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The Deepest Sleep

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Anesthesiologists are supposed to acknowledge and confront the fears that going under calls up in many of us—and the two most basic fears run at cross-purposes: We are afraid that we will go to sleep and never wake up, and we fear insufficient oblivion, inadequate pain relief, waking up too soon during surgery. We fear going too deep and staying too shallow.

“People who know I’m an anesthesiologist say to me, ‘Oh, you don’t have to talk to people.’ In fact, I have five to ten minutes to talk to people and convince them to put their life in my hands,” says Dr. Marc Bloom, director of the neuroanesthesiology program and of perioperative technology at the NYU Medical Center.

And so the idea of being put out retains its power and its terror and its mystery. Interestingly, there is a persistent mystery at the center of this mystery, as nobody fully understands how general anesthesia works. The gases discovered in the nineteenth century have been superseded by more sophisticated and well-controlled drugs, but we don’t fully know, after all the research and all the improvements, exactly how general anesthesia does what it does. Your likely response to a cocktail of medication can be anticipated by your age and size and medical history, but all such predictions can be off, and much of an anesthesiologist’s job is delicate and creative, tending to the aspects of physiologic function and keeping you as deep as you need to be, but no deeper. “We’re navigating a narrow path,” says Bloom, “constantly balancing your blood gas, the autonomic nervous system, your blood pressure.”

There has been a good deal of discussion in anesthesiology in recent years about the value of using machines to monitor brain function during surgery. The BIS monitor, the first on the market, uses a strip of electrodes applied to the patient’s forehead to read brain activity during anesthesia. This kind of monitoring—an ongoing EEG that yields a single index number signaling consciousness—is meant to give the anesthesiologist a more sensitive way to prevent any episodes of awareness or unnecessarily heavy dosing; some doctors and operating rooms use it routinely, some reserve it for patients for whom anesthesia is a more high-risk situation, and others choose not to use it at all.

As patients and as doctors, then, we struggle to understand anesthesia through monitors and metaphors: that the brain is an organ, measurable and mechanical; that consciousness and thought are on some level rooted in cell function and electrical activity, but that this organ and those processes are the source of thought, complexity, memory, creativity, and personality. When I go under anesthesia, am I still myself? Even if I cannot recognize myself or perceive myself? How am I to think about that time passed in the operating room, time that will not register on my senses or exist in my memory? As Shafer notes, the language doctors use when the patient is still conscious—polite, considerate, professional—is different from when that same patient goes under, outside of the conversation, draped and represented on X-ray boxes or computers and monitors. She calls this “the spreading out of the patient by representation.”

I don’t think I can really imagine life or medicine back before anesthesia, when there was no way at all to skip the most agonizing trauma that life might deal. But there are primal fears and longings called up by this modern, matter-of-fact capacity to escape your connection to the world, and then safely return to yourself again. Anesthesia can conjure the peace of not-knowing, but it is a gift that comes with the fears of losing yourself, of diving down too deep. It is the allure and the terror of leaving yourself behind.


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