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.
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.”
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?
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.
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.
> 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.
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.
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 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.
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!
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.
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:
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.
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.
> 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