Anesthesia, page 21
Once or twice, though, things happened that I couldn’t account for. One day as I was sitting on the couch in the room where she saw her clients I noticed a strange sensation. I was talking, I cannot recall what about. The memory is a feeling and an image: me talking, her listening, me talking and talking, and suddenly the sense that everything had shifted for a moment out of focus, as if sitting there in the room talking to my counselor was not only me but, alongside, peeking out from behind, or from within, another me, a transparent glittering sphere that now slid across into the periphery of my vision. It was as if the self that had always seemed unavoidably, irretrievably set—gummed down and clogged up in an endless cycle of thoughts and words and stories—had quietly and unaccountably detached itself, and hung now alongside me, a momentary bubble upon whose gleaming skin my life, or the version I had been recounting, was reflected back for a few seconds in fleeting iridescent colors. Provisional. Passing.
It was not an idea or a metaphor. It was a feeling, almost a vision: very precise. I can no longer recall what became of the bubble, whether it burst or floated away or simply slid back inside, but as it all took place I tried haltingly to explain to my counselor the feeling of what was happening (“Oh,” I think I said. “Oh.”) and when I looked back across at her I saw that she had tears on her face, which she wiped away with her hand, and I felt strange and light, as if nothing was solid.
It is hard to be certain, but sometimes I sense that my life is filled with such small slippages. And that what appears solid may simply be tiny islands of awareness surrounded by oceans of indeterminacy.
In any case, trying to interrogate even those parts of ourselves we are confident we do know is fraught. These days, the self that I know seems to me coherent, delineated. But in the end it is only the bits that are clear and delineated that make themselves available to be known—at least by the conscious me. In my life there are all sorts of gaps. In some of them I am sleeping, or on rare occasions fainting or even having an anesthetic, but in others I am not. In some I am failing to appear at a party at which I was to have given a speech; or to make a phone call I have promised to make; or write a letter or an email to a friend, or commit to anything much at all. “I know what you’re like,” a friend once said, neither unkindly nor happily. I sort of knew what she meant. But what was I like? What am I like? What am I like when I am not here? Is that what I am like—sometimes here, sometimes not?
It is difficult to know what to do with these gaps. Perhaps the most peaceable strategy is to ignore them. Often I do. But sometimes the gaps spread and join and become presences. Like that strange ominous feeling that has traveled with me now for so long. And these are harder to overlook.
In an attempt to shift the feeling that threatened at times to submerge me, I began practicing a Buddhist meditation technique called Tonglen. This was one in a big shapeless sack of strategies I rummaged through over the years (hypnosis, acupressure, herbs, talking therapy, walking therapy, white wine and red) to greater and lesser effect. Tonglen interested me in the ways in which it was similar to and different from anesthesia. Unlike some other meditation techniques working with the breath, Tonglen did not involve the comforting idea of breathing in things you wanted (love, light, new shoes) and breathing out all the rest; it involved instead deliberately breathing in difficulty (yours or other people’s: envy, pain, hunger, shit) and then breathing out something softer and lighter. It did not attempt to shift or excise, but rather to expand around hard things, and to bathe them in something like kindness.
Tonglen is the opposite of anesthesia. It is a decision to move into discomfort, rather than away. It wakes you up and keeps you present. The in-breath is hard work—sometimes too hard. The out-breath can be too, but after a while, if things aligned, I found it softening the muscles and membranes of my chest, loosening the taut drum of my diaphragm, sending warmth spiraling down through my body to the pelvis and igniting its tiny pilot light, buzzing the soles of my feet. It is a natural muscle relaxant. I breathe in, I breathe out. I keep breathing. I come along for the ride.
I suppose, without knowing it, Rachel Benmayor might have been practicing her own form of Tonglen when she turned around and burrowed into her pain that day on the operating table, until she pushed her way through and found herself in a vast space.
About halfway through the process of writing this book, I arrived for a two-week residency at Varuna, during which I had hoped to map out the structure of the book and work out exactly what it was I was trying to say. I knew I was writing a book about anesthesia, but I didn’t know why. Nor did I know why it mattered to me that I didn’t know. Why does anyone do anything? What I was struggling with during my stay at the yellow house, however, was not simply why I was writing (and consequently, I felt, what I was really writing about), but who was doing the writing. There seemed to be two “me”s—each with their own agendas and itineraries and neither able or prepared to communicate with the other. Everything one wrote, the other rejected. One I will call the journalist—a pragmatic procedural self, this “me” positioned myself as the objective observer reporting on what I found in my travels. The other I will call the dreamer. Not in the romantic sense, but the dreamer as fool, blundering around, kicking up fragments of a different story.
To the journalist this seemed highly suspect. It is one thing to have the “I”—the so-called “vertical pronoun”—writing itself into the story, offering opinions, musings and other such personal flourishes. But to have the “I” as a subject of research—to take the vertical pronoun and lay it on the psychoanalyst’s couch, or perhaps the surgeon’s trolley (the pronoun now prone, horizontal)—seemed improper: self-regarding.
And yet every time I tried to harness my “I” and wrest the book into a respectable journalistic narrative, it would thwart me. I would stand my pronoun ramrod straight, only to find it drooping and then subsiding wanly to the ground. Sometimes I would give in and decide to let it lie, only to be heckled by my conscious mind. Do you really think anyone cares? Get up! And so on. For several years already I had ricocheted between these two impulses, unable to reconcile them.
Finally, before this visit to the yellow house, I reached a decision that seemed firm. I would write a book about anesthesia: its triumphs, its complexities and its perils. I would report in the first person—the pronoun standing duly to attention—about the people I had interviewed and about what I knew to be true. I would speculate modestly about the myriad uncertainties of a science that even practitioners agree is more of an art, and which involves the removal or alteration of an entity—consciousness—that we cannot yet define, let alone understand.
Above all, I would remain in control.
•
I am trying to find my dog, which is going to be put down. Not a dog I live with in my waking life, but another, a black Labrador. The dog has already been taken away and is awaiting its death at a pound on the edge of town. This awful knowledge permeates my sleep. When I get there, however, my dog has gone. In its place, lying sick and exhausted on the concrete floor inside a large cage, is a young, very beautiful red setter. As I enter, the creature raises its head toward me and I see with slow shock that its muzzle has been sewn up with fishing line. The red dog pulls itself off the ground and limps toward me. Rising on its hind legs, it puts its forelegs on my shoulders, and rests its head against the left side of my neck. I can sense it begging me to save it. I feel great pity; I embrace and try to comfort it. But there is no sense that I can or will do anything to help it. The burden would be too great. Words come into my head. The dog’s name: Gadget. (Why Gadget? I wonder, even in the dream.) Then the thought—with which I am already justifying my decision to abandon it—that red setters are not very intelligent dogs. I step away. The animal stands there, hopeless. I touch it on the back and I leave.
What to do with a dream like that?
Over time, various astute readers have suggested to me that this particular dream might not belong in this particular book, that it is a dream that emanates from somewhere else and that ought to be left there. Yet to me the dream—that image of the silent, silenced dog—seems not only a visceral evocation of the plight of a person who might be both anesthetized and aware, but also to signify the chasm that exists between the conscious and unconscious minds: the one wordy, knowing, exclusive; the other voiceless, persistent, inclusive.
In the quiet after waking I lay curled on my side suffused with the knowledge of irrevocable loss. I had betrayed the red dog. And in doing so I understood that I had disavowed some helpless, voiceless part of me. The dream did not feel like a dream. The house was still and very dark. I did not know what the dog had been trying to say, but I could still feel almost physically the place above my left shoulder where it had nuzzled its head against my neck, and I accepted finally that I could not write this book without it.
General amnesia
June 2007. In a small room that leads into the operating theater, a middle-aged woman lies on a metal trolley. Her hair has recently been tinted with a soft gold rinse and she makes small talk with the staff before she is wheeled in to the theater. She is here for a hysterectomy, though no one mentions this, or the fact that she has cancer, which the doctors are hoping to contain by removing her womb. She has a cannula taped to the back of her left hand through which her anesthesiologist—a craggy compact man, handsome, with dark hair graying at the temples and deep-set eyes—will shortly administer a milky drug called propofol.
The anesthesiologist is Ian Russell. The woman, whom I will call Jenny, answers Russell’s questions in bright monosyllables and rolls onto her side and bends her knees obligingly to her stomach, as instructed, for the trainee anesthesiologist to insert first the injection of local anesthetic to the skin and then the epidural cannula through which the nerve-blocking drug will be pumped to switch off sensation in her lower torso. The doctors give directions and make small, cheerful jokes. “[This will be a] little bit ticklish,” says Russell, as the needle is about to enter, and then when Jenny appears not to notice, “Not ticklish. You’re no fun!”
Jenny laughs thinly.
“Awrigh’, nice and still then, darlin’,” says one of the assistants.
As he works, Russell issues instructions and explanations to the trainee anesthesiologist who is still trying to insert between two vertebrae the implausibly large epidural needle. Then we move through the double doors into an operating theater the size of a small classroom, with muted pink and blue linoleum tiles. ABBA on the radio: SOS. Machines bleat and instruments clatter as Russell and his trainee attach monitors: the pulse oximeter for measuring blood oxygen levels, the blood pressure cuff, the BIS monitor with its disposable electrode stuck like an oddly shaped Band-Aid on Jenny’s forehead. Russell puts a long perpendicular strip of Perspex under her body at shoulder height; on top of it is a black mold with a concave channel running its length. This supports Jenny’s extended right arm. Then he attaches a black cuff around her forearm. It is made of some strong synthetic fabric and it reads Lyall Willis & Co. Ltd. England latex free. At her elbow he attaches two more leads that will allow him to send small electric shocks to the nerves which run down her forearm into her hand, to make sure that her nerves and hand muscles are still working when the cuff is inflated.
Russell gives the instruction to start the infusion pumps, which will push the anesthetic into her bloodstream, and then puts a gas mask over her mouth and nose. “Take a big deep breath.” Within seconds she is gone.
In 1993, as a little-known anesthesiologist from the recursive Hull, Russell published a startling study. Using a technique almost primitive in its simplicity, he monitored thirty-two women undergoing major gynecological surgery at the Hull Royal Infirmary to assess their levels of consciousness. The results convinced him to stop the trial halfway through.
The women were put to sleep with a low-dose anesthetic cocktail that had been recently lauded as providing protection against awareness. The main ingredients were the (then) relatively new drug midazolam, along with a painkiller and muscle relaxant. Before the women were anesthetized, however, Russell attached what was essentially a blood-pressure cuff around each woman’s forearm. The cuff was then tightened to act as a tourniquet that prevented the flow of blood, and therefore muscle relaxant, to the right hand. As a young intern Russell had learned the method, known as the isolated forearm technique, from its inventor, anesthesiologist Mike Tunstall. He had modified it himself to make it suitable for longer operations. By preventing the paralyzing muscle relaxant from entering a patient’s forearm, he hoped to leave open a simple but ingenious channel of communication—like a priority phone line—on the off-chance that anyone was there to answer him.
Once the women were unconscious Russell put headphones over their ears through which, throughout all but the final minutes of the operation, he played a pre-recorded one-minute continuous loop cassette. Each message would begin with Russell’s voice repeating the patient’s name twice. Then each woman would hear an identical message. “This is Doctor Russell speaking. If you can hear me I would like you to open and close the fingers of your right hand, open and close the fingers of your right hand.”
Under the study design, if a patient appeared to move her hand in response to the taped command, Russell was to hold her hand, raise one of the earpieces and say her name, then deliver this instruction: “If you can hear me squeeze my fingers.” If the woman responded, Russell would ask her to let him know, by squeezing again, if she was feeling any pain. In either of these scenarios, he would then administer a hypnotic drug to put her back to sleep. By the time he had tested thirty-two women, twenty-three had squeezed his hand when asked if they could hear. Twenty of them indicated they were in pain. At this point he stopped the study. “My approval was to do a study of sixty patients altogether,” he recalled fourteen years later, “but I couldn’t really carry on, because they were all awake, nearly, you know.” When interviewed in the recovery room, none of the women claimed to remember anything, though three days later several showed some signs of recall. Two agreed after prompting that they had been asked to do something with their right hand. Neither of them could remember what it was, but while they were thinking about it, said Russell, both involuntarily opened and closed that hand. Fourteen of the patients who responded to Russell’s question also showed some other signs of light anesthesia (increased heart rate, blood-pressure changes, sweating, tears) during surgery, however ten did not. Overall, said Russell, such physical signs “seemed of little value” in predicting intraoperative consciousness.
He concluded thus:
If the aim of general anaesthesia is to ensure that a patient has no recognisable conscious recall of surgery, and views the perioperative period [during the surgery] as a “positive” experience, then . . . [this regimen] may fulfill that requirement. However, the definition of general anaesthesia would normally include unconsciousness and freedom from pain during surgery—factors not guaranteed by this technique.
For most of the women in his study, he continued, the state of mind produced by the anesthetic could not be viewed as general anesthesia. Rather, he said, “it should be regarded as general amnesia.”
The amnesic effects of hypnotic drugs are nothing new. The patient who, in 1845, ruined Horace Wells’s demonstration by crying out as Wells pulled his tooth later claimed to remember no pain. In fact anesthesiologists—and patients—have long relied upon the fact that, along with erasing consciousness, many hypnotic drugs prevent or disrupt memory. Amnesia—forgetting—is a useful and, many would argue, desirable side effect. For most of us it ensures that our first conscious memory after surgery will be of the recovery room or ward. It also means that if, as sometimes happens, a doctor deliberately wakes you during your spinal or brain surgery to check how you are going, you will probably answer her questions politely without recalling the conversation later. In recent years however there has been an increasing reliance on new short-acting intravenous anesthetic drugs with powerful amnesic side effects. Sometimes they are used alone, sometimes in combination. One of the best known today is the sedative hypnotic midazolam—the drug that Russell was using on the women in the abandoned 1993 study. Another is propofol—the drug that he has just given Jenny to put her to sleep, and which today is probably the most popular intravenous anesthetic in the world.
These drugs have many benefits in today’s hospitals. They allow for a smoother slide into unconsciousness and, because they pass through the body relatively quickly, they allow doctors and nurse anesthetists to give patients less anesthetic—putting them at lower risk of drug-related harm and allowing them to wake up quicker, and with less nausea. Anesthesiologists love them. And so do patients, on the whole.
What we as patients may not have considered, though, is that we are likely to start losing our memory for events well before we lose our consciousness of what is happening to us.
U.S. anesthesiologist Peter Sebel has described a disconcerting plane flight during which he ate a meal and made apparently coherent conversation with a fellow passenger, after which he went to sleep and woke up remembering nothing at all of the trip. Sebel, who later headed up a major U.S. study into anesthetic awareness, had taken a low dose of a drug known as a benzodiazepine (the best known are probably Xanax and Valium, but midazolam is another). He described the experience, or lack thereof, in a 1995 editorial, “Memory During Anesthesia: Gone but Not Forgotten?”:
