz band, and started a non-profit charity foundation for an orphanage in Costa Rica. Melody was on the debate team and the varsity tennis team, and for three years she worked with Alzheimer patients at a nursing home in Palo Alto. Meredith and Melody were sweating bullets waiting to hear if Stanford would accept them, even though they were both legacies since I went to undergrad and med school here.

“The college admission game is a bitch, Nico. It’s not like when we were kids. It’s almost impossible to get into a great school without some kind of massive gimmick. It’s a fact that Harvard rejects 75% of the high school valedictorians that apply. Can you believe that?”

I could believe it. And I didn’t really care, since my only kid was at this moment freaking out because his grades qualified him for San Jose State, not the Ivy League. I didn’t care to hear any more about the Chang daughters right now, either. To listen to Judith Chang, her daughters were the second and third coming of Judith Chang, destined for world domination. I was envious of the Chang sisters’ academic successes—what parent wouldn’t be? But I didn’t want to compare them to my own son.

“What are Johnny’s test scores like?” Dr. Chang said.

Ah, a bright spot, I thought. “He’s always excelled at taking standardized tests. His SAT reading, math, and writing scores are all at the 98th percentile or better. His grade point average and class rank don’t match his test scores.”

“Does he have many extracurricular activities?”

“Johnny’s extracurricular activities consist mostly of watching TV and playing games on his laptop. At the same time,” I said, as if the combination of the two pastimes signaled a superior intellect.

Dr. Chang grew quiet again. More silent condemnation of my son’s prospects. “Listen to me,” she said. “My brother is a pharmacist in Sioux Falls, South Dakota. His son got accepted to Princeton, and let me tell you, my nephew isn’t that bright. His test scores aren’t anywhere near as high as Johnny’s. But he just happens to live in South Dakota. He just happens to be a straight-A student in a rural state. He just happens to be one of the best students in South Dakota.”

“How much do you think that matters?”

“It matters big time. The top schools want geographic variety in their student body. Stanford wants diversity. The Ivy League wants diversity. Princeton can find fifty kids from Palo Alto who meet their admission requirements. They want kids from all walks of life. They want … the son of a pharmacist from Podunk, South Dakota. If Johnny lived in South Dakota, with those test scores he’d be a shoo-in with the Ivy League admissions committees.”

Judith Chang turned her back on the operating room table, and peeled off her surgical gloves. The bony plate was back in place, and her patient’s skull was intact again. The surgical resident would conclude the task of sewing the skin closed. Dr. Chang paused for a moment, turned her palms upward, and said, “Just move to the Dakotas, Nico.”

I stroked my chin. She made it sound so easy.

*
*
*
*

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

 

 

SERIALIZATION OF THE DOCTOR AND MR. DYLAN… CHAPTER ONE

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

1) GOING, GOING, GONE

            first-degree murder n. an unlawful killing which is deliberate and premeditated (planned, after lying in wait, by poison or as part of a scheme)

My name is Dr. Nico Antone. I’m an anesthesiologist, and my job is to keep people alive. Nothing could inspire me to harm a patient. Alexandra Antone was my wife. Alexandra and I hadn’t lived together for nearly a year. I dreaded every encounter with the woman. I wished she would board a boat, sail off into the sunset, and never return. She needed an urgent appendectomy on a snowy winter morning in a small Minnesota town. Anesthetist options were limited.

Life is a series of choices. I chose to be my wife’s doctor. It was an opportunity to silence her, and I took it.

Before her surgery, Alexandra reclined awake on the operating room table. Her eyes were closed, and she was unaware I’d entered the room. She was dressed in a faded paisley surgical gown, and she looked like a spook—her hair flying out from a bouffant cap, her eye makeup smeared, and the creases on her forehead looking deeper than I’d ever seen them. I stood above her and felt an absurd distance from the whole situation.

Alexandra opened her eyes and moaned, “Oh, God. Can you people just get this surgery over with? I feel like crap. When is Nico going to get here?”

“I’m three feet away from you,” I said.

Alexandra’s face lit up at the sound of my voice. She craned her neck to look at me and said, “You’re here. For a change I’m glad to see you.”

I ground my teeth. My wife’s condescending tone never ceased to irritate me. I turned away from her and said, “Give me a few minutes to review your medical records.” She’d arrived at the Emergency Room with abdominal pain at 1 a.m., and an ultrasound confirmed that her appendix was inflamed. Other than an elevated white blood cell count, all her laboratory results were normal. She already had an intravenous line in place, and she’d received a dose of morphine in the Emergency Room.

“Are you in pain?” I said.

Her eyes were dull, narcotized—pinpoint pupils under drooping lids. “I like the morphine,” she said. “Give me more.”

Another command. For two decades she’d worked hard to control every aspect of my life. I ignored her request and said, “I need to go over a few things with you first. In a few minutes, I’ll give you the anesthetic through your IV. You won’t have any pain or awareness, and I’ll be here with you the whole time you’re asleep.”

“Perfect,” she oozed.

“When you wake up afterward, you’ll feel drowsy and reasonably comfortable. As the general anesthetic fades and you awaken more, you may feel pain at the surgical site. You can request more morphine, and the nurse in the recovery room will give it to you.”

“Yes. More morphine would be nice.”

“During the surgery you’ll have a breathing tube in your throat. I’ll take it out before you wake up, and you’ll likely have a sore throat after the surgery. About one patient out of ten is nauseated after anesthesia. These are the common risks. The chance of anything more serious going wrong with your heart, lungs or brain isn’t zero, but it’s very, very close to zero. Do you have any questions?”

“No,” she sighed. “I’m sure you are very good at doing this. You’ve always been good at making me fall asleep.”

I rolled my eyes at her feeble joke. I stood at the anesthesia workstation and reviewed my checklist. The anesthesia machine, monitors, airway equipment, and necessary drugs were set up and ready to go. I filled a 20 cc syringe with the sedative propofol and a second syringe with 40 mg of the paralyzing drug rocuronium.

“I’m going to let you breathe some oxygen now,” I said as I lowered the anesthesia mask over Alexandra’s face.

She said, “Remember, no matter how much you might hate me, Nico, I’m still the mother of your child.”

Enough talk. I wanted her gone. I took a deep breath, exhaled slowly, and injected the anesthetic into her intravenous line. The milky whiteness of the propofol disappeared into the vein of her arm, and Alexandra Antone went to sleep for the last time.

*
*
*
*

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

 

 

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

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

“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?

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

INEXPERIENCED DOCTORS, OVERCONFIDENT DOCTORS, AND YOU

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

THE JULY EFFECT AND THE NOVEMBER EFFECT: In American teaching hospitals, newly minted doctors begin internships each July. The term “July Effect” was coined to describe this shift change in academic hospitals each July, when the arrival of inexperienced doctors may increase the risks of medical care. In the United Kingdom, newly minted doctors begin their internships each August. In Britain, August has been referred to as the “Killing Season,” because of a perceived increased risk of medical complications, morbidity, and mortality with new doctors during their first month on duty.

In American teaching hospitals, newly minted doctors begin internships each July. The term “July Effect” was coined to describe this shift change in academic hospitals each July, when the arrival of inexperienced doctors may increase the risks of medical care. In the United Kingdom, newly minted doctors begin their internships each August. In Britain, August has been referred to as the “Killing Season,” because of a perceived increased risk of medical complications, morbidity, and mortality with new doctors during their first month on duty.

Phillips found medication errors increased 10% during the month of July at American teaching hospitals, but not at neighboring community hospitals (1). In England, an Imperial College London study of records for 300,000 patients at 170 hospitals from 2000 and 2008 found death rates were 6% higher on the first Wednesday in August than on the previous Wednesday (2).

Multiple other studies have shown no change in mortality in American teaching hospitals in July, but the July Effect has real elements. There’s no way the competence of an academic hospital’s physician staff on July 1st can compare with that same hospital’s staff on June 30th. In the specialty of internal medicine, a residency is three years long (the first year of residency is also referred to as an internship). Each July 1st, third-year residents graduate and new medical school graduates replace one-third of the internal medicine team.

Imagine if a corporation like Google, Apple, Facebook, or General Electric dismissed one-third of their workforce once a year. There ‘s no way a company could be as productive after the change.

An anesthesia residency is three years long, preceded by one year of internship. One year after medical school, the same graduate who just completed twelve months of internship now reaches perhaps an even more difficult transition—the first months of anesthesia residency. Instead of writing histories, examining patients, making diagnoses, and prescribing medications as interns and internal medicine doctors do, anesthesia residents are rendering their patients unconscious, applying acute pharmacology, and inserting tubes and needles into patients in operating rooms at all hours of the day and night.

On July 1st of the first day of my anesthesia residency I reported at 0630 hours to the San Jose, California county hospital where I was assigned. I walked into the operating room and stared at the collection of anesthesia apparatus with complete bewilderment. I had no idea how the patient would even be connected to the anesthesia machine. As it turned out, the hoses that exited the machine weren’t installed yet, because I’d arrived before the anesthesia technicians who stocked the operating rooms. When it was time to begin the first anesthetic, the attending faculty anesthesiologist said to me, “I don’t think the operating room is a good place to learn in the beginning.” He injected sodium pentothal into the patient’s IV, placed the breathing tube into the patient’s windpipe, and hooked the patient up to the anesthesia machine. After ten minutes, he left to pursue other duties. I was alone, under-informed, and full of dread. I was on call that same night, and spent twenty-four hours in the hospital enduring case after case until six the next morning. When I left the hospital I had some rudimentary knowledge of how an anesthetic was done, but I’d failed to successfully place a breathing tube into any patient’s windpipe myself—a faculty member had to do every procedure for me. At the conclusion of the last anesthetic, I turned off the isoflurane (the predominant gas anesthetic at the time), switched off the ventilator, and waited, wondering why the patient wasn’t waking up. Many days later I learned that the isoflurane had no way to escape the patient’s lungs or brain unless I kept the ventilator on and continued ventilation of the patient’s lungs.

Anesthesia education today has improved since the 1980’s when I was a first-year resident, but the same themes persist. First-month trainees are very inexperienced. A supervising attending must teach them, mentor them, and lecture them—case by case—until each resident learns the basic skills.

Every month during anesthesia residency, the calendar turns to a new page and a new set of challenges. New rotations include specialty services in obstetrical anesthesia, pediatric anesthesia, trauma anesthesia, cardiac anesthesia, or regional block anesthesia. The most complex cases are saved for the second and third years of residency, but first-year residents will rotate through perhaps 80% of the array of cases during their first twelve months. During the earliest months of training, first-year anesthesia residents gain skills in the basic tasks of placing breathing tubes, intravenous lines, spinal blocks, epidural blocks, and arterial lines. They begin to feel confidence, and the anxiety of July fades.

It’s best if the jitters never fade away completely.

In my fifth year as an anesthesiologist, I was an attending at Stanford University, and I greeted one of my senior colleagues outside the locker room one morning. I asked him how he was doing, and he said, “I’m OK except for the customary pre-anesthesia anxiety.”

“What do you mean?” I said.

“Every morning I have to cope with the reality of what I do. I’m taking patients’ lives into my hands, and I can’t screw up.”

Think about that. Those workers at Google, Apple, Facebook, or General Electric have work pressures, but none of them has anxiety that they could harm a patient’s life forever.

Beyond the July Effect is the “November Effect.” The November Effect is the time when a physician feels confidence—even cockiness—and senses that they are well trained, experienced, in control, and can handle almost anything. The path to the November Effect is circuitous and the timing is variable. When I was an anesthesia resident, several of my colleagues never got there. One colleague succumbed to the stress of late night emergency anesthesia induction. He described to me the ordeal of trying to place a breathing tube urgently into a surgical patient who had a belly full of pizza and beer. I still remember the anesthesiologist’s face as he told the story. His eyes bugged out, his cheeks were pale, and he said, “I underestimated this specialty. I can’t do this for a whole career.” He quit. A second colleague had a near-disaster during the induction of anesthesia for an emergency Cesarean section. His anesthesia machine had no oxygen flow, so he blew into the mother’s breathing tube with his own mouth to keep the patient oxygenated. The patient and her baby survived, but his assessment was, “I can’t do this as a career. I need something less stressful.” He quit, too.

In November of my second year as an anesthesia resident I had 16 months of anesthesia training under my belt. I’d gained the swagger that comes with accomplishment, and lost some of the respect for the dangers of my specialty. I was on call in the hospital for obstetrics one night, and I tried to handle an emergency Cesarean section surgery at 1 a.m. by myself before my anesthesia faculty member arrived to assist me. I’ve chronicled the tale in a previous column (http://theanesthesiaconsultant.com/2012/07/15/an-anesthesia-anecdote-an-inept-anesthesia-provider-can-kill-a-patient-in-less-than-two-minutes). I was unable to place the patient’s breathing tube, she ran out of oxygen, and I thought I’d killed both her and her baby. My attending arrived in the nick of time, entered the operating room donned in his street clothes, and saved the day for all of us.

It was November, not July. I didn’t think I was a novice, but I was. It takes years, maybe a lifetime, to become an expert at anesthesia. Per Malcolm Gladwell’s book Outliers it takes 10,000 hours to become an expert at anything. For the specialty of anesthesia, even if one works 60 hours a week—which translates to about 3000 hours a year—it will take more than three years time to become an expert.

Even after those 10,000 hours, every patient presents a unique opportunity for events to stray from routine. Any case could go awry—there could be an unanticipated allergic reaction, an unexpected surgical bleed, an airway emergency or a mistaken diagnosis. Safe anesthesia practice demands a respectful level of anxiety at all times. Like a Boy Scout, an anesthesiologist needs to be prepared at all times.

Physician overconfidence is a current area of study. Meyer looked at 118 physicians who were each given 4 cases to diagnose (3). Two cases were easy and two were difficult, and the physicians were also asked how confident they were that they’d made the correct diagnosis. The physicians got 55% of the diagnoses correct for the two easier cases, and only 5% of the diagnoses correct for the more difficult cases. On a scale of 0-10, physicians rated their confidence as 7.2 on average for the easier cases, but as 6.4 on average for the more difficult cases. Physicians still had a very high level of confidence, even though their diagnostic accuracy dropped to a mere 5%. This was a striking statistic. Even physicians who are fully trained can be overconfident and can make misdiagnoses. Further data regarding physician overconfidence and how to correct it are welcomed.

An anesthesiologist’s work requires rapid, complex decisions that can be very susceptible to decision errors. Anesthesiologists work in a complex environment in the operating room, a setting where there is little room for mistakes. In acute care medicine, be it in the operating room, the emergency room, a battlefield, or an intensive care unit, the correct management of Airway-Breathing-Circulation is imperative to keep patients alive and well. Errors, be they caused by inexperience or overconfidence, can result in dire complications.

What does this mean for you?

If you’re a patient be wary of inexperienced doctors at a teaching hospital, especially in July and August. You might bring a friend or family member as a patient advocate to assure that more senior and experienced attending physicians are involved in your case. If you’re a patient and dealing with a confident doctor, be aware that confidence is not always well founded. Be skeptical of overconfidence and ask questions.

If you’re an anesthesiologist, look inward and assess whether you’re inexperienced or whether you tend toward overconfidence. Know yourself and better yourself. If you are inexperienced, then gain experience. If you tend to be overconfident, then humble yourself before the practice of medicine humbles you.

References:

(1) Phillips DP et al, A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents; J Gen Intern Med, May 2010;25(8): 774–779.

(2) Will patients really die this week because of new NHS hospital doctors? The Guardian. Retrieved 28 September 2013.

(3) Meyer ND et al, Physician’s Diagnostic Accuracy, Confidence, and Resource Requests, JAMA Intern Med. 2013;173(21):152-58.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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*
*

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

THE ACHILLES’ HEEL OF ANESTHESIOLOGY… WHAT IS THE GREATEST THREAT TO OUR SPECIALTY?

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

Anesthesiology is a wonderful profession, as I have described in many previous posts on theanesthesiaconsultant.com. But nothing is perfect, and anesthesia has one threat which could in time undermine the entire specialty. What is this threat? What is anesthesiology’s Achilles’ heel?

No, it’s not the nurse anesthetists, nor the stress of covering surgeries in the middle of the night, nor the stress of saving patients who are trying to die in front of our eyes during acute care emergencies.

Our Achilles’ heel is that we don’t have our own patients.

Primary care doctors have a bevy of patients who return to see them at regular intervals. Specialists and surgeons have a clinic full of patients who are referred to them from primary care physicians. Health care systems are acquiring primary care providers and top specialists as rapidly as they can, to assemble a sizable network of covered lives. This network of patients will serve to keep their clinics and hospitals full and profitable.

In the operating rooms, the patients are brought in by the surgeons. Anesthesia providers, be they physician anesthesiologists or nurse anesthetists, are tasked with providing safe and quality anesthesia care. Anesthesia providers are at best consultants, and at worst, “worker bees” called upon to provide a service.

Which of the following are commodities?

  1. Crude Oil
  2. Copper
  3. Soy beans
  4. Anesthesia services
  5. All of the above

Consider the answer to be E.

To hospital administrators and CEOs, anesthesia “worker bees” can be considered an expense or a commodity, somewhat similar to registered nurses, orderlies, surgical technicians, or even janitors. We can be regarded as a commodity because, like the nurses, technicians, and janitors, patient referrals do not originate with us. To a hospital CEO, each surgeon is an asset who brings surgical patients to surgery, whereas each anesthesia provider may be thought of as a worker necessary to do surgery.

Note that anesthesiologists who specialize in pain medicine in a clinic setting can be exceptions to this discussion. Pain specialists can generate their own patients from their clinics on which to do pain-relieving procedures. In their operating room role they more resemble the niche of a surgeon than that of an anesthetist.

In the current medical economy, when a hospital CEO, a health care system, or a surgery center is looking for anesthesia coverage, a priority is to acquire quality service of these anesthesia “worker bees” at the lowest possible cost. The hospital CEO, health care system, or surgery center may then grant an exclusive contract to the cheapest provider. This exclusive contract may go to a national anesthesia company, rather than the anesthesiologists currently on staff, or this exclusive contract may go to a newly hired anesthesia chairman, empowered to hire a new staff of anesthesiologists or nurse anesthetists at a budget rate.

You may be an outstanding anesthesiologist, but you are replaceable. Your anesthesia group may be an outstanding group, but your whole group is replaceable.

There are problems even if your group has an exclusive contract. Per the California Society of Anesthesiologists’ Dr. Keith Chamberlain, negative aspects of an anesthesia exclusive contract include:

  • “You can lose an exclusive contract. Anesthesia job security is based on quality, service, and (more recently) cost. Today, 80 per cent of anesthesia groups receive some subsidy from hospitals, which are strongly motivated to reduce it. Competitors often approach hospitals with business plans that eliminate the subsidy, and the decision for the hospital often comes down to cost. If your hospital privileges are tied to an exclusive contract, your ability to continue to practice will depend on your relationship with the new contract holder.
  • The contract holder will eventually experience pressure from the hospital to contract with its payers. There may be a phrase in the contract about “cooperation” with payers. Frequently this means that the contract holder must agree to a contract rate—good or bad.
  • If case volume or the number of anesthetizing locations increases, the contract may insist on the availability of additional providers, regardless of OR inefficiency or payer mix.
  • Many standard contracts allow either party to terminate without cause on 90 days following the first anniversary.”

(http://members.csahq.org/blog/2014/07/21/dont-count-exclusive-contract)

An Internet search documents specific examples of anesthesiology groups losing their jobs around the United States:

  • From Oregon, in 2010: “Turmoil at Good Samaritan: Up to 23 anesthesiologists will lose their jobs in September when Legacy Good Samaritan ends its contract with the Oregon Anesthesiology Group. The hospital plans to replace the doctors with nurse anesthetists. Unhappy physicians and their supporters have raised concerns about whether the switch puts cost savings ahead of patient safety (nurses make less than docs). Legacy spokesman Brian Terrett says the hospital will gain more control but not benefit financially from the transition because anesthesia costs are billed to patients. He added that the nurse anesthetists will be fully credentialed and supervised by doctors.” Willamette Week: July 7, 2010(https://www.oregon-crna.org/site/content/23-anesthesiologists-will-lose-their-jobs-september)
  • From the state of Virginia, in 2015: “A conflict between Riverside Regional Medical Center and its former anesthesia company has escalated to the point that Riverside is unable to perform open-heart surgery until April 23. Riverside did not renew its contract with Virginia Anesthesia and Perioperative Care Specialists and last week brought a new anesthesia company on board…. What happened? Riverside Regional Medical Center ended a long-standing relationship with a local anesthesiology group, Virginia Anesthesia and Perioperative Care Specialists, and contracted with a national management company, Soma Health Partners, effective April 7. Texas-based Soma is bringing in new anesthesiologists because, contractually, the local company’s employees cannot join the new company for two years.”( http://www.dailypress.com/news/dp-local_riverside_0415apr15,0,5448759.story?track=rss)
  • From California, in 2011: In her blog, A Penned Point, Dr. Karen Sibert writes “At Kaweah Delta Medical Center in Visalia, hospital administrators put out the anesthesia contract for competitive bidding in 2011, and the all-MD anesthesia group that had held the contract for years lost out to Somnia.  A new anesthesiology chief came on board, and a care team model with nurse anesthetists took over.” (http://apennedpoint.com)

What can anesthesiologists do to respond to this Achilles’ heel threat and create better job security? To reduce the urge for a hospital CEO to displace their current anesthesia providers, you need to:

  1. Provide the highest quality of medical care to your hospital and surgery centers.
  2. Provide high service to your hospital and surgery centers.
  3. Maintain high quality professional relationships with surgeons, other physician specialties, and administrators, so there is little incentive to demand a change.
  4. Become involved in hospital medical committees and politics, both for self-preservation and because these are roles typically filled by physicians, not nurse anesthetists.
  5. Avoid greed in negotiations over contracted rates and hospital stipends. By all means acquire the best deal you can, but realize that unreasonable expectations for monetary reimbursement may give the CEO an incentive to seek bids from a national anesthesia company or an alternative anesthesia group.
  6. Consider moving toward the new Perioperative Surgical Home model, as advocated by the American Society of Anesthesiologists. The PSH is a means for anesthesiologists to become valuable preoperative and postoperative necessities for their health care system, rather than just operating room anesthesia providers (which are easier to replace).

Hospital administrators and CEOs are trained to manage the bottom line. They will consider all reasonable means to reduce expenses. Be aware that your anesthesia group can be seen as a replaceable commodity. Consider points 1 – 6 above, and try not to give your hospital administrator a reason to look elsewhere for anesthesia coverage.

 

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?

 

*
*
*
*

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

 

 

DR. NOVAK’S DEBUT NOVEL: THE DOCTOR AND MR. DYLAN

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
Published in 2017:  The second edition of THE DOCTOR AND MR. DYLAN, a legal mystery which blends anesthesiology and the legacy of Nobel laureate Bob Dylan.

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

41wlRoWITkL

Why does an anesthesiologist write a novel?

Anesthesiology is fascinating. We anesthetize patients for operations of every kind, from cardiac, brain, and abdominal surgeries to trauma and organ transplant surgeries. We anesthetize people of all ages from newborns to one-hundred-year-olds, relieve the pain of childbirth and chronic malignancies, and attend to all types of individuals from millionaires to the homeless. No one knows the breadth of human suffering and recovery better than a physician, and no physician sees a wider range of patients than an anesthesiologist.

The story of The Doctor and Mr. Dylan deals with an anesthesia complication, a crumbling marriage, a son’s quest for elite college admission, and a courtroom drama, all set in Bob Dylan’s hometown of Hibbing, Minnesota.

Stanford professor Dr. Nico Antone leaves the wife he hates and the Stanford job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

 Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ FargoThe Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.

The opening pages to THE DOCTOR AND MR. DYLAN follow:

CHAPTER 1) GOING, GOING, GONE

            first-degree murder n. an unlawful killing which is deliberate and premeditated (planned, after lying in wait, by poison or as part of a scheme)

My name is Dr. Nico Antone. I’m an anesthesiologist, and my job is to keep people alive. Nothing could inspire me to harm a patient. Alexandra Antone was my wife. Alexandra and I hadn’t lived together for nearly a year. I dreaded every encounter with the woman. I wished she would board a boat, sail off into the sunset, and never return. She needed an urgent appendectomy on a snowy winter morning in a small Minnesota town. Anesthetist options were limited.

Life is a series of choices. I chose to be my wife’s doctor. It was an opportunity to silence her, and I took it.

Before her surgery, Alexandra reclined awake on the operating room table. Her eyes were closed, and she was unaware I’d entered the room. She was dressed in a faded paisley surgical gown, and she looked like a spook—her hair flying out from a bouffant cap, her eye makeup smeared, and the creases on her forehead looking deeper than I’d ever seen them. I stood above her and felt an absurd distance from the whole situation.

Alexandra opened her eyes and moaned, “Oh, God. Can you people just get this surgery over with? I feel like crap. When is Nico going to get here?”

“I’m three feet away from you,” I said.

Alexandra’s face lit up at the sound of my voice. She craned her neck to look at me and said, “You’re here. For a change I’m glad to see you.”

I ground my teeth. My wife’s condescending tone never ceased to irritate me. I turned away from her and said, “Give me a few minutes to review your medical records.” She’d arrived at the Emergency Room with abdominal pain at 1 a.m., and an ultrasound confirmed that her appendix was inflamed. Other than an elevated white blood cell count, all her laboratory results were normal. She already had an intravenous line in place, and she’d received a dose of morphine in the Emergency Room.

“Are you in pain?” I said.

Her eyes were dull, narcotized—pinpoint pupils under drooping lids. “I like the morphine,” she said. “Give me more.”

Another command. For two decades she’d worked hard to control every aspect of my life. I ignored her request and said, “I need to go over a few things with you first. In a few minutes, I’ll give you the anesthetic through your IV. You won’t have any pain or awareness, and I’ll be here with you the whole time you’re asleep.”

“Perfect,” she oozed.

“When you wake up afterward, you’ll feel drowsy and reasonably comfortable. As the general anesthetic fades and you awaken more, you may feel pain at the surgical site. You can request more morphine, and the nurse in the recovery room will give it to you.”

“Yes. More morphine would be nice.”

“During the surgery you’ll have a breathing tube in your throat. I’ll take it out before you wake up, and you’ll likely have a sore throat after the surgery. About one patient out of ten is nauseated after anesthesia. These are the common risks. The chance of anything more serious going wrong with your heart, lungs or brain isn’t zero, but it’s very, very close to zero. Do you have any questions?”

“No,” she sighed. “I’m sure you are very good at doing this. You’ve always been good at making me fall asleep.”

I rolled my eyes at her feeble joke. I stood at the anesthesia workstation and reviewed my checklist. The anesthesia machine, monitors, airway equipment, and necessary drugs were set up and ready to go. I filled a 20 cc syringe with the sedative propofol and a second syringe with 40 mg of the paralyzing drug rocuronium.

“I’m going to let you breathe some oxygen now,” I said as I lowered the anesthesia mask over Alexandra’s face.

She said, “Remember, no matter how much you might hate me, Nico, I’m still the mother of your child.”

Enough talk. I wanted her gone. I took a deep breath, exhaled slowly, and injected the anesthetic into her intravenous line. The milky whiteness of the propofol disappeared into the vein of her arm, and Alexandra Antone went to sleep for the last time.

CHAPTER 2) A PHARMACIST’S SON IN SOUTH DAKOTA

Eight months earlier

My cell phone pinged with a text message from my son Johnny. The text read:

911 call me

I was administering an anesthetic to a 41-year-old woman in an operating room at Stanford University, while a neurosurgeon worked to remove a meningioma tumor from her brain. I stood near my patient’s feet in an anesthesia cockpit surrounded by two ventilator hoses, three intravenous lines, and four computer monitor screens. Ten syringes loaded with ten different drugs lay on the table before me. My job was to control my patient’s breathing, blood pressure, and level of unconsciousness, but at that moment I could only stare at my cell phone as my heart rate climbed.

                                                                       911 call me

911? My son was in trouble, and I was stuck in surgery, unable to leave. I wanted to contact Johnny as soon as possible, but my patient was asleep, paralyzed, and helpless. Her life was my responsibility. I scanned the operating room monitors and confirmed that her vital signs were perfect. I had to make a decision: should I call him now, or attend to my anesthetic and call after the surgery was over? My patient was stable, and my son was in danger. I pulled out my cell phone and dialed his number. He picked up after the first ring….

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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.

 

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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

HOW MANY SYRINGES DOES IT TAKE TO GIVE A GENERAL ANESTHETIC?

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’re setting up to give anesthesia for a laparoscopic cholecystectomy.  How many syringes and labels do you draw up and prepare?  For a D & C?  For an open abdominal aortic aneurysm repair?

Discussion:  Try something new.  When  preparing for a cholecystectomy, open two syringes, both unlabelled, and don’t open any ampules until the patient is in the OR.  More on that later.

Let’s examine two questions:  Why do we label syringes, and why do we load syringes with drugs ahead of time?  The answer to the first question is easy — we label syringes because we want to know what’s inside of them.  The Institute of Medicine’s report from 1999, entitled, To Err is Human:  Building a Safer Health Care System, reported that 98,000 patients died in U.S. hospitals each year due to medical errors.  Administering the wrong drug is a known anesthesia risk which we all try to avoid.

In a study of 55,426 anesthetics in Norway over 36 months, drug error was reported in 63 cases, or 0.11% of cases. (Fasting S, Can J Anaesth.2004 Oct;51(8):853-4.)  Drug errors included 28 syringe swaps, 9 ampule swaps, 8 ‘other wrong drug’ cases, and 18 cases where the wrong dose of the correct drug was given.  In the second 18 months of their study, they switched to color-coded syringe labels, and found their results unchanged except for a decreased number of ampule swaps (P=.04).  They concluded that drug errors were uncommon, that syringe swaps occurred most often between syringes of equal size, and that drug errors were not eliminated by color-coding of labels.

In a study of 896 drug errors reported in Australia, syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labeled but given in error, and 187 (20.8%) due to selection of the wrong ampule or drug labeling errors. (Abeysekera A, Anaesthesia. 2005 Mar;60(3):220-7).  Contributing factors included inattention, haste, drug labeling error, communication failure, and fatigue.  Factors minimizing the events included prior experience and training.

According to the first reference, a drug error was reported about once per 1000 cases in Norway.  I’d ask you to consider how many incidents of drug error occur, versus how many are actually reported.  I submit that the real prevalence probably exceeds the amount of cases that anesthesiologists admit to, and the real prevalence is significantly greater than .11%.  And even though labeling syringes is important and mandated, it fails to decrease medication error to zero.  In the future, we may see computerized visual and auditory bar-code verification of ampules and/or labels just before drug administration.

My second question to you was “why do we load syringes with drugs ahead of time?”  Common sense answers might be, “because it makes our work more efficient,” or “we might need them fast, and we don’t want to draw the drugs up at the last moment.”  Opinions regarding the preparation of pre-drawn emergency syringes differ.  In a study from New Zealand, a quarter of respondent anesthesiologists routinely drew up emergency drugs, and a third either never or very infrequently did so(Ducat CM, Anaesth Intensive Care. 2000 Dec;28(6):692-7).  Among the drugs most commonly drawn up were succinylcholine, atropine, and ephedrine.  Pediatric, obstetric, or vascular cases were cited as factors which prompted anesthesiologists to draw up one or more of these drugs.

Drug wastage is a known to be a significant portion of anesthesia drug budgets.  In one fiscal year, the cost of unadministered drugs at Rhode Island Hospital was $165,667 (Gillerman RG, Anesth Analg. 2000 Oct;91(4):921-4).  Efficiency indexes, defined as the percent of a restocked drug that was actually administered to patients, were as follows:  succinylcholine, 33%, propofol, 49%, rocuronium, 61%, and thiopental, 31%.  In a study at UC San Diego, drug wastage was quantitated in 166 cases during  a two week period (Weinger MB, J Clin Anesth. 2001 Nov;13(7):491-7).  Based on hospital drug acquisition costs, $1802 of drugs were wasted in two weeks.  Six drugs accounted for three quarters of the total wastage:  phenylephrine (20.8%), propofol (14.5%), vecuronium (12.2%), midazolam (11.4%), labetolol (9.1%), and ephedrine (8.6%).

Think about it, my colleagues.  Do you really need to draw up atropine and ephedrine before every case?

I queried Fred Hurt from the Stanford OR Pharmacy, and he gave me the following drug ampule acquisition costs:  atropine $.23, ephedrine $.74, phenylephrine $2.47, vecuronium $2.51, rocuronium $18.89, succinylcholine $1.93, propofol 20ml $4.76, and propofol 50 ml $11.91.

I’ll admit, in the scope of the healthcare budget of the United States, these numbers are miniscule, and you may not give a damn if your unused atropine and ephedrine costs Stanford 97 cents.  But let’s go back to the first paragraph, and a technique to avoid drawing up a lot of drugs and labeling them.  Part of the rationale is to avoid drug wastage, but the greater issue is the KISS principle — Keep It Simple Stupid.  In a 20 year career you’ll do 14,000 cases, and any practice that avoids wasted time and energy on each case is of value.

Try this:  For a cholecystectomy, use an unlabelled 5 ml syringe to draw 2 mg of midazolam from its already labeled ampule, and inject it into the patient’s IV.  Minutes later, use the same syringe to draw 100 micrograms of fentanyl from its already labeled ampule, and inject it into the patient’s IV.  Then use a second syringe, a 20 ml syringe, to draw 200 mg of propofol from its already labeled ampule, and inject it into the patient’s IV.  Finally, use the first syringe to draw 10 ml of Lactated Ringers from the IV bag and inject it into an already labeled ampule of vecuronium, mix it up, and inject 0.1mg/kg of vecuronium into the patient’s IV.

Reusing the same syringe on the same patient for several single-patient use ampules is safe.  The ampules are already labeled — why add another intermediate step and store them in a labeled syringe?  The exception to this practice is for drugs that need to be diluted — this would include phenylephrine (for a case you expect you might need it, such as vascular surgery or geriatric surgery), or narcotics such as morphine and meperidine.  These syringes need to be prepared and labelled.  Syringes should not be carried over from one patient to the next.

Like Burger King used to say, “Have it your way!”  You don’t have to agree with or accept the above suggestions, but I’d be interested in hearing if you’ve changed your mind, 14,000 cases from now.

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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

 

 

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