Waking Up During Surgery (2019)(mosaicscience.com)
mosaicscience.com
Waking Up During Surgery (2019)
https://mosaicscience.com/story/anaesthesia-anesthesia-awake-awareness-surgery-operation-or-paralysed/
110 comments
Just an anecdote: I once had a procedure that required I be under a "light" general anesthesia (don't recall which). I was generally paranoid at the time though about everything, and strapped an audio recorder to my leg secretly. Turns out I did wake up mid procedure (the audio suggests doctor and nurse rushed to stop me from touching the area of operation of my face, and that I was distressed) but as the doctor promised, the sedative would have a strong effect on my short term memory and I remember not being able to recall any of what I had heard on the recording. I don't consider this at all traumatic: my memory was selectively wiped of that time period by virtue of the drug. Life just went on. It may not be popular to say, but I do feel from my experience that pain with no memory is pretty much as good as no pain, in the grand scheme of things.
I wonder if the journalist is asking the wrong people.
Instead of interviewing patients supposed to be under drug-induced amnesia, and finding the few who remembered, ask the doctors and nurses who are being asked to restrain patients in distress. A specialist in a procedure that requires light general anesthesia would, if this was true, have done surgery on thousands of people in various degrees of distress.
To me, that would be a pretty heavy secret to carry, and a 'conspiracy' that large would be impossible to conceal. I do agree, though, that pain without memory is pretty much as good as no pain. When you're conscious but unable to remember being conscious, are you still capable of suffering?
Instead of interviewing patients supposed to be under drug-induced amnesia, and finding the few who remembered, ask the doctors and nurses who are being asked to restrain patients in distress. A specialist in a procedure that requires light general anesthesia would, if this was true, have done surgery on thousands of people in various degrees of distress.
To me, that would be a pretty heavy secret to carry, and a 'conspiracy' that large would be impossible to conceal. I do agree, though, that pain without memory is pretty much as good as no pain. When you're conscious but unable to remember being conscious, are you still capable of suffering?
My initial intuition to your last question was, “No, suffering usually entails some sort of looking-back process that places the pain in that context.”
I then realized that animals can suffer, and either I’m confounding Buddhist and Western psychological definitions of suffering, or suffering doesn’t require consciousness of it occurring for it to be suffering.
I hope that makes sense!
I then realized that animals can suffer, and either I’m confounding Buddhist and Western psychological definitions of suffering, or suffering doesn’t require consciousness of it occurring for it to be suffering.
I hope that makes sense!
The difference is that when an animal suffers, they retain memories. One only need to consider something like this story I heard about a dog on Reddit, who was scared of obese people and men. Turns out, the dog was severely abused by a 500-lb man who was its former owner.
I recall hearing about this phenomenon about a decade ago, and at the time someone theorized that the specific memory may be lost but the effects were still present, and that these effects could cause general anxiety and distress without the person understanding the reasoning. I think it is perhaps more philosophical than rational, but it did give me pause to consider that perhaps not everyone forgets enough of a surgery to escape its effects, even in the best of circumstances.
Yeah, they've done experiments with patients with no long-term memory where they do things like shock them when they shake hands. People develop an aversion to it but can't explain why.
There are entire fields of study dedicated to studying the long-term effects of various trauma. Unfortunately it gets mixed in with the "repressed memories" and other pseudoscience ideas, so the pop-science news articles are not good sources of information.
That said, memory repression isn't the only type of anesthesia involved in these procedures. Patients are given multiple medications, which do everything from dampen the pain signals to relax the patient.
It's not equivalent to just forgetting the pain stimulus. The pain stimulus is massively reduced, even if it were to break through to the patient's awareness.
That said, memory repression isn't the only type of anesthesia involved in these procedures. Patients are given multiple medications, which do everything from dampen the pain signals to relax the patient.
It's not equivalent to just forgetting the pain stimulus. The pain stimulus is massively reduced, even if it were to break through to the patient's awareness.
Apparently upper GI endoscopy procedures are conducted under very very mild sedation, I believe typically using propofol.
The most recent one I got, I had disturbing hazy dreams the next two nights where I was conscious of the scope down my esophagus. I would not be surprised if it was less dream and more of a memory fragment.
The most recent one I got, I had disturbing hazy dreams the next two nights where I was conscious of the scope down my esophagus. I would not be surprised if it was less dream and more of a memory fragment.
>pain with no memory
reverse situation - all the memory and no pain. I had a surgery on my nose done under local, and it was kind of unreal experience when the surgeon stopped cutting and took what looked like a typical woodworking chisel and a small hammer and started to chisel away the bone in my nose - all without any pain, my head is just like a piece of wood - the force would transfer and the back of my head would feel the pressure every time the hammer would fall and the scraping vibrations of the chiseling would just reverberate through the scull. ... More than 20 years later ENT here was genuinely curious where did i get such a nice job done. USSR military surgeon :) And back in the USSR my mother had her appendix removed under local too, and the surgeon was communicating to her various stages of the surgery, like what he is going to do and how that may be felt/perceived.
I wonder about the merits of those different approaches. (very handwavy as IANAD) With the local the pain doesn't seem to reach the central nervous system. With the sedation or general it reaches i suppose, yet the central nervous system has no reaction. If one supposes that the strong pain may be a kind of neuron pathway/connection altering signal ("EEPROM burning"), it would be plausible to expect that that unfelt or felt-and-forgotten at the time pain under sedation or general may still have some effects down the road.
reverse situation - all the memory and no pain. I had a surgery on my nose done under local, and it was kind of unreal experience when the surgeon stopped cutting and took what looked like a typical woodworking chisel and a small hammer and started to chisel away the bone in my nose - all without any pain, my head is just like a piece of wood - the force would transfer and the back of my head would feel the pressure every time the hammer would fall and the scraping vibrations of the chiseling would just reverberate through the scull. ... More than 20 years later ENT here was genuinely curious where did i get such a nice job done. USSR military surgeon :) And back in the USSR my mother had her appendix removed under local too, and the surgeon was communicating to her various stages of the surgery, like what he is going to do and how that may be felt/perceived.
I wonder about the merits of those different approaches. (very handwavy as IANAD) With the local the pain doesn't seem to reach the central nervous system. With the sedation or general it reaches i suppose, yet the central nervous system has no reaction. If one supposes that the strong pain may be a kind of neuron pathway/connection altering signal ("EEPROM burning"), it would be plausible to expect that that unfelt or felt-and-forgotten at the time pain under sedation or general may still have some effects down the road.
I heard that in USSR the policy for apendectomy was that adults got only local anesthesia and kids would get general. No idea if that was the official policy or rumors only. I had appendectomy when I was 12 (that was USSR times) and got general anesthesia.
most probably it was some kind of officially established policy/practice. My mother got the appendectomy when she was an adult, and i got the nose job when i was almost 16, while the hernia surgery that i had at 5 was naturally under general.
My wife has actually had both, on separate occasions. About 15 years ago, she smashed her wrist, breaking it into multiple pieces. In the ER, they explained that the wouldn't give her an anesthetic to push things into place for a splint (to hold it together until surgery could be scheduled), but they'd give her meds so she would forget the pain. I was absolutely amazed that it worked. She vaguely remembers telling them "let's git 'er done" and then nothing for about an hour after that.
Fast forward about 5 years or so, she's on the operating table to have titanium plates inserted to hold her ankle together and she apparently wakes up in the middle of the procedure and started trying to rip her IV out while the surgeon and nurses struggle to hold her down (she's pretty strong) while the anesthesiologist puts her back under. She has no memory of this: the only reason we even know about it is that one of the nurses mentioned later that "you caused quite a stir in there."
Training horses is not for the faint of heart :-)
Fast forward about 5 years or so, she's on the operating table to have titanium plates inserted to hold her ankle together and she apparently wakes up in the middle of the procedure and started trying to rip her IV out while the surgeon and nurses struggle to hold her down (she's pretty strong) while the anesthesiologist puts her back under. She has no memory of this: the only reason we even know about it is that one of the nurses mentioned later that "you caused quite a stir in there."
Training horses is not for the faint of heart :-)
> Training horses is not for the faint of heart :-)
I was going to guess a motorbike, but I'm pretty sure horses are even worse!
I was going to guess a motorbike, but I'm pretty sure horses are even worse!
Probably. Motorcycles can't think for themselves.
> It may not be popular to say, but I do feel from my experience that pain with no memory is pretty much as good as no pain, in the grand scheme of things.
If given the choice, I'd choose this over over deeper sedation.
Sedation and Anesthesia are not entirely risk-free. Even routine Anesthesia has been correlated with various subtle cognitive differences in the days and weeks after a procedure in some (though not all) studies.
I'd rather be given the minimum dose necessary to get the job done than have a provider go overboard with medications to avoid the small chance of someone breaking through the sedation.
If given the choice, I'd choose this over over deeper sedation.
Sedation and Anesthesia are not entirely risk-free. Even routine Anesthesia has been correlated with various subtle cognitive differences in the days and weeks after a procedure in some (though not all) studies.
I'd rather be given the minimum dose necessary to get the job done than have a provider go overboard with medications to avoid the small chance of someone breaking through the sedation.
> pain with no memory is pretty much as good as no pain
I can't speak to your specific case, but in general that's not true.
Even if you have no conscious memory of trauma, it can manifest itself in ongoing stress, fear, and general PTSD-like symptoms.
You may have been lucky in waking up but perhaps without pain, but that's not the case with everyone.
I can't speak to your specific case, but in general that's not true.
Even if you have no conscious memory of trauma, it can manifest itself in ongoing stress, fear, and general PTSD-like symptoms.
You may have been lucky in waking up but perhaps without pain, but that's not the case with everyone.
Sedation without going into general anesthesia is not an easy thing at all, and even experienced anesthesia providers will sometimes struggle. However, patients moving or being otherwise disoriented is quite frequent and in itself is a non-event except when trying to reach for the surgical site, as you describe. As for distress, it's often not from pain but rather confusion, which can somtimes devolve into agitation and necessity to deepen the anesthesia. In my experience, true awareness is exceptionally rare. It's true that some procedures, such as cardiac or emergency C-section have an increased risk of event due to the particular context, though.
There is no such thing as ‘light’ general anaesthesia. It’s a terrible term used only by non-anaesthetists. Did you have sedation? Movement with sedation is extremely common and not a concern. With sedation, we aim to provide comfort and relief from the anxiety-inducing parts of the experience, not unresponsiveness to noxious stimuli and lack of recall.
Sorry, but there is nothing else to say except that you are extremely wrong. This kind of belief is exactly why male circumcision is not seen for the evil that it is. Please try to consider the possibility that trauma without conscious memory can have disastrous results - as other commenters are trying to get you to understand...
Circumcision (as commonly practiced) is generally seen as "evil" because infants lack the power of consent to refuse. I'll gladly consider pain without memory to be "disastrous" if you can marshall enough evidence for that.
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> you are extremely wrong
Can you point to evidence suggesting this? Not trying to be adversarial, just genuinely curious since almost everyone in this thread is just exchanging anecdata.
Can you point to evidence suggesting this? Not trying to be adversarial, just genuinely curious since almost everyone in this thread is just exchanging anecdata.
I remember waking up from general anesthesia during removal of my wisdom teeth. The oral surgeon seemed kind of surprised, cursed and asked the assistant to give me more anesthesia. I didn't find it all that traumatic either at the time, but I was only awake for a minute or so.
Was it true general (full intubation, paralysis, etc.) or "conscious sedation" (falling asleep with no memory and an oxygen tube next to your nose)?
Waking up and trying to move would make sense under conscious sedation. Seems very unlikely under general, given my (non professional) understanding.
I don't believe "light general" is a thing.
Waking up and trying to move would make sense under conscious sedation. Seems very unlikely under general, given my (non professional) understanding.
I don't believe "light general" is a thing.
Please don’t bring a recorder. It puts you at risk because when we ask if you have any devices, we expect an honest answer. If it is discovered you will lose the trust of your treating team. You can get electrical burns if certain equipment is used. You could have recorded conversations about other patients, which you are not entitled to do.
Yeah, not that'd I'd do it today because mental health is better, but it was pretty low risk. The surgery was on my nose, and the recorder was a cheap alkaline battery one (4.5 volts) strapped to my leg below the knee.
By this argument, living an entire life of suffering and then not remembering it when you’re dead would mean that it doesn’t matter and all suffering can be ignored. I hope that’s not the ethical code we settle on.
No need to be concerned. Exactly zero people are concluding that suffering can be ignored because someone is ok with not remembering pain during a medically necessary surgery.
The sedation prevents the memories from forming, and also prevents the person from processing what's going on. The actual pain signals are also significantly dampened.
It's not equivalent to a lifetime of suffering in any way.
It's not equivalent to a lifetime of suffering in any way.
"This all makes anaesthesia as much art as science"
This is one of the most important parts of the piece. It is something that most people out side of healthcare are not aware.
Anaesthesia is very much an art.
Anaesthesia is unlike other medications, "take xx mg over yy days."
Anaesthesia effects can vary wildly from person to person. Weight plays a big role, but so does bed position, condition, sex, body part etc. There is a variety of confounding factors. There is no textbook dosage for a given situation.
Anecdotally, acknowledging this before any surgery with a simple bedside conversation, may improve outcomes with anaesthesia.
Anaestheologists move from patient to patient quickly. Recognizing how their job is more than just inserting the needle, will make you stand out from other patients.
This is one of the most important parts of the piece. It is something that most people out side of healthcare are not aware.
Anaesthesia is very much an art.
Anaesthesia is unlike other medications, "take xx mg over yy days."
Anaesthesia effects can vary wildly from person to person. Weight plays a big role, but so does bed position, condition, sex, body part etc. There is a variety of confounding factors. There is no textbook dosage for a given situation.
Anecdotally, acknowledging this before any surgery with a simple bedside conversation, may improve outcomes with anaesthesia.
Anaestheologists move from patient to patient quickly. Recognizing how their job is more than just inserting the needle, will make you stand out from other patients.
That's really the case for medication, as well. I wish doctors would be better in this regard and pay more attention to individual needs. I understand that would be more difficult and would likely increase costs, but still.
The way it's done now is as you said, "take x mg at y interval" based on the tests done during drug development. If you don't respond to the medication the same way as the majority, you're in for a ride. If x drug doesn't work, try something else until something works. It's a pretty terrible approach, tbh.
It's rare to find a doctor who will keep in mind the many individual factors, often they have a lot of experience (to build that database of knowledge, which sadly is not shared) and actual interest in their work, a surprisingly rare thing.
The way it's done now is as you said, "take x mg at y interval" based on the tests done during drug development. If you don't respond to the medication the same way as the majority, you're in for a ride. If x drug doesn't work, try something else until something works. It's a pretty terrible approach, tbh.
It's rare to find a doctor who will keep in mind the many individual factors, often they have a lot of experience (to build that database of knowledge, which sadly is not shared) and actual interest in their work, a surprisingly rare thing.
That's well said.
Just because it is standard practice doesn't mean its the best approach. Its just the accepted approach.
Nassim Taleb has a quote on the subject that i love:
"The difference between medicine and poison... is dosage"
Just because it is standard practice doesn't mean its the best approach. Its just the accepted approach.
Nassim Taleb has a quote on the subject that i love:
"The difference between medicine and poison... is dosage"
Nearly 500 years ago, Swiss physician and chemist Paracelsus expressed the basic principle of toxicology: “All things are poison and nothing is without poison; only the dose makes a thing not a poison.”
This is the role of the modern pharmacist in the clinical team.
Nurse is the care expert
Physician is the diagnosis and treatment expert
Pharmacist is the medication expert
Nurse is the care expert
Physician is the diagnosis and treatment expert
Pharmacist is the medication expert
Reminds me of this somewhat relevant post about the mysteries of Anesthesia
https://medium.com/@lukehollomon/anesthesia-works-on-plants-...
https://medium.com/@lukehollomon/anesthesia-works-on-plants-...
Okay this is an interesting article and an interesting subject. But, it looks a lot like fear-mongering. I feel strongly about this because I had two procedures done under local for fear of exactly this situation (coming up but being sedated) and both experiences where tough.
> Founded in 2007, it has now collected more than 340 reports
So 24 self-reported cases a year in all of N America. There are 48 million in patient surgeries performed PA in USA so V conservative estimate is 5*10^-7 chance.
Later, on follow up, my doctor explained to me why they don't worry about patients coming up. It's because this traumatic experience the patient is describing, if they were awake and experience trauma, would result in a raised heart-rate and blood-pressure. The link between trauma and those physical responses is one to one.
If and when patients begin to get a raised heart or raised blood pressure you better believe they're getting a much higher dose and/or a change of anaesthetic.
> One of the largest and most thorough investigations was the fifth National Audit Project carried out by British and Irish anaesthetists’ associations, in which every public hospital in the UK and Ireland had to report any incidents of awareness for a year. The results, published in 2014, found that the overall prevalence was just 1 in 19,000 patients undergoing anaesthesia.
This is comparing apples with elephants. 'incident of awareness' is nothing like the idea of being fully awake and compos during a surgery.
>but many people may feel unable or unwilling to come forward, and would instead prefer to just put the experience behind them.
Speculation
> Founded in 2007, it has now collected more than 340 reports
So 24 self-reported cases a year in all of N America. There are 48 million in patient surgeries performed PA in USA so V conservative estimate is 5*10^-7 chance.
Later, on follow up, my doctor explained to me why they don't worry about patients coming up. It's because this traumatic experience the patient is describing, if they were awake and experience trauma, would result in a raised heart-rate and blood-pressure. The link between trauma and those physical responses is one to one.
If and when patients begin to get a raised heart or raised blood pressure you better believe they're getting a much higher dose and/or a change of anaesthetic.
> One of the largest and most thorough investigations was the fifth National Audit Project carried out by British and Irish anaesthetists’ associations, in which every public hospital in the UK and Ireland had to report any incidents of awareness for a year. The results, published in 2014, found that the overall prevalence was just 1 in 19,000 patients undergoing anaesthesia.
This is comparing apples with elephants. 'incident of awareness' is nothing like the idea of being fully awake and compos during a surgery.
>but many people may feel unable or unwilling to come forward, and would instead prefer to just put the experience behind them.
Speculation
They went on to describe the forearm experiment which showed a much higher rate of awareness. I don’t see why you’ve chosen to omit that. You seem to casually discard the idea that awareness without memory is irrelevant, but when I’ve informed patients of amnestics they’ve been horrified - maybe needlessly so, but I’m not so arrogant as to think “silly patient, your horror is wrong and therefore irrelevant.”
Many people don’t regard “you’ll be in pain and then forget” as the same as “no pain.”
And the idea that HR and BP are perfect indicators of pain is ridiculous. Anesthetics reduce the responsiveness of both; cardiac parameters don’t respond perfectly, and you don’t need perfect anesthesia to impair them.
In my hospital, at least, we don’t take for granted that we achieve perfect coverage. It’s normal to give patients a bolus of amnestic at the tail end of a procedure to cover any gap in pain/distress while we were bringing them back to consciousness.
Many people don’t regard “you’ll be in pain and then forget” as the same as “no pain.”
And the idea that HR and BP are perfect indicators of pain is ridiculous. Anesthetics reduce the responsiveness of both; cardiac parameters don’t respond perfectly, and you don’t need perfect anesthesia to impair them.
In my hospital, at least, we don’t take for granted that we achieve perfect coverage. It’s normal to give patients a bolus of amnestic at the tail end of a procedure to cover any gap in pain/distress while we were bringing them back to consciousness.
> Many people don’t regard “you’ll be in pain and then forget” as the same as “no pain.”
I find this incredibly fascinating. If people were to be offered a sum of money in exchange for feeling immense pain for an hour but then having that memory wiped, I wonder how many would shrug and say "I won't remember anything? Sure, sign me up." I wonder at the ethical and morality of such things. If the person's reality is based solely on their memories, is it even unethical? Like I said, fascinating.
Thank you for the intriguing thought experiment for today.
I find this incredibly fascinating. If people were to be offered a sum of money in exchange for feeling immense pain for an hour but then having that memory wiped, I wonder how many would shrug and say "I won't remember anything? Sure, sign me up." I wonder at the ethical and morality of such things. If the person's reality is based solely on their memories, is it even unethical? Like I said, fascinating.
Thank you for the intriguing thought experiment for today.
A few years back, I had a procedure that involved twilight sedation. That means you're aware of the experience while it's happening, but have no memory of it afterwards.
I thought about this exact thought experiment constantly leading up to the day of the procedure.
It's a fascinating philosophical question. Did I experience the pain of the procedure? A past me before the procedure agreed to commit some future me to pain. During the procedure, that me then certainly experienced pain. But the hypnotic drug washed that memory away leaving a third me that had the benefits of the procedure but no memory of the pain.
So what is the moral calculus to perform when signing your future self up to pain that your future future self will forget?
I thought about this exact thought experiment constantly leading up to the day of the procedure.
It's a fascinating philosophical question. Did I experience the pain of the procedure? A past me before the procedure agreed to commit some future me to pain. During the procedure, that me then certainly experienced pain. But the hypnotic drug washed that memory away leaving a third me that had the benefits of the procedure but no memory of the pain.
So what is the moral calculus to perform when signing your future self up to pain that your future future self will forget?
I think there are ethical questions for the beneficiaries. Isn't like subjecting someone else to intense pain for an hour in order to receive money?
Statistics on women who choose a "no painkiller" second childbirth after doing so the first time might exist.
That might be an aversion to using painkillers again after experiencing awful side-effects in the first delivery.
Ah, I meant those that go without painkillers a second time.
The lingering physical effects of a body experiencing trauma for that amount of time might be too damaging for some to be willing to accept amnesia as a panacea.
There might also be a difference between a) You will be in pain for an hour, remembering the whole thing, and at the end of that hour, your memory will be wiped; and b) You will be in pain for an hour, but you will not form any memory of any part of that hour in the first place. It's the difference between saving data to a huge file and then deleting it, versus piping the data to /dev/null as it comes in. AFAIK amnestic drugs are intended to be closer to the second method.
You might be interested in the radio programme "Brian Gulliver's Travels".
https://en.wikipedia.org/wiki/Brian_Gulliver%27s_Travels
https://www.bbc.co.uk/programmes/b01m29vt
They included an episode (Kognitia) where people are able to forget traumatic experiences. Here's a tiny clip: https://www.bbc.co.uk/sounds/play/p00yj97w
They're available on Archive.org here: https://archive.org/details/briangulliverstravels1-2
https://en.wikipedia.org/wiki/Brian_Gulliver%27s_Travels
https://www.bbc.co.uk/programmes/b01m29vt
They included an episode (Kognitia) where people are able to forget traumatic experiences. Here's a tiny clip: https://www.bbc.co.uk/sounds/play/p00yj97w
They're available on Archive.org here: https://archive.org/details/briangulliverstravels1-2
Okay, so how is this person in massive amounts of pain without having the physiological response of a raised heart rate and raised blood pressure?
> Many people don’t regard “you’ll be in pain and then forget” as the same as “no pain.”
This makes perfect sense to me. Forgetting the pain is nice for future-me, but doesn't do anything for current-me. There will be a period where I am in pain and am aware of it. Forgetting it later is good for your mental health presumably, but forgetting something doesn't erase it from existence.
This makes perfect sense to me. Forgetting the pain is nice for future-me, but doesn't do anything for current-me. There will be a period where I am in pain and am aware of it. Forgetting it later is good for your mental health presumably, but forgetting something doesn't erase it from existence.
I've had three general anaesthetics, all as a child or teenager. I only remember "the anaesthetic" for one of them: a large dose of what I now know to be propofol went in a cannula and the (attractive, for a 14-year-old) nurse stroked the cannula on the back of my hand after it was administered. That felt warm and nice. Purple butterflies them started to come up out of my hand, through the back of the venflon, and came around my vision, until I was surrounded by warm, beating wings and a pleasant drifting into unconsciousness (tinged with a feeling of contentment). I woke up -- much to my great chagrin -- in "moderate discomfort" what felt like instantaneously later, although several hours had gone.
None of my hallucinations were real. Everything that I "saw" probably took place in a 1-2s period as I was falling under, and was entirely a figment of my imagination. Were I worried about waking up during my procedure, it's entirely possible that my brain would have hallucinated something far less innocent. These reports are very difficult to substantiate, but a lot of monitoring is done under general anaesthesia: depending on the surgery and the anaesthetic this might range from measuring the inspirational and expirational partial pressures of O2, CO2, other relevant gasses such as N2O and the anaesthetic agent itself, e.g. desflurane or sevoflurane. Heart rate, blood pressure and the like are all routinely monitored. It's therefore possible to compute the effective concentration of agent in the blood stream and directly prove that the concentration is adequate. Sometimes EEGs are taken and can directly show brain activity, or nerve conduction pathways are mapped and can show conscious activation. Waking up during (competent) anaesthesia should never happen, and I think that the 5e-7 chance put above is probably an upper bound. At any rate, it pales in comparison with the complication rate from many surgeries, which, of course are usually several orders of magnitude higher: 1e-3 for death is often considered acceptable, for context.
None of my hallucinations were real. Everything that I "saw" probably took place in a 1-2s period as I was falling under, and was entirely a figment of my imagination. Were I worried about waking up during my procedure, it's entirely possible that my brain would have hallucinated something far less innocent. These reports are very difficult to substantiate, but a lot of monitoring is done under general anaesthesia: depending on the surgery and the anaesthetic this might range from measuring the inspirational and expirational partial pressures of O2, CO2, other relevant gasses such as N2O and the anaesthetic agent itself, e.g. desflurane or sevoflurane. Heart rate, blood pressure and the like are all routinely monitored. It's therefore possible to compute the effective concentration of agent in the blood stream and directly prove that the concentration is adequate. Sometimes EEGs are taken and can directly show brain activity, or nerve conduction pathways are mapped and can show conscious activation. Waking up during (competent) anaesthesia should never happen, and I think that the 5e-7 chance put above is probably an upper bound. At any rate, it pales in comparison with the complication rate from many surgeries, which, of course are usually several orders of magnitude higher: 1e-3 for death is often considered acceptable, for context.
Unfortunately, awareness during ‘competent’ general anaesthesia is not entirely avoidable. First, if we were to give all patients a dose of hypnotic agent that would absolutely prevent awareness, a not-insignificant number would die or be disabled from the acute cardiovascular effects. So, we don’t. We give doses that make the risk very small, but not zero. It’s a balance of risks.
Your personal experience has absolutely zero impact on the value of this article. The "it doesn't exist because i never experienced it" mindset is a dangerous one.
I'm making the point that I, and many other people, have experienced the downside of the baseless fear-mongering around 'waking up' during surgery.
I have had several surgeries with everything from a light to general anesthetic. I warn the nurses and doctor beforehand that I have a history of waking and remember previous operations. Most do not believe me. I remember the sound of my wisdom teeth being cracked open and opening my eyes while they were being cut out. I remember scaring the shit out of a nurse and doctor when I woke and started talking mid-procedure. I remember being held down when I kept trying to roll onto my side as if I were asleep. Typically, the reaction is something like "he is awake" followed by a flurry of action, then sleep. I don't know why this happens-- I suspect something makes the anesthesia wear off faster than normal. I also have an issue at the dentist with numbing-- they usually have to hit me twice. If that doesn't work fully, I just tell him to go ahead and I will deal with it.
Do you have red hair?
I ask because they're known to need more anesthesia.
I ask because they're known to need more anesthesia.
I also had this happen. Literally almost the exact same, don't remember whether I opened my eyes or not but I remember hearing crunching sounds coming from my mouth and realizing it was them drilling or hammering or doing something destructive to my wisdom teeth. But zero pain. Just a wtf that is weird af feeling. But then I passed back out (not sure if they did something to make me fall back asleep or if it occurred of its own accord).
That speculation at the end is truly bizzare. I’m sure that, if I suffered such an experience, the first thing I’d do upon waking would be to talk about it!
I remember the doctors asking me after partial removal of a brain tumour if I remembered them waking me up during the surgery.
I wish I did, but I remember absolutely nothing.
This was about 15 years ago, and I don't remember if they said they would wake me up prior to the surgery. Maybe to my parents.
I wish I did, but I remember absolutely nothing.
This was about 15 years ago, and I don't remember if they said they would wake me up prior to the surgery. Maybe to my parents.
Was that done to actively map your brain so that they could be especially careful around areas related to functions like speech?
Would you? It would probably be by far the worst agony you'd ever experienced, and given the circumstances you might also not be able to be certain you had actually experienced it. Beyond that, you'd likely face strong dissuasion if you did try to talk to anyone about it, even a doctor or nurse involved in your care, assuming the article is accurate in saying most don't really believe it can happen. It might be hard to argue with someone in a position of professional authority saying it was all just a bad dream, a pre-waking hallucination, or similar - nothing more than the anesthesia messing with your head a little, nothing you'd need to worry about. And you might well want very much to believe that was true, too.
I don't know, and I don't feel competent even to really guess. I have a degree of physical ability to tolerate pain that has drawn surprised comment from doctors and dentists in the past; between that and the mental and emotional toolkit I've had to develop in consequence of various painful illnesses for which I wasn't immediately able to obtain care, I might, very possibly, if the procedure was short and God was kind, be able to withstand something like this without being entirely crippled by trauma, maybe. Even then I don't know that I'd tell the surgeon; it would be a difficult and uncomfortable conversation to have at a time when I'd no doubt already be feeling unusually fragile. And that's me - for someone totally naïve to severe pain, and lacking any of the advantages I have in dealing with it? It's horrifying just to think about.
I don't know, and I don't feel competent even to really guess. I have a degree of physical ability to tolerate pain that has drawn surprised comment from doctors and dentists in the past; between that and the mental and emotional toolkit I've had to develop in consequence of various painful illnesses for which I wasn't immediately able to obtain care, I might, very possibly, if the procedure was short and God was kind, be able to withstand something like this without being entirely crippled by trauma, maybe. Even then I don't know that I'd tell the surgeon; it would be a difficult and uncomfortable conversation to have at a time when I'd no doubt already be feeling unusually fragile. And that's me - for someone totally naïve to severe pain, and lacking any of the advantages I have in dealing with it? It's horrifying just to think about.
It's not uncommon to wake people up during brain surgery, or do the surgery without fully anesthetizing the patient at all. They would anesthetize the skull area they cut through. And the brain tissue itself doesn't register pain when cut. They do it so the surgeons can interact with the patient to guide them in what areas they have to stay away from when removing a tumor or doing other work. Here's more:
https://www.mayoclinic.org/tests-procedures/awake-brain-surg...
https://www.mayoclinic.org/tests-procedures/awake-brain-surg...
Sure, I'm aware, and I don't know of any reports of emotional harm as a result of that. I think it'd probably be the combination of pain, helplessness, surprise, and recollection that'd be what causes the trauma in cases where people regain consciousness unintentionally. In the kind of surgery you describe, at most two of those seem likely ever to be present, and because the awareness is intentional I expect there'd be more and/or different pharmacological support to help insulate the patient from the full reality of the situation. So I don't think awake brain surgery is likely all that usefully comparable to the accidental awareness we're discussing here.
I thought you were referring to Tapland's report "I remember the doctors asking me after partial removal of a brain tumour if I remembered them waking me up during the surgery" when you said it "would probably be by far the worst agony you'd ever experienced."
Accidental awareness during surgery has always sounded massively traumatic to me. Even thinking about it makes me intensely uncomfortable.
Accidental awareness during surgery has always sounded massively traumatic to me. Even thinking about it makes me intensely uncomfortable.
I don't know. I have some fairly complex thoughts here, but I'm coming at it as someone for whom there is evidently something deeply weird going on with their whole perception of this category of sensation - I don't find opioids at all pleasurable, either, and it was only a few months ago that I found out how unusual that is. Not that I'd try to change any of this even if I thought I could, but I suppose it doesn't really equip me to talk on the subject in a way that'd likely be of use to anyone normal.
As said: speculation. A study would have found a meaningful number expressing hesitation to discuss but doing so anyway, plus those who won’t but clearly experienced trauma - pointing to a percentage actually quiet about the incident.
Of course it's speculation; as far as I know nobody's done much research of any kind into this phenomenon. Making it more widely known seems like a good way to improve the odds of someone doing such research, so in that sense the article is worthwhile, whether speculative or otherwise. And, again, how could it not be? The subject matter practically compels such consideration.
Most surgeons, at least males ones, will have another nurse present during recovery as some pretty weird memories can form.
I remember reading about a case where an older female patient wouldn’t talk to the surgeon after. Finally she admitted she was upset as “the surgeon has put his penis in her hand”.
Luckily he had a nurse present the entire time and what he had done is place two fingers in her palm and told her to squeeze.
Yet this patient was 100% convinced he had been inappropriate with her.
I remember reading about a case where an older female patient wouldn’t talk to the surgeon after. Finally she admitted she was upset as “the surgeon has put his penis in her hand”.
Luckily he had a nurse present the entire time and what he had done is place two fingers in her palm and told her to squeeze.
Yet this patient was 100% convinced he had been inappropriate with her.
I'm inclined to chalk this up to false memories. Especially if someone is going in with nervousness or awareness that "waking up without being able to alert the surgeon" is a specific point of anxiety of the patient. But, who knows.
https://en.wikipedia.org/wiki/False_memory
https://en.wikipedia.org/wiki/False_memory
It should be easy to disprove false memory, I'd think, at least in the case of procedures that are recorded. Ask the patient what they remember happening, and compare with the recording to see if those things did occur or didn't.
I'm not inclined to assume every report of this happening is due to false memory, which is itself a somewhat controversial topic. As the article points out but is not even slightly novel in saying, we don't have a firm understanding of why general anesthesia works, just that it does. That's good enough to be going on with, but not yet understanding the mechanism at work means it's reasonable to expect we also don't yet have perfect knowledge of why and when it doesn't work perfectly, and there is therefore nothing implausible about there being rare outliers such as those under discussion here.
I'm not inclined to assume every report of this happening is due to false memory, which is itself a somewhat controversial topic. As the article points out but is not even slightly novel in saying, we don't have a firm understanding of why general anesthesia works, just that it does. That's good enough to be going on with, but not yet understanding the mechanism at work means it's reasonable to expect we also don't yet have perfect knowledge of why and when it doesn't work perfectly, and there is therefore nothing implausible about there being rare outliers such as those under discussion here.
Doctors usually talk during (some parts of ) the surgery. About whatever is on their mind. If the patient can recite some details about that, it's probably not false memory.
I've read a story some years ago about a patient that didn't have any pain but did have some vague memories about the procedure that he should not have had if he was fully under. The patient was able to describe the topics of informal small talk during their procedure.
Check out the sibling comment in which lr4444lr recounts taking a secret audio recording device into surgery.
Another anecdotal data point:
I received full dental replacement implants (the all-on-four style) a couple of years ago. During the procedure, I came out of it enough to remember trying to get "something" out of my mouth that was bothering me, and a nurse literally shouting at me to stop.
My wife was waiting for me and could see down the hallway where my room was. She said that at one point the doctor came out of my room gagging and holding his throat. After a few minutes, he went back in.
Later, we discovered that I fought everyone in the room. I had punched the doctor in the throat, tried to rip my IVs out, etc. The incident I remember (the yelling) was just a part of it all.
I've since read up on anesthesia and the subject is both fascinating and scary ("science with a lot of art mixed in").
I received full dental replacement implants (the all-on-four style) a couple of years ago. During the procedure, I came out of it enough to remember trying to get "something" out of my mouth that was bothering me, and a nurse literally shouting at me to stop.
My wife was waiting for me and could see down the hallway where my room was. She said that at one point the doctor came out of my room gagging and holding his throat. After a few minutes, he went back in.
Later, we discovered that I fought everyone in the room. I had punched the doctor in the throat, tried to rip my IVs out, etc. The incident I remember (the yelling) was just a part of it all.
I've since read up on anesthesia and the subject is both fascinating and scary ("science with a lot of art mixed in").
Wow, this lady has 2 to 3 nightmares per night even ten years later, after an exploratory surgery? That's pretty extreme, I think most people wouldn't have had 6 to 8 thousand nightmares about this experience.
It’s a reasonably common response to traumatic events for people to have regular nightmares for decades afterwards. ~2-3 a night for a decade would be high, but not unheard of.
a study comparing Vietnam Veterans to civilians showed that 52% of combat Veterans with PTSD had nightmares fairly often. Only 3% of the civilians in the study reported that same level of nightmares. https://www.ptsd.va.gov/understand/related/nightmares.asp
a study comparing Vietnam Veterans to civilians showed that 52% of combat Veterans with PTSD had nightmares fairly often. Only 3% of the civilians in the study reported that same level of nightmares. https://www.ptsd.va.gov/understand/related/nightmares.asp
My dominant (practically exclusive, actually) nightmare for over 20 years involved forgetting a class schedule or where a classroom was. Initially triggered by the (enormous) middle school I attended for the first half of 6th grade, then it morphed into a whole new set of very-similar nightmares after I started attending college. I'm sure I had thousands of those nightmares. Hell, I so rarely remember any of my dreams on waking these days (used to recall a detailed, ordered history of my dreams each morning, without even trying) that for all I know I'm still having them several times a week without realizing it.
I'd believe thousands of nightmares over the span of a decade, for a traumatic surgery experience.
I'd believe thousands of nightmares over the span of a decade, for a traumatic surgery experience.
I would guess her actual memory of the up-waking would be very unreliable after thousands of nightmares.
Thought experiment: what if we were all aware during general anasthesia and felt all the pain and these cases differed only in that they retained a long term memory of it?
I know there are ways to measure pain, brain activity etc that most likely rule this out. But what if? Are experiences, even unpleasant ones, really experienced if they leave no trace at all, not even a memory?
I know there are ways to measure pain, brain activity etc that most likely rule this out. But what if? Are experiences, even unpleasant ones, really experienced if they leave no trace at all, not even a memory?
This is known to be kind of true. At least some part of the body remembers the pain. And it can have some long lasting effects (chronic pain, or stress). That's why nowadays during many surgeries they try to suppress the pain as much as possible locally.
So if you get surgery on your leg, it is best if you have additional anaesthesia or pain killers working in this particular leg. So you wouldn't feel all the pain even without general anaesthesia.
So if you get surgery on your leg, it is best if you have additional anaesthesia or pain killers working in this particular leg. So you wouldn't feel all the pain even without general anaesthesia.
Without going into too much spoilers, a horror video game Amnesia: The Dark Descent has some tropes around this topic.
Potentially relevant research discussing, in part, whether drugs that disrupt memory formation and/or sympathetic nervous system activation can improve outcomes after traumatic events: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4620711/
My idea was that anasthesia switches off consciousness itself. It is like closing your eye when you look at the Sun while using painkillers is like wearing sunglasses.
General anesthesia does have an analgesic effect. Many people who woke up during a surgery have reported not feeling any pain. My fear is that sedation, on the other hand, could lead to the patient suffering but not remembering (much of) it afterwards.
Yes, this is my fear. After surgery it is not a problem, but in the weeks leading up to a surgery it's terrifying.
Yes? You think you keep your memories when you die?
Interestingly, in Germany at least, when someone is killed in an accident, in determining the damages payable to the person's estate (i.e. other people) they take account of how much pain (it is speculated that) the person suffered in the seconds before they died. To me this seems ... weird. I don't think they're worried about psychological trauma in the afterlife, but who knows?
Is that weird tho?
If a type of accident is usually going to cause horrible pain if it causes death, this creates a bigger incentive to avoid serious injury in the first place (which also helps avoid death from those injuries).
If suffering is taken into account for injury, also taking it into account for death avoids situations where it would be preferable for the perpetrator to cause death rather than have the victim survive in pain. There's no threshold because the fatality is considered in addition to rather than instead of the suffering.
If a type of accident is usually going to cause horrible pain if it causes death, this creates a bigger incentive to avoid serious injury in the first place (which also helps avoid death from those injuries).
If suffering is taken into account for injury, also taking it into account for death avoids situations where it would be preferable for the perpetrator to cause death rather than have the victim survive in pain. There's no threshold because the fatality is considered in addition to rather than instead of the suffering.
I agree with it. Just because it ends doesn't mean it didn't happen.
I can't decide whether I agree or not.
For an extra level of weirdness, imagine the person who caused the accident collecting the damages. It's not very improbable: you could be driving a car with your parents as passengers and you crash it, through honest incompetence, without committing a criminal offence, and they die, painfully, while you survive. Your insurance pays money into the estate for the pain your parents suffered, and you then collect that money, minus inheritance tax. By adding to your feelings of guilt, perhaps it's a fair punishment?
For an extra level of weirdness, imagine the person who caused the accident collecting the damages. It's not very improbable: you could be driving a car with your parents as passengers and you crash it, through honest incompetence, without committing a criminal offence, and they die, painfully, while you survive. Your insurance pays money into the estate for the pain your parents suffered, and you then collect that money, minus inheritance tax. By adding to your feelings of guilt, perhaps it's a fair punishment?
Separate note. Don't make the mistake of thinking meaning and life are binary. People too often think life is meaningful (everything is eternally meaningful) or completely meaningless. Allow that neither of those are true, and that all things carry some meaning for some amount of time.
You're feelings of guilt have nothing to do with externally imposed punishment. Everybody is going to react differently. Since will feel tremendous guilt and some won't. Even if they do, some will handle it well and some won't. It's not an effective way to mete out punishment.
The world is senseless enough already. (I believe) the best we can do as humans is to try to make it a little more fair, which means connecting negative effects to negative causes. And when we do the opposite, we build systems that sow chaos. To that end, I have to say I'm actually philosophically offended by your suggestion.
The world is senseless enough already. (I believe) the best we can do as humans is to try to make it a little more fair, which means connecting negative effects to negative causes. And when we do the opposite, we build systems that sow chaos. To that end, I have to say I'm actually philosophically offended by your suggestion.
Well if a loved one died I for sure would feel even worse knowing that they suffered. I guess that’s the reason for bigger compensation.
If that were the reason, then surely the compensation ought to be paid directly to the lover or lovers rather than to the estate of the person who died, who might have left their money to charity, not to the lover or lovers. They almost certainly do have mechanisms in place for compensating family members directly, but compensation for pain suffered in the seconds before death goes to the estate of the dead person, not to the family, if what I read was accurate and still applies. That compensation is presumably independent of whether the deceased had any family and independent of who inherits it.
Here's something worse: for a while, curare was used on children when undergoing surgery. Turns out that rather than anesthetizing them, it simply paralyzed them. Kids came out of surgery describing how they felt the surgery, and doctors just insisted that that was post-surgery nightmares.
That's too bad, it seems like a pretty easy to confirm, but I suspect nobody gave a crap.
This is reminiscent of the lethal injection protocol. It consists of:
* A fast- and short-acting barbiturate to knock you out.
* A muscle relaxant to stop you breathing.
* Potassium chloride to induce a heart attack. It incidentally causes great pain.
If the effect of the barbiturate wore off too quickly this would be an appalling death. Does it? Quite possibly. The creator of the protocol said
> It never occurred to me when we set this up that we'd have complete idiots administering the drugs
But nobody gives a shit.
* A fast- and short-acting barbiturate to knock you out.
* A muscle relaxant to stop you breathing.
* Potassium chloride to induce a heart attack. It incidentally causes great pain.
If the effect of the barbiturate wore off too quickly this would be an appalling death. Does it? Quite possibly. The creator of the protocol said
> It never occurred to me when we set this up that we'd have complete idiots administering the drugs
But nobody gives a shit.
I wonder if a heroin overdose would be better.
I know someone this has happened to.
Nobody believed her, until she could tell them what the doctors were talking about during the surgery.
It was a special case though, a surgery during pregnancy. It is really hard to do that in a way not to harm the unborn child.
Nobody believed her, until she could tell them what the doctors were talking about during the surgery.
It was a special case though, a surgery during pregnancy. It is really hard to do that in a way not to harm the unborn child.
i certainly agree with the statements about people having varying tolerances to these medicines. prior to my hernia surgery, the nurse gave me propofol in my IV and told me i'd start to feel drowsy and fall asleep. yeah, right...
after surgery, my doctor asked me what i remembered. i told him i remember receiving the dose of propofol, 10 minutes being wheeled into the OR (we made a right turn, a left down a hallway, and a right into the OR), and the last thing i remember was the OR nurse jamming the mask on my face (and not answering a question i had asked her, as we were chit-chatting when they moved me to the operating room table!).
he couldn't believe that i recalled the propofol dose, the directions to the OR and that the last thing i recall was the nurse jamming the mask on my face to shut me up!
after surgery, my doctor asked me what i remembered. i told him i remember receiving the dose of propofol, 10 minutes being wheeled into the OR (we made a right turn, a left down a hallway, and a right into the OR), and the last thing i remember was the OR nurse jamming the mask on my face (and not answering a question i had asked her, as we were chit-chatting when they moved me to the operating room table!).
he couldn't believe that i recalled the propofol dose, the directions to the OR and that the last thing i recall was the nurse jamming the mask on my face to shut me up!
I woke up while having my wisdom teeth taken out (doubt it was general anesthesia, but it was something more than local anesthesia). It was incredibly painful. Fortunately they noticed pretty quickly and did something and I was out again pretty quick.
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This happened to me when I had teeth removed for braces while under N20. When the wisdom teeth came out I opted for sodium pentothol.
Yes, this has happened to me (Ativan wore off) too but I was more disoriented than in pain at that point.
Further reading: https://www.lesswrong.com/posts/wzj6WkudtrXQFqL8e/inverse-p-...
I once woke up during oral surgery. They just put me back under and continued. I wasn't sure if it had happened or I dreamed it and so I asked them. They confirmed that I had and said it occasionally happens, NBD.
I woke up during a procedure as a kid. I do have a faint memory of it, though no trauma (as far as I can tell) and I do not remember having any pain. Basically the doctors just gave me more anesthesia and I went back under.
I assumed that this was part of the reason why parients heart rate is monitored. If you’re paralyzed from the drugs but awake, conscious, in lain, and panicking then your heart rate would shoot way up and that would alert the operating team that something isn’t right, wouldn’t it?