“There was fun 80s music playing and the doctor and I talked the whole time that he was doing my surgery,” Stephanie Delorm of Vernon Hills says cheerfully about her recent hand surgery.
When given the choice between general and local anesthesia, Delorm opted for the local, which meant she would be awake throughout the surgery. She’s not alone. More people are opting to stay awake for surgery when it is possible to do so.
Dr. Robert Gray, a hand surgeon with the NorthShore Orthopaedic Institute and the doctor who operated on Delorm, has been performing surgery on conscious patients for the past seven years. Of the approximately 700 surgeries he performs each year, he says between 500 and 550 of them could be done under with local anesthesia while the patient is awake. He estimates that more than half of patients opt to go that route.
“Almost all the time I have patients tell me that it was so much easier than they thought it would be,” says Gray.
While surgery while awake may seem like a medical advance, Gray says that the technique “isn’t even remotely new.”
“If you can tolerate dental procedures without sedation, you can tolerate this without sedation. It’s never as bad as a root canal or a tooth extraction,” says Gray. “We are totally fine doing that under local anesthetic, because we’re used to it. As mindsets change, they may get used to some surgeries being done awake, too.”
Dr. Howard Nearman, an anesthesiologist at Cleveland Clinic, says, “When it comes to staying awake, you need a combination of the right type of procedure, the right type of patient, and right type of surgeon.”
Less anesthesia means less risk. The Mayo Clinic explains on its website that, while risk of complication typically stems more from the surgery being performed and the patient’s general health than from the anesthesia, some of the risks associated with general anesthesia include “postoperative confusion, pneumonia, or even stroke and heart attack.”
“While general anesthesia has gotten safer, certain patient populations, particularly the elderly, are more vulnerable to general anesthesia,” says Dr. Mary Hawn, chair of the Department of Surgery at Stanford Medicine.
“I was nervous, but I wanted to be awake because I was more nervous about being sedated and under general anesthesia,” says Delorm.
She’s not alone — anesthesia makes many people nervous, especially given that it’s an area of medicine full of unknowns.
Nearman says that “books about what we don’t know about anesthesia are thicker than those written about what we do know.” While general anesthesia has been around for well over a century, he says “we have very rudimentary knowledge about how it works, and we know it’s different than normal sleep.”
Two such recently published books, “Anesthesia: The Gift of Oblivion and the Mystery of Consciousness” by Kate Cole-Adams and “Counting Backwards: A Doctor’s Notes on Anesthesia” by Henry Jay Przybylo, MD, illuminate that much is not known about anesthesia.
The unknown often causes fear, and there’s also the issue of unintended intraoperative awareness, when an individual is at least partially awake during surgery but unable to communicate due to paralytics used as part of anesthesia. It’s a rare occurrence — the Mayo Clinic estimates that one or two people in every 10,000 may be partially awake during general anesthesia — but one that terrifies many.
According to Nearman, “A lot of people want to control things in their lives more, and that includes their state of mind in the operating room.”
Avoiding general anesthesia also means more control over how one feels following a procedure due to fewer side effects.
“General anesthesia impacts people in different ways, but everyone has a hangover,” says Nearman. “The less anesthesia you have, the clearer your mind is and the faster you’ll be getting your street legs back.”
Delorm wasn’t sure how her body would respond to general anesthesia and didn’t wish to find out. Not only was she not groggy after surgery, but she also felt good enough to work that afternoon.
Another benefit of a patient remaining conscious is that surgeons can be more certain in their work and check what they’re doing, whether that’s ensuring that the portion of the brain that controls speech is not impacted during a craniotomy or confirming proper positioning.
“I can check my work while I’m doing it,” Gray says, going on to explain, “When I pin someone’s finger fracture, I can have them move their hand and make sure the alignment is correct.” Delorm says knowing that Gray was satisfied with his work gave her extra peace of mind.
There’s also the issue of cost. Gray says sometimes the anesthesia costs as much as the surgery itself, and there’s also the issue of additional time in the hospital or surgery center. Early in the calendar year, which is often before people have met their insurance deductible, he says patients who he describes as “on the fence” often opt to forego general anesthesia when he brings up the cost savings.
Gray notes that while some people are worried about the pain from the injection of local anesthetic, he points out that it requires just one shot, whereas general anesthetic often requires receiving two injections.
While those are the benefits to local anesthetic, there are some drawbacks.
“One potential drawback is that if surgery ends up being bigger than you thought it could be, it gets difficult to extend surgery and the approach. It’s not impossible, but it can get tricky. However, that’s really rare and if I think there’s a risk of that happening, I don’t offer the option of staying awake.”
While surgery is painless, patients still feel other sensations. “They will feel tugging and pulling, which they may not be comfortable with,” says Nearman.
Delorm says that while she did feel the manipulation of her hand, what was a bit more jarring was the noise of the drill Gray used. “It’s weird to hear someone drilling into your bone,” she says and describes the sound as “the most nerve-wracking part” of her procedure.
Nearman says that’s common and that other sounds such as the clanging of instruments and chatter among members of the operating team catch patients off guard. He notes that the stimulus of the operating room, both sounds, sensations, and even the smell from the cauterization that’s often part of a procedure, should be part of the discussion a physician has with a patient weighing anesthesia options.
Hawn notes that while she has not seen a trend for “awake procedures,” she has observed an increase in the use of monitored anesthesia with patients in “twilight.”
Nearman points out that there are a lot of areas of gray when it comes to awake surgery. Sedation can make it possible for patients to hear and respond, allowing physicians to confirm their work, but may not be “totally awake.” Other surgeries involve sedation that make the patient feel “as if they have a good buzz on.”
Not all surgery can be performed with the patient at some stage of consciousness. And not all surgeons and patients are well-suited to the approach. Some, like Gray, find it enjoyable. “For me, it’s a lot more fun. I like talking to people,” he says. Others, however, do not.
“Patients should ask their surgeon and anesthesiologist about the options for their procedure and make a shared decision that takes into account the ability of the surgeon to complete the procedure, the comfort of the patient, and the safety of the approach,” Hawn advises, noting that if it was an option, she would choose to be sedated without general anesthesia.
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Shannan Younger is a writer living in the western suburbs of Chicago with her husband and teen daughter. Originally from Ohio, she received her undergraduate and law degrees from the University of Notre Dame. Her essays have been published in several anthologies and her work has been featured on a wide range of websites, from the Erma Bombeck Humor Writers Workshopto the BBC. She also blogs about parenting at Between Us Parents.
Shannan is the Illinois Champion Leader for [email protected], a campaign of the United Nations Foundation that supports vaccination efforts in developing countries to ensure life-saving vaccines reach the hardest to reach children. “Vaccines are one of the most effective ways to save the lives of children in developing countries and I’d love nothing more than to see diseases eradicated,” Shannan says. “We are so close to getting rid of polio for good!”