Dec/Jan 2018

The Body Politic

On the unsettling experience of being a patient

Charlotte Shane


Counting Backwards:

A Doctor's Notes on Anesthesia

by Henry Jay Przybylo MD

W. W. Norton & Company

$25.95 List Price

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Anesthesia:

The Gift of Oblivion and the Mystery of Consciousness

by Kate Cole-Adams

Counterpoint

$28.00 List Price

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Into the Gray Zone:

A Neuroscientist Explores the Border Between Life and Death

by Adrian Owen

Scribner

$28.00 List Price

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Anesthesia has been around for over 170 years, and in spite of its inherent drama it’s impressively nonlethal. Current estimates place the death toll at about one in two hundred thousand or even one in three hundred thousand, which means—according to the earnest nonprofit the National Safety Council—that you or I are more likely to die from insect stings, “excessive natural heat,” or “contact with sharp objects” than either of us is from being put under. Properly supervised anesthesia is not only exceedingly safe but also ubiquitous, and necessary for a slew of lifesaving and life-improving procedures. Yet in these heady days of organic, “toxin”-free lifestyle goals, wariness of medical convention abounds. People rush to point out that we (“we” meaning doctors, which “we” usually aren’t) don’t really know how anesthesia works, thereby implying that it’s fundamentally suspect. There are movements in opposition to advances like vaccines and hormonal birth control, so it makes sense that anesthesia, too, with its murky chemical magic, would be a source of unease.

Because anesthesia is unlikely to cause death outright, the case against it goes more or less as follows: It’s mysterious and it’s scary. The former is posited as the reason for the latter, but even if there were a flawless explanation for how anesthesia works, we’d still be disconcerted—it strips us of our awareness, movement, speech, and senses. It’s very rare for people to unexpectedly wake up during surgery; rarer still that they register pain; even rarer that they spontaneously wake up, feel pain, and remember it all afterward. But it hasn’t never happened. And even seamlessly successful anesthesia probably stokes some subconscious angst: You lack all agency, all means of protest, and your body is in the hands of strangers with knives.

In December of 2016, perhaps throwing a bone to parents legislated into unwillingly vaccinating their kids, the FDA partially validated anesthesia fears by issuing a warning that children under three and late-term fetuses might face “long-term effects” on behavior and learning if anesthetized. “Sedation drugs are necessary for infants, children, and pregnant women who require surgery,” the authors helpfully clarified. “In addition, untreated pain can be harmful.” In other words: If a child or someone who’s knocked up needs it, go ahead and knock them out. But let’s bring the era of capricious, multi-hour surgeries on babies to an end.

According to the anecdotes of Henry Jay Przybylo, author of Counting Backwards: A Doctor’s Notes on Anesthesia, parents hardly need incitements to further panic when their children are about to undergo an operation. He describes mothers fighting with him, yelling at him, and, worst of all, betraying their persistent dullness as he attempts to prepare them for what he’s about to do. “Amanda’s mother, unaware of anesthesia’s history and unconvinced by the description of my process, remained dubious that I could induce a chemical coma in Amanda in a minute or less,” Przybylo writes, as if Amanda’s mom were scoffing at his claim to have bested another man in a fistfight or caught a particularly large fish. Anesthesiologists are notoriously underappreciated by patients since they rarely see their wards awake after the procedure is complete, but judging from Przybylo’s account, that lack of gratitude has no mitigating effect on how godlike anesthesiologists feel. “I am an anesthesiologist,” he announces at the book’s opening. “I erase consciousness, deny memories, steal time, immobilize the body; I alter heart rate, blood pressure, and breathing. And then I reverse these effects.” Miracle, thy name is doctor! (Hubris, too, is a pretty notorious hallmark of those who administer medicine.)

An occasionally arrogant narrator is not the book’s only problem: There’s also the matter of the content itself. Counting Backwards is an inadvertent testament to just how boringly safe anesthesia is, given the many nonincidents Przybylo tries to spin as noteworthy episodes (and which may be included in part as a sincere attempt to display humility). He’s often left recounting unremarkable exchanges he has had with his patients, and for a man who prides himself on being beloved, he’s awfully cavalier about revealing his dreadful bedside manner. He badgers kids with a heterosexist and bizarrely nosy insistence that they must have a girlfriend or boyfriend, and even tells one recalcitrant teen that his anesthesia is a “truth serum” that will force her to give up the name of her beau. (To his credit, he later realizes that his “attempt at pre-anesthesia distraction seemed only to make [her] more uncomfortable.”)

In spite of the objectively good work he’s done throughout his career, demeanors like Przybylo’s make those who doubt medicine seem more sympathetic. He’s surprisingly harsh when writing about a “high-strung” girl whose fibula is missing, describing her “defect” as “nasty and disfiguring.” The doctor v. patient, expert v. layperson dynamic is a power struggle in which one party is multiply disadvantaged by being sick, in pain, and usually unable to cure the affliction on his or her own. Delivering yourself into the care of someone who can’t make you feel cared for only amplifies that indignity and exacerbates any existing dread. Surely empathy is warranted in this situation even more than most.

Though she says she liked the anesthesiologists she met while working on her book Anesthesia, Australian writer Kate Cole-Adams seems troubled by this power imbalance and is driven by a desire for patients to be treated as actively involved partners rather than raw material. “To enter a hospital as a surgical patient is to experience a series of small and escalating losses,” she writes. “Privacy, props, dignity, control and eventually, for many, consciousness.” She shares a psychiatrist’s intriguing suggestion that people who remember being abducted by aliens might really be recalling mental ghosts of previous anesthesia experiences: There is “nakedness, pain and a loss of control,” but the active figures are nevertheless “felt to be benevolent.”

That benevolence is key. It’s terrible to be disrespected or disregarded by your doctor; hubris has no place in medicine. Because Anesthesia is set against Cole-Adams’s own spinal surgery, her request that patients who receive anesthesia be treated as participants instead of blank receptacles is urgently personal and clearly valid. But we can’t be equal participants, not when a procedure’s success relies upon our paralysis and oblivion. How much can we give, really? And how much can we expect from those who are already working for our repair?

Cole-Adams’s ostensible core inquiry is a worthy one; as she asks, “Can whatever happens (or doesn’t happen) while we are under anesthesia continue to affect us in our waking lives?” What exactly does happen while we’re gone? Surely if anesthesia can cognitively impair the very young, as the FDA suggests, it could conceivably have similar repercussions in those who are older. But Anesthesia is a messy, frustrating book that rarely hews to concrete questions. Cole-Adams repeatedly mentions how long she spent turning over the book’s material, and the long timeline seems to have made her extra attached to her more personal passages, which suffocate the livelier, sciencey parts. For example, she describes an experiment in which a tourniquet keeps anesthesia from entering a patient’s forearm, and that patient, while otherwise unconscious, is asked to answer yes-or-no questions by squeezing a doctor’s hand—which they sometimes do. In one freak incident, a woman wakes up during her surgery, immobilized but with sensation, as her eye is “scooped and wrenched from its socket.” Cole-Adams even uncovers one old study that strongly suggests hypnosis can help patients lose less blood during surgery and tries it herself. (It appears to work; her surgeon later tells her she bled less than most.) I sorely missed the zingy precision of popular-science writer Mary Roach on these occasions. Cole-Adams uncovered lots of genuinely interesting oddities only to bury them under ruminations about herself and the directionlessness she felt while writing the very book we are reading.

Click to enlarge

Corinne May Botz, Operating Room 2 from Bedside Manner, 2015, ink-jet print, 50 40". Corinne May Botz/courtesy Benrubi Gallery, New York.

These opaque digressions are intended to highlight the nature of subjectivity itself, to express the baffling and numinous quality of consciousness. But they have the unintended effect of highlighting how trying it must be to treat Cole-Adams as a patient. It’s no wonder doctors can be curt sometimes, prone to assert their authority to speed the process along. Frankly, all of us, on occasion, simply do not listen to experts. (Cole-Adams remarks that several trusted readers told her to take out one of the dream passages in her book, but it only cemented her commitment to including it.) “Reading that book is like getting anesthetized,” my boyfriend quipped to me one day as I reached for my copy. “Have you been reading it?” I asked. “No,” he said, “just watching your face while you do.”

For the record, I’ve had general anesthesia seven times, and I find it far more enjoyable than mere boredom because it’s not boredom at all. It’s absence, which is weirder. If I, meaning my body, feel pain during surgery but I, meaning my consciousness, don’t register it, am “I” experiencing pain at all? Cartesian koans like this are the philosophical questions inherent in anesthesia’s work: Are we only our consciousness? What does it mean, metaphysically, that our consciousness can be taken away and then given back? If our subjectivity is created only through a particular activity in our brains, do we become an object during a lull in which that same brain activity is made impossible? The gaps in our understanding of anesthesia mirror the gaps in our comprehension of consciousness. But the mysteries of consciousness, to the great insult of liberal-arts majors everywhere, are sometimes better illustrated by evidence than lyricism. Why resort to the gauzy and poetic when plain facts can deliver so much impact on their own?

For instance, take a moment to digest this horrifying statistic: “15 to 20 percent of people in the vegetative state who are assumed to have no more awareness than a head of broccoli are fully conscious,” claims neuroscientist Adrian Owen, author of Into the Gray Zone. Owen started down the path to this discovery two decades ago, around the time Cole-Adams began Anesthesia, but reading his book was the first I’d heard about this breakthrough finding. And to speak lyrically for a moment, my mind was blown. Through a series of ingenious tests, Owen and his colleagues proved that some people in vegetative states could recognize the faces of loved ones, answer questions, and exercise agency. They were, in other words, conscious regardless of what their physical signs suggested. And sometimes they were in pain. Kate, the first vegetative woman Owen and his colleagues confirmed to be conscious, later recovered enough to explain that she had kept trying to commit suicide by holding her breath.

Owen’s subjects were not people diagnosed with locked-in syndrome, which was made famous by the 2007 film The Diving Bell and the Butterfly, because unlike locked-in sufferers they couldn’t consistently control their eyes or eyelids. Without this delicate tool of communication, they were usually assumed to be living but not quite sentient (hence the plant comparison). As Kate put it after her recovery, “They thought I wasn’t me; they thought I was just a body. It was horrendous. I still had feelings. I was still a person!” This theme comes up in Counting Backwards, too, when Przybylo recounts watching a documentary about an accomplished man with cerebral palsy who describes himself as being “a brain trapped in a box.” “I awakened to a world I had misread for far too long,” Przybylo writes, reflecting on how he’d treated some of his disabled patients. “I had failed, until now, to consider that a person so physically impaired and unable to speak might be able to absorb the surrounding environment.” He confesses that “after nearly fifteen thousand cases,” he finally confronted a stunning possibility: Someone incapable of describing a particular sensation might still be capable of experiencing it. “I had assumed that if the reaction was not possible, neither was the reception,” he writes.

This attitude is an example of ableism, the notion that if someone’s body functions differently than the promoted norm, the life in and of that body is inherently inferior. In Beasts of Burden (2017), a compelling exploration of our ignorance regarding the subjective experiences of other living beings, author Sunaura Taylor notes that “ableism is a force that expands beyond disabled people. All bodies are subjected to the oppression of ableism.” In certain circumstances, any living subject can come to be viewed, labeled, and treated as an object. And we participate in that value system all the time. It informs almost everything about how we live, from which strangers we smile at and which animals we protect to how we understand our own social worth, which is why it can be so destabilizing to be confronted with that system’s cruelty and carelessness—or to have it wielded against us by others. Though Taylor is especially interested in ableism’s role in how we use nonhuman animals, the recognition of our objectness describes the undercurrent of much anesthesia-related fear: You arrive at the hospital as a human being, but for a portion of your time there, you become something less.

Our mortal bodies are horrifying no matter how “able” they are, because we feel like we are more than them even as they are us—and there is no avoiding that they’ll degrade over time. But some of what soothes this existential stress is kindness, attention, and respect from fellow fragile bodies. While it would be trite to call that bundle of empathetic responses “the best medicine,” there’s little doubt it has a place in healing. Several of Owen’s patients made shocking, even unprecedented recoveries after their consciousness was confirmed, and one plausible explanation is that caretakers had begun treating them as human. “Psychological studies have shown the devastating effects that social isolation can have on the brain,” Owen writes. “Imagine being ignored and treated like an object for days, weeks, and months on end. Surely that’s the worst kind of social isolation.”

Doctors have long told themselves that empathy is an impediment to their performance, yet Owen, Cole-Adams, and Przybylo all make arguments for an increase in sensitivity and communication. Taylor’s work offers relevant wisdom about what might help doctors (and all of us) make this effort. She suggests that we redefine independence as “the ability to be in control of and make decisions about one’s life, rather than doing things alone or without help.” Adopting this frame would alleviate shame and anxiety for patients as well as mitigate the hierarchy currently intrinsic to medical care. If the giving and receiving of assistance is seen as cooperative and flexible, instances of acute dependency might not be so intimidating. And if doctors foreground the importance of patients’ decision-making, an improved exchange will naturally follow.

Such an approach might allay doctors’ fears, too. After all, it’s probable that most doctors hold patients at arm’s length not because they’re underinvested in any given patient’s suffering but because the patient’s extreme vulnerability reminds them of their own. Each body in an operating theater is not equally conscious, but they are all equally mortal. And the one awake today may be the one anesthetized tomorrow.

Charlotte Shane is the author of the memoir Prostitute Laundry (TigerBee, 2016).

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