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Anesthesia Awareness—What If I Am Awake During Surgery?

Updated on November 4, 2016

TahoeDoc HealDove

Anesthesia Awareness - Awake Under Anesthesia

Fear of being awake under anesthesia, called anesthesia awareness or intraoperative awareness, causes a lot of anxiety for patients facing surgery.

Having anesthesia is scary for most people. As an anesthesiologist, I usually meet patients right before their surgeries. People facing surgery have many apprehensions and fears. More and more are concerned about anesthesia awareness.

I repeatedly hear that patients are often more apprehensive about the anesthesia than the surgery itself. And of all the fears that people have about the anesthetic side effects and anesthetic complications, the one I hear most often is, "I'm afraid of waking up during the surgery."

Anesthesia awareness has received a great deal of attention in the press over the last few years and even a full-length movie, called "Awake," capitalized on this fearful concept (I have reluctantly included the trailer here). But what is it really? Why and to whom does it occur? Keep reading to find out why it most likely won't happen to you.

"Awake" - Sensationalizing Anesthesia Awareness

What Is Anesthesia Awareness?

Anesthesia awareness, also called intraoperative awareness refers to a specific situation where a person is under general anesthesia for surgery and regains consciousness during the surgical procedure.

The definition of general anesthesia includes induction and maintenance of loss of consciousness. This means that you should not be able to wake up until the surgery is over. You do not respond to voice or painful stimuli.

For various reasons, some people do regain consciousness when they are under general anesthesia. For most people, this involves a very brief, hazy memory. Some people are aware of what is being said, but cannot move or indicate that they are awake. Still, there is usually no sensation of pain or awareness of the operation. The very rare, unfortunate few are awake, cannot move and do feel the surgery being done.

What Is NOT True Anesthesia Awareness?

There are many situations that are confused with anesthesia awareness.

Sedation anesthesia. I often have patients tell me they had anesthesia awareness during their colonoscopy or other procedure. These procedures are commonly done under intravenous sedation anesthesia. While the intravenous sedation drugs do cause sleepiness and often amnesia- you don't remember the procedure, they do not cause unconsciousness. It is not at all abnormal to be awake and remember these procedures. With the sedation, pain medications are either injected at the surgical site or given in the IV or both. You should still not be uncomfortable, even if you are awake, during surgeries or procedures under sedation.

Sedation plus spinal or epidural. Neither sedation or spinal/epidural anesthesia makes you unconscious during your operation. If you have spinal or epidural anesthesia to block the pain of surgery, you are usually also given sedation. The same is true for local anesthesia as well. In this case, it is not unusual or abnormal to have memories of being in the operating room. This is not anesthetic awareness.

Dreaming. Some people actually dream during their anesthetic, or more likely, when transitioning from unconsciousness back to wakefulness at the end of surgery. These dreams are often interpreted as actual wakefulness, but are not.

Waking at the end of surgery, but not able to move. When you return to consciousness, sometimes your brain is more awake than your body. You are waking up, but cannot move for a couple minutes. You can hear the anesthesiologist talking to you or feel the nurses putting bandages on your incisions, but cannot yet respond. The anesthesia wears off at different rates for different people. If your surgery is over, but you are still in the operating room and have memories of this, it is a normal variant of the emergence phase from anesthesia. Most people are conscious when they leave the operating room, post anesthesia, and many are talking and asking questions, but may not remember it later. If you do remember this phase, it's ok. The same is true for the beginning of your anesthetic, the anesthesia induction. Vague, hazy memories of being in the operating room are confusing and can be mistaken for being awake during the anesthetic.

Risk Factors for Intraoperative Awareness

Certain risk factors make anesthesia awareness more likely.

Type of surgery and type of anesthesia. Certain types of surgery are associated with higher incidences of anesthesia awareness. Surgeries where using lower concentrations and amounts of anesthetics is necessary to protect patients lead to more intraoperative awareness. Emergency cesarean sections, trauma surgeries, and open heart surgeries are the most likely cases to be associated with anesthesia awareness. Anesthesia challenges the body's physiology. Heart rates vary and blood pressures drop. When they cannot be adequately managed by giving more medication, the anesthetic must be "lightened" in order to NOT endanger the patients' lives.

There are certain brain and spinal cord surgeries that require that no anesthesia gas be used in order to not interfere with the nerve monitoring being used to prevent paralysis. The anesthetic called TIVA (total intra-venous anesthesia) also predisposes to higher rates of anesthesia awareness.

Type of patient. Patients who use illegal drugs such as cocaine and methamphetamine may be more likely to have intraoperative awareness. Not only do these drugs cause dangerous fluctuations in heart rate and blood pressure, they make the metabolism of anesthetic drugs much more unpredictable.

Some prescription medications. Certain prescription medications may also increase the risk. Anesthetics are adjusted throughout the surgery based on surgical stimulation level, type of anesthesia and the heart rate, breathing rate and blood pressure of the patient. Patients who take medications that block the normal increases in heart rate or blood pressure may have their signs of light anesthesia masked by the medication.

Statistics on Awareness Under Anesthesia

The American Society of Anesthesiologists estimates that some degree of anesthesia awareness occurs in about 1 in 1000 general anesthetics. It is believed that the majority of these cases are during the induction (beginning) of the anesthetic when the drugs haven't fully taken effect. Likewise, a great many cases are at the end of surgery, during anesthetic emergence, when the anesthetic is wearing off but isn't completely gone. These are not intraoperative awareness as the surgery is not occurring. Because the memories are fuzzy and confusing, patients often don't know that this wasn't during the surgery itself.

There are no exact statistics on true intraoperative awareness cases that occur during the surgery and cause distress and lasting trauma to the patient. It is, however, an area of active study and research.

Again, talk to your doctors and ask questions if you are remotely concerned that this has happened to you.

Prevention: What You Can Do to Prevent Intraoperative Awareness.

Talk to your anesthesia doctor and provide accurate information. This is your best defense against intraoperative awareness.

So, be honest with your doctor about:

Your fears. Usually, this will help calm you. While no absolute guarantees can ever be made, your doctor can help pinpoint whether or not you have higher risk than average for this complication and let you know how he or she will address the risk. Alcohol consumption. Chronic, excessive alcohol intake results in a higher need for anesthetic medications. Illegal drugs use. Your anesthesiologist needs to know this to figure out which and how much anesthesia it will take to get you to sleep and keep you there. They are not there to judge you, but cannot keep you safe if they don't have all relevant information. All of your prescriptions and supplements. Different medications affect the metabolism of anesthesia differently. And just because supplements are "natural" or "alternative" doesn't mean they don't have side-effects or don't interfere with anesthetic medicines. How the Anesthesiologist Monitors During Surgery

The anesthesiologist, using intraoperative monitoring, will be watching your heart rate, blood pressure, and breathing rate (if a ventilator doesn't need to be used). Increases in these seen on the intraop monitors indicates that the anesthesia is too "light." These parameters generally increase before any awareness occurs. The anesthesiologist is constantly adjusting the delivery of the anesthesia gas and giving other medication in the IV to keep the anesthesia level where it needs to be. The anesthesia is increased to ensure adequate depth of anesthesia if it's too light. Likewise, even though you are unconscious, your body will reflexively move to stimulation if the anesthetic depth needs to be increased. This also occurs before awareness.

The various brain monitors on the market have not been shown to reduce anesthesia awareness, despite what the makers of these expensive devices say. They do provide other useful information and may or may not be used if your hospital has them, at the discretion of the anesthesiologist.

BIS Monitor

A study published in the "New England Journal of Medicine" (August 18, 2011) has actually shown that relying on a BIS (brain) monitor can actually increase the incidence of intraoperative awareness vs. using measurement of the anesthetic concentration (the usual technique). This sounds counter-intuitive, but to me is not surprising. Here's why...

The BIS monitor (which I use for other information) gives a number that is indicates the level of consciousness. Other indicators include heart rate, blood pressure and breathing rate/pattern changes (if the patient is breathing on their own). In my experience (disclaimer-based on only my experience, not scientific study), the changes in vital signs happen first. Heart rate goes up before you see a change in the BIS number. That means that providers who rely only on the BIS number and ignore the changes in vital signs may be missing the chance to prevent awareness. The awareness may have already happened before the change in BIS number is seen. There is a lag between the event and the change in BIS.

Personally, I try to use all the data available to me and not rely on the BIS monitor for prevention of awareness. Vital signs to me are more reliable, happen earlier (before awareness can occur in most cases) and should not be ignored to focus on the BIS monitor. The BIS does provide other useful info, but is not as reliable as the manufacturer may claim to prevent awareness.

Treatment for Anesthesia Awareness

If you have had a case of genuine intraoperative awareness, let your doctor, surgeon, or anesthesiologist know right away. Many people do well with just an explanation of why it might have happened. Others suffer short-term or even long-term post-traumatic stress disorder. In those cases, an evaluation by a psychologist or psychiatrist and possible medications may be needed, usually on a short-term basis.

If you aren't sure if you had true anesthesia awareness, speak to your surgeon or contact the anesthesiologist. Most people who aren't sure have had one of the other experiences -- like sedation, dreaming, or waking at the end and being confused about the time -- and feel much better after having their questions answered.

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Los Angeles, California, USA news

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95 percent of the victims of violence are men. Because women feel flattered when men fight each other and kill each other to prove that they are real men.

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LSD to be tested as a ‘cure for depression’ in Britain for the first time

Now a first-of-its-kind trial will test small doses of the drug in the UK – to see if it could help with depression.

Twenty volunteers will drop acid, then fill in psychological questionnaires and play the board game

The £300,000 experiment is funded by the Beckley Foundation – led by the Countess of Wemyss and March, Amanda Fielding.

She told The Sun, ‘There are studies that show LSD is a wonder drug for curing all sorts of things.

‘We will not be giving people such large doses that they hallucinate but enough to give them a lift.

‘I took it in the 1960s when it was legal and it improved my wellbeing.

‘If this small trial is successful, then we will consider applying to the government for more funding to run a larger experiment.’

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The United States Is Committing Brutal Acts of Torture Right Now

The grisly details of CIA torture have finally been at least partly aired through the release of the executive summary to a landmark Senate intelligence committee report. The extent of the torture has been covered extensively across the media, and is horrifying. But much of the media coverage of this issue is missing the crucial bigger picture: the deliberate rehabilitation of torture under the Obama administration, and its systematic use to manufacture false intelligence to justify endless war.

Torture victims, who had been detained by the US national security apparatus entirely outside any sort of recognizable functioning system of due process, endured a litany of extreme abuses normally associated with foreign dictatorships: 180-hour sleep deprivation, forced "rectal feeding," rectal "exams" using "excessive force," standing for dozens of hours on broken limbs, waterboarding, being submerged in iced baths, and on and on.

Yet for the most part, it has been assumed that the CIA's "enhanced interrogation program" originated under the Bush administration after 9/11 and was a major "aberration" from normal CIA practice, as one US former military prosecutor put it in the Guardian. On BBC Newsnight yesterday, presenter Emily Maitlis asked Zbigniew Brzezinski, former National Security Adviser under Carter, about the problem of "rogue elements in the CIA," and whether this was inevitable due to the need for secrecy in intelligence.

High-level sanction

Media coverage of the Senate report has largely whitewashed the extent to which torture has always been an integral and systematic intelligence practice since the second World War, continuing even today under the careful recalibration of Obama and his senior military intelligence officials. The key function of torture, largely overlooked by the pundits, is its role in manufacturing nebulous threats that legitimize the existence and expansion of the national security apparatus.

The CIA's post-9/11 torture program was formally approved at the highest levels of the civilian administration. We have known for years that torture was officially sanctioned by at least President Bush, Vice-President Cheney, former National Security Advisor Condoleezza Rice, Defense Secretary Donald Rumsfeld and Secretary of State Colin Powell, CIA directors George Tenet and Michael Hayden, and Attorney General John Ashcroft.

Yet the focus on the Bush administration serves a useful purpose. While the UN has called for prosecutions of Bush officials, Obama himself is excused on the pretext that he banned domestic torture in 2009, and reiterated the ban abroad this November.

Even Dan Froomklin of the Intercept congratulated the November move as a "win" for the "good guys." Indeed, with the release of the Senate report, Obama's declaration that he has ended "the CIA's detention and interrogation program" has been largely uncritically reported by both mainstream and progressive media, reinforcing this narrative.

Rehabilitating the torture regime

Yet Obama did not ban torture in 2009, and has not rescinded it now. He instead rehabilitated torture with a carefully crafted Executive Order that has received little scrutiny. He demanded, for instance, that interrogation techniques be made to fit the US Army Field Manual, which complies with the Geneva Convention and has prohibited torture since 1956.

But in 2006, revisions were made to the Army Field Manual, in particular through 'Appendix M', which contained interrogation techniques that went far beyond the original Geneva-inspired restrictions of the original version of the manual. This includes 19 methods of interrogation and the practice of extraordinary rendition. As pointed out by US psychologist Jeff Kaye who has worked extensively with torture victims, a new UN Committee Against Torture (UNCAT) review of the manual shows that a wide-range of torture techniques continue to be deployed by the US government, including isolation, sensory deprivation, stress positions, chemically-induced psychosis, adjustments of environmental and dietary rules, among others.

Indeed, the revelations contained in the Senate report are a mere fraction of the totality of torture techniques deployed by the CIA and other agencies. Murat Kurnaz, a Turkish citizen born and raised in Germany who was detained in Guantanomo for five years, has charged that he had been subjected to prolonged solitary confinement, repeated beatings, water-dunking, electric shock treatment, and suspension by his arms, by US forces.

On Jan. 22, 2009, retired Admiral Dennis Blair, then Obama's director of national intelligence, told the Senate intelligence committee that the Army Field Manual would be amended to allow new forms of harsh interrogation, but that these changes would remain classified:

"We have large amounts of unclassified doctrine for our troops to use, but we don't put anything in there that our enemies can use against us. And we'll figure it out for this manual... there will be some sort of document that's widely available in an unclassified form, but the specific techniques that can provide training value to adversaries, we will handle much more carefully."

Obama's supposed banning of the CIA's secret rendition programs was also a misnomer. While White House officials insisted that from now on, detainees would not be rendered to "any country that engages in torture," rendered detainees were already being sent to countries in the EU that purportedly do not sanction torture, where they were then tortured by the CIA.

Obama did not really ban the CIA's use of secret prisons either, permitting indefinite detention of people without due process "on a short-term transitory basis."

Half a century of torture as a system

What we are seeing now is not the Obama administration putting an end to torture, but rather putting an end to the open acknowledgement of the use of torture as a routine intelligence practice.

But the ways of old illustrate that we should not be shocked by the latest revelations. Declassified CIA training manuals from the 1960s, '70s, '80s and '90s, prove that the CIA has consistently practiced torture long before the Bush administration attempted to legitimize the practice publicly.

In his seminal study of the subject, A Question of Torture, US history professor Alfred W. McCoy of the University of Wisconsin-Madison proves using official documents and interviews with intelligence sources that the use of torture has been a systematic practice of US and British intelligence agencies, sanctioned at the highest levels, over "the past half century." Since the second World War, he writes, a "distinctive US covert-warfare doctrine... in which psychological torture has emerged as a central if clandestine facet of American foreign policy."

The psychological paradigm deployed the CIA fused two methods in particular, "sensory disorientation" and so-called "self-inflicted pain." These methods were based on intensive "behavioural research that made psychological torture NATO's secret weapon against communism and cognitive science the handmaiden of state security."

"From 1950 to 1962," McCoy found, "the CIA became involved in torture through a massive mind-control effort, with psychological warfare and secret research into human consciousness that reached a cost of a billion dollars annually."

The pinnacle of this effort was the CIA's Kubark Counterintelligence Interrogation handbook finalized in 1963, which determined the agency's interrogation methods around the world. In the ensuing decade, the agency trained over a million police officers across 47 countries in torture. A later incarnation of the CIA torture training doctrine emerged under Freedom of Information in the form of the 1983 Human Resources Training Exploitation Manual.

Power... and propaganda

One of the critical findings of the Senate report is that torture simply doesn't work, and consistently fails to produce meaningful intelligence. So why insist on its use? For McCoy, the addiction to torture itself is a symptom of a deep-seated psychological disorder, rather than a rational imperative: "In sum, the powerful often turn to torture in times of crisis, not because it works but because it salves their fears and insecurities with the psychic balm of empowerment."

He is right, but in the post-9/11 era, there is more to the national security apparatus' chronic torture addiction than this. It is not a mere accident that torture generates vacuous intelligence, yet continues to be used and justified for intelligence purposes. For instance, the CIA claimed that its torture of alleged 9/11 mastermind Khalid Sheikh Mohammed (KSM) led to the discovery and thwarting of a plot to hijack civilian planes at Heathrow and crash them into the airport and buildings in Canary Wharf. The entire plot, however, was an invention provoked by torture that included waterboarding, "facial and abdominal slaps, the facial grab, stress positions, standing sleep deprivation" and "rectal rehydration."

As one former senior CIA official who had read all KSM's interrogation reports told Vanity Fair, "90 percent of it was total fucking bullshit." Another ex-Pentagon analyst said that torturing KSM had produced "no actionable intelligence."

Torture also played a key role in the much-hyped London ricin plot. Algerian security services alerted British intelligence in January 2003 to the so-called plot after interrogating and torturing a "terrorist suspect," former British resident Mohammed Meguerba. We now know there was no plot. Four of the defendants were acquitted of terrorism and four others had the cases against them abandoned. Only Kamal Bourgass was convicted after he murdered Special Branch Detective Constable Stephen Oake during a raid. Former British ambassador to Uzbekistan, Craig Murray, has also blown the whistle on how the CIA would render "terror suspects" to the country to be tortured by Uzbek secret police, including being boiled alive. The confessions generated would be sent to the CIA and MI6 to be fed into "intelligence" reports. Murray described the reports as "bollocks," replete with false information not worth the "bloodstained paper" they were written on.

Many are unaware that the 9/11 Commission report is exactly such a document. Nearly a third of the report's footnotes reference information obtained from detainees subject to "enhanced" interrogation by the CIA. In 2004, the commission demanded that the CIA conduct "new rounds of interrogations" to get answers to its questions. As investigative reporter Philip Shennon pointed out in Newsweek, this has "troubling implications for the credibility of the commission's final report" and "its account of the 9/11 plot and al-Qaeda's history." Which is why lawyers for the chief 9/11 mastermind suspects now say after the release of the Senate report that the case for prosecution may well unravel.

That torture generates false information has long been known to the intelligence community. Much of the CIA's techniques are derived from reverse-engineering Survival Evasion Resistance and Escape (SERE) training, where US troops are briefly exposed in controlled settings to abusive interrogation techniques used by enemy forces, so that they can better resist treatment they might face if they are captured. SERE training, however, adopted tactics used by Chinese Communists against American soldiers during the Korean War for the purpose of eliciting false confessions for propaganda purposes, according to a Senate Armed Services Committee report in 2009.

Torture: core mechanism to legitimize threat projection

By deploying the same techniques, the intelligence community was not seeking to identify real threats; it was seeking to manufacture threats for the purpose of justifying war. As David Rose found after interviewing "numerous counterterrorist officials from agencies on both sides of the Atlantic," their unanimous verdict was that "coercive methods" had squandered massive resources to manufacture "false leads, chimerical plots, and unnecessary safety alerts." Far from exposing any deadly plots, torture led only to "more torture" of supposed accomplices of terror suspects "while also providing some misleading 'information' that boosted the administration's argument for invading Iraq." But the Iraq War was not about responding to terrorism. According to declassified British Foreign Office files, it was about securing control over Persian Gulf oil and gas resources, and opening them up to global markets to avert a portended energy crisis.

In other words, torture plays a pivotal role in the Pentagon's posture of permanent global war: generating spurious overblown intelligence that can be fed-in to official security narratives of imminent terrorist threats everywhere, in turn requiring evermore empowerment of the security agencies, and legitimizing military expansionism in strategic regions.

The Obama administration is now exploiting the new Senate report to convince the world that the intelligence community's systematic embroilment in torture was merely a Bush-era aberration that is now safely in the past.

Do not be fooled. Obama has rehabilitated and recalibrated the covert torture apparatus, and is attempting to leverage the torture report's damning findings to claim moral high ground his administration doesn't have. The torture regime is alive and well, but it has been put back in the box of classified secrecy to continue without public scrutiny.

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