Surgery, anesthesia, vomiting, emergencies...

Factual Questions
21

But the level of pain and terror must still have been overwhelming. I can’t even imagine what you must have gone through.

Yeah, it does. I’m not even sure that they know how often it happens and people survive, due to the amnesia that the anesthetics often produce. I.e, if you were conscious during part of the surgery, but due to induced amnesia you formed no memories during that time, then maybe you can’t tell anyone what happened. But the amnesia wouldn’t lessen the terror during the experience.

I wonder if there might not be some way to test for returning consciousness even if a person is fully paralyzed. I don’t know what that might be, as I don’t know beans about medicine, but it seems like an important enough thing to devote some effort to solving. Perhaps there might be detectable differences in brainwaves between someone who’s firmly “under” and someone who’s not?

–
peas on earth

22

Actually, since heart rate is constantly monitored & blood pressure is checked about every 5 minutes, the anesthesiologist would quite likely notice a sudden jump in either - rising consciousness would be one of the first considerations.

Unfortunately, this may not always be reliable, as many times, if erratic heart rate & blood pressure are predicted because of either the nature of the surgery or any pre-op conditions the patient may have, meds are given before & during surgery that could blunt or even eliminate these changes.

Sue from El Paso
members.aol.com/majormd/index.html

23

Cecil did a column about this sort of thing. They’ve recently invented an electronic gadget that somehow measurees your brain activity and determines how asleep you are, Anyone else know about this?

24

Recall under anesthesia is actually quite rare, though by no means unheard of. Most of the times patients who have recall under anesthesia do not hurt but there are those who do.
Cardiac surgery is at the highest risk for having recall. Usually, because the anesthetic is a ‘narcotic based’ anesthetic. I.E. high dose narcotic with little if any ‘anesthesia gas.’ Narcotics do not produce amnesia…anesthetic gasses in appropriate concentrations do. The reason for this is that narcotis produce less cardiovascular effects (hypotension, cardiac depression) than anesthetic gasses. Though, the trend is now-a-days to decrease the amount of narcotics used and to increase the concentration of either volatile anesthetics or infusions of hypnotic drugs i.e. propofol.
During anesthesia, patient’s volatile signs are continuously monitored. Based on several monitored parameters; blood pressure, heart rate, concentration of volatile anesthetic being exhaled (we know that for each volatile anesthetic there is a concentration called MAC in which 50% of patients will not move during surgical incision, the concentration for recall is less than MAC) we have a very good idea on how ‘deep’ a patient is under anesthesia.
There is a relatively new monitor out called a BIS (bispectral index) monitor which uses brain activity to provide a number from 0-100 (100 being awake, <80 asleep.) This monitor has been getting alot of press recently because of the horror stories being broadcast on show like 20/20, dateline etc. It’s an okay monitor but despite what the papers/newscasts say, it has never been proven to reduce recall.

25

Majormd mentioned that some of the drugs used were disinhibiters, and that some patients start flirting with the staff, etc. When I got a wisdom tooth out once, I was going under while looking the sexy nurse over and thinking to myself “man, I’d like a blow job from her”.

I always wondered if I embarrassed myself and her while I was out. If I did, I’m sure it was highly amusing. Do you guys who work in an ER have any good “disinhibition” stories to share with us?

26

Having the interest that I do in this topic, I have kept a close eye for info about it. It’s interesting… it’s very, very difficult to determine if a person is aware when their body is paralyzed. I distinctly recall one of the experiments, which obviously isn’t practical for general use, involved cutting off the circulation to one arm while they put the patient under, then talking to him and asking him to move that arm/hand if he was aware. How weird!!

This is a non-smoking area. If we see you smoking, we will assume you are on fire and act accordingly.

28

There is misinformation in this thread.

I am neither a surgeon nor an anesthetist but even as a mere internist feel confident in stating that the stomach is not “pumped” before emergency surgery. Rather, a so-called 'rapid sequence induction’ (sometimes called a ‘crash induction’) is performed.

Basically, this means the patient is first paralyzed, and then intubated very quickly. This is the opposite sequence for what is usually done for elective surgery. Don’t forget to look here.

29

I think a fourteen year old zombie may be a record here. It’s appropriate that it happened on Halloween.

Lets give it some anesthetic…

30

“Ever had surgery? You know how you are not supposed to eat or drink anything for 12 hours beforehand, because you could become dangerously ill, throwing up or drowning in your vomit or some such vileness…”

The danger is aspiration pneumonia, which is a lung infection that results from inhaling (also known as aspirating) vomit into your lungs.

“So what’s the deal with emergency surgery? What if the guy with the gunshot wound jsut ate 3 helpings of Thanksgiving dinner right before he got shot, including three servings of pie?? What happens to him when they put him under? And if he can survive it, why can’t others?”

In an emergency they’re really more concerned about saving the person’s life than they are about aspiration pneumonia. Not everyone vomits under anesthesia, and thankfully the inflated cuff of the endotracheal tube (the tube they put down your trachea to ventilate you during surgery) oftentimes will block any vomit from going down your trachea and into your lungs. In addition as soon as the anesthetist (who will be at the patient’s head nearly 100% of the time) noticed that the patient is regurgitating, he or she will use a small suction catheter to suction the stomach contents out of the patient’s mouth. Prior to extubating (removing the tube) they will most likely suction the mouth one more time as best they can and as a further precaution might extubate the patient with the cuff inflated (the cuff is usually deflated prior to removing the tube, as the trachea is sensitive and doesn’t need to have its walls abraded by the cuff), so that any vomit that may have made its way down the trachea and was stopped by the inflated cuff of the tube will be pulled back upwards and into the mouth to be suctioned out.

“Here’s another one: on ER they are forever slicing into the chests of people who have just passed out or “died”, cracking their ribs to start their hearts. It usually works. So…do such people wake up in screaming hysterical agony with their chests cracked open? Dead…cracked chest, zapped heart…awake…conscious…dead again from horror and pain.”

“Cracking the chest” is called a thoracotomy and when it is being performed in order to restart the heart, it is usually a last-ditch attempt and has a pretty dismal survival rate. If the patient is already unconscious then they are not anesthetized prior to intubation, but if they are awake they are promptly knocked out. I recall reading that patients who are conscious upon admission to the ER have a better survival rate than those who are unconscious, but that’s beside the point. As for analgesia, my guess is that they would start the patient on pain meds as soon as possible (i.e. constant rate infusion (CRI) of fentanyl or another potent drug), regardless of prognosis, not only because pain is managed better when meds are given preemptively, but because, unconscious or not, the body still reacts to pain (i.e. heart rate and BP increase, among other things).

31

I’m gonna try a slight hijack, on the basis that Stoid or Stoid’s descendants are unlikely to still be waiting on answers to a question posted back in the first millennium.

Isn’t it kind of hard that surgery usually involves working down in the bottom of a bleeding hole? And that for so many surgeries the patient is facing up, and is trying to breathe from the bottom of another hole that is secreting various fluids and not being cleared by normal swallowing? Though, of course, intubation fixes this as long as it lasts – but then extubation is happening in the bottom of same hole, so similar issues could apply. And even dentistry has this same situation, right?

I picture more and more surgery being done robotically in the future, and it makes me wonder if eventually it will become typical for the robot (which wouldn’t care) to be positioned under the patient and work upwards, so that all the various things that might interfere with access will tend to fall out of the wound. Or, even in the case of endoscopic surgery, if that is robotic, eventually it might be typical to position the patient so the surgical field tends to be uppermost in the cavity, so again fluids and interfering loose organs tend to move away from ground zero.

32

second millennium

33

“One, two…” Gee, you’re right! Not as bad as I thought!

34

Well, my mom woke up during the middle cardiac bypass surgery, most definitely with cracked open ribs and a spreader for 'em. She survived, but wasn’t believed until she repeated about 20 minutes worth of OR conversation.

“Horrific” doesn’t even begin to touch it. Not the least because while the anesthetic wore off early the paralytic did not, so she had no way to communicate the problem at the time.

I think most people in the ER with a trauma-induced cardiac arrest will probably not remember the experience of getting their chest open because, first of all, as you note the vast majority don’t survive and two, because a lot of trauma patients don’t remember the ER or ICU much, if at all.

It is possible, though, that someone might not only survive that last-ditch open chest heart massage (I know of at least one documented case where someone did) but recall it later. Unlikely, but possible.

35

[QUOTE=;116922]

  • the disinhibition is a key reason why many recovery rooms do not allow spouses to come in. Patients sometimes get very flirtatious with the recovery room staff, and even talk about things like past & present affairs & why the cute guy checking their dressing would be so much fun to give a blow job to…
    [/QUOTE]

I re-resurrected this thread in order to relate something I heard yesterday.
I was in for a quick outpatient procedure. Before going into the procedure room, I dealt with about a half-dozen hospital employees, the last one being a very nice but nondescript middle-aged woman named Allison.

When I woke up, I heard this coming from a nearby curtained partition.
Patient (loudly): Is Allison here?

Nurse: [inaudible]

Patient: Are you Allison?

Nurse: [inaudible]

Patient: I want to see Allison.

Nurse: [inaudible]

Patient: Because I love her.

Nurse: [inaudible]

Patient (calling): Allison!

(My doctor approaches me, but is sidetracked by the other patient.)

Patient: Doctor, do you have my address?

Doctor: Yeah, I have your address.

Patient: I want you to give it to Allison.

Nurse: [inaudible]

Patient: But I love her!

(My doctor sits down next to me and opens a manilla folder.)

The procedure went well. We found something unexpected, but it doesn’t —

Patient (calling): Doctor!

Doctor: Just a minute, Bill. (to me) It doesn’t seem to be anything —

Patient (calling): Doctor!

Doctor: Just a minute, Bill. (to me) — anything to worry about. Here are —

Patient (calling): Doctor!

Doctor: Just a minute, Bill. (to me) — the photos. As you —

Patient (calling): Allison!

Doctor: — can see, we managed —

Patient (calling): Allison!

Doctor: — to get all of it. Here’s —

Patient (calling): Allison!

Doctor: — the written report. Do you —

Patient (calling): ALLISON!

Doctor: — have anything you want —

Patient (calling): AL-LI-SON!

Doctor: — to ask me?

Patient (calling): AL-LI-SON!