Don’t be surprised if your patients start asking more questions than usual about awareness under anesthesia. We can all thank a recent article in The Atlantic magazine, with a large-print headline on the cover: “Awake Under the Knife”. Written by a UCSF medical student, the article not only assures everyone that awareness can happen, but takes pains to point out that anesthesiologists can’t always prevent it.
The article’s author, one Joshua Lang, seems sincere in his effort to describe the science behind the bispectral index (BIS) monitor and the even more interesting research of Dr. Giulio Tononi, at the University of Wisconsin, in the neuroscience of sleep and consciousness. But you had to read the entire article to get to that information. The first half, loaded with anecdotes about awareness, is superficial at best, and leads me to wonder if the author’s real aim is to make a name for himself as the next Atul Gawande. Perhaps he should take the trouble to finish medical school first.
The opening paragraphs spotlight a woman who describes having an appendectomy at the age of four, in the 1960s. She recalls being on the operating table, bright lights, and the image of “a man looming over her.” That’s all. She didn’t feel any pain or have any memory of actually undergoing surgery. My guess would be that she has accurate recall of how terrified she felt and what she saw just prior to the induction of anesthesia.
I think I speak for us all in feeling genuinely awful about a little girl having nightmares for years after such an experience, and wishing that someone had given her a better premedication to make her drowsy before she went to the operating room. But she interprets her memory of “absolute abject terror” and “the feeling that I am dying” as proof that she woke up during the operation, and the credulous author doesn’t question it.
Another anecdote tells of a 60-year-old man who was aware and in pain during an open gastric bypass, despite the use of a BIS monitor. The fact that the patient had recall is perfectly convincing, but other details are puzzling. We’re told that the patient was reliant on “painkillers,” which would increase his anesthetic requirement. We’re also told that the anesthesiologist was reluctant to give much anesthesia because of the patient’s “dangerously low blood pressure.”
So many questions arise. Was the blood pressure low prior to surgery? Did the patient have a failing heart? Did he need IV fluids or blood? Had he taken an antihypertensive medication prior to surgery? What steps were taken to correct the blood pressure? We can’t make anything of the story other than the fact that a BIS monitor didn’t protect the patient from an inadequate anesthetic, which comes as no surprise.
I understand perfectly well that Lang’s original piece would have been ruthlessly edited by The Atlantic, which spares subtlety in the interest of increasing readership. Lang may not be completely to blame for some of the excesses. Certainly it’s true that we haven’t identified anything like a consciousness receptor that would enable us to understand anesthesia in the same molecular way that we understand the action of morphine on narcotic receptors or estrogen on hormone receptors. But in the author’s words, this “ignorance gap” means that generations of dedicated researchers and clinical anesthesiologists are simply “clueless.”
Do you recall a 2007 movie called Awake that lasted a week or so in theaters? It was so preposterous and poorly acted that it went immediately to video. When it first appeared, anesthesiologists all over the country sighed, and proceeded to reassure anxious patients (most of whom hadn’t seen the movie but had heard of it) about all the safeguards that we routinely use to assure their unconsciousness and pain relief. But if you believe The Atlantic version, we became “defensive” and “fearful of malpractice suits,” and this silly movie forced us for the first time to seek the cause of intraoperative awareness when no one cared anything about it before. Really, the author should be embarrassed to face his mentors at UCSF, one of the premier institutions for anesthesiology research in the world.
Even if you already have a print copy of the article, I would encourage you to go online and read the many comments that readers have posted. These are far more enlightening than the article itself. As you would imagine, a number of readers describe their own experiences, and there is much to be learned from them. One reader described with perfect clarity being conscious and in pain but unable to move during the closing sutures of her thyroidectomy. Other readers recount distress at waking up during procedures that were probably done under regional anesthesia or sedation.
As a take-home lesson from the readers’ comments, I’ve made a list of my own “Notes to Self.” I append my top five, and invite readers to add their own to the list.
1. Don’t overuse muscle relaxants. A patient who moves a little or starts breathing over the ventilator is telling me that deeper anesthesia would be a good idea.
2. Don’t trust the BIS or any other monitor over common sense and experience.
3. Believe it when patients tell me they need more anesthesia than average.
4. Explain to patients when they are going to receive sedation and might wake up briefly during the procedure. If the patient doesn’t want to chance that at all, give deeper sedation or general anesthesia.
5. Fine-tune the art of deep extubation whenever possible, and explain to the patient in advance if waking up with a tube or staying intubated is likely. A patient who remembers having an endotracheal tube in place even briefly may not understand that the operation was over, and may interpret this as awareness under anesthesia.
Way back when I was a medical student, I underwent endoscopic sinus surgery. I remember quite clearly waking up for just a moment in the middle, feeling no pain but hearing a voice saying, “Better give her some more.” I didn’t panic, probably because I was familiar with the OR environment and am calm under most circumstances anyway. But I can easily see how other patients might find a similar experience traumatic, and how a psychologically fragile patient might have long-term anxiety and fear of future anesthetics.
It’s good for us never to forget how important unconsciousness is to the patients who entrust their care to us. But my question to Joshua Lang would be this: Did your article—and the sensational headline on the magazine’s cover—illuminate the profession of anesthesiology and the complex issue of awareness, or did you needlessly alarm more readers than you informed?