Monday, July 23, 2007

Happy Talk


"Thankzzzz doc yer th greatiszz.... No, rilly man.... yer the...... zzzzz ..."

"Huh? The operation's over? No way. You're kidding, right? Bandage? Oh yeah, lookit that. Wow. The operation's over? No way. You're kidding, right? Over? You're kidding, right? Is the operation over? You're kidding. Right? Bandage? Oh yeah..."

"I robbed a bank, y'know. Had to kill a guy. Put the money in a Swiss bank. The account number is...."

I've heard it all. Well, except that last one. And I've been asked frequently: "Did I say anything when I was out?" Readers of this blog have wondered the same. Evidently it's a pretty common concern: do people reveal stuff or otherwise embarrass themselves when under the effects of anesthesia drugs? Relax, people; the answer is "no." OK, gotta be truthful: it's also "yes."

Sodium pentothal, formerly used extensively in the operating room but now largely replaced, has been referred to as "truth serum." Whereas it's true that under the influence of some drugs people can get a little disinhibited, it's not the case that they'll get all revelatory. I haven't learned any secrets from my patients. When asked, however, I'd often say, "Well, you did tell me about that Swiss bank account." Only once did that result in a worried look....

Most surgical patients get a little something to relax them before they get wheeled into the OR. It's not unlike a couple of nice martinis -- without the olives. (No solid food before surgery.) So yeah, tongues loosen a little. Giggles sometimes; rarely, tears. "Wow, this feels great..." Stories get told. Amusingly, when the story is interrupted mid-sentence by the arrival in their brain of the knock-out punch, I've seen people wake up later and begin exactly where they left off, unaware of the passage of time. And yet, I've never heard anyone say anything they'd be sorry about. Unless telling me how wonderful I am is in that category...

Generally, I enjoy operating on a patient who's awake. We talk, usually light-heartedly. Given some sort of anti-anxiety drug, the conversations can be loose, chatty, funny. People will say the same thing over and over, ask the same questions repeatedly. My goal is to keep them comfortable; if they want to ramble on, it's fine with me. Most often they doze, wake up, talk a little, doze some more. It's pleasant, not confessional. Because such talk is commonplace, even when particularly entertaining it goes out the other side of my mind as quick as it enters; my head -- and, I'd aver, those of everyone else in the OR -- is a sieve that way. Talk like that is texture, not substance.

The flip side of this is a theoretical utility. Far as I know -- and the anesthesiologists who sometimes wander by (Mitch?) might be able to amplify -- studies of suggestibility under anesthesia are equivocal. Still, I liked to give some positive thoughts to my patients as they went off to sleep and when they emerged: "We'll take good care of you. You'll going to be comfortable when you wake up." And, after it's over, "Everything went great. You're going to be glad we did this. Comfortable, no nausea." I have no idea if it had an effect or not. I always made it a point to talk to my patients when they were awake in the recovery room, not only telling them how it went but -- unless it wasn't true -- telling them I expect things to be fine, give them some positive vibes. With practically no exceptions, no matter how engaged and appropriate they were in those conversations, people never remembered what was said, or even that I'd been there. Or that they'd asked me the same thing five times in a row.

If it were possible, I'd love to see a study of people wherein within a standard time of emergence they'd receive some suggestions. Some would hear words saying they'd be comfortable, be up and out of bed soon; others would hear something neutral, unrelated to pain. The floor nurses wouldn't know who heard what. Pain medication use would be recorded. I'd like to think the former group would need less. (The problem with any sort of surgical studies is that even when operations are "the same," they really aren't. Different surgeons, different operating times, incision size; different people getting the procedure. It's really hard to standardize. Still, it'd be interesting.)

26 comments:

rlbates said...

Sid, I have never learned anything (embarassing or harmful) from patients as fall asleep either. We sometimes tell them as they wake up that they will no longer want a cigarette. Can't say that it has ever helped.

buckeye surgeon said...

I had a lady rip off a stunning recitation of Tennyson's "Ulysses" on the way back to the OR. When I asked her about it afterwards, she said it had been 15 years since she even thought about the poem. Didn't even know the first two lines while sober.

makeminetrauma said...

Sid, I agree with the positive affirmations. Can't hurt. We had a very strange RN once who would chant? affirm? reinforce? positive vibes to patients as they were being induced. She insisted it made a difference, in her own mind of course. An official study would be great.

Do you still get people who, without prompting,start counting backwards from 100? I've seen that a few times. No one asked them to, they just thought that was the way it was done!

Lynn Price said...

Love the idea of a study, Sid. But, you're right, it'd be too hard to standardize. Mehmet Oz did some interesting work in that area with his cardiology cases.

Reserved Stipulation said...

I found this to be a very neat post. I've been under once, but I don't think it was the big drugs... maybe just versed and fentanyl for a dental operation. I just remember waking up and him (stupidly) asking if I wanted to see my teeth. Had I been in a more sober state of mind, I would have answered "HELL NO!"

I think the positive affirmations before and after are great to do, even if they may not really help. I think most people thrive on a positive mindset, if given the chance.

Bongi said...

my brother in sweden had a nasty episode involving a bowel obstruction and moronic doctors (long story). anyway, when they finally removed their fingers from their asses and operated, he had a rough ride, ending up in icu. when he woke up he spoke fluent swedish, which he could not speak up to that point. do you think the doctors did their positive affirmation in swedish?

Mitch Keamy said...

Hey Sid. This comment will be a little long, but I hope informative. When using midazolam/fentanyl or the like, I have always thought the sedation "sweet spot" was attained when the patient is cooperative, chatty, and will make the same comments or ask the same questions over and over, as you described. It is an interesting thing that they cognate sufficiently to ask the same question, but can't remember the answer; I suppose the formation of the question is based on environmental (sensory) stimulus, or perhaps, some sort of recurring cognitive loop (I don't want to computerize too much here, but...)
I love sedation cases; after 30 years they are the most artful and aesthetic. Incidentally, propofol is much easier to titrate, but muck less fun; patients are less chatty (in terms of meta-anesthetic theory, we would say that propofol is more of a hypnotic than narcotic/benzodiazepine combos). I have been known to get patients singing songs in the OR (three blind mice, row,row,row your boat, if they distract the surgeon too much; some guys don't like to be bothered. (I sing with them, of course - I do notice the cases seem to proceed more quickly when I sing.) The question of post anesthetic suggestibility is indirectly the subject of much study right now. Memory is divided into two categories by most investigators: explicit memory (conscious) and implicit memory (unconscious) an example of implicit memory would be your golf swing or playing the piano or recognizing the smell of a roasting turkey (I'm not sure about the third one); an example of explicit memory is my being able to quote dialog from say, "The Princess Bride" or "Caddyshack" or remembering your trauma posts from last week. Now we know that, with adequate levels of anesthesia, explicit memory is gone. The sort of post-hypnotic suggestion you are musing about would fall under the category of implicit memory. Firstly, not everyone believes implicit memory is a separate entity, but that's not a discussion for here. Data regarding implicit memory under anesthesia is mixed. Most recently (2005) data suggested it might be intact under anesthesia. Older data I have seen suggests not. In the in-between land of emergence, I suppose these steady state studies are irrelevant, anyway. I have never noticed (anecdotally, hundreds of cases) any enhanced suggestibility in patients on emergence. I do think anxiety is "contagious" in both directions, and I never tolerate critical language towards a patient from anyone in the OR regardless of the patients depth. I use the excuse that the patient might remember, but it is really simpler...
If you want PDF's of articles regarding any of this, I can email them to you. There is especially interesting thinking right now on the relationship of anesthesia to the ablation of consciousness. just let me know.

In trauma anesthesia we used to have a saying; if you can't get anesthesia, amnesia will do. But this is perhaps a good hook for a post on this topic over at our place; I've run on (as usual) I see, "on your nickel."

you're the man.

Mitch

Sid Schwab said...

Bongi: I suppose that's a joke, but I'd love to think it's not. It's like the "Hey doc, will I be able to play the piano after this operation?" "Of course." "That's amazing, because I can't play a lick now."

Mitch: great stuff. Thanks. I love to sing in the OR. The only time I don't get flak is when the patient is singing along. Some still talk about the time I sang a Russian patient to sleep with my repertoire of Russian folk songs. "Razsvetalie, yabloni i grushi..."
The memory stuff is fascinating. One of my pals from both college and med school is a research neurologist whose earlier field was memory (particulary, as I recall, retrograde memory loss, which is relevant to anesthesia...) but now is semi famous for having trained quadriplegics to move computer cursors with their brainwaves.

Buck: love that story.

mmt: yeah, or they ask, when should I start counting.

Doc's Girl said...

Too funny...:) I agree that positive feedback is good...

I would think a lot of people talk themselves to death... I may have done that back in my drinking career. :-P

SeaSpray said...

You had me going for a minute there! :)

This is all so very interesting - your post and the comments as well. Too bad you can't tell specifics without being identifying.

I think it is always a good idea to go into anything important with positive vibes, certainly the OR. And I agree - nothing derogatory should ever be said about the patient when they are in earshot- ever. Not in pre-op, during or post-op.

When I was 24 I woke up in post-op sobbing! I could hear myself sobbing before I could open my eyes. I heard the post-op nurse talking to some one on the phone saying, "I gotta get this one out of here. Shes driving me crazy! She won't stop crying!" I don't have a clue why I was crying. I was happy in my life except for the fact that I had been unable to conceive a baby. I was in the OR that day having a laparascopy/D&C and they did find that I had endometriosis. (Btw - they had me - a healthy 24 yr old in the hospital 3 days for that procedure! Had to go in the day before and they didn't let me go home until the day after. I had so much energy -it seemed so odd to have to be there!)

I did cry on my way into a procedure last year. Talk about humiliating. Something had happened the day before that couldn't be helped. I did cause it but there WERE reasons - it wasn't that I didn't care. By the morning of my procedure I had made peace with it, sort of anyway. But then, just before I was going into the OR someone brought it up and I felt bad all over again. Then the tears started streaming down my face. I kept wiping them away. Now they were wheeling me down the hall to the OR and the tears wouldn't stop. It felt like everyone noticed. I actually had to ask them to stop at one of the nurses stations and get me a tissue so I could dry the tears. (I should have just slid down under the sheets!) It was the longest ride to the OR-felt like the scenic route! Then they left me alone in pre-op which was fine with me. I looked up and at the opposite end of the hall there were two nurses intermittently peeking at me from around the corner talking in hushed voices. Maybe they and everyone along the way thought I was afraid to go in to the OR - which I wasn't. Tears kept falling but soon my Doc came by and was so sweet and that just got me thinking in a different direction and I was able to stop crying. The procedure went well.

Interesting about the brain picking up the story again where the patient left off. It seems that the brain put that into save mode and then activity resumed to continue the program. What was the brain doing in between that time? Awesome to think about.

Still...saying things you don't remember or having a stimulus response with lowered inhibitions...

Thanks for this post and the additional insights. I'm sure M.A.s "friend" is appreciative. :)

Anonymous said...

Just underwent several surgeries; not a scientific sampling, but my most beatific wake-up experience was after this:
Nurse: We'll take good care of you.
Me: Thank you. [zzzzzz]
...which is to say, all the kindness is appreciated, always.

Sid Schwab said...

Anon: couldn't agree more. In fact, as I reported here, that's exactly what I always say.

Greg P said...

It's entirely possible the positive comments have as much or more effect on the surgeon than the patient.

And that's not bad either.

Nurse Bear said...

I can't believe i'm the first one to say this:

Best. Picture. Ever.

Rachel said...

Ha. Before knee surgery (at 15), I insisted to my mother that I wanted to go to Disney World for Christmas. This was decidedly not true - I wasn't a big fan of the DW even at 7. Waking up from thyroid surgery, I simply asked the nurse, "Will the beds upstairs be more comfortable than this?"

Bongi said...

sid, amazingly enough it isn't a joke. my brother had lived in sweden long enough to sort of learn the language and had taken a few classes etc. it seems it was only his inhibitions holding him back from full out fluent speech. coming out of his near death experience the swedish came out of him.

SeaSpray said...

Greg P - That is an interesting perspective and one I have never considered but it makes sense.

Terry at Counting Sheep said...

I have always been fascinated with the whole idea of post-hypnotic suggestion, and use it during all of my anesthetic inductions. After administering 2 mg of Midazolam, I suggest positive and reassuring thoughts to my patients - "I am beginning to give you your anesthesia medication now. You will feel increasingly relaxed and comfortable. Slowly inhale, and slowly let that breath go. With each breath, you will feel more serene. I will be watching over you every second during your entire operation. I will make sure throughout your operation that you are comfortable and safe. When you wake up, you will be in the recovery room. You will feel relieved that your surgery is over, you will feel quite comfortable, and you will be a little hungry."

Things of this nature. I try to keep my suggestions on the positive side, as opposed to saying words like pain or nausea.

I'm not sure whether or not it works; I've always wanted to conduct a study or survey. But as anesthesia providers, we do administer hypnotic drugs - used properly, why not take advantage of chemical hypnosis?

Anonymous said...

Had a liver biopsy and asked for Versed before the procedure started. Doctor came in and asked me if I was ready, I said "Hey, you can biopsy whatever you want, right now I don't care!"

I woke up in recovery, singing like a bird. Yes, that's right, singing. The other folks in recovery didn't seem to mind either. Except maybe that one guy who sat straight up and stared bullets at me -- and I sing pretty good, so I know I wasn't off key...

Anonymous said...

Well, thanks for making me even more unhappy that I was slipped Midazolam against my wishes! I had no intention of being amusing or entertaining in the OR. Chatty and cooperative, but amnestic? OMG how horrifying! I do wish that my team had the decency not to make smarty pants comments about me when they thought I had amnesia, their remarks were humiliating. I also do NOT like the idea that you guys would "experiment" on us with post hypnotic suggestion. Wow! You have a lot of respect for us don't you? This VERSED problem is much deeper than I thought! No wonder my guy could hardly wait to get that "Vitamin V" into my bloodstream.

Sid Schwab said...

"Experiment." Interesting take. Lack of respect. Even more interesting. I consider it nurturing and holistic. I guess if you don't want positive vibes you should tell your caregivers. Maybe check out the doctor evaluating websites, find the people with lousy bedside manner, and go to them?

Anonymous said...

Positive vibes? Making nasty comments about me when they thought I was amnestic doesn't qualify. I hate VERSED and was shocked and unhappy to find out what they did to me. Imagine having an "Alice in Wonderland" conversation with caregivers who LIED to me about what they did to me. It took a while to convince them that my memory of ALL events was intact despite their efforts to give me amnesia. Frankly, I don't think I could have had a team with a worse bedside manner! I blame it on the VERSED. I hope that you guys DO follow the advise of one poster here; don't say anything in the presence of the supposedly "amnestic" patient that you don't want them to remember... Nurturing and holistic with a brain disconnecting poison like VERSED? I don't think so.

Anonymous said...

It's nice to know that likely most doctors and most anesthesiologists have the patient's interest at heart and practice honorably.

Unfortunately, I also strongly dislike Versed, and before my last surgery I added "please NO VERSED" and underlined that a bunchof times, then verbalized that demand to my doc and the anesth. Everybody all agreed, so I did too.

The anesth. came back, injected something into my IV, and I asked him what that was, he told me, in a low, fast mumble, "Midazolam". I said, "BUT! BUT! BUT!" and then blanked out.

From a patient's point of view, amnesia will not do if anesthesia is inneffective.

People may wake up parroting what the doctor said just before they wake up but it's more like a "brain echo" than a cogent thought.

In any case, do be aware that there are docs who don't give a rip about their patients, and it's hard to find a decent doc like you, Sid.

Thanks for having your website here.

Jane

Anonymous said...

I think that you guys practicing post hypnotic suggestion should be very careful. It is my understanding that you are a-n-e-s-t-h-e-s-i-a providers, not psychiatrists. You are only licensed to provide anesthesia correct? Are you also qualified to practice behavior modification tecniques with pharmacological help? Do you have informed consent from the patient to practice what amounts to brainwashing on them? This seems very dangerous, since you do not know these people at all and are unqualified to twiddle with their subconscious mind! Maybe this should be taken up by an ethics committee as this behavior is unethical, abusive and completely outside your purvue as anesthetists.

Anonymous said...

As a patient, I do NOT subscribe to the notion, "amnesia will do if anesthesia is ineffective." I was given an amnesic (midazolam) without my knowledge and consent regarding its memory corrupting effects during a TEE. Had I been given the courtesy and respect of being actually "informed" of the real purpose of this "sedative", I would have immediately prohibited its administration and demanded a general anesthetic. I was simply told I would be given something to help me relax and fentanyl (moderate sedation), and that I might not remember the procedure even though I would be awake.

To make matters worse, the midazolam started to wear off during the procedure and I found myself choking and in terrible pain every time I tried to reflexively swallow the cable in my esophagus. I don't know which is more barbaric and unethical - not being told that I would be given a drug that would obliterate any memory I might have of the procedure/torture, or that I was effectively tortured for 30 minutes.

The practice of administering amnesics to make patients unaware of what they went through needs to stop immediately. Saving time and money by utilizing conscious sadism in lieu of deep sedation or general anesthesia is by definition, obscene.

Sid Schwab said...

Anonymous: I'm sorry you had such an unpleasant experience; however, notwithstanding the comments above, it's not a "practice" to administer amnestics in lieu of decent anesthesia. Some people don't respond as expected to certain drugs; some people even get substandard care; but it's not a standard or "practice" in the way you seem to imply.