Anesthesia Read online

  The next morning, before each patient was wheeled into a theater, Levinson attached leads to his or her scalp to measure the fluctuations in electrical activity there, and then stood back to allow the anesthesiologist, a Dr. Viljoen, to administer an ether-based anesthetic. After the operations had begun, and only when Levinson was confident that each patient was deeply anesthetized—more deeply than would be usual in such an operation—he instructed the anesthesiologist to read out loud the following statement: “Just a moment! 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.” After pumping the breathing bag, Viljoen would then say, reassuringly, “There, that’s better now. You can carry on with the operation.”

  When the patients awoke a short time later, the theater staff behaved as if nothing had happened.

  One month later, Levinson interviewed the ten separately in his consulting rooms. First he asked what they could remember of the operation. Each said they recalled entering the anesthetic room and being given an injection. Their next memories were of waking in the ward. Then Levinson hypnotized them. Under hypnosis, he reported later, four of the ten patients could quote some of the anesthesiologist’s words verbatim. Another four could only remember snatches but became upset and agitated during questioning. One man remembered intense pain. “One woman said she felt she was spinning,” Levinson wrote later. “Each time the circle passed the anesthesiologist, she could make out a word. Before she could make any real sense out of his words, she spun out again in a circle.” Only two said they remembered nothing.

  In the years since, the Levinson experiment has acquired an almost folkloric status, both for what it did and did not do. Critics have dismissed it as breaking basic rules of the scientific method. First, Levinson did not use a control group of patients who were not exposed to a crisis. Second, the experiment was not blinded—Levinson knew exactly what had happened in the operating room before he hypnotized the patients and so, arguably, knew what to expect and may have unwittingly prompted his patients’ answers. Yet the great irony of Levinson’s experiment was that its apparent success has made it impossible to replicate. Even though his methods were criticized, the fact that under later hypnosis so many of his patients apparently remembered what had been said—or were visibly upset—means it would be unethical to purposely risk subjecting new patients to similar stress.

  When I first heard of this experiment, two things struck me forcefully. The first was that I had always assumed, without ever feeling the need to examine that assumption, that having surgery under general anesthesia meant that I would have no awareness of what was going on within or around me at the time. The second was that in operating theaters around the globe, similar conversations to Levinson’s must happen every day.

  I came across the first of many references to Levinson’s mock crisis not long after I started researching anesthesia. Often it was discussed in relation to another experiment carried out thirty years later by a famous American anesthesiologist who set out to replicate Levinson’s study—with intriguing results. Along the way, I also found other studies, some of them very weird—studies in which anesthetized patients could later identify words read to them during surgery despite having no conscious memory of having heard them. Studies in which unconscious patients who were told to perform particular actions on awakening would later assure researchers they remembered nothing, all the while doing as they had been instructed. Another in which a doctor from northern England used a simple device that allowed him to communicate during surgery with paralyzed and seemingly unconscious women—only to find that many of them were awake. Later the women remembered nothing.

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  One of the great puzzles of general anesthesia is that by definition it is impossible for a patient to report on the experience. Like death, you go there alone; and, like birth, you emerge seemingly empty-handed. What happens in between might at the time feel like nothing, or it might feel like something. But the “you” that wakes in the recovery room is in some critical ways not the “you” that was lying open on the operating table having the experience of being operated upon. The self has been interrupted.

  So why might this matter to me or to you or to anyone else? To try to answer this question, I have had to divide myself into two selves, or rather to acknowledge an existing division. The first—the one I recognize as my day-to-day self (the one who goes to work and watches reality TV and thinks about unconsciousness)—would answer thus, possibly in bullet points:

  It might matter because there is evidence that what we experience while inert on the operating table—whether or not we remember it—can change the way we feel and behave in the hours, weeks and perhaps years after surgery.

  These changes need not be bad. They might even be good. But they are so little discussed as to be unrecognized by most doctors, let alone the rest of us.

  This carries risks and opportunities.

  This is the self I know. A thinking-self. The self I think of as “me.”

  The other self that has been involved in the writing of this book has no need of bullet points, or maybe even of language. This self made itself known to me close to twenty years ago when I dimly recognized I had entered an unfamiliar inner realm or state. For many years now I have simply called it “the feeling” because I have no other words for it, though at times it can seem like grief or fear or anger or even love. Its bodily sense is of a constriction in my chest and throat, a physical unease that, if I can relax or nudge it gently, gives way sometimes to a pervasive, inarticulate sense of loss.

  For a long time I treated this feeling-self as something separate from me, an enemy who had arrived uninvited and taken up residence in my chest, an incubus that must be seen off. For a long time I hoped I might be able to do this with magic or by force of will. More recently I have come to see the feeling as a process, a dynamic interplay between intellect and instinct; head and heart. An interior shadow play that continues at times to unnerve and grieve me, but whose outlines and flickering concerns I see expressed in part through my long preoccupation with anesthesia.

  Over that time I have witnessed operations in three continents and interviewed some of the world’s best-known anesthesiologists. I have seen a heart pulsing in its red pond and watched a womb being snipped from its moorings. I have sat through conferences, scoured professional journals and medical libraries for reports and studies, hounded psychiatrists and psychologists, and cornered dozens of friends and strangers and asked them to talk about their own experiences of surgery.

  The world of anesthesia is a peculiar blend of the mundane and the mysterious: a land of complex, decipherable codes and amorphous, unanswerable questions. As a stranger in this land, I found myself frequently lost in tangles of technology, or pushing uphill through thickets of anesthetic jargon—a language in which tears become “lacrimation,” a scalpel wound a “noxious stimulus.” Often I felt like giving up.

  Every time this happened, I would find myself somehow in conversation with someone who would tell me about their own (or a friend’s or family member’s) unexpected anesthetic experience. And it was these conversations, as random as they were, that in the end persuaded me (the day-to-day me) to continue.

  One woman described being able to hear what was going on during a medical procedure but feeling that she was imprisoned beneath a sheet of glass. Another talked of the vertiginous sensation during surgery of moving in and out of her body. Others described flashbacks, dreams, emotional disturbances. Many had never talked about these experiences before. Several had avoided general anesthetics ever since.

  Most were not the sort of events to make it into the newspapers or professional journals. Often they were not so much anesthetics that had failed as medical interactions that had failed: confused, anxious patients; absent, unaware doctors. But the repercussions were sometimes profound. Enough to suggest that doctors and nursing staff might markedly improve their patients’ surgical experiences, and even outcomes, by changing the way they think about, and relate with, their charges—before, after and even during anesthesia. And that herein lies an enormous untapped potential—one that some doctors and researchers have already been exploring with surprising results.

  But what it also points to is that we as patients might do well to change the way we think, or fail to think, about ourselves under anesthesia. That we may have the ability to influence our own anesthetic experience and outcome; that the information and attitudes we take into surgery with us, consciously and otherwise, can affect not only how we wake up from surgery, but how we fare during it: how many drugs we need to keep us unconscious, the length of the operation, even perhaps how much blood we lose while on the operating table.

  When I began writing this book I did not know that before I was finished I would have a lengthy opportunity to investigate anesthesia firsthand. Nor did I expect to have the chance to stage an unrepeatable experiment of my own, with myself as its subject. That (entirely unscientific) experiment has helped me draw some of my own conclusions about the extraordinary process that we call anesthesia, and its significance for anyone facing surgery—in particular the importance of the stories we carry in and out of the darkness. What it took me much longer to understand was that what I was exploring was not just the anesthetic unconscious, its charted and uncharted realms, but the dumb depths of my own unconscious self.

  It began, as things tend to, with a chance meeting.

  Awake

  Many years ago now, in the Blue Mountains outside Sydney, I was invited to a dinner to celebrate the birthday of a friend. There were eight women at the dinner, some of whom I did not know, around a long trestle
table covered with a white sheet and many small candles. Between courses one of the women, Rachel, told us the story of the birth of her second child. After she finished, there was silence; it was hard to know what to say.

  Not long after that dinner I moved with my family—my partner, our son and me—back to Melbourne. But I kept thinking about Rachel’s story. I did not know why, but it was like a bit of grit: I found myself growing ideas around it. I spoke to the friend who had hosted the dinner, who gave me a phone number. For months afterward I put off calling, afraid she would not want to talk publicly about what had happened. But when I rang her one April evening from my home in Melbourne, she said yes.

  Rachel Benmayor’s story—of a general anesthetic that failed; a caesarean birth endured conscious, paralyzed and in agony; and a near-death encounter with what she saw as a great, implacable consciousness—became the starting point for this book, although the story had, in the way of all stories, begun long before.

  We spoke by phone over two nights: Rachel in the house that she and her husband, Glenn, were renovating in the mountains, me squatting on the floor next to the filing cabinet in our Melbourne home office; she in her soft New Zealand lilt—the flattened vowels and unexpected upward inflections—me in a series of vague half-forays, repetitions and mmmms. It didn’t matter. She wanted to talk. She spoke at a rhythmic, even pace, as if describing a familiar dream or film, slowing sometimes, at others clearing her throat or coughing, but rarely stopping except when I interjected. I could not quite remember what she looked like except for an impression, incomplete as it turned out, of softness—brown curls, a shortish figure, an open, appealing face. Something quiet about her, almost arrested. All of which merged over the phone into the steady forward tread of her voice.

  “So,” said Rachel, “I remember going onto the operating table. I remember an injection in my arm, and I remember the gas going over, and Glenn and Sue [her midwife] standing beside me. And then I blacked out. And then the first thing I can remember is being conscious, basically, of pain. And being conscious of a sound that was loud and then echoed away. A rhythmical sound, almost like a ticking, I guess, or a tapping that was just like a march and it just went round and round and round and I could hear it.

  “And pain. I remember feeling a most incredible pressure on my belly, as though a truck was driving back and forth, back and forth across it.”

  Rachel had been admitted to the hospital, eight and a half months pregnant, a few days earlier. Her blood pressure had risen rapidly and her doctor had told her to stay in bed and get as much rest as possible before the baby came. But her blood pressure kept rising—the condition, known as preeclampsia, is not uncommon but can lead to sometimes-fatal complications—and the doctors decided to induce the birth. When her cervix failed to dilate properly after seventeen hours of labor, they decided instead to deliver the child by caesarean section. Rachel had hoped to have an epidural injection into the base of her spine so that she could be awake for the birth. But she was in a smallish country hospital and that day there was no one available to perform the procedure. Instead she was told she would have to have a general anesthetic. She remembers her disappointment. She remembers being wheeled into the operating theater. She remembers the mask, the gas. And then she woke up.

  A few months after the operation someone explained to Rachel that when you open up the abdominal cavity, the air rushing onto the unprotected internal organs gives rise to a feeling of great pressure. But in that moment she still had no idea what was happening. She thought she had been in a car accident. “All I knew was that I could hear things . . . and that I could feel the most terrible pain. I didn’t know where I was. I didn’t know I was having an operation. I was just conscious of the pain.”

  Gradually she became aware of voices, though not of what was being said. She realized she was not breathing, and started trying to inhale. “I was just trying desperately to breathe, to breathe in. I realized that if I didn’t breathe soon, I was going to die.”

  She didn’t breathe and she didn’t die. She didn’t know there was a machine breathing for her. “In the end I realized that I couldn’t breathe and that I should just let happen what was going to happen, so I stopped fighting it.” By now, however, she was in panic. “I couldn’t cope with the pain. It seemed to be going on and on and on and I didn’t know what it was.” Then she started hearing the voices again. And this time she could understand them. “I could hear them talking about things, like about people, what they did on the weekend, and then I could hear them saying, Oh look, here she is, here the baby is, and things like that, and I realized then that I was conscious during the operation. I tried to start letting them know at that point. I tried moving, and I realized that I was totally and completely paralyzed.”

  It occurred to Rachel that she was close to death. “I was just beginning to go mad with the pain, and I knew that it was going to kill me. It was a funny feeling, I just knew that I couldn’t cope. And I knew that they weren’t going to hear me, or realize what was happening.”

  Then she remembered something someone had said to her many years before. Faced with great pain, the only thing to do was to go into it, not to try to get away from it. It is not the sort of advice most of us want to follow—until, perhaps, there is no choice. “So I consciously turned myself around, and started feeling the pain and going into the pain, and just letting the pain sort of enclose me. There was a feeling of going down, a feeling of descending, and I just went further and further down, deeper and deeper into the pain.”

  I asked her if the pain lessened as she went into it. Rachel laughed, but not humorously. No, she told me, if anything the pain got stronger. “But I just kept on going down, down, down. And then I started feeling like I was going through something, like through the pain, and then I got to a point where the pain was there, and nothing had changed, except I no longer really cared about it.

  “It was like I could be conscious to other things, because my consciousness had turned itself off from the pain. And then I realized that I was in a really amazing place, and I realized that I was very close to dying. I felt like I only needed to move a little bit deeper and a little bit further and across something, and that I would be dead.”

  In that place, said Rachel, she felt the presence of people she had known, and some she had not, all the while still hearing the voices around her in the operating theater: Oh look, look, it’s a little girl. Just pull her up a little bit higher. Look it’s a little girl. Glenn, look, you’ve got a little girl. Isn’t she big? Oh she’s urinating on Rachel. Quickly. She’s urinating. We’ll have to cut the cord.

  But Rachel was gone. “I was way away from there. I could hear it, but I was just a long way away.” She felt safe. “I was so relieved to not . . . to have found this place where the pain was happening in my body but I knew that I couldn’t tune into it—that I had to stay where I was, otherwise I wouldn’t survive, so I stayed in that space.”

  Some years after this conversation I visited the Melbourne office of an anesthesiologist called Kate Leslie. She was crouched in a tiny cubicle furnished with twin filing cabinets in pink and taupe. Her windows looked out along a diminishing cream brick wall punctuated by other similar windows. It was a room distinguished mainly by its drabness, though brightened on this particular day by the strains of classical music drifting from further down the hall.

  “Elgar,” said Leslie, dipping her head in the direction of the sound. She was not actually crouched. It was more that there was something about her that made the room seem small around her. Not only was she quite tall, but she had a vitality that made her seem bigger still, so when I think of her now I have the impression of her scrunched like an oversized Alice into a space she had already outgrown. There was something rakish about her, too, with her denim jacket, hippy skirt and tall black boots: you might have picked her as a rock chick. In fact, she had recently been involved in a study that would help make her quite famous in anesthetic circles, at least in the circle interested in experiences such as Rachel Benmayor’s. None of which you would have known from her office, or her demeanor, which was appealingly direct and forthright. If I was going to have an anesthetic, I decided, Kate Leslie would be an excellent person to do it.