Awakening

Since its introduction in 1846, anesthesia has allowed for medical miracles. Limbs can be removed, tumors examined, organs replaced—and a patient will feel and remember nothing. Or so we choose to believe. In reality, tens of thousands of patients each year in the United States alone wake up at some point during surgery. Since their eyes are taped shut and their bodies are usually paralyzed, they cannot alert anyone to their condition. In efforts to eradicate this phenomenon, medicine has been forced to confront how little we really know about anesthesia’s effects on the brain. The doctor who may be closest to a solution may also answer a question that has confounded centuries’ worth of scientists and philosophers: What does it mean to be conscious?
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Max Aguilera-Hellweg

Linda Campbell was not quite 4 years old when her appendix burst, spilling its bacteria-rich contents throughout her abdomen. She was in severe pain, had a high fever, and wouldn’t stop crying. Her parents, in a state of panic, brought her to the emergency room in Atlanta, where they lived. Knowing that Campbell’s organs were beginning to fail and her heart was on the brink of shutting down, doctors rushed her into surgery.

Today, removing an appendix leaves only a few droplet-size scars. But back then, in the 1960s, the procedure was much more involved. As Campbell recalls, an anesthesiologist told her to count backward from 10 while he flooded her lungs with anesthetic ether gas, allowing a surgeon to slice into her torso, cut out her earthworm-size appendix, and drain her abdomen of infectious slop, leaving behind a lengthy, longitudinal scar.

The operation was successful, but not long after Campbell returned home, her mother sensed that something was wrong. The calm, precocious girl who went into the surgery was not the same one who emerged. Campbell began flinging food from her high chair. She suffered random episodes of uncontrollable vomiting. She threw violent temper tantrums during the day and had disturbing dreams at night. “They were about people being cut open, lots of blood, lots of violence,” Campbell remembers. She refused to be alone, but avoided anyone outside her immediate circle. Her parents took her to physicians and therapists. None could determine the cause of her distress. When she was in eighth grade, her parents pulled her from school for rehabilitation.

Over time, Campbell’s most severe symptoms subsided, and she learned how to cope with those that remained. She managed to move on, become an accountant, and start a family of her own, but she wasn’t cured. Her nightmares continued, and nearly anything could trigger a panic attack: car horns, sudden bright lights, wearing tight-fitting pants or snug collars, even lying flat in a bed. She explored the possibility of post-traumatic stress disorder with her therapists, but could not identify a triggering event. One clue that did eventually surface, though, hinted at a possibly traumatic experience. During a session with a hypnotherapist, Campbell remembered an image, accompanied by an acute feeling of fear, of a man looming over her.

Then, one fall afternoon in 2006, four decades after her symptoms began, Campbell met an anesthesiologist at a hypnotherapy workshop. Over lunch, she found herself telling the anesthesiologist about her condition. She mentioned the appendectomy she’d had not long before everything changed.

The anesthesiologist was intrigued. He told her about a phenomenon that had sometimes accompanied early gas anesthetics, particularly ether, in which patients reacted to the gas by coughing and choking, as if they were suffocating.

The comment sparked something in Campbell. “I started having all these flashes,” she remembers. “The flashes were me being on the table. The flashes were of the room. The flashes were of the bright lights over me.” A man—the same one from her memory?—was there. At some point, the room went black. “And then I got to the place where I was on the table, and I just remember feeling terror,” she says. “That’s all I remember. I don’t see anything. I don’t feel anything. It’s absolute, abject terror. And the feeling that I am dying.” At that moment, Campbell realized that something had happened to her during her appendectomy, something that changed her forever. After several years of investigation, she figured it out: she had woken up on the table.

This experience is called “intraoperative recall” or “anesthesia awareness,” and it’s more common than you might think. Although studies diverge, most experts estimate that for every 1,000 patients who undergo general anesthesia each year in the United States, one to two will experience awareness. Patients who awake hear surgeons’ small talk, the swish and stretch of organs, the suctioning of blood; they feel the probing of fingers, the yanks and tugs on innards; they smell cauterized flesh and singed hair. But because one of the first steps of surgery is to tape patients’ eyes shut, they can’t see. And because another common step is to paralyze patients to prevent muscle twitching, they have no way to alert doctors that they are awake.

Many of these cases are benign: vague, hazy flashbacks. But up to 70 percent of patients who experience awareness suffer long-term psychological distress, including PTSD—a rate five times higher than that of soldiers returning from Iraq and Afghanistan. Campbell now understands that this is what happened to her, although she didn’t believe it at first. “The whole idea of anesthesia awareness seemed over-the-top,” she told me. “It took years to begin to say, ‘I think this is what happened to me.’ ” She describes her memories of the surgery like those from a car accident: the moments before and after are clear, but the actual event is a shadowy blur of emotion. She searched online for people with similar experiences, found a coalition of victims, and eventually traveled up the East Coast to speak with some of them. They all shared a constellation of symptoms: nightmares, fear of confinement, the inability to lie flat (many sleep in chairs), and a sense of having died and returned to life. Campbell (whose name and certain other identifying details have been changed) struggles especially with the knowledge that there is no way for her to prove that she woke up, and that many, if not most, people might not believe her. “Anesthesia awareness is an intrapersonal event,” she says. “No one else sees it. No one else knows it. You’re the only one.”

Sizemore complained of being unable to breathe and claimed that people were trying to bury him alive. He suffered from insomnia; when he could sleep, he had vivid nightmares.

In most cases of awareness, patients are awake but still dulled to pain. But that was not the case for Sherman Sizemore Jr., a Baptist minister and former coal miner who was 73 when he underwent an exploratory laparotomy in early 2006 to pinpoint the cause of recurring abdominal pain. In this type of procedure, surgeons methodically explore a patient’s viscera for evidence of abnormalities. Although there are no official accounts of Sizemore’s experience, his family maintained in a lawsuit that he was awake—and feeling pain—throughout the surgery. (The suit was settled in 2008.) He reportedly emerged from the operation behaving strangely. He was afraid to be left alone. He complained of being unable to breathe and claimed that people were trying to bury him alive. He refused to be around his grandchildren. He suffered from insomnia; when he could sleep, he had vivid nightmares.

The lawsuit claimed that Sizemore was tormented by doubt, wondering whether he had imagined the horrific pain. No one advised Sizemore to seek psychiatric help, his family alleged, and no one mentioned the fact that many patients who experience awareness suffer from PTSD. On February 2, 2006, two weeks after his surgery, Sizemore shot himself. He had no history of psychiatric illness.

Before the introduction of ether in the mid‑19th century, surgery was a rare and gruesome business. One of the most common operations was amputation. Surgeons used saws and knives to remove the offending appendage, and boiling oil and scalding irons to cauterize the wound. They resorted to a variety of methods, some more dangerous than others, to manage patients’ pain. James Wardrop, a surgeon to the British royal family in the 19th century, wrote of a procedure called deliquium animi, in which he bled patients into quiescence. Others used alcohol, opiates, ice, tourniquets, or simple distraction.

The promise of painless surgery remained a preposterous idea in mainstream medicine until October 16, 1846. On that day, at the Harvard-affiliated Massachusetts General Hospital, a dentist named William Thomas Green Morton gave the first public demonstration of ether gas, administering it to a patient whose neck tumor was then removed by a surgeon. The event took place in a domed amphitheater now known as the “ether dome,” and earned Harvard Medical School a truly international reputation. Oliver Wendell Holmes Sr., who coined the term anesthesia (from the Greek word anaisthēsia, meaning “lack of sensation”), rejoiced that “the fierce extremity of suffering has been steeped in the waters of forgetfulness, and the deepest furrow in the knotted brow of agony has been smoothed for ever.” In 2007, when the British Medical Journal asked subscribers to name the most-significant medical developments since 1840, anesthesia was among the top three, along with antibiotics and modern sanitation.

The miracle of anesthesia transcends pain. Painkillers—mainly opiates and alcohol—existed before ether, but they weren’t sufficient to quell the nightmare of surgery. Ether accomplished something altogether different: it eliminated both experience and memory. When the drug wore off and patients woke up, their bodies stitched together and their minds intact, it was almost as though the intervening hours hadn’t happened. The field that emerged from that historic moment in the ether dome was less concerned with the broad goal of curing disease than with a single task: the mastery of consciousness.

Anesthesia is often taken for granted in the daily routine of medicine today, both by health professionals and by the tens of millions of Americans who undergo surgery each year. Anesthesiologists are imbued with an almost heavenly power: with a mere push of their thumb on a clear plastic syringe, you go under. But in the past decade or so, several highly publicized cases, including Sherman Sizemore Jr.’s, have brought anesthesia awareness into the public forum. In 1998, a woman named Carol Weihrer, who claimed to have suffered awareness while having her eye removed, founded the Anesthesia Awareness Campaign, an advocacy group and resource for victims, and made the talk-show rounds. In 2007, the Hollywood thriller Awake intended, according to a producer, to “do to surgery what Jaws did to swimming in the ocean.” Fearful of malpractice lawsuits, the profession grew defensive. The American Society of Anesthesiologists promised to find the cause of and solution for awareness. “Even one case is one too many,” wrote the society’s president in 2007.

This promise, however, is not so easily fulfilled. Despite 167 years of research, anesthesiologists still have little idea how their drugs unlock the mind. Which gears turn and unwind to produce oblivion? How do they turn back into place? These questions, as important as they are for preventing anesthesia awareness, are dwarfed by a central riddle that has puzzled scientists and philosophers—not to mention most mildly introspective people—for hundreds, if not thousands, of years: What does it mean to be conscious?

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