April 13, 2012

"If a patient is conscious during surgery but doesn’t remember any of it, is that good enough?"

Wait! How can you even ask that question! Obviously, not!
It’s a bit like the tree falling in the forest with nobody to hear it. 
What?! No, it's not.
An anesthesiologist’s koan. If even the patient has no recollection of surgery, was he aware?

And how could we possibly know?
Maybe we don't want to know.

53 comments:

America's Politico said...

Just at the Oval room for the HH. All focus is how to escape from Rosen and all that issue. The focus is to change the topic and go after Romney. One strategy is to connect Romney to Rick and Newt. Make him a loony, out of touch, etc. Expect the focus to be anything but women starting this weekend. Now, Chicago HQ has a key message for all surrogates. Please report to HQ before saying. Use a teleprompter, but no on the fly talk. Also, the HQ has asked people to not visit WH. Instead, people visit the Oval Room, where I am now with the blonde....

sydney said...

It's what you don't know you know that hurts.

Bart Hall (Kansas, USA) said...

Earlier research has also suggested that consciousness is not a simple state that is either on or off. There are gradations. Uh, yeah. Ever hear of the bi-spectral index? Very weak reporting.

No mention that narcotics also provide analgesia.

What I SUSPECT this is really about is the use of ketamine in abortions, especially if supplemented by something like Versed in the diazepam family.

Except for abortions dissociatives like ketamine are basically veterinary agents in the western world, though used a lot in places like northern Uganda.

traditionalguy said...

Since Crawford W Long invented ether for use in surgery( only in 1842,) the surgical patients were gotten drunk on alcohol in hopes they felt little pain and remembered less.

Two years ago I returned for two weeks to my place of birth at Crawford Long Hospital. But I don't remember anything about the 4 days while intubated in an induced coma. And than I woke up and wanted that damned airway etc removed.

Life, there is nothing like it. Warm sun and cool breezes and singing birds in the morning.

Our life IS our blood in circulation, just as the zygote in a fertilized egg in a mom's womb starting to circulate blood begins our life, our heart circulation stoppage ends our life, at least it does sometime after 9 flat lined minutes...and I don't want to try for the record any longer than that.

obladioblada said...

Is this from a NYT editorial on "unnecessary" medical expenses?

(Only 3 attempts to make it through wv this time, hurray!)

Freddy Hill said...

Isn't this what "sedation" is all about? I'm lucky that in my 60 years I have never been fully anesthetized, but I have been sedated many times (dental work, colonoscopies, even, in a milder form, Lasik).

I have confused memories of these procedures. In one case, I vividly "remember" the heart monitor go from beep-beep-beep to flatline: beeeeeeeeeppppp. I remember thinking I was dead, without much anxiety. I also "remember" the dental surgeon saying, "it's doing it again," and the nurse shaking the machine whereupon the beep-beep restarted. There was some detached relief in my part: "ok, maybe I'm not dead yet." I have no idea if this actually happened, but the surgeon denied it afterwards while looking (to my mind) insincere.

All things considered, I'd rather not remember.

Amartel said...

Did America's Politico just wake up in the middle of a brain surgery?

edutcher said...

As The Blonde will tell you, the big risk of anesthesia is to get you as close to death as possible, so "twilight", as they call it, may be safer.

caseym54 said...

One would think the surgeon would note a difference between a patient who was unconscious and one who was screaming in pain, but forgetful.

Revenant said...

For pity's sake...

If a woman is roofied during non-consenting sex so she doesn't remember it, is it still rape? The word "duh" comes to mind.

Consciousness is a fascinating area of study, but some questions have common-sensical answers.

AllieOop said...

The suffering that the patient experiences during surgery will affect him/her negatively, whether they remember it or not. The body dumps stress hormones when in extreme pain. Also the subconscious will remember the pain and the patient will likely experience distress if not outright PTSD.

Ann Althouse said...

" In one case, I vividly "remember" the heart monitor go from beep-beep-beep to flatline: beeeeeeeeeppppp. I remember thinking I was dead, without much anxiety. I also "remember" the dental surgeon saying, "it's doing it again," and the nurse shaking the machine whereupon the beep-beep restarted."

Are you sure you weren't watching Weird Al's "Like a Surgeon"?

Christoph said...

I recently watched the 2007 movie Awake starring Hayden Christensen, Jessica Alba, Terrence Howard, and Lena Olin. It touches on this theme.

To say the least, that is one crappy movie. (The acting isn't bad. It's actually watchable on that level. The writing is ... well, yeah.

Christoph said...

"The suffering that the patient experiences during surgery will affect him/her negatively, whether they remember it or not. The body dumps stress hormones when in extreme pain. Also the subconscious will remember the pain and the patient will likely experience distress if not outright PTSD."

I'm real skeptical about this. I've had major surgery and minor surgery including awake surgery, and I sure don't recall being traumatized.


By other things at other times, yes.

Now, are there catabolic hormones released? Sure. But trauma/PTSD? Meh.

And trust me, I believe in both.

rhhardin said...

The part of the brain connected to the bladder wakes up first.

Ex-Dissident said...

Someone brought up this point already but the point is not to ensure no memory of events. The point is to ensure that no suffering occurs and that the procedure doesn't cause health problems afterwards. If there is no memory of the surgery but the patient had a heart attack because his blood pressure was sky high from the pain caused by inadequate anesthesia, then it's not good enough.

Elliott A said...

It is amazing how many times I have had regular conversations with patients who have had conscious sedation with triazolam, and that evening they have no recollection, yet they may recall some comment I or my assistant made during the procedure when they were clearly out.There is an interesting outgrowth of this topic which is the definition of suffering, usually concerning animals. You cannot suffer if you do not have both a recollection of the current pain in the immediate past and a certainty of its continuation into the immediate future. I believe sedated people's amnesia makes any pain that occurs incidental, since it always happens only in the present.

Synova said...

I had surgery once and they *promised* that I'd be awake for it, that they weren't putting me under.

I went under. I was *pissed*.

John Lynch said...

Robert A. Heinlein imagined a "lethe field" that worked exactly like this. You hurt, but didn't remember it.

LarsPorsena said...

I asked my physician 'If I feel pain while under versed, but don't remember it,did I feel pain?'

He smiled.

If a tree falls in the woods.......

Mike and Sue said...

I am an anesthesiologist. I worry about unanticipated intraoperative awareness during every single case I perform. I am payed to worry.

Consciousness. Awareness. It is what separates us from mere collections of atoms. I am priveledged to deal in this mystery every single day.

ronalddewitt said...

Would there be a moral difference between this procedure and putting a condemned prisoner to death in a painful manner? There would be no memories of the pain in either case.

Lem said...

Unconsciousness is not close to Godliness.

traditionalguy said...
This comment has been removed by the author.
Dante said...

Everyone dies. They lose their consciousness. Therefore anything goes.

Lem said...

Consciousness is "real" magic..

Bruce Hayden said...

I am an anesthesiologist. I worry about unanticipated intraoperative awareness during every single case I perform. I am payed to worry.

GF seemed to do that a lot. Seems that she metabolized (or whatever) the anesthetics too quickly. Something like that. Got so that we would warn the anesthesiologist, and that seemed to help. And, then the last several surgeries have had the same guy, and he gets it right. It was weird though - sometimes she would remember things during the surgery, and sometimes not, and in one case, woke up all bruised. It appears that she rolled off the table, or something like that. That time, she didn't remember, but I think she was able to unofficially confirm it through a surgeon friend asking the surgeon operating on her. Something like that.

A question though for our expert here - I was under the impression that one of the drugs that you gave was to disable memories. Is that true? Or, is that just a side effect of the anesthetics?

Lem said...

The part of the brain connected to the bladder wakes up first.

It seemed to be the opposite with me.. when I was young and sleeping.

David said...

Was the author of that essay awake when it was written? Was the editor awake when editing? Surely a conscious human selected by the New York Times can write better than that.

David said...

Lem it will again when you are old and sleeping.

Chef Mojo said...

Oh, wow. I should not have clicked or checked the comments.

On the 19th, I go in to get a rather significant length of colon removed as part of my treatment for colon cancer.

I really don't want to be aware of it, or remember any of it. I'm thinking I'm wise to go with the epidural.

Yeesh.

Pogo said...

Shit, Mojo, best of luck man.

Lem said...

I was reluctant to share this for reasons that will be obvious in a minute..

I remember being half conscious during some parts of my circumcision.. I was around eight years old.

Of course I didn't know that was not supposed to happen and I was not asked any questions afterwards.

I never told this to anyone.. for reasons that remain a mystery to me.

I remember the sensation of cutting but I didn't feel any pain..

I remember what I now assume was the anesthesia. A series of needle punctures around the base.. about an inch off the base of the structure.. the structure that was getting a face off.. if you know what I mean.

I also remember something that sounded like a conversation but I don't remember what they were talking about.

Chip Ahoy said...

I have considered carefully the tree in the woods making a sound conundrum and I've come to a decision, and now that I've decided the subject is dead to me.

So now I will describe that dead thing. Not to revitalize it, no, it is dead, but to describe it as if looking over old photographs that make you kind of sad.

The solution rests on the definition of sound. Agree on that and it is ended. Let's take the first definition and settle for that. No need to go any deeper.

define: sound

Noun:
Vibrations that travel through the air or another medium and can be heard when they reach a person's or animal's ear.

Verb:
Emit sound.

There you have it. Those waves are not sound without an ear or some vibration detector to perceive them. This destroys my earlier conclusion that has sound independent of any receiving agency.

MSG said...

There are two elements. There is the misery the paralyzed patient feels at the time. And then, for the rest of patient's life, there is a cringing feeling or worse whenever the patient remembers the event. The patient who is made to forget suffers the first element but not the second. Some people have such horror of the second element that they probably underestimate the first, and guilty surgeons have an interest in embracing and encouraging this view.

Freeman Hunt said...

I woke up in the middle of having my wisdom teeth out. (They had to cut open my gums to get them, all of them being sideways under there.) The surgeon was exerting great effort in pulling out one of the tooth pieces. I had time to think, "Weird! This REALLY hurts, but I don't care," before they saw that I was awake and knocked me back out. Very odd to have, for a moment, the emotive part seemingly disconnected from the pain part.

Freeman Hunt said...

The look on a surgeon's face when he notices you're watching him is priceless.

Synova said...

"When Gabby Giffords was near death, I could not stand reading many comments here hoping she died or that was severly brain damaged because she was a Democrat."

Quotes or shut up.

Ass.

Freeman Hunt said...

There's a scifi book where people go under for years at a time, (I don't remember why.) and spend the entire time in excruciating pain but don't remember it afterward. Anyone know what book that was?

Gave me a fear of that happening in anesthesia.

Michael K said...

I have had patients who remembered the operation but had no pain. It's not that unusual. I remember a case where the woman was smiling at some of the chatter going on. She later told me what I was saying. Fortunately it was harmless. On another occasion, much earlier in my career, we had a patient who arrested as the skin incision was made for heart valve replacement. The patient was on bypass rapidly although we had not been prepared for the events.

After the valve replacement, we could not get him off bypass. The surgery chief finally sat down in the corner and said something like, "This is the first heart case we have lost in several months."

Finally, after hours of open heart massage and attempts to get his heart going again, we were successful. He recovered and remembered the conversation. We assured him it was all a dream.

That was a long time ago. 1961

Michael K said...

There are cases where the patient feels the pain. Dwight Harkin was a famous heart surgeon at Peter Brent Brigham hospital, in Boston. He had to have a thoracotomy (I can't remember why) and the guy giving the anesthesia was Henry K Beecher, Chief of anesthesia at Harvard. A character and if I may digress, moment, don't ask the chief of anesthesia to do your case. Get a good resident who does 10 cases a day.

Anyway, Harkin woke up in the middle of the case and was in tremendous pain. He thought to himself, "Henry will notice my blood pressure is sky high and put me back to sleep." At that moment, he heard Beecher say, "Dwight's blood pressure is high. He better have that looked into." Beecher gave him some blood pressure medication. He never got put back to sleep and laughed about it years later.

I also later scrubbed on a case of a women who had a mitral valve surgery without anesthesia and spent several years in a psych hospital afterward. We were replacing her valve and it must have taken great courage to go through it again. Needless to say, everybody took great care with her but the level of anesthesia is tough to determine.

yashu said...

Quotes or shut up.

I was gonna say. Had the same reaction as Synova. Don't have the slightest recollection of anyone saying anything like that here, ever. I guess I must have been under anesthesia. Or maybe that never happened except in your imagination, tradguy.

And if so (as I believe), that's surprisingly shabby coming from you.

Dante said...

@chipAyoh: what the "tree falling in the forest" is all about is that for some phenomenon a state is indeterminate in the real world. For instance, the circular motion on photons is not known until it is "observed," which is a physics word that doesn't make a lot of sense to me.

You can get a sense for how crazy this is by seeing this short "Dr. Quantum" video:

http://www.youtube.com/watch?v=Jh8uZUzuRhk

And this longer one will explain the strangeness a bit more:


http://www.metacafe.com/watch/4096579/dr_quantum_double_slit_experiment_entanglement/

Mark said...

I came up during my ACL surgery. Didn't feel any pain, but could feel the surgeon tugging and pulling on the parts inside the knew. I said "I can feel what you're doing" and the surgeon said "Oh really? Describe it." I said "You're pulling on something from the top inside of my leg toward the center.

The surgeon said to anesthesiologist "I think he needs a little more".

I said to the anesthesiologist "You're beautiful" because she was.

That was the last I remember of the procedure.

John Lynch said...

Freeman Hunt-

I believe it was "The Worthing Chronicles," by Orson Scott Card.

People went into (painful) cryo-sleep as a form of immortality. The higher status you were, the longer you'd be out.

John Lynch said...

Oops, not quite right, it was this one-
The Worthing Saga.

John Lynch said...

"Somec creates an unbearable, torturous burning sensation throughout the body while pushing the patient to suspended animation. However, the somec process exterminates the user's memory, and so these memories are recorded and stored separately shortly before they go under, to be returned to the body after they have awakened, and so the memory of the process itself cannot be retained. Thus, each somec patient experiences the panic of burning hot sleep "for the first time" (as far as their memory goes) no matter how many times they have taken somec before."

gerry said...

Ever hear of amnesics? I was conscious and pain-free during my colonoscopy, and it was fascinating to watch. And recovery was a cinch.

Lucius said...

Whatever the chances, however slight, of experiencing some or all of the real physical pain that acts of surgery would inflict upon a conscious patient, amnesia can never morally excuse that suffering.

Indeed, to the horror of being cut open would be added the emotional and moral horror of knowing that you'd never be able to report this horror, or help spare others from suffering it. You would imagine the abyss of suffering you might consolingly commend loved ones to in the future ("really honey, there's nothing to worry about-- you don't feel a thing . . .") and know, wretched, that there is this terrible thing, this hell, waiting for at least some few wretches who go under, but not well enough.

David said...

Can someone ask the New York Times if we can torture prisoners if we make sure they don't remember it afterwards? Is that good enough?

Beldar said...
This comment has been removed by the author.
Beldar said...

Results vary widely from individual to individual. Before I had my vasectomy, the urologist explained to me that the anesthetic, Versed (pronounced "VER-said"), would wipe my short-term memories going back to a short while before the surgery. I nevertheless awoke with a perfectly distinct recollection of him saying to the young urology resident who was assisting on the procedure; "Doing a vasectomy on a lawyer? Man, I'd do this all day -- for free! -- if only they'd let me!" I asked the resident about that line as I was leaving, whether I had merely dreamt that or whether it was genuine. His attempt to avoid my question, coupled with his instant full-face blush, gave me my answer.

Kelly said...

Althouse: Maybe we don't want to know.

Reminds me of one of my favorite "Deep Thoughts" by Jack Handey:

If trees could scream, would we be so cavalier about cutting them down? We might, if they screamed all the time, and for no reason.