More patients open their eyes to surgery without sedation
Curiosity, cost keep many awake during operations
BENSALEM, Pa. — “Do you want to see your tendons?”
Dr. Asif Ilyas, a hand and wrist surgeon, was about to close his patient’s wound. But first he offered her the opportunity to behold the source of her radiating pain: a band of tendons that looked like pale pink ribbon candy. With a slender surgical instrument, he pushed outward to demonstrate their newly liberated flexibility.
“That’s pretty neat,” the patient, Esther Voynow, managed to gasp.
The operation Ilyas performed, called a De Quervain’s release, is usually done with the patient under anesthesia. But Voynow, her medical inquisitiveness piqued and her distaste for anesthesia pronounced, had chosen to remain awake, her forearm rendered numb with only an injection of a local anesthetic.
More surgery is being performed with the patient awake and looking on, for both financial and medical reasons. But as surgical patients are electing to keep their eyes wide open, doctor-patient protocol has not kept pace with the new practice. Patients can become unnerved by a seemingly ominous silence, or put off by what passes for office humor.
Doctors are only beginning to realize that when a patient is alert, it is just not OK to say, “Oops!” or “I wasn’t expecting that,” or even “Oh, my God, what are you doing?!”
Choosing to watch your own surgery is one more manifestation of the patient autonomy movement, in which patients, pushing back against physician paternalism, are eager to involve themselves more deeply in their own medical treatment.
But Dr. Alexander Langerman, senior author of a recent study on surgeon-patient communication during awake procedures, published in the American Journal of Surgery and a head and neck surgeon on the faculty of Vanderbilt University Medical Center in Nashville, Tenn., said that a patient’s decision to remain awake during an operation also reflected a growing suspicion, generally, of authority figures.
Noting how pedestrians pull out smartphones to capture police activity, he said: “There’s an element in that for patients, too. The occasional scandals that emerge while patients are sedated continue to erode their trust in us.”
But patients also are intrigued by what is being done to them while they are asleep.
Indeed, a few studies suggest that some patients feel less anxious about staying awake during surgery than they do about being sedated.
Some operations require the patient to be awake for critical communication. But as anesthesia alternatives like regional nerve blocks and site injections become increasingly sophisticated, many more procedures are possible with the patient fully alert or moderately sedated.
Orthopedics is the chief specialty for such procedures, but surgery in breast, colorectal, thoracic, vascular, otolaryngological, urological, ophthalmological and cosmetic specialties is also moving in this direction.
Studies show that regional anesthesia has fewer complications and is less expensive. Recovery time is swifter and side effects are fewer, which can reduce the need for postoperative opioids.
Patient satisfaction tends to be high. Voynow did not need a preoperative physical exam, blood work, an IV drip or even an attending anesthesiologist. As nurses wheeled her on a gurney out of the O.R., she looked pleasantly surprised.
“I’ve had root canals that were worse,” she said.
Scarcely a half-hour after the surgery, she drove herself home, using her right hand, which had just been operated on.