How Anesthesia Works


Josh: Josh Clark

Chuck: Charles W. "Chuck" Bryant

Vo: Voiceover Speaker

[MUSIC]

Chuck: Hey, West Coast.

Josh: What, what.

Chuck: We are so happy to say that San Francisco, Portland, and Seattle are fully sold out on our West Coast jaunt in March and early April, and Los Angeles, you are the only place that is not sold out, so get on it.

Josh: Yeah, get on it, L.A. And if you live I guess within a day's driving distance of L.A., get on it too.

Chuck: Yeah. If you want details here for Los Angeles, we're at the Palace Theatre, and it is on-

Josh: March 30th.

Chuck: March 30th, that's right, which is a Monday, so there is not anything going on.

Josh: No.

Chuck: And we need to thank our friend Squarespace, because they set us up as sponsors on this tour and they have a great website they put up just for us, SYSKLive.com, and that's where you can get all the details and you can find your ticket information for Los Angeles.

Josh: Yeah. So San Francisco, Seattle, Portland, we'll see you guys. L.A., we'll see you there too. Go to SYSKLive.com.

Vo: Welcome to Stuff You Should Know from HowStuffWorks.com.

[MUSIC]

Josh: Hey, and welcome to the podcast. I'm Josh Clark. There is Charles W. "Chuck" Bryant, and there is Jeri, who is about to go the hardware store any second now.

Chuck: I wish.

Josh: No, Jeri doesn't find that very funny.

Chuck: Yeah. Do you want to give the background there or just leave people wondering?

Josh: Well, we need a trash can and a dimmer. Background.

Chuck: We've been asking for, I feel like months, but it can't be months because we haven't even been here that long.

Josh: It's been like four days, but what is the problem here? Why isn't there any movement on this?

Chuck: [LAUGHS] There is a Home Depot 1,000 yards from our-

Josh: Across the street, yeah. I specifically didn't mention their name, but yes, it is the closest-

Chuck: Well, an orange, big box hardware retailer.

Josh: Right. We could also support local business and go to an Ace instead.

Chuck: Yeah.

Josh: Or we could just talk about anesthesia like we were supposed to.

Chuck: Ace is a big chain, too, though.

Josh: Yeah, but I think they're locally owned.

Chuck: Oh right, like Henry's Ace Hardware.

Josh: Sure.

Chuck: Sure. [LAUGHS] I like Ace.

Josh: Yeah, it's good stuff.

Chuck: Very helpful.

Josh: Very knowledgeable staff. Good guys.

Chuck: Much more helpful than some of the other big box that are orange and blue. [LAUGHTER]

Josh: Okay.

Chuck: All right, that was a great start to anesthesia.

Josh: That was a weird one, man. Chuck?

Chuck: Yes.

Josh: Do you know how to spell anesthesia?

Chuck: I have a-I struggle, it's one of those. And in fact when you were out of the room getting your coffee, Jeri was asking how to spell it.

Josh: I know.

Chuck: And I think she spelled it right, or maybe missed a letter, missed one letter.

Josh: I'll bet you missed an E, didn't you Jeri?

Chuck: I think she put an A where there was supposed to be an E.

Josh: Oh, well, I think that used to be an accepted spelling, how in some distant times, like the '40s or the '30s.

Chuck: Which Jeri identifies with.

Josh: And anesthesia would have been spelled with an AE rather than just an E because there was another sound, the "ae."

Chuck: Yeah. It is a tricky one, though.

Josh: Okay. Well, then my next question, Chuck, do you know what anesthesia means?

Chuck: I do. It's from Greek, like a lot of medical terms, and this one stands for the loss of sensation. And we'll talk about our personal experiences, I assume, but I've never been under general anesthesia.

Josh: Yeah, the big daddy, general.

Chuck: Yeah, I've never been fully under. Have you?

Josh: No.

Chuck: No. So neither one of us has had major surgery like that, then.

Josh: No.

Chuck: Knock wood.

Josh: Yeah. Because after doing some research on this, I don't know that I ever would want to. It's scary.

Chuck: Yeah, I mean-

Josh: And let me just say also to anybody who is listening to this prior to undergoing a surgical procedure that requires general anesthesia, we don't mean to scare you.

Chuck: No, because it's-we'll talk about rate of death and problems with it, which there are, still, but it's super safe now for the most part.

Josh: Yes.

Chuck: But when I was reading this, I was like, "Man, what they're doing is like bringing you toward death, and then stopping at a certain point."

Josh: Yeah, and just letting you hover there, and then bringing you out when they're good and ready to.

Chuck: Yeah, with a lot of crazy, heavy, heavy drugs that are only slightly different from what they used in the early history, which we're about to talk about. But it's really kind of nuts, and they still don't know exactly how it works.

Josh: No. And the reason why they don't know how it works is especially-we understand local anesthesia and twilight sedation.

Chuck: Sure.

Josh: What we don't understand is general anesthesia, and the reason why we don't understand is because we don't understand how consciousness works, so how can we understand how unconsciousness works?

Chuck: Yeah, it's pretty weird. But it works.

Josh: Yes. It definitely does. And although there are some risks associated with it, it is far, far, far better than the alternative, which is no anesthesia, which was the way it was for a very long time. I mean, anesthesia is a relatively recent thing.

Chuck: Yeah. Or getting you super drunk or hitting you in the head and knocking you unconscious.

Josh: Which is not-so knocking you unconscious, that qualifies as anesthesia, but it's still not medical anesthesia. Getting you drunk, giving you morphine, giving you marijuana, jimson weed.

Chuck: Mandrake.

Josh: Yeah. Rubbing stinging nettles on you to distract you from the pain of having your leg cut off.

Chuck: Belladonna.

Josh: Using ice, all of the stuff, these are soporifics, these are narcotics, these are just plain old distractions, but they don't qualify as anesthesia. And the big difference, the thing that was such a huge, huge progression forward with anesthesia is that it doesn't just dull the pain, it dulls the pain, it takes away your consciousness, and it also prevents you from creating memories during this experience.

Chuck: If gives you amnesia.

Josh: So it basically cuts a chunk out of your lifetime that, as far as your subjective experience goes, does not exist; it didn't happen. You were on the gurney going into to the OR room, and you wake up and you're in the hospital bed and you have stitches, but there is nothing there in between, ideally.

Chuck: Yeah, for general anesthesia.

Josh: Right. And that's how we can conduct surgery. Because before that, there was surgery, but it was very rare, and it was very, very awful.

Chuck: Yeah. And we flew by some of those, but we did mention a lot of the soporifics and narcotics that they used. They did knock you in the head, they did get you drunk. In fact, in the mid-1840s, those were, opium and alcohol were the two go-tos, and a towel to bite on, I guess, and just to make you be able to tolerate the pain.

Josh: Which didn't really help.

Chuck: No. I mean, I'm sure it helped, it dulled the pain, but it's not going to do what you want, which is to kill it completely or knock you out or render you amnesiatic.

Josh: Right.

Chuck: Amnesiatic?

Josh: Sure.

Chuck: All right.

Josh: So those were the two go-tos that they used-I mean there were other ones, too, like bloodletting until a stupor or basically a coma was induced, like you lost so much blood. That's pretty dangerous. But these were the go-to painkillers for surgery, and they still didn't work very well. But what's weird is in the 1840s, all that changed: not one, not two, but three anesthesias came into-were basically discovered for medical use, almost all at the same time.

Chuck: Yeah. People now basically say Crawford Long, from right here in Georgia, a University of Georgia graduate, a fellow Bulldog, he was the first. He performed a surgery and removed a tumor from a neck from a Mr. Venable in late March 1842. And also later did an amputation and a childbirth with ether. And he was the guy, but he was-it was pretty regional and people just didn't know about it, basically.

Josh: I also get the impression that he wasn't as much of a self-promoter as Dr. William Morton.

Chuck: Yeah, he did-well, William Morton in 1846, we might as well go ahead and say he demonstrated it for the first time in a public surgical theater. And said, "Here is what I'm doing, and this is new, and it's exciting, and I'm in Massachusetts, so I'm not some yokel in Georgia."

Josh: Pretty much, and that's how he gained the acclaim, but yeah, I guess Crawford Long was able to prove that he had done it, he had used ether earlier, he's just like, "I just wasn't being a bigshot about it, I was just using it." But he discovered ether by hanging out with friends who were huffing ether at a party. And supposedly he saw one guy run into a door and cut his head open, and Crawford Long, being a doctor, was like, "Are you okay?" And the guy was like, "Yeah, what are you talking about?" with blood spurting out of his forehead. And Crawford Long went, "Genius, ether."

Chuck: That's pretty funny. And he went on to tell Congress about it, as did Dr. Charles Jackson, who said that he had done it before Morton, as well. They both independently went to Congress and was like, "Hey, man, I did that first." So a bit of self-promotion.

Josh Yeah. But Morton is the guy who gets the credit; he's the one who really introduced it to the public.

Chuck: Well, gets the credit as the first demonstrator, yeah.

Josh: Right. He is the one that you hear of typically.

Chuck: Yeah. I would say Crawford Long, though.

Josh: Yeah, I guess you're right.

Chuck: We got lots of hospitals named after him.

Josh: At least one.

Chuck: Here.

Josh: Although now, no, it's not Crawford Long anymore.

Chuck: Yeah, didn't they change it?

Josh: Yeah, to Home Depot.

Chuck: [LAUGHS] So a little bit later on, there was a dentist, Dr. Horace Wells, who used, the first dude to use nitrous oxide to pull teeth. And then chloroform was used by Dr. James Simpson, and these things, you don't want to be using that, though; it's toxic.

Josh: So, Dr. Horace Wells actually is a pretty interesting story. It's where chloroform and nitrous oxide converge.

Chuck: That beautiful place. [LAUGHS]

Josh: So he tried-he extracted one of his own teeth on nitrous and was like, "This is great." Did you read that history of hippie crack article?

Chuck: Yeah.

Josh: So this all came after somebody, a guy named Joseph Priestley in the 18th century, synthesized nitrous oxide. And then very shortly after that, a teenage prodigy named Humphry Davy started huffing it. And he actually had a box built for himself, and was placed in it for over an hour once, just huffing nitrous oxide.

Chuck: I'm surprised he lived through that.

Josh: I am too, and he did.

Chuck: Because that stuff is dangerous.

Josh: Yes, it is, but this guy was huffing it like crazy. There must have been some escaping or other air getting in, something, but he huffed it for an hour, just for self-experimentation. By the time Horace Wells tried it on a tooth, there was a lot of confidence in the understanding of nitrous oxide. He was able to successfully remove his own tooth. When he demonstrated it, he didn't dose the patient properly and the patient apparently cried out. And so Wells, who had staked all of his reputation on this demonstration, just failed utterly, and ended up on skid row in New York, went on a chloroform bender, and ended up throwing acid on a couple of women. Was put in-

Chuck: What?

Josh: Yeah. Was put in jail and ended up committing suicide by slashing his femoral artery with a razor from a shaving kit, but he was on chloroform, so he was anesthetized, ironically, when he died.

Chuck: Oh, well, that's good?

Josh: Isn't that weird?

Chuck: [LAUGHS] Yeah, what a strange history.

Josh: But so, the point is, is in the 1840s, chloroform, nitrous oxide, and ether all emerged to form anesthesia.

Chuck: Yeah, and I mean it would have come around eventually, but it's so different today. Like I said, we're still using heavy-duty drugs to knock people clean out and monitor them so they don't die from it. It's pretty crazy.

Josh: Well, one other thing about the introduction of anesthesia is that it took another 50 or so years before the medical establishment said, "Yes, we need to use this widely and as part of standard and best practices." And part of that was because pain was seen as necessary, it was a sign that the patient was alive, was still vital; there is a bit of a macho edge to it, from what I understand; and then there was also a reluctance to draw attention to the fact that surgery is extremely painful.

Chuck: Yeah, because they didn't want people to not go to the doctor as much.

Josh: Right. Yeah, so it took 50 years to catch on. So imagine being one of those patients where the modern medicine is well aware of anesthesia, but hasn't adopted it yet. That's worse than being a patient before they understood there was such a thing as anesthesia.

Chuck: Yeah. Or imagine being-because there was a lot of figuring it out along the way, as far as dosage and stuff like that goes, so there were a lot of unwitting guinea pigs, I guess.

Josh: There were.

Chuck: "Doc, that hurts." "Well, take a little more."

Josh: That or, "Doc, I'm dead."

Chuck: Exactly.

Josh: Do you remember the castration episode we did?

Chuck: Ooh, boy, do I.

Josh: And they talked about how they would use opium as an anesthesia but it was very easy to accidently overdose the little boys when you were removing their testicles.

Chuck: Sure.

Josh: I think the same thing happened when you were cutting off a man's leg in the Civil War.

Chuck: Wait, removing testicles?

Josh: Yeah, for castration.

Chuck: Oh.

Josh: Not circumcision, the castration.

Chuck: I thought you said circumcision.

Josh: Man, we've done both.

Chuck: Yeah, but I thought, I was like, "Man, I thought circumcision was something different." [LAUGHS]

Josh: No, that means the circumcision has gone horribly awry.

Chuck: Yeah. Man, we've covered some gruesome stuff.

Josh: We really have.

Chuck: All right. Well, I guess we'll take a break here and talk about some of the different methods of anesthesia right after this.

[MUSIC]

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Chuck: All right. Before we broke we teased you a little bit with the different types, and here we go. And up first is my favorite, twilight sleep. If you've had your wisdom teeth out or maybe endoscopy-there is plenty of procedures that use it-you might have had twilight sleep or conscious sedation, or twilight anesthesia. And I had some for when I had my tooth replaced, my front tooth, and it's always fun because it feels great going in, you just relish those 10 or 15 seconds [LAUGHS] and then it feels fun coming out because you don't know what's going on. Or it's more fun when you're picking up your loved one.

Josh: Right.

Chuck: I picked up Emily after her endoscopy and I went in and I don't know why I didn't think to have my video going already, but she was like, "I think everyone is throwing a party for me." I was like, "What?" She went, "The people behind the curtain, they're throwing a party, I saw balloons." And it was very cute because they're so out of it. And when I came out of my wisdom teeth, I think I may have told this before, but my friend told me that this particular doctor put bunny ears on you and took a picture because you're all puffed up and you have bandages around your face, and I was like, "That's not going to happen to me, I guarantee it." And I remember distinctly seeing the lady come in with the bunny ears, put them on my head, and get the Polaroid out, and said, "Smile," and I just went [NOISE] and gave a big smile.

Josh: So that actually-

Chuck: They mess with you.

Josh: Well, that's definitely twilight sedation-

Chuck: Yeah, so it was pretty fun.

Josh: -because you are out of it, but you're still conscious and you're still able to follow instructions.

Chuck: Yeah, but you don't know that.

Josh: Right.

Chuck: When you "wake up," quote-unquote, you feel like nothing happened. But they're like, "No, you were talking to us and stuff."

Josh: Right.

Chuck: It's so weird.

Josh: It is very weird and the twilight sedation, they use virtually the same drugs, in a lot of cases, that they use for general anesthesia.

Chuck: Yeah, just not as much.

Josh: Right, just smaller doses. So they'll use a sedative or something like that.

Chuck: Like ketamine.

Josh: Right.

Chuck: Like we said, major drugs. I mean if you've heard of falling into a k-hole, that's the same drug.

Josh: Right, ketamine.

Chuck: Yeah. But it's just crazy that we're like, "Oh back in the days they used cocaine on people and that's nuts." But we use ketamine on people. [LAUGHTER]

Josh: A big difference. Yeah, so there is ketamine, they might use something like Valium, or Ativan, or something like that. They'll probably also use a dissociative, which apparently disconnects your nerves from your brain.

Chuck: Yeah, that's what Valium is.

Josh: Okay, that make sense.

Chuck: Yeah.

Josh: And then also they'll use an analgesic, which is just another word for painkiller.

Chuck: That's right.

Josh: So you've got all of these things working in combination, probably given to you intravenously, and you're a little bit wasted. But, the point of twilight sleep and the thing that separates it from other types of anesthesia is that you are not so wasted that you can't breathe on your own, or that your heartbeat-or your heart can't beat on its own. It needs to be-you'll be monitored, but really, they've given you such a low dose of this cocktail of chemicals that you're still able to do things like smile when the dentist puts bunny ears on you.

Chuck: Yeah, too, I also remember when I woke up, I remember seeing a poster that said "locomotive lasagna" on the wall. And of course it didn't say that, unless they went so far as to switch out posters to mess with you.

Josh: I could see that.

Chuck: Because this dentist clearly had a sense of humor if he's putting bunny ears on people.

Josh: Yeah. He's like Tim Whatley from Seinfeld.

Chuck: Yeah, but I was a little kid; I'd never even had a drop of alcohol, so I'd never had my head altered in anyway, so I was like, "This is crazy."

Josh: Did you start going to the dentist every Friday?

Chuck: I did. I had all 50 wisdom teeth removed.

Josh: You're like, "I know there is another one in there."

Chuck: The other good thing about the twilight sleep is it's not going to have the after effects as general, like you probably won't have nausea, or dizziness, or vomiting, maybe a little bit. They will give you a prescription probably, but you probably won't need to use it. You know?

Josh: Yeah.

Chuck: Anti-nausea stuff.

Josh: So that's twilight sleep, a.k.a. procedural sedation. I don't know if we ever called it that. That's the clinical term for it. Twilight sleep is the prettier name for it.

Chuck: Yeah.

Josh: Then there is also a local anesthetic, which is the other common type of anesthesia, where basically a small area or a specific region of the body is basically numbed.

Chuck: Yeah, that's when you get the worst thing that can happen to you in life, which is shots into the gum, a needle in the gum at the dentist.

Josh: Which is why the dentist will frequently use a topical anesthesia.

Chuck: It helps a little.

Josh: Right. So that it will numb your gums when they put the needle in.

Chuck: Yeah, they'll put that gel and that'll numb it a little bit, or if you're getting sometimes an IV in the arm, they'll spray it with the cold stuff and that all helps, for sure.

Josh: It does. You'll still feel the pressure of the needle going into your jaws, but you don't feel the pain. The reason why these things work is a local anesthetic actually goes to the area it's delivered to and blocks the nerve receptors. It actually keeps your potassium and your sodium ions from firing, right?

Chuck: That's right.

Josh: Which means that it's not conducting electricity, which means that your nerves aren't capable of passing along the sensation of pain to your brain; they're just shut down. That's what a local anesthetic does. And if you pay attention, local anesthetics all end in "-ain," and for a pretty good reason.

Chuck: Like lidocaine or Novocain, even though they don't use Novocain that much anymore. It's a derivative of cocaine. And cocaine has a topical numbing effect, and they used to use it to do that.

Josh: Yes, right. And then they said, "Why is everybody showing up to the dentist all the time?" And then they said, "Oh yes, it's because of the cocaine. So let's a figure out a synthesized version of it," and they came up with Novocain, lidocaine, all that. And they stopped using Novocain apparently because there were a lot-the potential for adverse reactions was greater. But people still do have allergies to local anesthetics once and a while. But it turns out it's not the local anesthetic itself, it's not the Novocain, it's not the lidocaine, what it is when you use a local anesthetic, it has the effect of vasodilation, which means that it makes your blood vessels relax, which lowers your blood pressure, which is good, but it also, it's not so good. So they add epinephrine, which is a vasoconstrictor, and it actually makes the local anesthetic work better. So if you get a local anesthetic, you're getting the local anesthetic like lidocaine, mixed with epinephrine, and a preservative to keep the epinephrine fresh, and it's the preservative that you're having the adverse reaction to.

Chuck: Yeah. And again, just a well-balanced cocktail to give you exactly what you need. Local is going to wear off in a few hours; it depends on how much you have. When you leave the dentist, you'll still have your mouth numb for a while and they always warn you not to eat or talk too much because you can accidentally bite your tongue or your cheek and not know it, which actually happened to me recently and I did bite my cheek.

Josh: Man alive.

Chuck: Yeah, it bled a little bit too.

Josh: You all right?

Chuck: Yeah, I'm fine. [LAUGHS]

Josh: So it's not just dental that you're going to get a local anesthetic, you could also be given a local anesthetic for what's called awake brain surgery.

Chuck: What?

Josh: Yes. So in some types of brain surgery, you need to be conscious, you can't be unconscious. They need to keep track of what the brain is doing and they need it to be in a conscious state. So they will give you some drugs where you're not necessarily, you might be sedated in the-you might on a little bit of Valium or something like that, but you're not-you're still conscious, you're still able to respond to questions, but they give you a local anesthetic because they take the top of your head off and work on your brain. I think it's in Hellraiser, there's like an awake brain surgery is shown.

Chuck: Yeah, I think I've seen that in another movie, too. Yeah, because they need to be able to ask you things like-

Josh: Isn't this nuts?

Chuck: Yeah, can you believe that your brain is exposed? Isn't that crazy?

Josh: You're like, "Uh-uh, this is weird."

Chuck: Are we on to regional?

Josh: I believe so.

Chuck: Regional anesthesia is sort of like local but it covers a wider area or your body. So if you need your whole leg numbed for an operation, and not just a small portion of your leg, that would be regional. It's also called a nerve block. Basically because you're just taking a single nerve or a bundle of nerves and blocking that.

Josh: Right. They're going after one of the big daddies rather than a little one.

Chuck: Yeah. But again, localized. Like if women who have given birth sometimes will get an epidural, and that's what that is. It is injected via catheter into the epidural space in the lower back, but that doesn't necessarily mean directly into the spine, which also can happen with a spinal block, right into that cerebrospinal fluid, which is about as direct as you can get. And if you get a C-section or maybe hernia surgery, that's when they want you awake, again, during the surgery.

Josh: And with epidurals, Chuck, I was wondering, so an epidural, it's in the space outside of the spinal column.

Chuck: Yeah.

Josh: But it's used to numb you from the waist down, like when you're giving birth or something like that, right?

Chuck: That's right.

Josh: And it's actually a catheter is introduced and a continuous IV cocktail is given to your-into almost your spine.

Chuck: Yeah, but not into the spine.

Josh: No.

Chuck: Yeah.

Josh: That would be a spinal.

Chuck: That's right.

Josh: I wondered, how do they make it so it's your waist down that's getting number, why isn't it your waist up?

Chuck: Oh, like how do they know the path is going downward?

Josh: Yes. So I looked it up and it turns out it doesn't always.

Chuck: Yeah.

Josh: Sometimes it can reverse and numb you from the waist up, in which case you're in-that's a problem because your breathing can stop, your heart can stop, there is a bunch of stuff that can stop, but apparently it's extraordinarily rare, but it can happen where the intended area is reversed when they give you an epidural.

Chuck: Yeah. There can also be complications from the epidural that aren't great. So hopefully that doesn't happen if you're giving birth.

Josh: Right. Well, the same with the spinal, as well. There are complications, like you can get a meningeal infection, or an abscess, something like that.

Chuck: That happened to a friend of ours, that's why I got dodgy; I didn't want to say it on the air.

Josh: Oh, I gotcha.

Chuck: I'll tell you after.

Josh: Okay. [LAUGHS] Just write it down.

Chuck: Okay. [LAUGHS] Yeah, but I talked about the spinal block. There is a little bit more risk, like we said, than local obviously, like seizures and heart attacks. And sometimes it doesn't give enough pain relief and you have to move on to general, they're like, "Doc, this ain't working. Can you just knock me out?" Because some patients want to be awake and some patients don't, and sometimes they will defer to you on that.

Josh: Who will defer to who?

Chuck: The doctor in anesthesia-

Josh: Oh yeah, sure.

Chuck: -will be like, "Do you want to be awake for this or not?"

Josh: Especially during childbirth, too.

Chuck: Sure.

Josh: Like, "Give me the drugs, give me the drugs," is a common refrain.

Chuck: Yeah. Or, "I want to be awake at least, but give me the epidural." Like, I'll go in thinking natural childbirth is the way to go, and then I change my mind.

Josh: Give me the drugs.

Chuck: Which is, hey, that's you're right.

Josh: Yeah, sure.

Chuck: Giving birth, you should do it however you want to.

Josh: Toats.

Chuck: At home, in a tub, water birth.

Josh: In a boat, with a goat.

Chuck: [LAUGHS] Very funny.

Josh: So Chuck, you had a pretty great segue way that we just trod all over, into general anesthesia. Again, the big daddy is what I think most people call it.

Chuck: That's when you're put under, and that is when you are out, you don't remember anything, you're asleep.

Josh: You're unconscious.

Chuck: And that's the one where they don't completely understand how it works, which is a little scary.

Josh: It is a little scary. And there have been people who have tried to figure out how to quantify it using magical boxes and transmagnetic-transcranial magnetic simulation-stimulation, and I flubbed that one.

Chuck: The thinking cap?

Josh: Yeah. But ultimately we just, we don't know. So there is a general idea, basically a working theory and that is that anesthesia, the drugs that we use, and it's a bunch of different ones working in conjunction, but they depress the activity of the spinal cord, so you're paralyzed. The brain stem reticular activating system, which is basically they think responsible for sleepiness and wakefulness, that's stimulated, or depressed, depending on your way of looking at it, and then your cerebral cortex is affected, as well, so you're not thinking, you're not forming memories, you're not making associations with any of this. And all of that, in conjunction with one another, comes to anesthesia, general anesthesia, which is utter and complete unconsciousness.

Chuck: That's right. And it can last a few hours or up to six hours if you're having serious, complicated surgery. But there is a limit. They can't just be like, "This is a 12-hour surgery."

Josh: Yeah, I thought there were surgeries like that where they're like, "The surgery lasted 72 hours but the guy's face-

Chuck: Yeah, that's true.

Josh: -was successfully transplanted.

Chuck: Yeah, that is true.

Josh: So how do they do that?

Chuck: I don't know actually.

Josh: Because it does seem really dangerous to keep someone under general anesthesia for that long.

Chuck: Yeah, that's a good point. I meant to look into that. Someone will let us know.

Josh: Sure.

Chuck: We'll follow up on that for sure. If you are going to be put under general anesthesia, you don't just walk in and start huffing the gas. There's a lot of work that goes into that.

Josh: You have to be invited.

Chuck: You have to be invited by your-you have to get a party invite from your anesthesiologist. You will meet with them and he or she will basically ask you a bunch of questions about your lifestyle and your medical history.

Josh: Are you a natural redhead?

Chuck: Yeah, because we covered that in the redhead episode; you might need a little more.

Josh: Yeah. Are you a little kid?

Chuck: [LAUGHS] Yeah, I can tell by looking.

Josh: Yeah, because little kids' livers process these drugs a lot faster so they need a higher dose basically. Are you a huge alcoholic?

Chuck: Not-well, it depends on what you say, sir. [LAUGHS]

Josh: Are you a heroin addict?

Chuck: Not anymore.

Josh: So depending on the answers to these questions, they're going to need to adjust your dose depending. Do you have low blood pressure, high blood pressure?

Chuck: Yeah, and this is where you want to be super honest about your drinking and drugs.

Josh: Yeah, if you're a heroin addict, you need to fess up. You can be like, "Hey man, can you be cool and keep a secret?"

Chuck: Yeah. Don't lie like you do to your shrink, you know. You really want to be honest because you want this to work well and be safe. After they have all that, they're going to basically put together your program on what you're going to need. And then they're going to tell you not to eat, because if you eat before you go under anesthesia, you can aspirate and basically breathe in what's in your stomach.

Josh: Right. So this is-not everybody believes this any longer supposedly.

Chuck: About eating before surgery?

Josh: There is-what I understand is that when-there are so few cases of aspiration of under anesthesia, especially twilight sedation-

Chuck: It's because you're not eating.

Josh: -that-well, no-well, yeah, that's a pretty good-that's a good point I hadn't thought of. But apparently, well, yeah, you just answered that question.

Chuck: What were you going to say?

Josh: Well, from what I understood, there was a study that looked at all of these different cases of aspiration and found it's very rare. And they concluded that the danger, the potential danger of aspirating under sedation is low enough that it's outweighed by the benefits of eating. Because if you don't eat and you undergo sedation on an empty stomach, which is what they want you to do, it's a lot harder on your system; you're much more likely to be nauseated, to vomit afterward, to be dizzy. Whereas if you eat something, your body can process these drugs a little better.

Chuck: So are they advising people to eat now?

Josh: I think that they're starting to get to that point, but I don't believe it's current, widespread practice.

Chuck: Yeah, I don't think I would. I don't know, maybe I'm superstitious. I don't know if I'd be chowing on a burrito before I go in for my heart surgery.

Josh: Well, just for the surgeon's benefit, I think you might want to avoid burritos before going under, before being knocked unconscious.

Chuck: Yeah, you're right. You will be wearing a breathing mask when you're under general anesthesia, or a breathing tube, because basically your muscles are so relaxed that your airways won't stay open, so that's a little creepy in itself. And they're going to be monitoring lots and lots of things while you're under. They are in the room, and probably have an assistant in the room with them to monitor all this stuff, like blood pressure, heart rate, O2 levels, CO2 levels, temperature, brain activity, and there is even a little alarm if your O2 level drops, which is great. I think they should have an alarm for everything.

Josh: Yeah. The more alarms the better in that case.

Chuck: And I guess we should talk about the four stages of general anesthetic.

Josh: Yeah. Stage one is the induction stage, or the one you were talking about, those 15 seconds where you're like, "Mm."

Chuck: Pure bliss. [LAUGHS]

Josh: Right. And then that quickly moves to stage two, which is the twitchy stage, where you're just kind of like twitching. It's your body going like, "What the heck is going on? What is this?" And then you move quickly to stage three, which is the stage that they're after, where you're not twitching anymore, you're not conscious any longer, and you are under a state of general anesthesia.

Chuck: You are anesthetized.

Josh: Right. And this is where you want to be. But there is, like you said, a fourth stage.

Chuck: Yeah, you don't want to go there.

Josh: No, that's the overdose stage. And once you're in this stage it is now a medical emergency and you have to be managed, brought out of before you suffer brain damage or death or all sorts of other problems.

Chuck: Yeah. And I remember when I read this the first time I thought, "Well, why do they even have this fourth stage?"

Josh: [LAUGHS] I don't think they-I think it's just there.

Chuck: Yeah, but it's-anesthesia is a thing, it doesn't mean-like if you don't have a great anesthesiologist, there can be that fourth stage.

Josh: Sure, I think even with a good anesthesiologist having a bad day.

Chuck: Sure, things can happen.

Josh: "Oh, I hit a squirrel, and now this guy is dead."

Chuck: When you do go under, you are, like I said, going to get the gas or an IV or both. There are lots of different drugs that they will combine-again, ketamine, Valium, sodium pentothal.

Josh: Oh, the go-to is they're going to knock you out first with the IV, usually, and almost across the board it's propofol, Michael Jackson's milk.

Chuck: That's right.

Josh: And that's what they do to initially knock you out and then they're going to put-

Chuck: It's so sad that he actually needed that to sleep.

Josh: And it didn't even work is the crazy thing. He was so wound up that even propofol wouldn't work.

Chuck: That's just unbelievable.

Josh: It is sad.

Chuck: So sad.

Josh: What a sad way to go.

Chuck: You might also get a muscle relaxer to make sure that paralysis really talks hold.

Josh: Yeah, and if this is all kind of familiar, go back and listen to our lethal injection episode because that is stage four, and technically stage five in general anesthesia is lethal injection.

Chuck: Yeah, again, that's why this is so nuts, is they're almost killing you.

Josh: Yeah.

Chuck: Well, maybe that's overstating it. But they're not bringing you to the brink of death, but they want you close enough to where you're out. After surgery, you don't just get up and dance out of the room. You're going to go to the PACU, the post-anesthesia care unit, and then you're going to keep getting monitored, you're going to be dehydrated and cold because you're heading toward death, so they're going to warm you up with some warm IVs.

Josh: There are also some drugs that they've started to use now, I had some oral surgery and Umi picked me up, and I can't remember any of the stories or whatever.

Chuck: Oh, really?

Josh: But I remember going from being out to just being totally with it, and apparently I had been given a drug that's like a reverse sedation drug.

Chuck: Oh, to wake you up?

Josh: Yeah. There is one called flumazenil, and another called naloxone, and it's just basically-they also use them for overdoses of certain kinds in the ER, but they can use them post-sedation to get you going again pretty quickly.

Chuck: Do they stick it directly in your heart through your breastplate?

Josh: Boy, and the-yeah, and you just sit up and inhale deeply.

Chuck: Wow. I don't think I had then when I had mine.

Josh: Yeah, oh well, I'm cutting-edge.

Chuck: Yeah. [LAUGHS]

Josh: I still couldn't eat ahead of time, though.

Chuck: Oh, really?

Josh: Yeah.

Chuck: But you did anyway? You're like, "I read that it was fine."

Josh: "Chuck said I could have a burrito."

Chuck: [LAUGHS] You might actually get a little morphine, too, for the pain after your recovery.

Josh: Afterward, yeah.

Chuck: Yeah. But you might also have those side effects like we talked about, with the vomiting and nausea, and you'll be pretty out of it. You might fall over if you get up to use the bathroom. You need some help.

Josh: Probably the worst potential side effect of anesthesia possible is something called anesthesia awareness, and we'll get into that.

Chuck: Well, I would say death, but we'll talk about both of those.

Josh: Okay. All right. We'll get into both after this.

[MUSIC]

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Chuck: My two favorite words: free snacks.

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Chuck: Yeah, man, in that afternoon slump I get those dark cocoa almonds, good stuff, man.

Josh: Yeah, and the Peanut Butter Nom Noms.

Chuck: Love 'em.

Josh: Yeah, they're pretty easy to pound, Chuck.

Chuck: Yeah, and you know what, we're going to give our listeners a chance to try NatureBox for free, because they can get a trial box featuring five of their most popular snacks for free.

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[MUSIC]

Josh: So Chuck, we're going to talk about anesthesia awareness, but we should probably talk about anesthesiologists first, right?

Chuck: Yeah, there is many levels of anesthesiology jobs.

Josh: Okay.

Chuck: [LAUGHS] You can be an anesthesiologist, full-blown, which means you've gone to premed, undergrad, you've gone to med school, you have done your two-year residency, sometimes three-.

Josh: Ninety-five percent of income goes to malpractice insurance.

Chuck: Does it really?

Josh: I would guess.

Chuck: Not that much, but a lot.

Josh: Yeah.

Chuck: And you can-I didn't see where you had to be certified, but you are eligible to take the ABA exam, and I think if you want to be a physician anesthesiologist, you actually have to be certified.

Josh: All you have to do is be able to say "anesthesiologist" correctly.

Chuck: Actually, that's not true. It's 75% of physician anesthesiologists are certified. And most of the physicians, anesthesiologists do a one-year of specialty training, as well, with either there are several different subspecialties like hospice and palliative medicine, critical care medicine, and pain medicine. So basically just it's almost like post-graduate graduate school.

Josh: Right.

Chuck: Or you can be an assistant, which means you have your four-year undergrad in premed, and then you've gone through an accredited program and then taken an exam. Or you can nurse anesthetist.

Josh: Anesthetist.

Chuck: Anesthetist. Man, I sound like such a dope.

Josh: Those are some tough words, man.

Chuck: I know.

Josh: It's okay.

Chuck: There's a lot of stuff going on in there, a lot of T's and H's and S's. That means you are a registered nurse who has completed a training program, which lasts two to three years; you're going to have your BS degree. And at the end of one year of practice experience is when you go through training program and take an exam. So again, many years. It's serious, serious stuff. It's not like, "Oh, I want to be a doctor but I don't want to go through all the schooling, so I'll just be an anesthesiologist."

Josh: I want to have access to the finest drugs available on planet earth.

Chuck: Right. No, it's still serious, like you're a doctor, you know. It's not like you're any lesser of a-

Josh: You're a nurse.

Chuck: What do you mean?

Josh: An anesthetist you said was a nurse, right?

Chuck: Oh no, I'm just talking about all of those jobs require lots and lots of schooling. It's not like the easy way out.

Josh: I certainly hope not.

Chuck: No, no, it's a very serious job.

Josh: Okay, so it is a very serious job. Again, we said you are being brought to the brink of death, or stupor, or unconsciousness, or whatever you want to call it, and then brought back without any side effects, or as few side effects as possible.

Chuck: That's right.

Josh: And certainly no lasting side effects. But there is something, there is a pernicious syndrome that doctors have been aware of, that anesthesiologists have been aware of at least since the '60s, which is called anesthesia awareness. And basically anesthesia awareness is where you are given anesthesia, which includes a paralytic, which means you can't move your body at all, and your eyes have been taped shut, so you can't see, but you are conscious, you are aware during surgery. So the painkillers would have probably worked, too, but something went wrong and you're not unconscious, so you're able to form memories, you're able to hear the doctors talking about you like you're a piece of meat, you're able to hear the cutting, the squishing, the tearing of your organs being moved around.

Chuck: You can smell the singed hair and cauterized flesh.

Josh: Yeah. You're able to feel genuine fear. In some cases, if the pain reliever hasn't worked, you're able to experience this excruciating pain and you're not able, as badly as you want to, to alert anybody on the surgical team.

Chuck: Yeah, it's like you're locked in.

Josh: That you're-yes, that you're experience-yes. It's like performing surgery on a locked-in person without any kind of painkiller or anything like that.

Chuck: Yeah, I didn't know your eyes were taped shut during surgery, either, because you never see that on TV shows, do you? I've never noticed that.

Josh: Yeah, I don't-I've seen it before, but probably on one of those-remember they used to have real surgeries on, maybe Discovery in the early days.

Chuck: Yeah, back when they were doing stuff like that. [LAUGHS]

Josh: Yeah.

Chuck: I looked into that, though, and that's for a couple of reasons. Obviously to keep the eyes from drying out, because apparently eyelids do not close in 59% of patients when under general anesthesia; they'll just be staying wide open.

Josh: [LAUGHS] That is creepy.

Chuck: So it's to keep the eyes from drying, and I didn't realize this, it's to prevent corneal abrasion. Apparently that had been, or can be a real problem, even if your surgery is not on your eyes; there is just a lot of activity around your face. Like a stethoscope can scratch your eye-

Josh: Oh yeah, that makes sense.

Chuck: -or just, yeah, a lot of stuff can happen, so they'll tape your eye shut.

Josh: So they tape it shut so you can't see, but again, you can still hear, you can still feel, and even if you're not feeling pain you can still feel the pressure-remember, even with local anesthetic, you can't feel the pain but you can feel the pressure of the needle going in your jaw; this is the same thing with stomach surgery, or your heart being taken from your chest or what have you. So a lot of people, apparently studies have found since the '60s that about 2 out of every 1,000 patients or surgeries will experience anesthesia awareness.

Chuck: Yeah, they said that's super rare. That's not rare enough for me, man.

Josh: No, no.

Chuck: I was hoping to see 1 in 100,000.

Josh: Or 100 million.

Chuck: Yeah.

Josh: No, it's 2 out of every 1,000. And supposedly 70% of people who experience anesthesia awareness suffer from clinical PTSD, which is five times more than soldiers returning from Iraq and Afghanistan. And we're getting this stuff from an Atlantic article called "Awakening" by Joshua Lang, just go read it. It's a really great article.

Chuck: Yeah, they gave this one case, there's a bunch of cases in there, but this one, Sherman Sizemore, Jr. was a Baptist minister and coal miner, former coal miner, he was 73 and he had exploratory laparotomy. [LAUGHS] Is that right?

Josh: Yeah.

Chuck: In 2006. And any kind of exploratory surgery it's not fun because they're basically looking around for stuff and moving things around.

Josh: Yeah, they cut away like the flesh and his belly fat and all that stuff and were looking at the film that hold your guts in place.

Chuck: Yeah, they're poking around in there. And he of course had intraoperative recall.

Josh: Which is another term for anesthesia awareness.

Chuck: That's right. Basically his family couldn't understand what was going on with him. A lot of times you'll have these bad dreams, these nightmares about blood and people coming at you and trapping you and it's severe PTSD. And he eventually killed himself, even though he had no history of psychiatric illness.

Josh: Within two weeks of his surgery.

Chuck: Yeah, shot himself dead and his family settled with a lawsuit because they claimed that no one even said that this could happen or you should seek counseling or anything like that. It's so sad.

Josh: Oh yeah, it's very sad. Supposedly people who suffer from PTSD from anesthesia awareness, almost across the board, can't lay down and sleep; they have to sleep in chairs because laying down would-

Chuck: Bring that back up.

Josh: -stir up memories of, yeah, being on the OR table. And again, anesthesiologists, philosophers, any kind of scientist, they don't know how this is happening, because we don't understand consciousness, so we don't understand the mechanism that produces unconsciousness. And then even further, we don't understand when that mechanism that's supposed to produce unconsciousness fails to produce unconsciousness and someone remains conscious and experiences anesthesia awareness.

Chuck: Yeah, I would think there has got to be some failsafe for this by now.

Josh: There's not, no.

Chuck: Like un-tape the eyes midway and say like, "Blink if you can feel me, feel this."

Josh: Right. But you've been paralyzed, you can't move, you're under a paralytic.

Chuck: You can't even blink?

Josh: No.

Chuck: It seems like they should-I mean, I don't know, it seems like there has got to be something they could do.

Josh: There is a machine that has to breathe for you because your lungs can't even move.

Chuck: Well, and that's why they tape your eyes shut to begin with, I guess, because you can't blink.

Josh: Yeah. That's creepy that people, like their eyes remain open even if they're unconscious.

Chuck: Yeah, I wonder-

Josh: It's like the mom from Throw Momma from the Train.

Chuck: Even if you can't blink, I wonder if there is any kind of sign that you could give.

Josh: Well, so in this "Awakening" article, they talk about, there was a guy who came up with this box that was meant to-it gave a number between 0 and 100 that supposedly reflected a level of consciousness to be used in the operating room for anesthesia so that the anesthesiologist could be confident that somebody wasn't experiencing anesthesia awareness, and they found that it doesn't really work. So there are people who have undertaken this quest to basically show somehow there's some outward sign of whether someone is conscious or not, but we just haven't licked it yet.

Chuck: Yeah, I can't believe there is not some sort of machine that could pick up on that but-

Josh: They've tried.

Chuck: Or maybe they're just, so if it's 2 in every 1,000, I can live with those numbers. [LAUGHS]

Josh: No, that's not-that's way too common. Man, that scares me to death.

Chuck: Yeah, well, you said that's the worst thing that can happen. I vote for death as the worst thing.

Josh: Yeah?

Chuck: In the 1940s, for every 1 million patients who had full anesthesia, 640 of them died. By the '80s that was down to four for every million, which to be that is good and rare.

Josh: Four out of every million.

Chuck: Yeah, but that number is actually scarily on the rise since the 1980s. A German publication called Deutsche Ärzteblatt, it's the German Medical Association's science journal, and they said that worldwide death rate is on the rise to about seven now, per million. And the number of deaths within one year after general anesthesia is 1 in 20, of if you're over 65, 1 in 10.

Josh: What?

Chuck: And that's within the year after.

Josh: Oh. Yeah, but even still, that's not good.

Chuck: No, and it doesn't necessarily mean that's due to the anesthesia, because they make the point that it's not the quality of anesthesiological care is different, it's that older people are having surgery these days.

Josh: Oh, that's a good point. That is a very good point.

Chuck: Yeah, that's probably what it's due to.

Josh: Correlation is not causation.

Chuck: Yeah. I mean they said for a patient to actually die on the operating table is super, super rare, from anesthesiology overdose

Josh: It's apparently much more common to experience anesthesia awareness.

Chuck: Two in every thousand. Why don't they say 1 in 500?

Josh: Yeah, really.

Chuck: They're trying to pump it up.

Josh: You're like, "Oh, two in every thousand," and they say it like that, too. One in 500.

Chuck: I know.

Josh: Agh. And that's not 1 in 500 patients, that's 1 in 500 surgeries. There's a lot more surgeries than patients.

Chuck: Yeah. And when you go-when you take your pets in, they undergo general anesthesia, too, for surgery, and they always say like, "Your pet could die." It's rare and it happens this often, but it can happen and you have to sign the waivers and that's always, especially if you have an older animal, it's a little bit of a quandary you're in, you know, whether or not to get the surgery, is it worth the risk, all of that stuff.

Josh: Sure.

Chuck: That's all I got.

Josh: I've got nothing else, too.

Chuck: Tada.

Josh: That's anesthesia. If you are feeling confident about spelling that word correctly, go ahead and type it into the search bar at HowStuffWorks.com. And I said "search bar," everybody, which means it's time for listener mail.

[CHIMES]

Chuck: This one I'm going to call ESP, we heard from a lot of people on this one so far.

Josh: Yeah, but it wasn't as bad as I thought.

Chuck: No. "Hey, guys, just listened to ESP, it was as great usual. Your podcasts help me get through my workday and make me laugh, as I learn new and random things. With regards to ESP, or whatever people want to call it, I don't know if I believe in it exactly, but I do strongly believe that some individuals are much more intuitive or connected than others, and here is an example. When I was eleven my mother died. We were living at Vancouver at the time and she had died at home. We had not yet called any of the family to notify them until a few hours later, but about 15 minutes after she passed away, my paternal grandmother, who was in Hong Kong, called and said, 'Is Lana okay? I suddenly got a very strong and bad feeling about her and I thought I should call.' And again, we hadn't told anyone yet and it had only been 15 minutes. My grandmother has always been very intuitive, and it always felt like no matter where our family was, she was always somehow had her eye on us in a comforting way, not creepy." [LAUGHTER]

Josh: Right.

Chuck: She points out. "She was a devout and practicing Buddhist her whole life, and it is partly her devotion to Buddhism that somehow makes me believe that she was a soul deeply connected to the rest of the world." Yeah, kind of cool.

Josh: Yeah.

Chuck: Explain that.

Josh: I think we pointed out in the ESP podcast that probably the likeliest explanation is that the Buddha hands it out to his most devout followers.

Chuck: There you have it. It looks like granny, I don't have her last name, but that is from Joy and-

Josh: Granny in Hong Kong.

Chuck: That's right, even though Joy is in Australia, Canberra.

Josh: Canberra.

Chuck: Canberra, Australia.

Josh: Anesthesia.

Chuck: Hong Kong. Joy.

Josh: [LAUGHS] Right.

Chuck: Thanks, Joy.

Josh: Yeah, thanks a lot, Joy, that's a good story. And we got some like that actually, didn't we?

Chuck: Mm-hmm.

Josh: Probably more of those than "ESP doesn't work." We got very few of those, I was really surprised.

Chuck: Yeah, I thought we did a good job of laying it out there.

Josh: Uh, yeah. Well, if you want to share a good family story like Joy did, you can tweet to us @SYSKPodcast, you can join us on Facebook.com/StuffYouShouldKnow, you can send us an email to StuffPodcast@HowStuffWorks.com, and you can visit our home on the web, StuffYouShouldKnow.com.

[MUSIC]

Vo: For more on this and thousands of other topics, visit HowStuffWorks.com.

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