General Anesthesia is really a drug induced coma

I am very particular that patients understand enough about anesthesia to be appropriately concerned regarding what they are about to agree to undergo. In my youth, I supervised an anesthetist who routinely minimized what she said so as to not "upset" the patients. ("you are going to take a little nap while Dr Smith does your surgery...") Nonsense. That's not what we do, and it's not the way patients ought to think about what we do (and what they are agreeing to endure...)  This little conceit creates a false basis for informed consent and trivializes what we do. (we're not just "passing gas" here...) Patients don't believe it, anyway; they know that surgery and anesthesia involve risk and pain, and that anyone who says differently is just selling something.

Grandpa:  ...I'm explaining to you because you look nervous.
Grandson: I wasn't nervous. Maybe I was a little bit "concerned" but that's not the same thing.

    The Princess Bride

Informed consent is not primarily about a laundry list of possible complications, either (we might chip a tooth, you might have a headache, you might be nauseated, etc). Laundry lists are for lawyers, lawsuits, and hotels. Anyway, you'd have to go pretty far to find a real case involving money given to an injured patient specifically because the trier of fact believed that the anesthesiologist didn't tell the patient the complication could happen. Yes, I know there are a few notorious cases out there. There is also the recent case where a poor wretch was burned when lightning hit his IPOD, so I guess I better stop listening on my daily walk. (well, almost daily walk...) And yes, I know that plaintiff attorneys use lack of detailed informed consent to suggest to juries that the defendant is sloppy. But they also will use your late payment of your state society dues the same way, so be prompt in writing those checks... Informed consent as a moral act is something else; it is a mutual understanding between me and my patient that anesthesia and surgery are generally risky, that I will do my best to minimize that risk, and that my best may not be good enough. Good informed consent involves a touch of humility; a recognition that sometimes things are beyond our mortal control. As a prelude to informed consent, I generally tell my patients:

"sleep is what you do at night,and you don't need my expensive help for that. But if your surgeon were to creep into your bedroom and cut you with a scalpel, you would immediately wake up in pain. What I do is place you in a drug induced coma, which I monitor and reverse when the surgery is over. If you are not carefully and continuously monitored, the anesthetic unconsciousness along with the side effects of the surgeon's operating would be dangerous for you. I will stay with you the whole time and adjust the anesthetic and make it as safe as possible, which, by the way, is pretty safe. I trained a long time, I have been doing this a long time, and I am good at it. Would you like to know more before agreeing to proceed?"

This takes about 45 seconds. I frequently hold a hand while saying this, and I try to maintain eye contact. Some people want to know more, Most say something like; "no doc-it's ok. let's do it." Nobody refuses to proceed. Nobody is more scared at the end of that little monologue than they were at the beginning. Nobody ever is allowed to confuse anesthesia with sleep. Everybody takes me seriously, because I take what I do seriously (and because I have a grey beard and a bowtie).

Obviously, children don't get talked to in this way, but their parents do. If they are nervous about it; well, they should be. When I send my own kids to the OR, I'm a wreck; aren't you? I don't play much pretend with kids, either. I tell them it might hurt some, but that we'll do our best to make it not hurt at all. The important thing I do with kids is I sit on the floor; I never look down at a child-always across to or up at them. It makes a big difference; don't ask me why. I'm no mammalian behaviorist. I just know that they trust me more and are less scared if they are looking across at me. And since I'm in my fifties, fat, and wear bright bow ties, I suppose I'm a sight creaking my way down and back up; let'em all laugh. Laughing is good... I always talk to the child or adolescent, even if the answers are coming from the parent; after the interview part is done, I'll connect with the folks; first things first. If it takes me five minutes to connect, well, that's five minutes well spent in my book (I drive busy surgeons crazy, I'm afraid. Oh Well!) If I can't connect with a child pre-op (or any patient, for that matter) it's a lousy case for me, no matter how well the anesthetic and surgery go. It's just the way I'm made, I guess.

I put mortality in the context of a career. I expect to do 50000 cases in my career. I tell healthy people who want to know that the anesthesia death rate for the healthy is about 1 in 150k to 200k. Therefore, currently, three or four anesthesiologists might have one anesthetic death in a healthy person between them during their whole careers. Normally, open heart patients have a much exaggerated perception of their risk of mortality; when I tell a routine CABG family they have a statistical 1 or 1.5% risk of death, they are invariably relieved. Patients with diabetes, renal failure or CHF have a higher risk of course, as do patients for valves. I remind my higher risk patients that the team strives to do everything right, and that even if we do everything right, the outcome may not be what we and they would like. I tell them that that little extra thing is either luck or divine providence, whichever they believe. Incidentally, some surgeons have a hard time saying this; it's not that they are arrogant (well, not always, anyway....) it's more that an acknowledgment that they are not in total control makes them anxious, too. I gave up any pretense of total control a long time ago (I have teenage and adult kids!), so it's easy for me.

The most common question I get concerns awareness; more and more people are concerned about this. I think it's great; somebody who is worried about awareness isn't likely to take my care for granted, and they are paying attention. (Since we all have BIS monitors, and we all are obsessive about checking our vaporizer fill levels as part of our scans, and since we all set our anesthetic concentration alarms, awareness is only about early trauma resuscitation management, isn't it? As an aside, is there any reason why ALL new vaporizers do not have an "empty" alarm like desflurane? Come on, Drager and GE Medical, and FDA...) Normally, I find that once I express my own concern that such a thing not happen, and describe how I avoid it (check concentrations of inhalation agent, BIS, etc.) people are sufficiently re-assured.

Clausewitz, the German Officer/author of "ON WAR" wrote of combat; "Everything is very simple in war, but the simplest thing is difficult." So it is with anesthesiology. It isn't sleep; it's a reversible, drug induced coma; simple? maybe. Easy? Not if you're doing it right.

Comments

[Marie Theresa]

The best teacher my boys ever had taught third grade. When my older son had him for third grade, my younger son was in kindergarten. The first day of school, the younger one was anxious about how he would get to the room where the afterschool program was at the end of the day. I brought him to my older son's third-grade classroom and asked the teacher to let my thirdgrader go down to the kindergarten room at the end of the day to pick him up and take him to the afterschool room. The teacher got down on the floor, looked my kindergartner in the eye and told him not to worry because he would make sure his brother came down to get him. I never forgot how that teacher made my son feel like his concerns were important.

[DMJ]

Dear Experts,

I have had impaired brain fuction as the result of general anesthetics. I know that proving a causal connection is difficult. However it seems that too many people seem to think that simply being unable to prove something necessarily disproves it.

Following more than one occasion of recieving GA at the age of 36 I awoke with terrible head pain which was unendurable. On scale 1-10 it was off the scale. (Childbirth 4)Following this I found I had lost a massive amount of brain function.

Subsequently I had many ops under local until I came to a surgeon who did not believe that there was a problem. As a result he used GA against my consent resulting in catastrophic effects. He later cliamed it was only for sedation. I became immediately unconscious and was out for three hours. I have constant and debilitating headaches, lost a gt deal of brain function and have become absurdly sensitive to a wide range of chemicals. Comments and recommendations please.DMJ.

[Amy Russell]

I had general anaethesia a for a hip replacement 3 weeks ago. Healing going well. Physical therapy 3x week. Most days I nap after lunch. Problem is that when I wake up I feel as tho I returned to "coma-like" or "hibernation-like" state of anaethesia. I have difficulty breathing, just as I did right after surgery. I feel groggy and unable to think clearly. These symptoms last a few hours then clear up.

What is this? Should I be concerned? Any recommendations for what to do? Thank you.

[feannie Winkelman]

Can inhaled anesthesia exacerbate essential tremor and cause enough cell death to "tip someone over" into Parkinson's disease?
I awoke from anesthesia shaking terrible--allmost rattling my bones against tthe table--and haven't been the same since. The days post surgery my arms were shaky and i had trouble dialing the phone. I could no longer pick the guitar. The other symptoms came on more gradually. Did teh anesthsia do this? Was I moer vulnerable due to essential tremor?

[mkeamy]

Hi. The shaking you experienced was almost certainly shivering, a common side effect (5-10%) of general anesthesia. It occurs when the patient is cold/hypothermic following anesthesia, or sometimes, just from drug effects of the anesthetic, and is usually treated with demerol, although the mechanism by which demerol alleviates this shivering is not understood. Data suggests that it does work, however.

While inhalation anesthesia is known to be mildly neuro-toxic (kills brain cells), I am aware of no data to suggest that an uneventful anesthetic would exacerbate (worsen) existing tremors or initiate the onset of parkinsonism. Arm weakness/shakiness can be caused by tightness of the spinal canal at the neck, and other mechanical problems of the brain/spinal cord. I assume that you underwent a careful evaluation to rule out the many possible causes of such distressing symptoms.

I hope that you have found a diagnosis and some relief from this problem. If you are in or near a big city or academic center, a consultation with a neurologist who specializes in motion disorders would be a good next step.

Good luck to you and thanks for dropping by