Anesthesia, page 24
The solution, he said, lay in understanding the complex systems involved, and making them reliable (which is perhaps a little like saying the solution lay in introducing the hydrogen economy or solving the mystery of consciousness). In practical terms, this meant understanding how each component of anesthesia—particularly those elusive processes relating to consciousness, memory and pain—worked, and developing reliable monitors to measure them. Until then, he conceded, “it is always safer and more reassuring to err on the side of over-medication.”
Toward the end of our conversation, I told him about my father and his ether dream. Veselis told me about one of the family’s adopted dogs. This one had clearly been abused, he said, before coming to them. The animal would growl if anyone approached it from behind; and it was afraid of tall men. Veselis is a tall man. When we spoke, the dog had been with the family for fifteen years. It was still wary of Veselis, though not of his wife. It still growled if anyone came near its rump. “It is fascinating how some memories stay there no matter what you do.”
Night football. Down at the oval, the girls’ team is training. A little way back, a girl—dark glossy skin, dark glossy hair, maybe sixteen—looks on with a small ambiguous smile as the dogs, blonde and black, lollop toward where she sits, legs crossed, on a wooden bench, watching the game. At first I think she is pleased (the smile keeps flickering across her face), but then I notice the small movements of her hands. (Away. Away.) I call the dogs, who oblige for now. The girl apologizes. She’s trying to get better, she says, with dogs. I apologize back. I ask if she was ever bitten. She says that no, but when she was a small child . . . So, where is she from? Sudan. (Oh, yes, of course, the dogs.) They used to run in packs, she says, around the streets. She left when she was four. A long time ago. But anyway. Now she is trying to train herself. The black dog, more than usually silly, snuffles once more toward her. Again the slight shrinking, the wavering smile.
Veselis has warned too against doctors relying on amnestic (forgetting) drugs to erase memories of events that have already taken place (“the much sought after retrograde memory effect”). “Many practitioners remember an experience of a patient opening their eyes and looking at them when they should have been fully asleep!” he wrote in his BJA editorial on propofol. “A typical response in such a situation is to give a sizeable dose of a readily available hypnotic/sedative drug. The nervous practitioner was [sic] then reassured when no memory of this event was present at the postoperative visit.” In reality, he said, any amnesia would have been due to drugs given before the event, not afterward.
None of which would be news to Rolf Sandin, the Swedish anesthesiologist whose team in 2000 showed that patients’ ability to recall waking during surgery comes and goes depending on how long after the operation you speak with them. While benzodiazepines such as midazolam are useful for reducing anxiety, he wrote, their widespread use before surgery may have as much to do with their reputation for bringing about amnesia. This was a risky assumption, he said, given that the drug effects varied. “More importantly, we believe that to carry out anaesthesia in a way that would require deliberate pre-emptive amnesia for intraoperative experiences is ethically unsound.”
One: it may not work. Two: it shouldn’t have to.
As to how many people wake like this without later remembering; who knows? A new international study—the biggest so far—suggests that things may be quite a lot better than imagined. Or quite a lot worse. It depends on your perspective. After using the isolated forearm technique to test the responses of 260 surgical patients who had just been intubated under general anesthesia, researchers found twelve people—4.6 percent—who demonstrated what they called “connected consciousness” (connected to the outside world, that is, rather than to their dreams or other internal states); five of whom indicated they were in pain; none of whom remembered later. This is a lot less than the previous estimate of 37 percent. But a lot more than the one or two in a thousand people who generally report having been awake in large-scale trials. Twenty to fifty times more. (And this isn’t even counting the additional 7 percent who during the study moved a hand unbidden after having the tube put in, but before researchers popped the question.) Nor does it resolve the question of what it is exactly the researchers were measuring.
Ian Russell, for his part, remains convinced that a lot more patients are awake for part of their surgeries than they—or their doctors—know.
But so what?
“Robert Veselis says that might be part of adequate anesthesia,” I suggested to Russell.
“I would say that it is probably possible that it is normal anesthesia, I wouldn’t say that it was adequate anesthesia.”
Again, so what? Despite some strongly held beliefs and a well-polished collection of odd anecdotes, there is little solid evidence for those who are convinced not only that many patients may be at least partially present during surgery but that this might matter later.
In Hull in 2004, on the second day of that perplexing memory and awareness conference, psychologist Michael Wang delivered a brief verbal report about a study he had carried out with Ian Russell and another researcher, looking at the mental state of eighty women in the three months after hysterectomy surgery. Based in part on the women’s arm movements as measured by the isolated forearm technique during their operations, the researchers divided the women into two groups deemed to have been lightly anesthetized (“wakeful”) or heavily anesthetized (“non-wakeful”). None of the women reported any memories of the surgery, but psychological testing—one month and three months after surgery—showed “a consistent pattern of higher mean levels of psychopathology in the “light” group in comparison with the “deep” group.” Basically, the lightly anesthetized women were more anxious than the others.
On the same day in Hull, Wang and Russell presented another brief “poster session.” This one related to a follow-up to Russell’s disturbing 1993 study: the one he aborted after two-thirds of the supposedly unconscious women squeezed his hand to indicate that they were not only awake but in pain. Ten years later Russell, Wang and another researcher tracked down as many of the women as they could find and interviewed them about their mental health over the past decade. Although the numbers were too small for statistical analysis, the results were curious. Three patients in the group who had indicated during their surgeries that they were awake had suffered some sort of psychiatric disturbance since the operation. None of them had any previous psychiatric history. Nobody in the control group—those who had not responded to the command to squeeze Russell’s hand during the operation—showed any evidence of distress.
Wang says he and Russell would have liked to expand the studies into larger trials that might provide some more definitive answers but lacked the resources to do so. Both remain concerned about what these experiences might mean for some patients’ longer-term health.
Here is U.S. medical psychiatrist Richard Blacher writing in 1984:
It might behoove us to rethink the routine use of amnestic drugs. While these have seemed to serve a most useful purpose in creating a calm aftermath to surgery, they mainly may, in reality, protect us from hearing upsetting details from patients, details that are now stored in the cerebral cortex but no longer recalled consciously . . . [T]he unconscious storing of a traumatic memory may well act as a chronic psychic irritant . . .
Not one of the anesthesiologists I spoke with, apart from Ian Russell, supported this suggestion. Most argued in fact that it was immoral not to use amnestics, particularly if a patient was known to have been or suspected of having been awake, because traumatic memories could trigger post traumatic stress disorder. “If someone woke up in the middle of one of my anesthetics and I knew about it I would certainly give them an amnesic drug there and then,” one Australian anesthesiologist told me. “You might consider,” he continued, “that if you could forget about it and don’t remember it and don’t go into any of the post traumatic stress disorder problems, that you’ve actually treated it.” German doctor and Nobel Laureate Albert Schweitzer might have been right when he said that happiness was nothing more than good health and a bad memory. (Schweitzer’s wife, as it happens, was an anesthesiologist.) Several anesthesiologists I interviewed told me they had patients whose sole request before surgery was that they not remember anything of the operation.
I think of my son, now twenty, whom I recently retrieved after he had his wisdom teeth extracted under general anesthesia. I found him sitting up in bed, grinning hugely and scooping enormous gobs of green into his bandaged face. The nurse regarded him wryly, gestured to me the flailing of arms. “Most teenage boys wake up a bit feisty after dental surgery.” My son kept on beaming: “Jelly and ice cream! Best day ever!”
Even so, the patient may not be the only beneficiary of such oblivion.
Twenty years ago, if you were having your varicose veins treated you would have entered hospital the night before and been woken in the morning by a nurse to swallow your “premed”—usually a powerful benzodiazepine sedative such as Valium—to make you sleepy and relaxed before going into a theater. You would have woken some time after the operation, probably feeling quite nauseated, and would have spent that night in the ward before going home the next day.
Today you are more likely to arrive at the hospital on the morning of the operation and go straight to the theater, where, as part of the anesthetic brew, you will get a dose of a potent amnesic drug such as propofol. This allows doctors to use lower doses of the other anesthetic agents, meaning you wake quicker, feeling better, and go home sooner. While this has benefits for you as a patient, including a lower risk of catching a hospital-borne infection, it also saves hospitals time and money. Occasionally a lot of money. People who wake up during operations—or at least people who remember waking up—sometimes sue. Traumatized patients in the United States have reportedly been awarded damages in the hundreds of thousands of dollars. Others, including Carol Weihrer, have settled out of court.
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New York psychiatrist David Forrest has a novel theory. He believes some patients might mistake surgical staff for aliens. Some years ago Forrest, a clinical professor of psychiatry at Columbia University, came across a book by Harvard postdoctoral psychology student Susan Clancy about people who believed they had been abducted by aliens. Clancy had noted that the abductees shared similarities including a history of sleep paralysis and the ability to be hypnotized: also, perhaps unsurprisingly, “a preoccupation with the paranormal and extraterrestrial.”
Forrest went on to propose another possible link. Many of the reports of abduction, he said, bore “more than a passing resemblance to medical–surgical procedures.” In a paper presented to the American Academy of Psychoanalysis and Dynamic Psychiatry in 2007, he went on to ask:
Could dimly or subconsciously recalled memories of surgery play a part? One is in a state of altered consciousness (anesthesia), surrounded by green figures (surgeons) whose eyes are more noticeable above their masks, in a high tech ambience with a round saucer-like bright object above (the OR light), and the body’s boundaries are being breached by intubation, catheters, intravenous needles and the surgery itself. Perhaps surgery in childhood would be especially contributory . . .
He thought such forgotten memories might have been formed in the operating theater before the patient passed out, or unconsciously during surgery. Like many of the stories of alien abduction, Forrest noted, surgery involved nakedness, pain and a loss of control—yet in both scenarios the probing figures were often felt to be benevolent. The similarities, he has since argued, are too great to ignore. He also suggests that physiological changes in the heart rate, blood pressure and muscle tone of self-professed abductees might be comparable to those found in surgical patients.
(I was excited to discover, after speaking with Forrest, that during the original B-Aware study of the BIS monitor, one patient did later report having dreamed about aliens, and thinking that “aliens had taken over the operation.” It turned out, however, that theater staff had been chatting about extraterrestrials during the procedure.)
Forrest admits that his hypothesis may be hard to test, partly because it is difficult to find authentic “abductees” (as opposed to enthusiastic hoaxers) willing to participate in such formal investigations, but he says this doesn’t mean it shouldn’t be tested. If doctors are indeed causing such experiences “in a small but vulnerable proportion of the population, which still might number in the millions,” he says, “we should know about it.”
Aliens aside, this anesthetic amnesia leaves us in the strange position of not being the keepers of our own memories. Instead the experience, or at least the recollection of the experience, is owned by other people: by doctors, nurses and other staff. By strangers. In some ways of course, this is true of much of life, and most particularly childhood. We forget what others remember. Strain as I might, I can only reconstitute at will a handful of memories before the age of about five. A concrete paddling pool in a park in Wimbledon, where I lived between the ages of one and three with my parents and later my infant sister, Sarah: me at one end of the pool all but submerged, eyes level with the dark glassy expanse of water, the late afternoon sun. Another afternoon in the kitchen at Box Hill, perhaps aged five; my baby sister Jennet in the high chair; a knock at the door. Even these memories now exist more as markers, a reproduction of a memory that I used to have. Most of my early childhood exists, or can be narrated, only through the stories of my parents and to a lesser extent my sisters. And I in turn carry in my memory many of the remaining traces of my son’s and daughter’s early years. It seems to me a huge responsibility: to know so much more about a person than they can know about themselves. Or than they know that they know. (“Do you remember your fourth birthday?” asked psychiatrist Graham Burrows. “Because it’s all inside you . . .”)
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I have found a new pool. A pool that is in reality two pools, in my mind superimposed one upon or within the other. Ringed by gum trees; ringed by apartment blocks and traffic. One is close to my house, one is a little further away. Both are long and lean and topped by sky and once my head is underwater they are the same. Dappling. Sometimes, like today, when the sun is out, the dappled shadows beneath me take the form of small three-dimensional structures that skate and warp along the tiled floor just ahead of me. Fluctuating versions of those 3D models of atoms or molecules or chemical compounds I sometimes come across in books on anesthesia. Other days they stretch into an uneven whitish membrane more like the connective tissue you peel from the outside of lamb shanks. Or the shapes I see when I look into someone else’s eye. I swim with goggles, and as I track up and down, up and down, I sometimes notice a small dark filament that floats in front of me within the pool of my own eye, keeping pace as I slide above the dapples.
Today I suddenly felt that the eye, my eye, was all around me and that I was the tiny speck hanging darkly before myself, a floating spindle around which the world and all its perspectives rushed.
The perfect anesthetic
A while ago my father went into the hospital again, as an outpatient, to have a colonoscopy. After the doctors had threaded a probe through the coils of his large intestine and found, or not found, what they were looking for, someone rang my mother. She returned to the hospital where she found my father lying in the recovery room, and asked, “How did it go?” He looked at her with a weary disgruntled expression. “I don’t know. I’m still bloody waiting to go in!” This, from the point of view of Robert Veselis and almost every other anesthesiologist in the world—not to mention my father—was the perfect anesthetic.
Yet it is odd to think that my father may have been not only awake, but able to answer questions, follow instructions and perhaps even make conversation during all or part of the procedure. I picture him there in his indeterminate hospital gown, my private and dignified father, curled on his side, grunting in response to some probe or question. (Are you comfortable, Mr. Cole-Adams?) Actually, I don’t want to picture it. But it is here, within a continuum of sedative states designed to ameliorate (and distract from) the discomfort of various minor but unpleasant medical procedures, that the largely ignored ethical conundrum posed by doctors’ use of amnestic drugs is clearest. Exploiting the fact that under many anesthetics, you or I will start forgetting things well before we stop experiencing them, the practice allows doctors to place patients for a time in a sort of limbo—not quite here or there—washing around in a perceptual semi-present until the procedure is over.
When I first asked my friend who worked as a nurse in the endoscopy clinic if patients were ever awake during their procedures, she said that no, they were anesthetized. When I asked if they sometimes woke up or talked during procedures, she said again that, no, she didn’t think so. Then she thought a bit more, and said, “Mind you, there was this man the other day . . .” The man had been having an endoscopy and what she had noticed first was the gagging sounds he made as staff pushed the tube down his airway. This was not all that unusual; the gag reflex can last well after a patient is unconscious. What caught her attention, however, was that the man was blinking his eyes rapidly open and shut, open and shut. He kept doing it until the anesthesiologist gave him more propofol. Had he been awake? She didn’t know. She hoped not. He didn’t mention anything about it later.
Another day, she said, there was a minor emergency. A patient who was unconscious with a tube down his throat breathed fluid into his lungs. This is how people drown. The team immediately began suctioning the liquid out. During the drama the man woke, gasping, distressed. “It’s all right, everything’s fine,” my friend heard staff tell him. “You’re just waking up in recovery. You’ve been having a dream.”
