The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Sunday, October 30, 2005

Here's a Secret...

... People wake up during surgery ALL THE TIME. Well, when I say 'wake up' I don't mean they sit up and start chatting with the surgeon about last week's episode of Survivor... but more awake you'd think.

I don't remember when the first time I saw it was, but I guess it was back when I was a med student. If you're not warned beforehand and the patient suddenly starts bucking, it is a truly scary thing. At the time, what shocked me even more was how nonchalant everyone was about it. The surgeon calmly called the anesthesiologist's attention to the fact that the patient 'was a little light'. This wasn't readily apparent to the anesthesiologist because once the patient is asleep they are likely to be napping, reading a book, doing a crossword puzzle, checking their e-mail, talking on the phone, or, in one of my most bizarre OR experiences to date, constructing an elaborate tent out of sterile drapes and towel clips to shield themselves from a draft.

So the anesthesiologist, alerted to the fact that their patient seems to be two seconds away from taking the scalpel from the surgeons hand and circumcising him with it, calmly drew up a little more rocuronium (paralytic) and injected it. Crazy. Now usually, there would be signs that the patient was not as deeply under anesthetic as he should be... in response to pain, even unconscious people will show an increased heart rate and blood pressure. Usually, the anesthesiologist will pick up on that and top them up, either with stinky gas or with the good stuff (fentanyl, sufentanil). I'm not sure why this time was different. I have a hypothesis though... see my previous post on medical errors.

Luckily, even if the patient DID wake up in the middle of surgery they'd never remember it. The main drug used in anesthesia (the one that actually puts you to sleep most of the time) not only puts you under, but is a pretty potent amnestic agent. (Insert evil laugh here)

So good luck the next time you have to go in for surgery.



Anonymous Anonymous said...

I woke up twice during knee replacement surgery-I had a spinal. I said to the anesthesiologist "is that a saw" and then I was not aware anymore. Later when I again was awake I said that my eyes where itchy and the surgeon said, "knock her the hell out" and thank heavens, the next time I woke up it was in recovery. Same thing happened during my last colonoscopy, why doesn't anyone listen. I have told the last 3 anesthesiologist that not only do I not go under right away but I don't stay under. They pat my hand and say "Oh that will not happen" condescending tone of voice, complete with smirk.

5:05 PM

Anonymous Anonymous said...

I recently had a colonoscopy and woke up also. The pain was so bad I pulled on the bed rail until I injured my bycep. It was awful.
I was told it was because I take a lot of pain medicine as well as wear a duregesic patch and my body has a very high tolerance. Another doctor told me they should always use some different medication to put me to sleep. Can't remember name.

1:38 PM

Blogger Barry said...

The problem is that the anesthesiologist (or endoscopist) shouldn't ever promise people that they won't remember anything when they have a spinal or a colonoscopy. The spinal is a regional anesthetic (i.e., you aren't asleep, just numb), and sedation is just "a little something to take the edge off." Think of sedation as just like being might remember or you might not. Neither one is meant to do what a general anesthetic (GA) is meant to (prevent any recall). I warn all my patients having sedation or regional anesthesia that they might remember events in the OR. If they expect it, it usually isn't terrifying. If they are so wound up that they can't accept that, regional is a poor choice, and they should have a GA. As far as colonoscopy is concerned, many people have them without sedation or anesthesia. I had a colonoscopy without either once. Uncomfortable, but not unmanageable.

In terms of a GA, it takes about twice as much "gas" to keep someone still as it does to keep them from remembering. Patients often move under anesthesia, but they only remember events while under GA about 1/500-1/1000 times. Giving an anesthetic is a delicate balancing act, where one has to weigh circulatory collapse against movement/awareness/hypertension. Also, levels of stimulation vary enormously during surgery, and while stimulation changes abruptly, depth of anesthesia doesn't. Medications have to be absorbed when they are given. The problem is that (over) use of muscle relaxants, which ironically contributes to the problem of intraop. recall, has engendered the expectation that a patient will never move during surgery.

Even brain-dead patients (having organs harvested) will move during surgery. This is due to spinal reflexes, and doesn't mean the patient is "waking up."

The best thing I can counsel for any physician-in-training is to try to do a 2-4 week elective rotation in anesthesiology. It will help you understand the challenges of maintaining a patient in a state of relaxation, amnesia, and adequate pain relieve during an operation.

10:46 AM


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