Anesthesia, page 9
The room, a functional rectangle looking onto a brick wall, did nothing to settle me although, apart from a strange modular bathroom, it was inoffensive. But I knew that I was teetering on the edge of something. I could feel myself starting to collapse inward; afraid of being lonely, afraid of getting sick, afraid of being afraid—a set of stairs descending to nowhere.
•
I am afraid of dying. I know this is unremarkable but I think about it a lot. How can someone be here and then not? How can that ever make sense? It does my head in. When I was a child I would try to lie awake in wait for the moment—the actual instant—when I would cross from my waking self to that other. I think I believed that if I could only capture the intruder sleep I would be able to prevent it running off with my thoughts and all the things that made me feel like me.
I am six? Maybe seven. A weatherboard house in Melbourne’s outer eastern suburbs. It is dark, I am in bed and this terrible knowledge rises and rises around me. I can’t remember which realization comes first: that I will die, or that my parents will. One knowing leads quickly to the next. Either way, there arrives the appalling certainty that I will have to go to this place and I will have to go there alone. No one will look after me. No one can come with me. I will never see my mother or father again. I feel that the bed beneath me and the floorboards beneath it and the ground beneath them have ceased in this instant to exist and that I am plummeting. I simply cannot grasp the immensity of what has happened. I lie here for a long time and the sense of horror does not abate, nor my sense of outrage in the face of it. When I wake in the morning it is still there and nothing is quite the same.
My parents, who both started practicing early with the deaths of their own parents, have often seemed to me pragmatic to the point of fatalism about mortality. I grew up assuming they would be dead or close to it by the time I hit my twenties. I worried when they went out that they would not return. I imagined car crashes and roof collapses and absence and loss.
Anesthesia is not, I understand, the same as death (although sometimes it is; it was for Michael Jackson). But it feels like death. Not so much the experience (although who knows?) but the fact of it. The extinction of self. It worries me. So does the idea of being paralyzed. And the idea of being buried alive. Not of course that your doctor is going to bury you alive—but to be paralyzed, and unheard . . . And of course the idea—not just the idea, the certainty—of losing control.
There was a stage in my life, probably a too-long one, when I liked to lose control. I liked drinking, I liked roller coasters. And I liked getting on airplanes, buckling up and relinquishing myself to the ministrations and constraints, the hot face towel, the regimented, geometric meals, the little screen halfway up the aisle showing obscure or yet-to-be-released films (this was the olden days). The destination set and irrevocable. On a plane I would enter a kind of trance, a perfect passivity born of the almost complete absence of options. So that each little choice seemed delightful. Chicken or beef. Red or white. All the while hurtling through a strangely unreal sky (day night day) perhaps toward some distant, more perfect version of myself. I think that was it. I loved it.
Until one day I didn’t.
I was in my late twenties in a plane en route to France when I became aware of an unfamiliar unease that quickly coalesced into dread. Belted into my narrow seat in that inexplicable metal cylinder, what terrified me was not that the plane would plummet or explode or hit another plane, but that any second now, unless I could exercise an unthinkable degree of control, I would start to scream. I could feel my hands and feet twitching with the need to leap up. My throat shrank with the effort of staying silent. It seemed to last hours, though the worst of it was over by the time we stopped to refuel somewhere in the Middle East. There I accosted a Frenchman and begged for one of his cigarettes. He gave me two, which I smoked in succession, drawing the hot grimy air deep into my lungs with gratitude and relief. I have no idea what I would have cried out if I had risen to my feet in the plane and started to yell. But for some years after that, whenever I entered an airport I would begin to feel the same sort of spiraling incapacity as now enveloped me in the anonymous hotel room in Hull.
This is a special way of being afraid / No trick dispels, wrote poet Philip Larkin in his tart, somber rumination on death, “Aubade.” Larkin spent most of his working life in the Brynmor Jones Library at the University of Hull, where the MAA6 conference was now being held. I don’t know how many of the anesthesiologists knew the poem. It wasn’t mentioned in the conference material . . . no sight, no sound / No touch or taste or smell, nothing to think with / Nothing to love or link with / The anaesthetic from which none come round.
I took some deep breaths and spoke to myself out loud—sensible soothing words—and after a while I sat at the desk and started to write down the day’s events. As I wrote, I began to feel better. Lulled by language, by my version of the day, I started to feel real again. After an hour or so I decided that I needed food, and that it might be depressing eating at the hotel, and that I would go out and find somewhere to have a meal.
The girl at reception directed me to an undistinguished Indian restaurant around the corner. I was the only customer. Two staff, both men, were playing some sort of game—dice or maybe counters—at one of the tables, and in the too-quietness of the dining room my unease again took hold as I ordered. After delivering my food and a glass of wine, the waiter and bartender resumed their game, paying me no particular attention. But a mean, angular fear had closed around me and with each mouthful I became more convinced that something terrible would happen—that, for instance, I would not leave the restaurant alive, that they would hurt me, then kill me and that no one would know where I was. I knew this was improbable, ludicrous, probably racist, but the knowing came from such a long way off that it barely nudged into the bulging membrane of my imaginings. By the time I finally paid and left amid polite farewells, I was almost nauseated with fear—no longer of the staff but of myself, my coiled thoughts.
Back in my room I brushed my teeth and avoided looking at myself in the mirror. I glanced at the abstracts of the following day’s events. The keynote address to be delivered by Anthony Angel of the University of Sheffield was about the effects of anesthetic agents on senses such as sight and sound and touch. In the absence of a single, distinct pharmacological action, said Angel, the best question was not how anesthetics worked, but where. He pointed to the thalamus—or thalami—which nest like a pair of tiny doves above the brain stem, decoding and relaying messages between the sense organs and the cerebral cortex—that great folded mass that allows us to remember, contemplate and describe our worlds. This pulpy sheath sits directly beneath the skull and wraps around the rest of the brain. With its fissured lobes—temporal to the side, and then, pushing from the rear of the skull toward the forehead, the occipital, parietal and, most spectacularly from an evolutionary standpoint, frontal—it dominates the inner landscape in size and sheer clout. Here are the capacities that gave us Stonehenge, Sudoku and climate change: language, problem solving, analysis, planning, reflecting, as well as high-level sensory processing. Angel, in any event, reminded us that anesthetics did not shut down sight, sound or touch in the eyes, ears or skin and muscle, but in the brain, and speculated that anesthetics somehow curtailed the ability of the thalamus to communicate with the cortex. “And thus,” he concluded, “for the patients the world goes silent, black and with no sense of touch or taste.”
As it happened, among the fears assailing me that night the most obvious (though to me least apparent) was the prospect—distant, but decreasingly so—that I might one day end up alone in a small white room rather like this one, waiting to be taken downstairs and operated upon. It was the fear I had been holding at bay since my spine began to twist in adolescence. Over the years I had my regular reviews, some of which showed the curve advancing. But it was by now so familiar it was part of me, a distant smudge that seemed somehow to rest always on the horizon. In recent years, however, following my pregnancy and the birth of my son, and presaged by a growing discomfort in my body, the smudge had been gradually becoming less distant, less blurred. I hurt more. I stooped. None of this had I yet allowed myself to know.
In the dining area the next morning a smooth-skulled American pulled out a chair and gestured me to join him and a small group of fellow conference-goers. He had an intense compressed energy, at once hospitable and edgy, and it turned out he was speaking later the same morning. He was a psychologist. I, despite my cough and my general feeling of weirdness, was a journalist. I pulled out my tape recorder and placed it in front of him.
“My name is Hank Bennett. I’m an associate professor at the University of Medicine and Dentistry of New Jersey. I’m not telling you my social security number.” Bennett was what is known in the media as good talent. He was articulate and clearly spoken with a facility for metaphors and thumbnail sketches. He was also the only person at the table for whom English was a first language, and I gravitated to him more or less shamelessly.
The day’s program included sessions on the effect of anesthetics on the brain, and a comparison of the ways in which different brainwave monitors attempted to measure how deeply any given patient was anesthetized. But it turned out that Bennett was not at all convinced by the whole premise. The real question, he argued, was not so much how to measure anesthetic depth, but what to measure. Rather than anesthesiologists simply trying to decipher the jagged fluctuations of the various brainwave monitors, he argued, patients might be better served by a device that also measured the body’s responses to pain. Intriguingly, however, he was not just referring to the pain that might be felt by someone such as Rachel Benmayor, undergoing surgery awake but paralyzed, but to the experience of patients who remained unconscious during general anesthesia.
Bennett did not, by the way, use the word pain. Pain by definition involves not only a so-called noxious stimulus (such as a scalpel might inflict) and the body’s reflexive response, but the brain’s conscious registration of that response. To be in pain, in other words, you have to know that you’re in pain.
Bennett instead talked of nociception. Nociceptors are nerves that have evolved to respond to physical damage, or even the possibility of damage, in an organism (such as, for example, a patient). One set of neurons (the “afferent” ones) shoot these messages along nerve pathways up the spine to the brain; while “efferent” pathways stream from the brain back to the muscles and glands and other cells, carrying the unambiguous message: owww, you are in pain; act now to protect yourself. What anesthetics—at least inhaled general anesthetics—do, said Bennett, is disrupt the second part of the process, not the first. The body still broadcasts its storm warnings along the wiring of the central nervous system and into the brain, but here the signal is blocked or scrambled. While the older brain centers sitting above the spinal column register the information, the brain’s owner neither perceives pain nor remembers it afterward. Instead, as Anthony Angel might argue, the world is silent and black and with no sense of touch or taste.
But how could Angel or anybody else be so sure?
One of the reasons why the discovery of curare, and the paralyzing (or “relaxing”) drugs that followed, has been so important is that they make patients lie still. Without paralyzing drugs, unconscious patients may still twitch, jerk, wince and grimace as their nerves are dissected by scalpels and diathermy wands. While this doesn’t mean that they are experiencing pain in the way that you or I understand it (even a cat whose cortex has been largely removed will arch in response to messages its brain can no longer process or act upon) it shows clearly that at some level the body is still responding to what is happening to it, albeit unconsciously.
So what?
Apply an electric shock to the side of a giant sea slug, and the response of its neurons can be graphed in a single narrow peak. Up, down: ouch. Apply the same shock twenty-four hours later on the other side, and you get the same reaction. But repeat the shock at the original site, and the pattern is now quite different. Instead of a single peak, there is a mountain range, a jagged outline of pain stretching to the end of the graph. U.S. anesthesiologist Daniel Carr has used this example to support his belief that the memory of pain—the body’s memory of pain, that is—can be more damaging than the original experience, conscious or otherwise. I had heard Carr speak in Australia in 2001 when he argued that when it came to the operating theater it was not enough simply to cloak pain signals with hypnotic drugs. Doctors needed to prevent the messages from getting to the brain in the first place. “In practice,” said Carr, “many anesthesiologists administer an inhaled anesthetic gas during the operation with little or no intravenous ‘painkiller,’ and then titrate small incremental doses of pain medicine as the patient emerges postoperatively from general anesthesia.”
When I approached Carr after the conference, he referred me to the work of U.S. anesthesiologist and pain researcher Clifford Woolf, who had established that pain, even unconscious pain, could trigger chronic responses in the spinal cord that could later coalesce into pain the patient would be all too aware of months, sometimes years, after the operation was over. Woolf had argued that strong pain relief should be given during surgery and maybe even before (though the evidence for this remains patchy), as well as when the patient was waking up, to avoid “sensitization” of the central nervous system. Today most general anesthetics include painkillers—aiming to dampen the body’s stress responses (rising heart rate and blood pressure, grimacing, twitching), if only to reduce the chances that their patients will start to wake up. But Carr, now director of Tufts University’s pain research education and policy program, still argues that analgesia during surgery—particularly the ever-more-popular day procedures—is often too little too late, and that this has implications for long-term pain.
Hank Bennett too was convinced that under general anesthesia, pain—or at least its precursor—was often not so much banished as hiding. Unlike nitrous oxide, which blunts sensation even before people pass out (as Horace Wells noticed at that demonstration), today’s potent gases are not generally analgesics. And while most anesthetic cocktails include a painkiller, there is no way of knowing for sure what an individual patient is feeling in the moment, or might feel later.
•
Spend any amount of time around anesthesiologists and you are bound to hear a fair bit about the brain and its constituent parts. Cerebrum, cerebral cortex, corpus callosum, hippocampus, thalamus, brain stem, amygdala, cerebellum—like players in a Greek drama, each contributing its own story, its own viewpoint and version of events.
The best way of visualizing the brain that I have come across is a simple exercise that involves lightly clenching both your fists around their thumb and then resting them together, wrist to wrist, forearm to forearm in front of your face. Now you are looking at your brain, or a digital representation (each fist a hemisphere). At the base of this mass, where the wrists connect, pulse to pulse, is the brain stem, the most primitive part of the brain in evolutionary terms, which rises above the spinal cord (running down between the forearms) that carries the multitude of messages, afferent and efferent included, that in any instant tick up and down the nervous system’s superhighway.
The brain stem is the survival center for creatures as diverse as toads, tapirs and tattoo artists. It is the body’s autopilot, overseeing the basic functions of life: respiration, perspiration, salivation, heart rate, blood pressure, balance, sleep and waking, for starters. Above, where the thumbs disappear into the fold between the fingers and the palms, is the limbic system—the emotional or so-called mammalian brain, common to humans and other mammals—which modulates functions including emotion and memory, along with the capacities that enable us not only to learn from experience but to live in groups. In humans this buried treasure includes the hippocampus (which lets us remember our car’s license plate, dog’s name and what happened yesterday, and without which we would have no conscious memories at all), the amygdala (an almond-shaped cluster that helps us store and retrieve emotional memories, particularly fearful ones), the thalamus, and an elegant arc known as the cingulate gyrus that helps in communication and social behavior, as well as governing sensations such as fear, anxiety and pleasure.
And it is here, in the limbic center, argued Hank Bennett, that pain signals reaching the anesthetized mind might be marooned, unable to pass their messages to the outer and most peculiarly human section of the brain, the cerebral cortex (represented by the fingers and backs of your hands) to be translated, acknowledged and acted upon.
•
Back at the university the next day, not a lot of attention was being paid to pain that no one could see or recall. Unsurprisingly, pain that no one knows they are experiencing is trumped by pain that stampedes up and down the afferent and efferent pathways of people who are not only conscious but who can also remember it later. At one point in the conference, during a session on the impact of anesthetic awareness, I heard from within the auditorium a sharply indrawn breath from the audience and a woman’s tight sharp voice. “No!”
The speaker had just described a paper published in the early 1960s by a doctor who reported operating on paralyzed patients without anesthesia in the misguided belief that once a patient had been sedated and knocked out with a short-acting induction drug, all that was needed to keep him that way was curare—and lots of oxygen. The indrawn breath was, I felt sure, that of Carol Weihrer, the woman whose own eye surgery and subsequent public campaign had helped publicize the prevalence of anesthetic awareness. Weihrer herself had addressed the audience in the previous session, describing in grueling detail her experience and its emotional and psychological legacy.
