Anesthesia, page 29
But I suspected that for all their intellectual heft and technological whizz-bangery, what these breakthroughs were on the way to solving was philosopher David Chalmers’s easy problem. And what interested me much more was the hard one.
That may be why I felt more comfortable sitting one scrappy autumn day in a not-very-nice outdoor cafe on Circular Quay with my old acquaintance Michael Wang, the British psychologist. And why I perked up when he said, “I have to say this stuff doesn’t turn me on.”
Wang (stripy T-shirt, blue cap, the big open smile of a man who has just spent a week sailing the Great Barrier Reef) said the preoccupation with multi-million-dollar brain imaging machines was distorting the research agenda, imposing hi-tech solutions on a problem whose parameters had not yet been adequately defined. “I think there’s an awful lot of stuff in neuroscience literature that is totally without merit or meaning in terms of—well you found one little part of your brain lit up or didn’t light up. So what?”
In the event of anyone ever giving him a great pile of money for research, Wang said, he would like to stage a large study in which he too lowered volunteers slowly under—but in which he looked not at what was happening inside their brains, but their minds. “What mechanisms are at play? What sort of emotional meanings are there for people at different levels of consciousness? How is memory distorted during those planes of consciousness? That’s the experiment I would be interested in doing.”
He called this “the psychology of what’s going on,” and said these insights would be more useful than any number of neurological studies.
Wang is a psychologist, so it is unsurprising that he might say this. But he believes his approach would have practical implications for anyone going under a general anesthetic. In the operating theater, he argues, his experiment could help understand what you or I might experience if, during surgery, we started to rise toward consciousness. “And how that might open doors to primitive parts of the brain and memory and processing that are really important emotionally.”
Because in the end, of course, a monitor, no matter how effective, can only ever be one part of an equation that must also include the doctors and technicians who are operating and interpreting that monitor, and, crucially, the human being it is attached to, and whose pulsations and palpitations, currents and calamities it is designed to identify and interpret.
Wang knows no one is ever going to give him that pile of money. But despite having retired from teaching he intends to continue his research. “I just think that we’re messing around with things that could be quite serious. And we just don’t know what we’re doing. And most anesthetists aren’t really interested.”
He is pretty sure he knows of one person who would have backed him, had he been around in the days of general anesthetics. “What a fabulous opportunity to really get down to studying what consciousness is all about. I think Freud would have given his right arm to do some of this stuff.”
•
At the around the time of her first diagnosis, my mother started working on some new paintings. Again, the grids. Again the high, clear eye. But now they are different. And perhaps it is also that now I can see them differently. We each have one, my sisters and I; mine is on the wall in my study. Here the lines are finer, their colors stronger. A mesh of white and red and orange resting over a flat-spread world of remnant green and dun earth. But something changes in the looking. It takes patience; this not an image to glance at. It is, I now realize, a portal. Thirty seconds. Longer. Long. And then things start to move. At first I think it is the grid, then I think it is the land beneath, then I think it must be the space between. I stand, with my back to my desk and the window and the garden beyond, and let my gaze settle on my mother’s painting. Quietly, calmly. And the colors start to shimmer. It’s like looking out from your window seat and seeing, far below, the shadows of the clouds above you as they break apart. Things dapple. Spread. Leap around the canvas. It is uncanny. Light appears from nowhere. Nowhere. It happens (I understand with my thinking brain) not in the canvas but in the relationship between the canvas and the viewer. The painting has not changed (surely?) but something in me has (must have). And now, as I gaze into my mother’s marks, the grid at the center starts to expand and throb, a steadfast beat; and the world beyond it tilts and opens; pulses
The shallows
The day after I rang the Brisbane anesthesia providers to confess my anxieties about my looming anesthetic, I picked up my phone to a call from a stranger. He introduced himself as the anesthesiologist who was going to put me under and hopefully keep me there for the duration of my surgery. I’ll call him John.
He was lovely. Chatty, informative, reassuring. It was very important, he said at the start, that I not be anxious. He was going to do everything he could to make sure I wasn’t. He started by telling me exactly what he proposed to do. He would put me to sleep with propofol and midazolam via a drip in my hand. He would then put another drip in to keep my blood pressure low. And once I was unconscious, he would keep me asleep with a potent anesthetic gas, a modern relative of ether.
He managed to say all of this without making me feel foolish. Without my asking, he volunteered that he would be using at least one BIS monitor. He knew of Kate Leslie and Paul Myles and their B-Aware study. “I always try and use the BIS.” Nor would he be using paralyzing drugs except at the start of the procedure, to relax my muscles while he put the breathing tube down my airway. Then, he said, the assembled theater staff would flip me, “like a turkey,” onto my belly. (This was the only moment in the conversation I felt un-soothed.) He would be monitoring me the entire time. He would not be discussing films or golf or playing Sudoku. And he was very confident that I would remember nothing. “It’s never happened in the twelve years I’ve been giving anesthetics. I’d have to work hard to give someone awareness.”
But it is easy to give someone information.
Emery Brown, the Boston anesthesiologist whose team have discovered what they call a neural signature for unconsciousness, would like his patients to know a bit more about the insides of their heads. Not as much as he does, obviously, but enough to have some sort of language for what is going to happen to them. Heart, lung, kidneys, the dark sump of the liver: as proprietors of these organs, we have at least some sense of what they do in our bodies, and of what might happen if they stopped doing it.
The brain less so. Our brains are mysterious not only because scientists don’t know everything about them, but because we, the owners of those brains, know almost nothing about them. Yet if Emery Brown tells me there is a pulpy region inside my skull that helps me form memories, and another that tells me when I am in pain, and still others that are keeping me alert right now, and if he explains that anesthetics temporarily “turn down” or “snip” the connections between these brain regions by producing large disruptive rhythms, it all starts to seem a lot less mysterious. Almost straightforward.
The fact that he doesn’t understand what it is he is taking away doesn’t seem to worry him. “All we have to do is agree that there’s a certain set of circuits which could, when active, allow you to have conscious processing. I may not understand how key brain areas work together to do that, but all I have to do is figure out how I can turn them off. Or on. And I’m done.” Easy.
And talk, as it turns out, is not only cheap but effective (a preoperative visit from an anesthesiologist has been shown to be better than a tranquilizer at keeping patients calm). I know from experience how intensely reassuring such a conversation can be. For me it was not just the information, or even mainly the information (although I clung to it); it was the fact of the human contact, of being treated as an equal, of being included, rather than feeling an appendage to a process to which I was, after all, central. But if you were my anesthesiologist, I hope you would tell me about more than just the pulpy regions inside my head; more even than my anesthesiologist, John, told me in that phone call. Above all I would want you to tell me about paralysis.
Hank Bennett, the American psychologist I met in Hull, remembers a young girl whose mother brought her to see him in some time after the girl had her adenoids removed. The surgeon referred the mother to Bennett after she had returned to him anxious about her child. The surgery had been straightforward, but the mother felt that something was very wrong with her previously happy daughter: the child had withdrawn from her family and friends and had stopped working at school. She could no longer fall asleep without her mother sitting with her, and was afraid of the dark.
Bennett spoke with the girl. He told her there must be a reason she had changed her behavior, and asked if it might have something to do with the operation.
And she said, “Yes.” (I was very clear, she said that.) “They said that they were going to put me to sleep, but the next thing that I know I couldn’t breathe, and I felt as though I couldn’t breathe anything.”
Now, she was only momentarily like that—she does not remember the breathing tube going in—but when I asked why she was doing these things differently at school and at home, she said, “Well, I have to concentrate and I can’t be bothered by anything. I’ve got to make sure that I can breathe.”
Bennett referred the girl to a child psychologist and within weeks she was back to herself. Today she would be approaching middle age. “But let’s say, that was just luck,” Bennett says now. “What if nothing had been picked up about that? Would she have been permanently changed? I think that you would say, yes, she probably would have been.”
Recently, doctors in the United Kingdom undertook a hugely ambitious project. Over three years, they audited and analyzed three million general anesthetics carried out in every public hospital in Britain and Ireland to try to establish who reports waking during general anesthesia, what happens when they do awaken, and what might be done to stop it happening again. It was an astonishing effort. To start with, the Royal College of Anaesthetists’ 5th National Audit Project on accidental awareness during general anesthesia (NAP5 for short) gathered and scrutinized more cases of awareness than all those ever reported in all the previous literature combined. It provided some extraordinarily detailed information about the experience of anesthetic awareness and its impact on sufferers. Among its many findings were that, despite most episodes apparently lasting less than five minutes, half those patients went on to suffer longer-term psychological problems. What the audit also confirmed beyond doubt were the potential risks in paralyzing patients. Fewer than half all general anesthetics in the UK included a muscle relaxant, but 93 percent of reports to the audit involved patients who had been paralyzed. Even brief experiences of paralysis could be devastating.
The experience most strongly associated with psychological sequelae was distress at the time of the event. This in turn was strongly associated with a sensation of paralysis. The majority of patients reporting paralysis developed moderate or severe longer-term sequelae.
What was also striking was that the solution, or part of it, had been there all along. Among the many recommendations about anesthetic regimes and training and monitoring and safety checks, the simplest and most plentiful advice to anesthesiologists was to communicate—with each other, and particularly with their patients. To tell them beforehand that they might briefly wake and find themselves unable to move, and that this would pass; to reassure them during surgery if there was even a hint of them having woken; to speak to them as they emerged, explaining what was happening; and finally, to listen respectfully and sympathetically if they later complained of having been aware.
After Rachel Benmayor was wheeled, wide awake, from the operating theater all those years ago, the first thing she did was to start trying to call for her husband, Glenn. The paralyzing drugs were finally beginning to wear off, and she recalls a nurse coming across and standing over her. What happened next has stayed with her ever since.
She started talking to me really loudly, like I was a child, in a way. I was trying to say “Get Glenn.” And she’s going “Mrs. Benmayor, you’ve had a lovely baby. You’ve had a lovely little girl.”
And I’m like, “I know. I know. She’s fine. I know. Get Glenn!” I kept on trying but I was really blurred and she kept on rabbiting on and just treating me like I was—it was very controlling and gross. There was no space for me there, whatsoever.
And I realized really powerfully that all over the world when people come out of general anesthetics at that point they are very close to their own inner consciousness, and they are very vulnerable, and often have seen things or felt things that they may not have seen or felt for a long time. And when you’ve got staff practically bellowing at you because they think that you’re unconscious—I was just so clear that it was such a wrong way to deal with people.
•
I have only ever entered a hospital as a visitor, a patient, or, from time to time, a journalist. I can only imagine the pressures of working each week in a world of limited and often contracting resources, of overarching and often competing priorities, in which every day there is a risk you might kill a client. No surprise that a patient’s emotional needs will sometimes come a far second to their survival. Even then, I have heard many stories of kindness: the Italian nurses who wordlessly stroked an English-speaking friend who found herself alone and afraid in a foreign hospital; the Australian theater nurse who reached for a violently shivering young woman about to go into surgery and held her quaking body to her own until the patient was warm and calm. I suspect the reality is that most theater staff are professional, and many are much, much more. But some are not.
Reston, Virginia, April 2013. A man later identified in court documents only as D. B. is about to have a colonoscopy. Knowing there is a chance he will be woozy when the doctor talks to him after the anesthetic, he pushes the record button on his mobile phone. Later, remembering nothing, he plays it back. Here is his anesthesiologist: “After five minutes of talking to you in pre-op, I wanted to punch you in the face and man you up a little bit.” She calls D. B. a “retard.” She tells the other theater staff he probably has syphilis and tuberculosis of the penis. She is awful.
The trial lasts three days. One of those to testify is a former president of the Academy of Anesthesiology, Kathryn McGoldrick. “These types of conversations are not only offensive but frankly stupid,” she tells the court, “because we can never be certain that our patients are asleep and wouldn’t have recall.” D. B. describes months of anxiety and sleeplessness. The jury awards him half a million dollars.
What motivated that anesthesiologist? Was this her usual bedside manner? Who knows. You can only hope that this sort of sadism is vanishingly rare. But operating theaters, like any other theater of human endeavor, teem with the frailties that come with being human. And staff—even those who know they are being watched—sometimes say or do spectacularly inappropriate things.
Some years back, I spoke with a researcher who had sat in on an operation in which a woman was having breast implants inserted. “The patient looked completely normal from my point of view—but she clearly was very unhappy about how she looked to want to go through that sort of procedure.” The woman was unconscious. “And the surgeon and a male nurse were kind of juggling with these different implants and making comments about how she would look if she had one this big, or this big, or what about a massive one like this? You know, ‘Cor!’” The researcher, who did not want to named, had found the behavior more stupid than offensive, but felt that the patient might have been very much more vulnerable. “She was already prepared to have a general anesthetic and surgery to change the way she looked, so I assumed she was pretty unhappy with how she looked at the time. So for her those might have been quite important comments, had she been able to hear them or process them.”
We’ll never know.
What we do know is that while most people seem to settle back into their lives pretty easily after general anesthesia, quite a few don’t. Recently a team including George Mashour spent around two years monitoring a series of patients who had undergone elective surgery. They found that even in patients who gave no evidence of having been awake during their operations, 15 percent later showed signs of PTSD. There are various possible explanations—social isolation, previous medical experience, personal frailties and so on—but in the end, for whatever reasons, it seems fair to assume that a significant minority of patients will undergo their surgery at a heightened risk of emerging less psychologically healthy than they went in. This doesn’t mean they are mad or bad. It just means they are vulnerable. We are vulnerable.
So if you were my anesthesiologist and I your patient, there are some other things I’d hope you would do in the operating theater. Things that Kate Leslie and Paul Myles and many others already do. Be kind. Talk to me. Nothing highbrow, just a bit of information and reassurance. Use my name. Patients who remember waking are often greatly relieved at having been told what was happening to them, and reassured that this was OK and that they would now drift back to sleep.
The patient’s interpretation of what is happening at the time of the awareness seemed central to later impact; explanation and reassurance during suspected accidental awareness during general anaesthesia or at the time of report seemed beneficial.
