Surgeon Makes Tutorial DVD For Conscious Open-Heart Surgery

Lanxon writes "Swaroup Anand, 23, from Bangalore, was fully conscious as he underwent open-heart surgery. An epidural to the neck, administered at the city’s Wockhardt Hospital, numbed his body during the procedure. Dr Vivek Jawali pioneered the technique ten years ago and has recently released a tutorial on DVD, which gives a step-by-step guide to the procedure for other surgeons to watch and learn from."

Comments

Absolutely

[Theaetetus]

Doctor: Would you like to be awake for this procedure?

Patient: WTF???

Doctor: We'll put up a screen so you can watch Spongebob and give you a bunch of morphine and a spinal epidural so you can't feel shiat, but if we put you completely under, your blood pressure may drop due to different autonomous reactions, and since we're doing heart surgery, that could be bad... So this improves the chances that you're awake after the operation, rather than on a slab in the morgue. Got it?

Re:Absolutely

[Anonymous Coward]

It's a brilliant cartoon regardless, especially seasons 1 & 2 where Stephen Hillenburg was writing the episodes.

Re:Would you like to be awake for this procedure?

[MightyMartian]

It's likely because there are greater risks involved in general anesthetic. Where possible, it's seen as safer for the patient to use only locals.

No. And I liked it that way.

[dazedNconfuzed]

I had open-heart surgery. General & deep anesthesia is a wonderful thing. "Lie here ... ok ... we're going to give you a little something now to make you comfortable ..." And then I woke up a few hours later. No sense of time passing, just one moment in the OR and then the next moment I'm in the recovery room.

Now, given what happened in the recovery room, wouldn't want to extrapolate back to the idea of being awake for the procedure.
"Waking up" consisted of returning consciousness, but with no vision or hearing, and the totality of my existence being devoted to getting the breathing tube out, engaging enough self-control to know it's supposed to be there and to not panic (!!!!!), and discover that my hands were restrained to prevent acting on exactly that reaction. Then I was aware that something horrible had been done to my chest. And then ... well, it gets kinda fuzzy and unpleasant from there.

Now, if awake thru the whole procedure, that would mean not only being aware of the chit-chat ("scalpel ... clamp ... ") and other mundane activity, but the process of ramming that d@mn pipe down my throat, the sensation (however muted) of having my rib cage sawed up and pried open with a car jack, buckets of ice cubes being dumped into the gaping chest cavity, heart being stopped and partially disconnected, and generally knowing that a whole lotta things are being done to ME that are not naturally part of human existence - apart from, well, being dead (which, arguably, I was).

My wife didn't take it well in the waiting room when told "your husband is doing fine ... they just stopped his heart." Somehow I don't think I'd like being awake for observing it first-hand. And I don't think the doctors would be keen on having to watch their language/behavior knowing that the patient is watching & listening; I want them focused on the job, not on how I'll respond to their commentary.

You aren't exactly wide awake...

[sirwired]

There are many different surgeries done now where the patient is not rendered unconscious. Advances in technique and in local anesthetics have made the precision nerve blocks required possible. However, make no mistake, you aren't wide awake and cracking jokes while the surgeon does his thing; you are doped to the gills with tranquilizers. It would be very bad if you panicked or tried to move around during the surgery. Keeping you awake is done because it is easier to keep you from not dying when they aren't trying to put you to sleep, shut down sensation of pain, and cut your memory. They don't do it because it's really cool, or to educate the patient.

SirWired

Re:You aren't exactly wide awake...

[demonlapin]

This is not exactly true. There are a lot of medications used in anesthesia, but the short list includes:

• General anesthetics. Come in IV (propofol, thiopental) and gas (there are more modern ones, but ether and chloroform are the ones people know) forms. Produce global depression of nerve function so that unconsciousness results.
• Opioids. Morphine, fentanyl, etc. Produce relief of pain without necessarily depressing consciousness. Dangerous in overdoses because they depress the respiratory drive - people quit breathing and die. This is not usually a problem during general anesthesia because there's a tube in your throat that's hooked up to a ventilator - we breathe for you.
• Paralytics. Particularly important at two points: at the beginning, they make putting that tube down easier (you don't fight), and during abdominal or orthopedic surgery, they relax the muscles so that the surgeon can work.
• Anxiolytics. These are IV versions of Valium or Xanax, used to calm people down and make them forget what's happening.

Now, there is a problem with postoperative cognitive dysfunction in the elderly, one that is currently a very hot topic of research, but the elderly don't have a lot of plastic surgery - if they're in for surgery, they usually need it to continue living.

Finally, very few people die - the risk is somewhere less than 1 in 150k for elective surgery, with risks rising for those who are having risky surgeries or who are very ill to start with. Anesthesiologists made a conscious decision in the early 1980s to reduce the risks of anesthesia, and created the Anesthesia Patient Safety Foundation to review all closed claims - that's lawsuits, settled in or out of court - and to look for common factors. We have been enormously successful at this task. Drugs have been pulled off the market because the APSF identified them in series of deaths. Safety equipment has been mandated - for example, the size of the connectors for breathing masks, breathing tubes, and ventilators is specified so that all of it interoperates, regardless of manufacturer.

If you prefer to be unconscious for surgery, it can usually be done safely. Of course, if you want to be awake, that can usually be done safely as well. Ask your anesthesiologist.

Advantage? Yes.

[gbutler69]

Full (unconscious) anesthesia is dangerous. That's why a special doctor (anesthesiologist) is required to be present to monitor during the entire surgery. Being awake is safer.

Re:Would you like to be awake for this procedure?

[pz]

It's likely because there are greater risks involved in general anesthetic. Where possible, it's seen as safer for the patient to use only locals.

And the patient is far from normally conscious under procedures like this. They are sedated, whereby it's generally meant the patient is socked to the gills with drugs like benzodiazepines.

As a gross generalization, I find that the medical profession (and I'm on the fringes of it) tends to overmedicate when it comes to sedation. As one example, my father was going to have a small bone spur removed from a toe. Yes, that can be painful, but a good circumdigit block with lidocaine will fix that. But he was supposed to be sedated for the procedure sufficiently that he would not be able to drive himself home. He called me to arrange for a ride before the fact, more than a little annoyed that a 10 minute procedure would entail such an ordeal, and I replied, "well, just refuse the sedative." He did, and was fine.

Now fixing a toe is very different from open heart surgery. The so-called awake patient during open heart surgery likely will be only slightly topside of conscious. However, there's a big difference between that and the deep general anesthesia that would be required without local anesthetics to block the pain. One of the big reasons for using less anesthesia is basic danger, as other posters have commented. But as we learn more about general anesthesia, and specifically in relation to open heart surgery, there's a significant toll it seems to take on the mind. It's considered a dirty little secret that patients are waking up after major surgery a little dumber than they were before. And, by "dirty little secret," I mean, it's an area ripe for significant research into the improvement of health care. In any case, combining a good epidural block with sedation to achieve the same surgical plane (that's the term used to describe depth of anesthesia) as previously achieved with general anesthesia is going to be a good step forward.

Re:Would you like to be awake for this procedure?

[demonlapin]

I think if you put it in at, say, T6, and really, really carefully dosed your local, you could make it work - produce your block from C8 to T10/12. But I share your concerns about staying extrapleural, and even then the loss of intercostals, etc., would kill their tidal volumes. And the guy in the article summary is really young - maybe a straightforward valve in an otherwise ASA I? I emailed the Wired UK editors, asking for a contact point at the hospital so I can see this for myself. Maybe I can take it to our CT surgeons when I'm done... :)

Re:Would you like to be awake for this procedure?

[tugboat0902]

I haven't done a CT case for 10 years but who knows. I have done a cholecystectomy under epidural before, I would not imagine this technique is less expensive but maybe. I saw video in residency of a Chinese woman having a massive tumor removed from her chest under acupuncture and hypnosis. I guess anything is possible.