Going Under the Knife, With Eyes and Ears Wide Open

Going Under the Knife, With Eyes and Ears Wide Open
By JAN HOFFMAN
Mar 25 2017
https://www.nytimes.com/2017/03/25/health/surgery-awake-anesthesia.html

Choosing to watch your own surgery is one more manifestation of the patient autonomy movement, in which patients, pushing back against physician paternalism, are eager to involve themselves more deeply in their own medical treatment.

But Dr. Alexander Langerman, the senior author of the communication study and a head and neck surgeon on the faculty of Vanderbilt University Medical Center in Nashville, said that a patient’s decision to remain awake during an operation also reflects a growing suspicion, generally, of authority figures. Noting how pedestrians pull out smartphones to capture police activity, he said, “There’s an element in that for patients, too. The occasional scandals that emerge while patients are sedated continue to erode their trust in us.”

But patients are also intrigued by what is being done to them while they are asleep. In choosing to stay awake, added Dr. Langerman, “there’s a curiosity and desire to have control over your experience.”

Indeed, a few studies suggest that some patients feel less anxious about staying awake during surgery, despite possible gruesome sights, than they do about being sedated. Other patients, studies show, are very anxious about general anesthesia, particularly right before an operation, afraid they will not be able to wake up afterward.

Some operations, including deep brain stimulations, require the patient to be awake for critical communication. But as anesthesia alternatives like regional nerve blocks and site injections become increasingly sophisticated, many more procedures are possible with the patient fully alert or moderately sedated. Orthopedics is the chief specialty for such procedures, but surgery in breast, colorectal, thoracic, vascular, otolaryngological, urological, ophthalmological and cosmetic specialties is also moving in this direction.

Studies show that regional anesthesia has fewer complications than general anesthesia and is less expensive. Recovery time is swifter and side effects are fewer, which can reduce the need for postoperative opioids.

Proponents like Dr. Ilyas, who operates at the Rothman Orthopaedic Specialty Hospital in Bensalem, praise awake surgery as a step forward in transparency. “It’s all about communication, comfort and experience,” he said. “It is definitely catching on and creating a different kind of surgeon-patient relationship.”

But many doctors view awake surgery with apprehension. What happens if the patient becomes too anxious? Distracts the surgeon with too many questions? Or objects vigorously when a trainee scrubs in — a mainstay of surgical education?

Dr. Langerman said that many surgeons do not like being observed for other reasons, too. “They often have a fear of litigation, or a fear of disappointing the patient.”

Patient satisfaction, however, tends to be high. Ms. Voynow did not need a preoperative physical exam, blood work, an I.V. drip or even an attending anesthesiologist. As nurses wheeled her on a gurney out of the O.R., she looked pleasantly surprised. “I’ve had root canals that were worse,” she said.

Scarcely a half-hour after the surgery, she drove herself home, using her right hand, which had just been operated on. By contrast, if she had been given general anesthesia, she would most likely have needed several hours to recover, possibly had side effects like dizziness and nausea, and required someone to drive her. An anesthesiologist would have been necessary throughout the operation. And billed accordingly.

“If I want sedation, I’ll have a beer,” said David S. Howes, who has had several awake procedures (and who is himself a doctor, an emergency physician in Chicago). During his awake colonoscopy, he discussed fly-fishing with the gastroenterologist. He had two total knee replacements with only regional nerve blocks.

“It’s not for the faint of heart,” he said. “They have to cut the capsule of the knee, which is quite thick. I could feel the vibration of the saw cutting through the leg bones. Then they hammer, and it sends a shock wave slamming into your knee. It doesn’t hurt, but you feel the pressure. And you smell burning flesh.”

Knowing that the knee replacement would take several hours, Dr. Howes came prepared. While surgeons put in the new joint, he read The Economist.

[snip]

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