Anesthesia, page 34
Of the past seven-and-a-half hours I remember nothing, not even the conversation I have just had with Mum. Nor obviously do I have a clue what is to come: the weeks and then months of morphine, the halting reassembly of the self. I certainly don’t know yet that tomorrow or the next day, my anesthesiologist, John, will stand beside me and confess sadly that despite his best efforts, once the operation was underway and I had been turned over (like a turkey, I keep thinking), he had been unable to reattach either of the precious BIS monitors for fear of obstructing the surgeon working at the base of my neck—so I would never know how far down I went, or up, none of which would by then seem relevant. Nor do I know what my surgeon will say when I finally find the energy some days hence to ask how much blood I lost during the operation. (I did not mention to him the patients in Hank Bennett’s study who, like me, had listened beforehand to his instruction to shunt the blood away from their wounds, and who lost on average 650 milliliters of blood—a third less than the control group.)
“Oh,” the surgeon will tell my future self cheerfully. “Surprisingly little! Only about four hundred mils.”
“So did I say anything?” I will ask my mother casually at last, and she will look at me a little quizzically (as if to say, don’t go reading too much into this) and say, “Yes, though I couldn’t make most of it out.”
“And?”
“All I could hear was mumble mumble mumble, and then—”
“Yes?”
“All I could make out was, ‘bad playground.’”
Bad playground.
I like that.
For now, though, I am in a different kind of playground. Surging along the corridor on a wave of synthetic morphine, my mother and uncle contracting and expanding in my wake, and beyond it all—the bulb-bright pain, the wings, the streaming walls—is the extraordinary good fortune of my continued existence.
In intensive care the nurse (sitting in an illuminated cubicle near the end of my bed, dissected by tubes and cables) tells me to stop pushing the button in my right hand—my “patient controlled analgesia.”
“Why?” I ask, surprised.
“Because you’re hallucinating,” she says.
“No, I’m not.” (Puzzled.)
“Yes, you are. You’re talking to yourself.”
“No, I’m not!” (Indignant.) “I’m talking to my friends.”
They are very convincing, my friends, though I cannot quite remember their names. (“Is she awake?” asks someone.) Each time I close my eyes, they are there, in ones and twos, and I move down the line, chatting as I go, filling them in on all that has happened. I am very intent and thorough, imparting information; deeply engrossed.
“You’ll make yourself vomit,” says the nurse. But I won’t.
My wings are pulsing, glorious—I am.
Acknowledgments
This book has had a long gestation. So many people have contributed their time, insights, specialist knowledge, personal stories, patience, good will and support that it is hard to know where to begin.
I am greatly indebted to the scientists, medical practitioners, historians, philosophers and other experts who gave me access to their minds, writings, work spaces and sometimes much more. Some appear in the book, others don’t (thanks Malcolm Hogg for your insights on pain). Either way, their forbearance and generosity were indispensible in navigating material that was at times complex, nuanced and technical.
I am equally and deeply thankful to the people who shared with me their own experiences of anesthesia and beyond, many of whom allowed me to include their accounts here. In particular, Rachel Benmayor’s extraordinary story provided an emotional and philosophical pivot around which I have circled for nearly two decades; her courage and dignity are inspiring. There are many others who don’t appear in these pages but whose accounts have informed and enriched the book. They include Harriet Davis and Deborah Shaw.
Underpinning the research are countless conversations—with friends, colleagues, strangers—that have helped me plot a path through a topic as slippery, layered and entirely fascinating as anesthesia.
The extraordinary community of staff and writers at the Varuna writers’ center provided intellectual, creative and physical sustenance (in Sheila Atkinson’s case, magical comfort food), and crucial feedback, as well as a surprising number of odd stories about anesthetics. This book benefited greatly from a three-week fellowship at the center as well as regular sojourns, including a workshop with Robin Hemley. My particular thanks again to former creative director Peter Bishop, whose insights and expansive, permissive curiosity helped keep me open and honest.
My agent, Jenny Darling, backed the book from the start, commented wisely on early drafts and then waited patiently for nearly a decade until a workable version finally lobbed.
Once again, the team at Text Publishing have been everything I could hope for: supportive, enthusiastic and rigorous. Particular thanks to Michael Heyward for championing the book; to Khadija Caffoor, Anne Beilby and Jane Finemore for working to get it out into the world; to Danielle Bagnato for help with social media, and to Sandy Cull for the beautiful cover design. Above all to my editor Mandy Brett for her fierce advocacy, fine ear and shrewd, perceptive guidance.
Readers who offered valuable perspectives on drafts of the manuscript include Peter Kenneally, Sophie Cunningham, Karen Kissane, Margaret Simons, Peter Cole-Adams, Jennet Cole-Adams and Kate Leslie. Others who read and commented on sections include Penelope Trevor, Kim Langley, Anne Crawford, Mary Anne Butler and Brigid Cole-Adams. I am grateful for their insights and candor.
Practical support came from Sally Ruljancich who transcribed many interviews and did some additional early research. James Button, May Lam, Shane Higgs, Penny Gibson, Kerry Proctor and Clive Meltzer offered peaceful working spaces at crucial points; Siegi Edward designed me one of my own. Bobbi Mahlab asked the right questions and offered strategic advice. Angie Paton provided psychological support and existential theories. And the staff of the Australian and New Zealand College of Anaesthetists were unfailingly friendly and helpful as I wandered in and out of their library over a decade or more.
Much of the research and related travel was made possible with an Australia Council grant. My thanks also to the estates of Philip Larkin, for use of the poem “Aubade,” and R. D. Laing, for kind permission to quote sections of The Politics of Experience.
In all this, my husband, Peter Kenneally, has been an astute and enabling presence, managing by and large not to glaze over during sundry impromptu tutorials on anesthesia, amnesia, memory and forgetting. My children, Finn and Francesca, have spent most of their lives sharing me with this project. Despite this—and along with my sisters, Sarah Boyd and Jennet Cole-Adams, and father, Peter Cole-Adams—they submitted graciously to being coopted as characters in a drama not of their own making. I am deeply grateful for their support.
My thanks also to my uncle and aunt Jim and Aldyth Love who shared with me their medical knowledge and, in the weeks after my surgery, their home. And to my late grandfather Harold Russell Love, whom I never met, but sections of whose unfinished manuscript found their way into this book. I don’t know what he would have made of the result.
And, finally, to my mother, Brigid, who died before I had finished writing or she reading, but whose faith in me was constant and whose clarity and spirit have informed and imbued the book.
Notes
Into the blue
This chapter draws on books including: Eger et al., The Wondrous Story of Anesthesia; Keys, The History of Surgical Anesthesia; Davies et al., All About Anaesthesia; Dormandy, The Worst of Evils.
Sections of this chapter first appeared in the articles “Switching off brain and pain,” Age, September 4, 2010: www.smh.com.au/national/switching-off-brain-and-pain-20100903-14uhr.html; and “Eyes Wide Shut,” Good Weekend Magazine, February 10, 2001.
“Suffering so great as I underwent cannot be expressed in words”—Eger, The Wondrous Story of Anesthesia, p. 13.
Until the mid-1800s, surgery was almost always an agonizing last resort—There had been intermittent reports of other doctors using ether or other drugs to operate on their own patients, but none that had been widely broadcast or publicly demonstrated: Izuo, 2004; Hammonds et al., 1993.
A Napoleonic surgeon called Langeback claimed—Melanie Thernstrom, The Pain Chronicles, p. 143.
“To avoid pain, in surgical operations, is a chimera”—This is one of various translations from the French, which you can read here: www.histanestrea-france.org/Velpeau.html (accessed December 3, 2016).
Levinson, then thirty-nine, persuaded a professor of surgery—Levinson, 1965 and 1989.
Awake
Sections of this chapter first appeared in the article “Eyes Wide Shut,” Good Weekend Magazine, February 10, 2001.
Many years ago, in the Blue Mountains—It was 1999, in a weatherboard house in Lawson.
. . . one to two patients in a thousand report waking under anesthesia—Avidan and Mashour, 2013; Bischoff and Rundshagen, 2011; Mashour and Avidan, 2015; Sandin et al., 2000; Sebel et al., 2004.
More, it seems, in China—Xu et al., 2009; Shi, 2013.
More again in Spain—Errando et al., 2008.
. . . twenty thousand to forty thousand people are estimated to remember waking each year in the United States alone—Avidan et al., 2008; Sebel et al., 2004.
Last time I searched, the paper had been adjusted slightly—sydney.edu.au/medicine/anaesthesia/resources/lectures/anaesthesia_basics.html (accessed November 28, 2016).
One study in the 1980s found that close to half—43 percent: Bogetz and Katz, 1984.
Children wake far more often than adults—Davidson et al., 2005.
Some people might simply have a genetic predisposition to awareness—Kate Leslie has been investigating this possibility.
. . . all of this training helps explain why the death rate from general anesthesia has dropped—Li et al., 2009; Gibbs and Borton, 2000.
“If you have an inclination to travel, take the ether”—www.general-anaesthesia.com/people/henry-thoreau.html (accessed December 3, 2016).
Jeffrey Mifflin—has since retired, but when I met him he was the Massachusetts General Hospital archivist.
It was here, on Friday, October 16, 1846—The history of the discovery of surgical anesthesia is well documented, though the knives are still out over who gets recognized as the founder of modern anesthesia. Some of the historic material in this chapter is based on accounts in Fenster, Julie M. Ether Day and Snow, Stephanie J. Blessed Days of Anaesthesia.
For most of them it ended very badly—It really did: Fenster, Julie Ether Day.
“Why cannot a man have a tooth extracted and not feel it under the effects of the gas?”—www.americanheritage.com/content/%E2%80%9Cgentlemen-no-humbug%E2%80%9D?page=3 (accessed November 28, 2016).
. . . at a rented hall in Boston—The popular version of this story has Wells’s demonstration also taking place in the Ether Dome, but medical historian Rajesh Haridas’s research suggests otherwise. Haridas, 2013.
“a glorious conquest for humanity”—www.lib.uchicago.edu/ead/pdf/ofcpreshjb-0048-009.pdf (p. 7).
“During the operation the patient muttered”—Bigelow, 1846.
It took until 1942 for Canadian anesthesiologists to act on what Sir Walter Raleigh had known in 1596—Feldman, Poison Arrows; www.med.uottawa.ca/historyofmedicine/hetenyi/milner.html.
About half the people who wake unexpectedly during surgery are apparently OK with it—Cook et al., 2014.
One Italian woman who woke peacefully—Bonke, Fitch and Millar (eds.) Memory and Awareness in Anaesthesia, p. 246.
To compensate, anesthesiologists still routinely overestimate the amount of anesthetic—Short et al., 2015.
Denial
Sections of this chapter first appeared in the article “Eyes Wide Shut,” Good Weekend Magazine, February 10, 2001.
In the early 1990s, New Idea invited readers to write in—Cobcroft and Forsdick,1993.
. . . they greatly underestimate the chances of patients—particularly their patients—waking up under the knife—Myles et al., 2003.
The authors of a 2014 British study wondered—Pandit et al., 2014.
A recent report from a North American registry of awareness patients—Kent et al., 2015.
I had been struck by a 2005 interview in which Frank Guerra—www.washingtonpost.com/wp-dyn/articles/A4207-2004Nov22.html (accessed November 23, 2016).
“And I refused all elective surgery as an adult”—“I had a benign testicular tumor that I refused to have surgically removed due to my fear of having anesthesia. The tumor grew over a 5 year period until it was so big that the heat sensing devices used at airports triggered an alarm. I had to be physically examined by the security to ensure it was not some sort of explosive device. Soon after that I had the tumor removed under epidural anesthesia. I distrusted anesthesiologists to the extent that I returned to the department that I was a resident and had one of my teachers give me the epidural. In 2011 I was 57 years of age. This was approximately 50 years after my awareness experience.” (Email to Kate Cole-Adams, October 24, 2016.)
America’s Joint Commission on Accreditation of Healthcare Organizations finally issued an alert—www.ahcmedia.com/articles/4393-jcaho-awareness-during-anesthesia-is-a-problem (accessed December 2, 2016).
The American Society of Anesthesiologists subsequently acknowledged—in its 2006 Practice Advisory for Intraoperative Awareness and Brain Function Monitoring: anesthesiology.pubs.asahq.org/article.aspx?articleid=1923386 (accessed December 2, 2016).
Before that, however, then ASA president Roger Litwiller made a small but telling observation—This was during a JCAHO teleconference marking the release of its sentinel alert on October 6, 2004.
More than half of all patients worry about pain, paralysis and distress—Sandin et al., 2000.
“You cannot stare straight into the face of the sun or death.”—Yalom, Irvin D. Staring at the Sun.
In the early nineties a Dutch team tracked down—Moerman et al., 1993.
“It is difficult to imagine a more exquisite form of torture”—Wang, 1998.
In a 2005 interview, Wang—www.theguardian.com/lifeandstyle/2005/feb/19/weekend.iansample (accessed November 28, 2016).
In a study published in The Lancet in 2000—Sandin et al., 2000.
Paralysis
“The apparent corpse before us hears and distinguishes all that is done”—Fishkin, Mark Twain’s Book of Animals, p. 139.
. . . harrowing early references to doctors operating on paralyzed patients who were awake—Winterbottom, 1950.
Take that Swedish study—Sandin et al., 2000.
. . . the Swedish team decided to follow up the same group of eighteen awareness patients—Lennmarken et al., 2002.
. . . similar stories I had heard, one from a dear school friend—Harriet Davis woke from an anesthetic paralyzed after the birth of her second son. She thinks it was close to an hour before she could move. These days she says she will do anything to avoid going under. “I don’t care how much blood or whatever. I want to be there. I want to be able to see what’s going on. I know it’s crazy—it’s like I don’t feel safe in a plane but I do feel safe in a car because I can see the road, it’s nonsense, I know that, but, God, it makes a difference. It’s that blank that’s terrifying to me. Absolutely terrifying.”
It turns out that about two-thirds of awareness cases happen like this—Cook et al., 2014.
American psychologist Peter Levine has written a lot about paralysis—Levine, Waking the Tiger.
Two hearts
Sections of this chapter first appeared in the article “Eyes Wide Shut,” Good Weekend Magazine, February 10, 2001.
“When voluntary movement ceases, with the eyes fixed in an upward gaze”—Power et al., 1998.
The first case of awareness involving muscle relaxants was officially reported in 1950—Winterbottom, 1950.
Ten years later a study put the incidence at an alarming 1.2 percent—Hutchinson, 1961.
Then in January 1998, an American musician called Carol Weihrer underwent anesthesia for eye surgery—www.theguardian.com/lifeandstyle/2005/feb/19/weekend.iansample (accessed October 8, 2016); news.bbc.co.uk/2/hi/health/3769245.stm (accessed November 28, 2016).
“Nothing gets much darker than those seconds”—speaking at the 6th International Symposium on Memory and Awareness in Anaesthesia and Intensive Care, Hull, England.
Weihrer’s website—www.anesthesiaawareness.com/ (accessed November 28, 2016).
Questions without answers
His team . . . had just published the results of their three-year B-Aware trial—Myles et al., 2004.
Apply an electric shock to the side of a giant sea slug—This information is from Carr’s presentation to the annual scientific meeting of the Australian and New Zealand College of Anaesthetists in 2000.
. . . Clifford Woolf, who had established that pain, even unconscious pain, could trigger chronic responses in the spinal cord—Woolf and Chong, 1993.
. . . a paper published in the early 1960s by a doctor who reported operating on paralyzed patients without anesthesia—Burn, 1963.
Much later I would come to understand other things about pain—This is a very compressed version of a long and fascinating conversation with Melbourne pain doctor and anesthesiologist Malcolm Hogg.
