Anyone here had a pt with awareness?

[CremeSickle]

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We have not had (to any of the attendings knowledge) a pt who has had awareness. Has anyone else?

 

[deleted9493]

A patient during my anesthesiology rotation told me that she had an out of body experience during a thyroidectomy she had received several years ago. She described in detail the equipment (ie. retractors, cautery etc.), the positions of the people in the room, as well as specifics regarding the conversation of the room. Now, this was a woman who was completely ignorant with regards to things of a medical bent, leaving no doubt in my mind that what she spoke of was true.

In one sense it did surprise me to hear her story because I know that it's not an overly common experience. In another sense it didn't surprise me at all, coming from a personal belief that as human beings we are most fundamentally spiritual.

 

[stanleykristian]

Had one patient who had awareness during a procedure had to run VERY light anesthetic as BP was low.
Another thought they had awareness as they have recollection of induction sequence.

 

[Noyac]

Yes, I have pt who have awareness everyday. They don't seem to complain about it though. 😱

Actually, I just use a lot of regional and we try to do most of our total joints under spinal with some sedation. The pts seem to really like it and the surgeons love it.

As far as awareness after a general anesthetic. Never, at least not yet. I have done a ton of trauma as well with little to no BP and hearts with little reserve. Still never had a case of recall.

 

[VolatileAgent]

A patient during my anesthesiology rotation told me that she had an out of body experience during a thyroidectomy she had received several years ago. She described in detail the equipment (ie. retractors, cautery etc.), the positions of the people in the room, as well as specifics regarding the conversation of the room. Now, this was a woman who was completely ignorant with regards to things of a medical bent, leaving no doubt in my mind that what she spoke of was true.

In one sense it did surprise me to hear her story because I know that it's not an overly common experience. In another sense it didn't surprise me at all, coming from a personal belief that as human beings we are most fundamentally spiritual.

there is a neurophysiologic basis to this "experience":

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

in anesthesiology, we use powerful drugs that disrupt normal cognitive and neuronal function. it is not unreasonable to suggest or assume that the OBE is an epiphenomenon occurring in the presence of these agents.

iow, don't let your untestable, unprovable personal biases taint your commitment to scientific integrity.

 

[jetproppilot]

We have not had (to any of the attendings knowledge) a pt who has had awareness. Has anyone else?

Yep.

I've had it.

😱

Thankfully not for an entire case.

But the beginning of it.

Emergency case...transected RCA from a stent deployment in the cath lab...

This was one of those HURRY! HURRY! cases.

Cath lab team rolls the patient directly into the OR (none of them had hats or masks )

Pretty wide awake dude.

A scramble to get the monitors on, pre 02...

midaz 2 mg, etomidate, sux...

intubated, radial a line started (we used the femoral for induction), right IJ 9.0...

uneventful case.

Pt does fine.

Until the post op visit...

...pt had an uneventful post-op course, despite the emergent surgery needed to correct the cath-lab catastrophe.

Turns out he had recall though....through the placement of his IJ central line.

He was aware through going to sleep (even though he wasnt asleep), recalled the intubation, then recalled a pain in his right wrist (A-line) and a pain in his neck (IJ).

He pointed to the spots that he recalled pain post-operatively....

Accurately.

😱

Then, thankfully, the drugs apparently took over and his recall ended.

Dude wasnt pissed, freaked, etc.

Actually he was thankful for our efforts.

He recognized the significance of his cath-lab complication.

So no litigation worries.

But its still interesting.

In addition to the induction agent (etom), I threw in a little benzo just in case....

and it didnt cover the amnestic base.

At least it didnt cover it thoroughly.

Don't know what I wouldda done different.

But this case brings up an interesting, important topic:

Not all people you save from death will spare you litigation.

I was lucky.

This dude was shaking my hand, despite his (partial) recall.

Talk to me about how I could've ONE-UPPED myself, in terms of amnestic protection of this patient....something, I may add, that can fall by the wayside when you've got someone with a mortal injury....and you are attuned to saving their life..... don't worry about their memory, right? wrong....remember the litiginous society we live in....despite the critical nature of the situation...always reassess....could anything have been done differently to assure amnesia in a crashing cath-lab-patient-gone-wrong???

 

[Gr8GooglyMoogly]

In one sense it did surprise me to hear her story because I know that it's not an overly common experience. In another sense it didn't surprise me at all, coming from a personal belief that as human beings we are most fundamentally spiritual.

*******************************************************
I apologize for the brazen response--I imagine that your intentions are good, and this is alone is admirable, albeit off the mark. This type of thinking from an educated person is worrisome. I would argue that "God" is responsible for most of the misery that C.S Lewis seems to think is "all that we call human history." Though I am humble enough to vouch that great thinkers of yore may have had sharper minds than my own, this does not preclude me from using my 21st century vantage point to corrrect them on matters of neurobiology. The following are excerpts from letters I sent to the eternal souls of such intellectual giants, who, theoretically, can even today, frown at my sarcasm:

Dear C.S. Lewis, there is no biological substrate for the soul or spirit. Furthermore, it is firmly established that the universe was created by random events about 14.6 billion years ago, and that the human species is an animal evolved from monkeys. There is no God.

Dear DesCartes, the pineal gland is not, in fact, the reciever/antenna through which the soul communicates with the body (http://www.crystalinks.com/thirdeyepineal.html)--it seems to play a role in the regulation of circadian rhythms.

Sincerely,

Great Googly Moogly
********************************************************

Subsequently, I must take issue with the assertion that human beings are "fundamentally spiritual?" If nothing else, I would have hoped that medical school would have firmly cemented that human beings are anything but "spiritual." There are valid scientific claims to be made about the ability of humans to alter their "consciousness" (read: their EEGs patterns) which, to a subjective human observer may seem "spiritual," (please appreciate the pre-existing contextual framework necessary to describe this type of experience as such). Other than this confusion, this type of thinking from an educated scientist is, again, worrisome.

Which part of medical school reinforced this spiritual belief? To have completed a medical education without understanding that (1) a physician's personal belief without appropriate (read: not bogus metaphysical "proof") supporting evidence and (2) consciousness is a complex neurobiological representation of one's existence to the one's "self" as the observer is tantamount to at best, ignorance, and, at worst, malpractice. If we have a soul that directs our movements, thoughts and actions--consciousness-- then it either physically exists somewhere in the body or it doesn't--this is an empirical question to which there is a definite answer. Either it does or it doesn't. If it exists in the body, we should be able to find it. If it does not, then some explanations are in order: where does it exist? how does it direct our actions? why do physical events have such profound effects on a non-physical soul? For example, why do drugs (that physically affect ion potentials) and strokes (that physically kill neurons) produce such profound effects on (the allegedly non-physical) consciousness, for example, a right-sided lesion resulting in hemineglect? Like it or not, as physicians we are, or at least have a duty to ourselves and to our patients, to be SCIENTISTS! There is absolutely no evidence that there is anything even closely approximating a spirit that can exist separate from the ion potentials that we so mistakenly and egocentrically mistake for our "selves!"

I encourage rebuttal to this stance, but, for the sake of validity, I urge two things, that the substrate for the soul or spirit be suggested without resorting to magic (i.e. the nonsensical argument that the soul exists outside the realm of science and is, consequently/fortunately for religious people, undetectable) or archaic, mysogynistic, miraculous texts. Miracles have been on the retreat since the Age of Enlightenment.

 

[jetproppilot]

*******************************************************
I apologize for the brazen response--I imagine that your intentions are good, and this is alone is admirable, albeit off the mark. This type of thinking from an educated person is worrisome. I would argue that "God" is responsible for most of the misery that C.S Lewis seems to think is "all that we call human history." Though I am humble enough to vouch that great thinkers of yore may have had sharper minds than my own, this does not preclude me from using my 21st century vantage point to corrrect them on matters of neurobiology. The following are excerpts from letters I sent to the eternal souls of such intellectual giants, who, theoretically, can even today, frown at my sarcasm:

Dear C.S. Lewis, there is no biological substrate for the soul or spirit. Furthermore, it is firmly established that the universe was created by random events about 14.6 billion years ago, and that the human species is an animal evolved from monkeys. There is no God.

Dear DesCartes, the pineal gland is not, in fact, the reciever/antenna through which the soul communicates with the body (http://www.crystalinks.com/thirdeyepineal.html)--it seems to play a role in the regulation of circadian rhythms.

Sincerely,

Great Googly Moogly
********************************************************

Subsequently, I must take issue with the assertion that human beings are "fundamentally spiritual?" If nothing else, I would have hoped that medical school would have firmly cemented that human beings are anything but "spiritual." There are valid scientific claims to be made about the ability of humans to alter their "consciousness" (read: their EEGs patterns) which, to a subjective human observer may seem "spiritual," (please appreciate the pre-existing contextual framework necessary to describe this type of experience as such). Other than this confusion, this type of thinking from an educated scientist is, again, worrisome.

Which part of medical school reinforced this spiritual belief? To have completed a medical education without understanding that (1) a physician's personal belief without appropriate (read: not bogus metaphysical "proof") supporting evidence and (2) consciousness is a complex neurobiological representation of one's existence to the one's "self" as the observer is tantamount to at best, ignorance, and, at worst, malpractice. If we have a soul that directs our movements, thoughts and actions--consciousness-- then it either physically exists somewhere in the body or it doesn't--this is an empirical question to which there is a definite answer. Either it does or it doesn't. If it exists in the body, we should be able to find it. If it does not, then some explanations are in order: where does it exist? how does it direct our actions? why do physical events have such profound effects on a non-physical soul? For example, why do drugs (that physically affect ion potentials) and strokes (that physically kill neurons) produce such profound effects on (the allegedly non-physical) consciousness, for example, a right-sided lesion resulting in hemineglect? Like it or not, as physicians we are, or at least have a duty to ourselves and to our patients, to be SCIENTISTS! There is absolutely no evidence that there is anything even closely approximating a spirit that can exist separate from the ion potentials that we so mistakenly and egocentrically mistake for our "selves!"

I encourage rebuttal to this stance, but, for the sake of validity, I urge two things, that the substrate for the soul or spirit be suggested without resorting to magic (i.e. the nonsensical argument that the soul exists outside the realm of science and is, consequently/fortunately for religious people, undetectable) or archaic, mysogynistic, miraculous texts. Miracles have been on the retreat since the Age of Enlightenment.

.

 

[jetproppilot]

*******************************************************
I apologize for the brazen response--I imagine that your intentions are good, and this is alone is admirable, albeit off the mark. This type of thinking from an educated person is worrisome. I would argue that "God" is responsible for most of the misery that C.S Lewis seems to think is "all that we call human history." Though I am humble enough to vouch that great thinkers of yore may have had sharper minds than my own, this does not preclude me from using my 21st century vantage point to corrrect them on matters of neurobiology. The following are excerpts from letters I sent to the eternal souls of such intellectual giants, who, theoretically, can even today, frown at my sarcasm:

Dear C.S. Lewis, there is no biological substrate for the soul or spirit. Furthermore, it is firmly established that the universe was created by random events about 14.6 billion years ago, and that the human species is an animal evolved from monkeys. There is no God.

Dear DesCartes, the pineal gland is not, in fact, the reciever/antenna through which the soul communicates with the body (http://www.crystalinks.com/thirdeyepineal.html)--it seems to play a role in the regulation of circadian rhythms.

Sincerely,

Great Googly Moogly
********************************************************

Subsequently, I must take issue with the assertion that human beings are "fundamentally spiritual?" If nothing else, I would have hoped that medical school would have firmly cemented that human beings are anything but "spiritual." There are valid scientific claims to be made about the ability of humans to alter their "consciousness" (read: their EEGs patterns) which, to a subjective human observer may seem "spiritual," (please appreciate the pre-existing contextual framework necessary to describe this type of experience as such). Other than this confusion, this type of thinking from an educated scientist is, again, worrisome.

Which part of medical school reinforced this spiritual belief? To have completed a medical education without understanding that (1) a physician's personal belief without appropriate (read: not bogus metaphysical "proof") supporting evidence and (2) consciousness is a complex neurobiological representation of one's existence to the one's "self" as the observer is tantamount to at best, ignorance, and, at worst, malpractice. If we have a soul that directs our movements, thoughts and actions--consciousness-- then it either physically exists somewhere in the body or it doesn't--this is an empirical question to which there is a definite answer. Either it does or it doesn't. If it exists in the body, we should be able to find it. If it does not, then some explanations are in order: where does it exist? how does it direct our actions? why do physical events have such profound effects on a non-physical soul? For example, why do drugs (that physically affect ion potentials) and strokes (that physically kill neurons) produce such profound effects on (the allegedly non-physical) consciousness, for example, a right-sided lesion resulting in hemineglect? Like it or not, as physicians we are, or at least have a duty to ourselves and to our patients, to be SCIENTISTS! There is absolutely no evidence that there is anything even closely approximating a spirit that can exist separate from the ion potentials that we so mistakenly and egocentrically mistake for our "selves!"

I encourage rebuttal to this stance, but, for the sake of validity, I urge two things, that the substrate for the soul or spirit be suggested without resorting to magic (i.e. the nonsensical argument that the soul exists outside the realm of science and is, consequently/fortunately for religious people, undetectable) or archaic, mysogynistic, miraculous texts. Miracles have been on the retreat since the Age of Enlightenment.

Dude, for the sake of our forum,

REDUCE TO JUST ONE HIT.

Cuz the s h it youre trippin' on is taking you into outer space. 😕

 

[jetproppilot]

*******************************************************
I apologize for the brazen response--I imagine that your intentions are good, and this is alone is admirable, albeit off the mark. This type of thinking from an educated person is worrisome. I would argue that "God" is responsible for most of the misery that C.S Lewis seems to think is "all that we call human history." Though I am humble enough to vouch that great thinkers of yore may have had sharper minds than my own, this does not preclude me from using my 21st century vantage point to corrrect them on matters of neurobiology. The following are excerpts from letters I sent to the eternal souls of such intellectual giants, who, theoretically, can even today, frown at my sarcasm:

Dear C.S. Lewis, there is no biological substrate for the soul or spirit. Furthermore, it is firmly established that the universe was created by random events about 14.6 billion years ago, and that the human species is an animal evolved from monkeys. There is no God.

Dear DesCartes, the pineal gland is not, in fact, the reciever/antenna through which the soul communicates with the body (http://www.crystalinks.com/thirdeyepineal.html)--it seems to play a role in the regulation of circadian rhythms.

Sincerely,

Great Googly Moogly
********************************************************

Subsequently, I must take issue with the assertion that human beings are "fundamentally spiritual?" If nothing else, I would have hoped that medical school would have firmly cemented that human beings are anything but "spiritual." There are valid scientific claims to be made about the ability of humans to alter their "consciousness" (read: their EEGs patterns) which, to a subjective human observer may seem "spiritual," (please appreciate the pre-existing contextual framework necessary to describe this type of experience as such). Other than this confusion, this type of thinking from an educated scientist is, again, worrisome.

Which part of medical school reinforced this spiritual belief? To have completed a medical education without understanding that (1) a physician's personal belief without appropriate (read: not bogus metaphysical "proof") supporting evidence and (2) consciousness is a complex neurobiological representation of one's existence to the one's "self" as the observer is tantamount to at best, ignorance, and, at worst, malpractice. If we have a soul that directs our movements, thoughts and actions--consciousness-- then it either physically exists somewhere in the body or it doesn't--this is an empirical question to which there is a definite answer. Either it does or it doesn't. If it exists in the body, we should be able to find it. If it does not, then some explanations are in order: where does it exist? how does it direct our actions? why do physical events have such profound effects on a non-physical soul? For example, why do drugs (that physically affect ion potentials) and strokes (that physically kill neurons) produce such profound effects on (the allegedly non-physical) consciousness, for example, a right-sided lesion resulting in hemineglect? Like it or not, as physicians we are, or at least have a duty to ourselves and to our patients, to be SCIENTISTS! There is absolutely no evidence that there is anything even closely approximating a spirit that can exist separate from the ion potentials that we so mistakenly and egocentrically mistake for our "selves!"

I encourage rebuttal to this stance, but, for the sake of validity, I urge two things, that the substrate for the soul or spirit be suggested without resorting to magic (i.e. the nonsensical argument that the soul exists outside the realm of science and is, consequently/fortunately for religious people, undetectable) or archaic, mysogynistic, miraculous texts. Miracles have been on the retreat since the Age of Enlightenment.

.

 

[BlackSails]

Do any of you use those EEG monitor things to see if the patient might be aware?

 

[InGasWeTrust]

JPP,

I will always throw in a dose of scopolamine in all trauma patients and even a kidney TSPL if I need to run em light or with gas off....so far no recall yet.

 

[deleted9493]

*******************************************************
I apologize for the brazen response--I imagine that your intentions are good, and this is alone is admirable, albeit off the mark. This type of thinking from an educated person is worrisome. I would argue that "God" is responsible for most of the misery that C.S Lewis seems to think is "all that we call human history." Though I am humble enough to vouch that great thinkers of yore may have had sharper minds than my own, this does not preclude me from using my 21st century vantage point to corrrect them on matters of neurobiology. The following are excerpts from letters I sent to the eternal souls of such intellectual giants, who, theoretically, can even today, frown at my sarcasm:

Dear C.S. Lewis, there is no biological substrate for the soul or spirit. Furthermore, it is firmly established that the universe was created by random events about 14.6 billion years ago, and that the human species is an animal evolved from monkeys. There is no God.

Dear DesCartes, the pineal gland is not, in fact, the reciever/antenna through which the soul communicates with the body (http://www.crystalinks.com/thirdeyepineal.html)--it seems to play a role in the regulation of circadian rhythms.

Sincerely,

Great Googly Moogly
********************************************************

Subsequently, I must take issue with the assertion that human beings are "fundamentally spiritual?" If nothing else, I would have hoped that medical school would have firmly cemented that human beings are anything but "spiritual." There are valid scientific claims to be made about the ability of humans to alter their "consciousness" (read: their EEGs patterns) which, to a subjective human observer may seem "spiritual," (please appreciate the pre-existing contextual framework necessary to describe this type of experience as such). Other than this confusion, this type of thinking from an educated scientist is, again, worrisome.

Which part of medical school reinforced this spiritual belief? To have completed a medical education without understanding that (1) a physician's personal belief without appropriate (read: not bogus metaphysical "proof") supporting evidence and (2) consciousness is a complex neurobiological representation of one's existence to the one's "self" as the observer is tantamount to at best, ignorance, and, at worst, malpractice. If we have a soul that directs our movements, thoughts and actions--consciousness-- then it either physically exists somewhere in the body or it doesn't--this is an empirical question to which there is a definite answer. Either it does or it doesn't. If it exists in the body, we should be able to find it. If it does not, then some explanations are in order: where does it exist? how does it direct our actions? why do physical events have such profound effects on a non-physical soul? For example, why do drugs (that physically affect ion potentials) and strokes (that physically kill neurons) produce such profound effects on (the allegedly non-physical) consciousness, for example, a right-sided lesion resulting in hemineglect? Like it or not, as physicians we are, or at least have a duty to ourselves and to our patients, to be SCIENTISTS! There is absolutely no evidence that there is anything even closely approximating a spirit that can exist separate from the ion potentials that we so mistakenly and egocentrically mistake for our "selves!"

I encourage rebuttal to this stance, but, for the sake of validity, I urge two things, that the substrate for the soul or spirit be suggested without resorting to magic (i.e. the nonsensical argument that the soul exists outside the realm of science and is, consequently/fortunately for religious people, undetectable) or archaic, mysogynistic, miraculous texts. Miracles have been on the retreat since the Age of Enlightenment.

Physical associations of science cannot exclude the spiritual. The idea that anything measurable with regards to these phenomena is further evidence of the absence of the human soul is an assumption that you simply cannot make.

Turning the tables to consider the converse demonstrates the problem with this rationality. If the soul was measurable in some way (which it is not, but consider the "if"), the rationale used in this thread suggests that it would be to the exclusion of any neurobiological manifestion. That's an absurd statement and not a jump that you can make! A parallel example might be something like, "Patients who have had MI's have elevated CRP levels and this has been shown in several good studies, therefore, lifestyles have no bearing on cardiac events." In other words, you cannot make a statement about lifestyle effects based on your study of CRP, just as you cannot make a statment about the spiritual, based on studies of biological association. In reality, physical and spiritual may well affect each other, as lifestyle habits no doubt affect markers of inflammation.

Ignore this "soul" aspect of your patients and fellow man if you like, but don't tell me that you've proven its non-existence based on a few studies that are largely theoretical. Yes, the evidence of the spiritual is experiential and not scientific but it has been accepted by the greatest minds of our world...from Socrates/Plato to Newton/Einstein and the majority in between and after them.

 

[Planktonmd]

Jet,

Your example just reminds me of how crappy Etomiudate is, as an induction agent.
I wouldn't have done anything different though.

 

[OldManDave]

Hey, if you cats wish to debate the more metaphysical aspects of medicine & humanity, that is fine. However, please do not hijack this thread to do it - feel free to start a different one.

And, above all else, do NOT turn it into a name-calling, mud-slinging bully-fest because we will not tolerate it. But, it is a topic of interest & for legit discussion. So, have fun with it...just leave the emotions at home & off of the keyboard - keep it above the belt - and we might all benefit from it.

 

[jetproppilot]

Do any of you use those EEG monitor things to see if the patient might be aware?

To date there are no studies supporting Bis's marketing propeganda stating their monitor protects against intraoperative awareness.

 

[2ndyear]

I agree that the data isn't great, and certainly not foolproof when agents like Ketamine are used (BIS will be higher but pt will be unaware, or maybe they're aware but they just don't care and won't remember it). In any case I really like the idea of the BIS in the sense that the BIS someday in a more refined form will be used to titrate anesthetic depth to. MAC seems so rudimentary, end tidal only really works well for the inhaled agents. And less anesthesia in a global sense is generally better.

 

[jetproppilot]

I agree that the data isn't great, and certainly not foolproof when agents like Ketamine are used (BIS will be higher but pt will be unaware, or maybe they're aware but they just don't care and won't remember it). In any case I really like the idea of the BIS in the sense that the BIS someday in a more refined form will be used to titrate anesthetic depth to. MAC seems so rudimentary, end tidal only really works well for the inhaled agents. And less anesthesia in a global sense is generally better.

Totally agree.

Great monitor for enhancing our understanding and manipulation of anesthetic depth.


But so far, not a proven adjunct for reducing intraoperative awareness.

 

[fval28]

I am torn on the BIS- I have used it at a few jobs where I noticed that I could titrate my inhalation and IV anesthetics to effect quicker wake ups and recovery- especially when using Propofol infusions- so I think it has some utility as a means to decrease pharmacology and recovery room costs, maybe some utility in reducing turnover time.

As far as a consciousness monitor, I think BIS's utility is largely if not completely unproven- and I have a problem with the way they have marketed the product in past.

 

[VentdependenT]

Wait for this pile of crap to come out:
http://movies.about.com/od/christensenhayden/a/awake090105.htm

I've had one recall experience. Prone butt case. Guy was a heavy drinker, crack smoker, etc. Had him at 0.8% sevo and 50% Nitrous. He started coughing prone. So I deepened him and hit him with some roc.

Next day he said he breifly remembered being on his stomach, something in his throat, and coughing and then he said it went black again shortly afterwords.

He didn't seem to mind he just thought it was a little weird. He said he was comfortable however. So I left it at that.

 

[CremeSickle]

Vent

You did a nice job discussing it with him honestly. I think that the big reason people have gotten sued for 'awareness' has to do with not acknowledging the event or minimizing it.

 

[VentdependenT]

Here's a quote about the movie AWAKE:

Producer Joana Vicente told Variety that "Awake" "will do to surgery what 'Jaws' did to swimming in the ocean." Filming is expected to begin next month.



THANKS A-HOLES. CANT WAIT TILL THEY HAVE TO HAVE SURGERY.