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

Would you like to be awake for this procedure?

[istartedi]

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

Patient: WTF???

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

[gstoddart]

Patient: WTF???

My thoughts exactly.

I'm sure there's probably some valid medical reason for doing this -- I just have no idea of what it is. I don't want to be awake when the heart-rate monitor goes to a flat tone. Well, I guess you'd no longer be awake at that point, so it's moot. ;-)

Cheers

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

[Chris Burke]

I'd do it in a second, but I'm betting they put up a screen or something below your head so you can't watch, much less put a monitor/camera above my head so I can easily see what they're doing. Which kinda defeats the purpose, from my end at least. :)

I've been given the option to be awake for several procedures, and I always say yes, but then they always change their minds at the last minute and knock me out. Maybe they're put off by how eager I sound. Kinda like when the phlebotomist is about to draw blood and sees me staring at vein on my arm, and she says "Do you want to look away?" and I go "nope!", their look changes from one of sympathy to one of being a little weirded out.

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

[sycodon]

Dr.: WTF?
Paitent: Huh?
Nurse: Ohh...that's isn't good.
Patient: WT.......

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.

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

[Monkeedude1212]

This text only interface for communication doesn't sufficiently deliver the same weird look I'm giving you right now.

I wish I had a webcam and photobucket available right now.

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

[clone53421]

Plus, a conscious patient can tell you if something starts going wrong.

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

[corbettw]

I wish I had a webcam and photobucket available right now.

How interesting, the rest of us are thankful you do not.

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?

[tugboat0902]

I cannot imagine anything more dangerous than a 'neck down' regional anesthetic. Now, IAAA (I am an anesthesiologist) and from my experience, the risk of a general anesthetic for open heart surgery would be far less than the risk of this. In order to be high enough, the block would have to deprive the patient of one remarkably important activity involved in being awake, the ability to breathe. Additionally, if a selective block could be done that would permit enough muscle strength to breathe, there are serious problems in trying to breathe with an open chest. Without a sealed cavity, the lungs simply collapse. If the surgeon could stay extra-pleural, and you had a remarkably healthy and motivated patient it possibly could be done, I just cannot imagine why. Maybe this was all explained in TFA, but this is slashdot after all........

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

[Rich0]

Yup, my friend had a stent placed in a carotid artery while awake for precisely this reason. They apparently like to assess your mental state while it is going on to detect strokes immediately.

They do tend to dope you up quite a bit though, mainly to avoid anxiety and they don't want you squirming while they put a 2mm piece of tubing in a largely-clogged artery servicing your brain via a catheter that extends from your leg to your neck...

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

[digitalunity]

I had a wisdom tooth pulled. The anesthetic shots(all 6 of them) were terribly painful, extracting just a couple of precious tears from my eyes.

About 15 minutes later, I couldn't feel the right lower half of my face and talking to the incredibly attractive assistant was becoming amusing. Oral surgeon walks in, sticks a prybar looking thing between a couple teeth, yanks it a couple times, puts funny looking pliars in my mouth and picks up my tooth. Good fucking god it's amazing how long the roots are for wisdom teeth.

All in all, the worst part of the procedure was the shots, and the inability to form words using the mass of meat I once called a tongue. Luckily the entire experience, including anesthetic was over in a few hours and was quite tolerable.

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?

[mariox19]

The two of you are crowding out the kids posting from their mom's basement. Please, get off the Internet.

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.

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

[toadlife]

Now, IAAA (I am an anesthesiologist) and...

Oh come on now. We all knew what you meant by IAAA. No need to talk down to us.

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

[Tiger4]

Yep, I noticed the "dirty little secret" with my father after a heart bypass. He was a retired mathematician, learned in the old days with slide rules. He could do sums in his head faster than most people with a calculator. After the surgery, not so much. It took weeks and months before he got close to being as sharp as before. He's still very good, but not at the top pitch he was before the surgery.

Beep, Beep, Beeeeeeee

[gimmebeer]

Uh hey Doc, what's that sound mean? Am I gonna.....uuurgggh.

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

[hardburn]

I bet Spongebob is awesome on morphine.

Re:Absolutely

[insufflate10mg]

It's the best after insufflating approximately ten milligrams.

Re:Absolutely

[demonlapin]

That's a pretty small dose.

Re:Absolutely

[adamstew]

A sponge is pretty small.

Re:Bad Idea!

[gstoddart]

If me and my roomates can learn to preform open heart surgery on each other - why on Earth will we need to go to a surgeon!!!

Oh, I can foresee a whole new category of Darwin awards being handed out for that one. :-P

Cheers

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...

[Hurricane78]

From what a nurse told me, it’s just that the narcotics have a very small area between “doesn’t do anything” and “kills you instantly”. So it’s very hard to get it right.
Which is why still so many people die in the process!
Especially older people often simply go crazy from it. And die more often too.

She told me, from her experience, that whenever you can, avoid full narcosis at any cost! It’s very far from the convenient trick to get around experiencing it. The one deciding on the dose sweats blood and tears because every time, he makes a decision that can kill you.

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

[MindlessAutomata]

You have a duty to your fellow man to continue paying taxes.

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.

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

[Rick17JJ]

I once had a colonoscopy where I was awake for most of the procedure. I was told that I might be awake in sort of a twilight sleep, but that I would not remember anything afterwards. However, I actually did remember everything afterwards.

The procedure started a small camera being shoved up my rear end. In front of me, I could see a color television screen showing the constantly the changing view of the inside of my colon. I was surprised at how spotlessly clean it was (except for occasional puddles of dirty water). I jokingly asked if I could get a VHS tape to show to other people. They said that the best that they could do was give me a printout with color photos.

After a while the doctor and the anesthesiologist (or someone) started asking each other why they were not there yet. As time went on they sounded increasingly puzzled and concerned that they had not yet reached where they were going. They would say things like, we should have been there long ago. They briefly considered the possibility of it having somehow having turned around and started going back the other way.

They were having increasing difficulty getting the cable with the camera to go much further and were discussing the possibility of having to give up. But then, the entrance to my appendix came into view in the distance as well as two polyps also visible up ahead. But, for a while they were not able to get the cable to move any further.

I asked what they would do if they could not reach the polyp. I was told that they would fire a harpoon and reel it in. But, then a moment later, I realized that he was kidding.

I then mentioned, that I could feel two places in my abdomen were it felt like the cable was binding up with the most pressure. The anesthesiologist (or the doctor) than pushed firmly on certain portions of my abdomen which finally brought the camera up to the two polyps. I remember them then taking a sample from the first polyp, and then I fell asleep after that.

Afterwards, they gave me a printout with several high resolution color photos, showing the inside of my colon (sorry about not having a link). Later on, I was eventually told that both polyps had been removed and that one of them would have probably eventually turned into cancer.

When I had a follow-up colonoscopy from another doctor a couple of years later, I was out the entire time. But, before the procedure, I warned the doctor that she should use the longest cable that she had.

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:Advantage? Yes.

[Anonymous Coward]

Too bad there's no "-1 Pansy" mod.

Re:Advantage? Yes.

[Arthur Grumbine]

Do you enjoy sunbathing? If so, have you ever considered the possibility that you're a reverse vampire?

Re:Advantage? Yes.

[MindlessAutomata]

You'd think a reverse vampire would put blood into people, though.

Re:Advantage? Yes.

[mqduck]

Well he did say he volunteered at a blood drive. Doesn't that count?

Not for the weak of heart

[Rikiji7]

It's recursive

Re:Bad Idea!

[shutdown -p now]

If me and my roomates can learn to preform open heart surgery on each other - why on Earth will we need to go to a surgeon!!!

Unions? ~

Re:Hi doctor nick

[Anonymous Coward]

Hi everybody!

Interesting.

[demonlapin]

This would be utterly fascinating to watch. I would be interested to see how he managed the patient's temperature. In patients undergoing general anesthesia for this procedure, the body is generally cooled in order to reduce the risk of tissues dying due to low blood flow, but that's not as easy an option in this case - the patients can still move their legs, for example, and shivering would be A Bad Thing, as well as subjectively unpleasant.

There's also the small matter of maintaining the integrity of the pleural space - if you expose lungs, the patient can no longer breathe. It's impressive that they've made it work.

Old people

[DarthVain]

The reason why this is big news is that some people (mostly old people) who get knocked out, never wake up again, and it has little to do with the surgery itself but with the drug induced unconsciousness. Having a method or ability to do this without knocking someone completely out would reduce risk for those in the high risk to die while under. This is why you always have to sign a consent form when getting a general. I had some oral surgery a couple of years ago in my late 20's and I still had to sign a bunch of stuff that says I am aware of the risks and that I might die from being knocked out, and please do not have your relations sue us if that is the case. Now if your in your 80's and have the same procedure, it might be better to keep you awake during the procedure.

(I was awake for the "tooth extraction" which translates to the most horrific medieval hammer and fscking chisel, and horrible horrible sounds and pressures you do not want to remember. So when it came time for the "tooth implant" I decided to get knocked the heck out. It cost me an extra 300$ bucks I think, but I was not going through that nightmare again. Not sure if it was as bad, but I wasn't taking any chances. If I had to do it again, I would have had them knocked me out for the "extraction" and would recommend anyone who has to get a tooth implant in this fashion do the same.)

However when I read the title I envisioned the surgeon performing open heart surgery on himself while awake... now that would take some balls!

Re:Old people

[Cyberax]

"I was awake for the "tooth extraction" which translates to the most horrific medieval hammer and fscking chisel, and horrible horrible sounds and pressures you do not want to remember."

Try tooth extraction without anesthesia someday. Now that's an experience (yes, I know it firsthand).

Re:Old people

[DarthVain]

I would say if the Novocaine isn't working, to screw off.

At least give me whatever drugs are in your desk, and the bottle of whiskey in your filing cabinet!

Here's the real tutorial.

[Chas]

1: Ignore the screaming patient on the table.
2: Use leather restraints on the patient. The web ones are too easily snapped by someone in a full fight-or-flight frenzy.
3: Avoid the use of the word "oops"
4: Avoid the use of the phrase "uh oh"
5: NEVER use "oh shit", "oh crap" or any other variants thereof.
6: Have a mallet ready for "topical anesthesia" if necessary. If the need exists, apply to patient's forehead both vigorously and repeatedly.
7: Use surgical drapes, most patients freak (hard!) if they can see their own inside pieces and parts.
8: Avoid calling your surgical assistant "Igor", even if that is his name.
9: Refrain from cackling maniacally.

My wife had an epidural during childbirth...

[mbourgon]

And it wasn't 100%. I think that either way, effective or not, you'd want to say "Ow! That hurts!"