Going under the knife, with eyes and ears wide open

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 O.K. to say: “Oops!” or “I wasn’t expecting that,” or even “Oh, my God, what are you doing?!” As a heads-up to staff members, some hospitals now post warning signs on the O.R. door: PATIENT AWAKE.

“For a thousand years, we talked about the operating theater,” said Dr. Mark Siegler, a medical ethicist at the University of Chicago and an author of a recent study on surgeon-patient communication during awake procedures, published in the American Journal of Surgery. “And for the first time, in recent years the patient has joined the cast.”

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, the senior author of the communication study and a head and neck surgeon on the faculty of Vanderbilt University Medical Center in Nashville, said that a patient’s decision to remain awake during an operation also reflects a growing suspicion, generally, of authority figures.

A few studies suggest that some patients feel less anxious about staying awake during surgery, despite possible gruesome sights, than they do about being sedated. Other patients, studies show, are very anxious about general anesthesia, particularly right before an operation, afraid they will not be able to wake up afterward.

Some operations, including deep brain stimulations, 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 than general anesthesia and is less expensive. Recovery time is swifter and side effects are fewer, which can reduce the need for postoperative opioids.

But many doctors view awake surgery with apprehension. What happens if the patient becomes too anxious? Distracts the surgeon with too many questions? Or objects vigorously when a trainee scrubs in – a mainstay of surgical education?

Whether the patient is offered the option of staying awake depends on many factors: the amenability of the surgery, the willingness of the surgeon, the flexibility of the anesthesiologist and the ability of a busy hospital to customize procedures.

Although typically patients meet and make decisions with an anesthesiologist moments before an operation, Dr. David M. Dickerson, an assistant professor of anesthesia at the University of Chicago, confers with patients earlier, at a surgical clinic intended to coordinate and personalize medical care.

Patients are evaluated for their likelihood to succumb to stress while awake; they learn about sedation alternatives if, midsurgery, they become overwhelmed. While a satisfying personal experience would be ideal, the patient is told, the most important driver is safety, including the ability of the surgeon to focus and communicate with other medical staff members without interruption. So managing the patient during surgery often falls to the anesthesiologist.

New York Times has the article.