The Best American Science and Nature Writing 2014 (29 page)

Over time Campbell's most severe symptoms subsided, and she learned how to cope with those that remained. She managed to move on, become an accountant, and start a family of her own, but she wasn't cured. Her nightmares continued, and nearly anything could trigger a panic attack: car horns, sudden bright lights, wearing tight-fitting pants or snug collars, even lying flat in a bed. She explored the possibility of posttraumatic stress disorder with her therapists but could not identify a triggering event. One clue that did eventually surface, though, hinted at a possibly traumatic experience. During a session with a hypnotherapist, Campbell remembered an image, accompanied by an acute feeling of fear, of a man looming over her.

Then, one fall afternoon in 2006, four decades after her symptoms began, Campbell met an anesthesiologist at a hypnotherapy workshop. Over lunch she found herself telling the anesthesiologist about her condition. She mentioned the appendectomy she'd had not long before everything changed.

The anesthesiologist was intrigued. He told her about a phenomenon that had sometimes accompanied early gas anesthetics, particularly ether, in which patients reacted to the gas by coughing and choking, as if they were suffocating.

The comment sparked something in Campbell. “I started having all these flashes,” she remembers. “The flashes were me being on the table. The flashes were of the room. The flashes were of the bright lights over me.” A man—the same one from her memory?—was there. At some point the room went black. “And then I got to the place where I was on the table, and I just remember feeling terror,” she says. “That's all I remember. I don't see anything. I don't feel anything. It's absolute, abject terror. And the feeling that I am dying.” At that moment, Campbell realized that something had happened to her during her appendectomy, something that changed her forever. After several years of investigation, she figured it out: she had woken up on the table.

This experience is called “intraoperative recall” or “anesthesia awareness,” and it's more common than you might think. Although studies diverge, most experts estimate that for every thousand patients who undergo general anesthesia each year in the United States, one to two will experience awareness. Patients who awake hear surgeons' small talk, the swish and stretch of organs, the suctioning of blood; they feel the probing of fingers, the yanks and tugs on innards; they smell cauterized flesh and singed hair. But because one of the first steps of surgery is to tape patients' eyes shut, they can't see. And because another common step is to paralyze patients to prevent muscle twitching, they have no way to alert doctors that they are awake.

Many of these cases are benign: vague, hazy flashbacks. But up to 70 percent of patients who experience awareness suffer long-term psychological distress, including PTSD—a rate five times higher than that of soldiers returning from Iraq and Afghanistan. Campbell now understands that this is what happened to her, although she didn't believe it at first. “The whole idea of anesthesia awareness seemed over-the-top,” she told me. “It took years to begin to say, ‘I think this is what happened to me.'” She describes her memories of the surgery as being like those from a car accident: the moments before and after are clear, but the actual event is a shadowy blur of emotion. She searched online for people with similar experiences, found a coalition of victims, and eventually traveled up the East Coast to speak with some of them. They all shared a constellation of symptoms: nightmares, fear of confinement, the inability to lie flat (many sleep in chairs), and a sense of having died and returned to life. Campbell (whose name and certain other identifying details have been changed) struggles especially with the knowledge that there is no way for her to prove that she woke up and that many, if not most, people might not believe her. “Anesthesia awareness is an intrapersonal event,” she says. “No one else sees it. No one else knows it. You're the only one.”

In most cases of awareness, patients are awake but still dulled to pain. But that was not the case for Sherman Sizemore Jr., a Baptist minister and former coal miner who was seventy-three when he underwent an exploratory laparotomy in early 2006 to pinpoint the cause of recurring abdominal pain. In this type of procedure, surgeons methodically explore a patient's viscera for evidence of abnormalities. Although there are no official accounts of Sizemore's experience, his family maintained in a lawsuit that he was awake—and feeling pain—throughout the surgery. (The suit was settled in 2008.) He reportedly emerged from the operation behaving strangely. He was afraid to be left alone. He complained of being unable to breathe and claimed that people were trying to bury him alive. He refused to be around his grandchildren. He suffered from insomnia; when he could sleep, he had vivid nightmares.

The lawsuit claimed that Sizemore was tormented by doubt, wondering whether he had imagined the horrific pain. No one advised Sizemore to seek psychiatric help, his family alleged, and no one mentioned the fact that many patients who experience awareness suffer from PTSD. On February 2, 2006, two weeks after his surgery, Sizemore shot himself. He had no history of psychiatric illness.

Before the introduction of ether in the mid-nineteenth century, surgery was a rare and gruesome business. One of the most common operations was amputation. Surgeons used saws and knives to remove the offending appendage, and boiling oil and scalding irons to cauterize the wound. They resorted to a variety of methods, some more dangerous than others, to manage patients' pain. James Wardrop, a surgeon to the British royal family in the nineteenth century, wrote of a procedure called
deliquium animi
, in which he bled patients into quiescence. Others used alcohol, opiates, ice, tourniquets, or simple distraction.

The promise of painless surgery remained a preposterous idea in mainstream medicine until October 16, 1846. On that day, at the Harvard-affiliated Massachusetts General Hospital, a dentist named William Thomas Green Morton gave the first public demonstration of ether gas, administering it to a patient whose neck tumor was then removed by a surgeon. The event took place in a domed amphitheater now known as the “ether dome,” and earned Harvard Medical School a truly international reputation. Oliver Wendell Holmes Sr., who coined the term
anesthesia
(from the Greek word
anaisthe¯sia
, meaning “lack of sensation”), rejoiced that “the fierce extremity of suffering has been steeped in the waters of forgetfulness, and the deepest furrow in the knotted brow of agony has been smoothed for ever.” In 2007, when the
British Medical Journal
asked subscribers to name the most significant medical developments since 1840, anesthesia was among the top three, along with antibiotics and modern sanitation.

The miracle of anesthesia transcends pain. Painkillers—mainly opiates and alcohol—existed before ether, but they weren't sufficient to quell the nightmare of surgery. Ether accomplished something altogether different: it eliminated both experience and memory. When the drug wore off and patients woke up, their bodies stitched together and their minds intact, it was almost as though the intervening hours hadn't happened. The field that emerged from that historic moment in the ether dome was less concerned with the broad goal of curing disease than with a single task: the mastery of consciousness.

Anesthesia is often taken for granted in the daily routine of medicine today, both by health professionals and by the tens of millions of Americans who undergo surgery each year. Anesthesiologists are imbued with an almost heavenly power: with a mere push of their thumb on a clear plastic syringe, you go under. But in the past decade or so, several highly publicized cases, including Sherman Sizemore Jr.'s, have brought anesthesia awareness into the public forum. In 1998 a woman named Carol Weihrer, who claimed to have suffered awareness while having her eye removed, founded the Anesthesia Awareness Campaign, an advocacy group and resource for victims, and made the talk-show rounds. In 2007 the Hollywood thriller
Awake
intended, according to a producer, to “do to surgery what
Jaws
did to swimming in the ocean.” Fearful of malpractice lawsuits, the profession grew defensive. The American Society of Anesthesiologists promised to find the cause of and solution for awareness. “Even one case is one too many,” wrote the society's president in 2007.

This promise, however, is not so easily fulfilled. Despite 167 years of research, anesthesiologists still have little idea how their drugs unlock the mind. Which gears turn and unwind to produce oblivion? How do they turn back into place? These questions, as important as they are for preventing anesthesia awareness, are dwarfed by a central riddle that has puzzled scientists and philosophers—not to mention most mildly introspective people—for hundreds, if not thousands, of years: What does it mean to be conscious?

Doctors began investigating how anesthesia affects consciousness during the 1960s, shortly after the first reports of awareness. One South African researcher was especially curious about whether and how one might recall memories from a surgery. Perhaps a near-death experience? Pushing well beyond the limits of what would today be considered ethical, he collected ten volunteers undergoing dental surgery. The procedures went along as normal until, midway through, the room went silent and the medical staff reached for scripts.

“Just a moment!” the anesthesiologist would say. “I don't like the patient's color. Much too blue. His [or her] lips are very blue. I'm going to give a little more oxygen.”

The anesthesiologist would then act out a medical emergency, rushing to the patient's bedside to ventilate his or her lungs, as if this action were necessary to save the patient's life. After several moments, the team would breathe a collective sigh of relief.

“There, that's better now,” the anesthesiologist would affirm. “You can carry on with the operation.”

A month later, the patients were hypnotized and asked to remember the day of the surgery. One female patient said she could hear someone talking in the operating theater.

“Who is it who's talking?” the interviewer asked.

“Dr. Viljoen,” she said, referring to the anesthesiologist. “He's saying my color is gray.”

“Yes?”

“He's going to give me some oxygen.”

“What are his words?”

A long pause followed.

“He said that I will be all right now.”

“Yes?”

“They're going to start again now. I can feel him bending close to me.”

Of the ten volunteers, four remembered the words accurately; four retained vague memories; and two had no recollection of the surgery. The eight patients who did remember it displayed anxiety during the interview, many of them bursting from hypnosis, unable to continue. But when out of hypnosis, it was as though nothing had happened. They had no memory of the incident. The terror and anxiety seemed permanently buried in their subconscious.

This experiment revealed a fundamental problem for the study of awareness, the frequency of which can be measured only through reported accounts. For some victims, it can take weeks for memories to surface. For Linda Campbell, it took forty years. But what if no memory remains? Did awareness happen? Does it matter?

An anesthesiologist's job is surprisingly subjective. The same patient could be put under general anesthesia in a number of different ways, all to accomplish the same fundamental goal: to render him unconscious and immune to pain. Many methods also induce paralysis and prevent the formation of memory. Getting the patient under, and quickly, is almost always accomplished with propofol, a drug now famous for killing Michael Jackson. It is milky and viscous, almost like yogurt, in a fat syringe. When injected, it has a nearly instant hypnotic effect: blood pressure falls, heart rate increases, and breathing stops. (Anesthesiologists use additional drugs, as well as ventilation, to immediately correct for these effects.)

Other drugs in the anesthetic arsenal include fentanyl, which kills pain, and midazolam, which does little for pain but induces sleepiness, relieves anxiety, and interrupts memory formation. Rocuronium disconnects the brain from the muscles, creating a neuromuscular blockade, also known as paralysis. Sevoflurane is a multipurpose gaseous wonder, making it one of the most commonly used general anesthetics in the United States today—even though anesthesiologists are still relatively clueless as to how it produces unconsciousness. It crosses from the lungs into the blood, and from the blood to the brain, but . . . then what?

Other mysteries
have
been untangled. Redheads are known to feel pain especially acutely. This confused researchers until someone realized that the same genetic mutation that causes red hair also increases sensitivity to pain. One study found that redheaded patients require about 20 percent more general anesthesia than brunettes. Like redheads, children also require stronger anesthesia; their youthful livers clear drugs from the system much more quickly than adults' livers do. Patients with drug or alcohol problems, on the other hand, may be desensitized to anesthesia and require more—unless the patient is intoxicated at that moment, in which case less drug is needed.

After delivering the appropriate cocktail, anesthesiologists carefully monitor a patient's reactions. One way they do this is by tracking vital signs: blood pressure, heart rate, and temperature; fluid intake and urine output; oxygen saturation in arteries. They also observe muscles, pupils, breathing, and pallor, among many other indicators.

One organ, however, has remained stubbornly beyond their watch. Even though anesthesiologists are not entirely sure how their drugs work, they do know where they go: the brain. All changes in your vital signs are only the peripheral reverberations of anesthetic drugs' hammering on the soft mass inside your skull. Determining consciousness by measuring anything besides brain activity is like trying to decide whether a friend is angry by studying his or her facial expressions instead of asking directly, “Are you mad?”