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Counting Backwards: A Doctor's Notes on Anesthesia
For many of the 40 million Americans who undergo anesthesia each year, it is the source of great fear and fascination. From the famous first demonstration of anesthesia in the Ether Dome at Massachusetts General Hospital in 1846 to today’s routine procedure that controls anxiety, memory formation, pain relief, and more, anesthesia has come a long way. But it remains one of the most extraordinary, unexplored corners of the medical world.
In Counting Backwards, Dr. Henry Jay Przybylo—a pediatric anesthesiologist with more than thirty years of experience—delivers an unforgettable account of the procedure’s daily dramas and fundamental mysteries. Przybylo has administered anesthesia more than 30,000 times in his career—erasing consciousness, denying memory, and immobilizing the body, and then reversing all of these effects—on newborn babies, screaming toddlers, sullen teenagers, even a gorilla. With compassion and candor, he weaves his experiences into an intimate exploration of the nature of consciousness, the politics of pain relief, and the wonder of modern medicine.
Filled with intensity and humanity, with moments of near-disaster, life-saving success, and simple grace, Counting Backwards is for anyone curious about what happens after we lose consciousness.
In Counting Backwards, Dr. Henry Jay Przybylo—a pediatric anesthesiologist with more than thirty years of experience—delivers an unforgettable account of the procedure’s daily dramas and fundamental mysteries. Przybylo has administered anesthesia more than 30,000 times in his career—erasing consciousness, denying memory, and immobilizing the body, and then reversing all of these effects—on newborn babies, screaming toddlers, sullen teenagers, even a gorilla. With compassion and candor, he weaves his experiences into an intimate exploration of the nature of consciousness, the politics of pain relief, and the wonder of modern medicine.
Filled with intensity and humanity, with moments of near-disaster, life-saving success, and simple grace, Counting Backwards is for anyone curious about what happens after we lose consciousness.
256 pages, Hardcover
First published November 14, 2017
176 people are currently reading
3091 people want to read
About the author
Henry Jay Przybylo
1 book13 followersHenry Jay Przybylo, MD is an associate professor of anesthesiology at Northwestern University School of Medicine. He also holds an MFA in creative nonfiction from Goucher College. He lives in Chicago.
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Displaying 1 - 30 of 170 reviews
November 29, 2017
My late father had a triple bypass where the anaesthetic didn't work. As his muscles were completely paralysed as they have to be, he was unable to let anyone know that he was in excrutiating pain. Afterwards he repeated to the surgeon things he had said and the surgeon was very apologetic but that was all. (If he'd been American he could have sued!)
I thought maybe this was a one-off but then last year I had surgery in the Bumrungrad in Bangkok, the world's 9th best hospital, so I expected top-notch care. The anaesthetic didn't work on me either but I wasn't paralysed and could tell the surgeon who said he was sorry but he couldn't do anything about it as I'd had the maximum amount of drugs they could give, but he would give nerve blocks.
You know those phenomenally painful injections they do in your mouth at the dentist? Well, every few minutes I had to have one or two of those for the duration of the operation. It was agony one way or another, just plain agony. I need to have a further procedure but cannot as Irma and Maria have screwed things up, so maybe next year. With full anaesthesia.
My surgeon on the island, an English doctor of considerable reknown (as a world-class racing sailor though) used to use a magical form of anaesthesia. He used intravenous valium for a light sleep, ketamine (yes, the club drug but also the one used in road-side accidents where the pain or danger is too great for opioids) to take you away into another world, mine was always light and fluffy and filled with colourful hallucinations, and also those vile sharp-pointed needle nerve blocks, except I couldn't feel them being as I wasn't 'there'.
He's not allowed to give ketamine any more. Sad that, you woke up from an operation feeling totally rested from a dream-filled sleep rather than nauseous and with a scratched throat from a general anaesthetic.
I was interested then in the job of the anaethetist whom I had not really thought of as just the guy who keeps you asleep while the Really Important Doctor, thebutcher surgeon does their thing. However, the book explained that far from the person who keeps you (hopefully) asleep and (hopefully) pain free, the anaethetist is the doctor who is keeping you alive and is calling the shots on how and if the operation can proceed. It is fairly detailed as to layout of the anaethetist's area in the operating theatre, the gasses, tests, equipment and drugs used. That was interesting.
Two things kind of got me about the book though. One he only ever heard of one patient (not his) who had woken up under anaesthesia, really? So my father and I were that rare? I don't think so. I think there is a lot of covering of mistakes going on. Secondly when the author dedicates himself to pain relief before, during and after surgery he gets guilty about the patients like ones with cerebral palsy who couldn't advocate for themselves. He said he figured they'd moan louder if it really hurt and that if they couldn't talk or control their muscles then they were unlikely to be any more aware intellectually. What????
He saw a documentary where a CP sufferer using a computer generated voice said that having CP was like having a brain locked in a box. Then he saw the light. I had never presumed that someone physically disabled was necessarily mentally so too, I don't even see the correlation.
My late uncle was, in his sphere as an anaethetist very famous. He took part in the UK's first heart transplant and the experimental surgery that led up to that, including the one where the pig (the subject) escaped and ran amok in the West End of London. He invented the concept of Intensive Care. I wonder if he ever had people wake up in operations and say, as I did to my surgeon, wow that was wonderful can I have some more ketamine please? (No, was the answer, you aren't in pain and there is only the sewing up to do. btw the sewing-up was done by a theatre nurse whose hobby was embroidery. Small island life...)
I thought maybe this was a one-off but then last year I had surgery in the Bumrungrad in Bangkok, the world's 9th best hospital, so I expected top-notch care. The anaesthetic didn't work on me either but I wasn't paralysed and could tell the surgeon who said he was sorry but he couldn't do anything about it as I'd had the maximum amount of drugs they could give, but he would give nerve blocks.
You know those phenomenally painful injections they do in your mouth at the dentist? Well, every few minutes I had to have one or two of those for the duration of the operation. It was agony one way or another, just plain agony. I need to have a further procedure but cannot as Irma and Maria have screwed things up, so maybe next year. With full anaesthesia.
My surgeon on the island, an English doctor of considerable reknown (as a world-class racing sailor though) used to use a magical form of anaesthesia. He used intravenous valium for a light sleep, ketamine (yes, the club drug but also the one used in road-side accidents where the pain or danger is too great for opioids) to take you away into another world, mine was always light and fluffy and filled with colourful hallucinations, and also those vile sharp-pointed needle nerve blocks, except I couldn't feel them being as I wasn't 'there'.
He's not allowed to give ketamine any more. Sad that, you woke up from an operation feeling totally rested from a dream-filled sleep rather than nauseous and with a scratched throat from a general anaesthetic.
I was interested then in the job of the anaethetist whom I had not really thought of as just the guy who keeps you asleep while the Really Important Doctor, the
Two things kind of got me about the book though. One he only ever heard of one patient (not his) who had woken up under anaesthesia, really? So my father and I were that rare? I don't think so. I think there is a lot of covering of mistakes going on. Secondly when the author dedicates himself to pain relief before, during and after surgery he gets guilty about the patients like ones with cerebral palsy who couldn't advocate for themselves. He said he figured they'd moan louder if it really hurt and that if they couldn't talk or control their muscles then they were unlikely to be any more aware intellectually. What????
He saw a documentary where a CP sufferer using a computer generated voice said that having CP was like having a brain locked in a box. Then he saw the light. I had never presumed that someone physically disabled was necessarily mentally so too, I don't even see the correlation.
My late uncle was, in his sphere as an anaethetist very famous. He took part in the UK's first heart transplant and the experimental surgery that led up to that, including the one where the pig (the subject) escaped and ran amok in the West End of London. He invented the concept of Intensive Care. I wonder if he ever had people wake up in operations and say, as I did to my surgeon, wow that was wonderful can I have some more ketamine please? (No, was the answer, you aren't in pain and there is only the sewing up to do. btw the sewing-up was done by a theatre nurse whose hobby was embroidery. Small island life...)
July 26, 2019
***Just reread my review and I reread it for my book group in the nonfiction genre, we all enjoyed it and I wanted to recommend it now as a great book club book, lots to discuss***
I would rate this book a 3.5 rounded up to a 4!
I am always interested in any books related to the medical field and this sounded like a great one. I’ve had several surgeries and I’ve always wondered what it must be like to be the anesthesiologist, the one who really holds your life in his or her hand!
What I loved about this book were his descriptions of interactions with his pediatric patients. He seems to have figured out a way to calm his patients so they aren’t so fearful about being “put under”. He has to deal with all sorts of children, some who have had multiple surgeries try to come up with a way to stop the procedure. There is a section about a little boy who tries to convince the doctor that “I had Cap’n Crunch” cereal, which of course is not allowed before the induction of anesthesia. Dr. Jay spent so much time trying to verify with the nurses that he had nothing to eat that morning only to find out later that the little boy had taken some cereal from another patient’s breakfast. Wow, dealing with kids has to be difficult!
There were times where I did lose some interest in the book when he was talking about the history of anesthesia, how it all works, even the “philosophy” of anesthesia. Perhaps some of the technical parts of the book could have been shortened or omitted to make the book flow a little better.
My very favorite part of the book, because I’m an animal lover, has to be the special case where he and his fellow physicians completed an operation on a gorilla, Tabibu, to be exact. She was very ill with a GI issue and would have died without the operation. Dr. Jay surprised his daughter, who dreams of becoming an animal nurse, and leads her into the recovery area where Tabibu was being cared for. His daughter was awed by the experience of being able to touch and stroke the gorilla and trying to comfort her. Dr. Jay stated "Most amazing to me, however, was watching Annie hold Tabibu and comfort this magnificent animal. It left me in awe. What joy." I should also mention
that the doctors and care givers volunteered their time and the space because the zoo couldn't afford the care that the gorilla needed.
I would recommend this book as a very good memoir, well written, about an anesthesiologist who cares deeply for his patients!
I received an ARC of this book from the publisher and NetGalley.
I would rate this book a 3.5 rounded up to a 4!
I am always interested in any books related to the medical field and this sounded like a great one. I’ve had several surgeries and I’ve always wondered what it must be like to be the anesthesiologist, the one who really holds your life in his or her hand!
What I loved about this book were his descriptions of interactions with his pediatric patients. He seems to have figured out a way to calm his patients so they aren’t so fearful about being “put under”. He has to deal with all sorts of children, some who have had multiple surgeries try to come up with a way to stop the procedure. There is a section about a little boy who tries to convince the doctor that “I had Cap’n Crunch” cereal, which of course is not allowed before the induction of anesthesia. Dr. Jay spent so much time trying to verify with the nurses that he had nothing to eat that morning only to find out later that the little boy had taken some cereal from another patient’s breakfast. Wow, dealing with kids has to be difficult!
There were times where I did lose some interest in the book when he was talking about the history of anesthesia, how it all works, even the “philosophy” of anesthesia. Perhaps some of the technical parts of the book could have been shortened or omitted to make the book flow a little better.
My very favorite part of the book, because I’m an animal lover, has to be the special case where he and his fellow physicians completed an operation on a gorilla, Tabibu, to be exact. She was very ill with a GI issue and would have died without the operation. Dr. Jay surprised his daughter, who dreams of becoming an animal nurse, and leads her into the recovery area where Tabibu was being cared for. His daughter was awed by the experience of being able to touch and stroke the gorilla and trying to comfort her. Dr. Jay stated "Most amazing to me, however, was watching Annie hold Tabibu and comfort this magnificent animal. It left me in awe. What joy." I should also mention
that the doctors and care givers volunteered their time and the space because the zoo couldn't afford the care that the gorilla needed.
I would recommend this book as a very good memoir, well written, about an anesthesiologist who cares deeply for his patients!
I received an ARC of this book from the publisher and NetGalley.
July 4, 2017
This is a simple but fascinating memoir about the life of one particular anesthesiologist. The book provides pertinent history, medical knowledge, case studies and musings about the job and it's art. There is much more to the job than I thought. The anesthesiologist must examine the patient, decide on an anesthesia plan, put them out, keep them out, avoid mishaps, deal with emergencies, bring them back, and manage their postoperative pain. What I loved about the book is the author is humble, humane, and honest with a great love for his job. I have been knocked out twice in my life and the experience was scary, weird, and interesting. Where does one go when you get to 97 and your conscious tether is released. This book gives you some clues but "going under" is still a mystery.
September 23, 2020
Anaesthesia is really incredible. Most of us are familiar with having a mask over our face and having a chat with the anaesthesiologist, feeling a little dizzy, and then suddenly become aware of our surroundings, perhaps many hours later, with absolutely zero recollection of what happened during the interval, even if, in some cases, that means literally having one's heart ripped out of one's chest and replaced with a new one.
Okay, carefully snipped out of one's chest, but you get the idea.
One thing I learned in this book is that the amnesia is not a freebie with anaesthesia. A separate drug is induced to produce the amnesia; it isn't strictly necessary, but it's generally considered preferable for the patient NOT to overhear and remember everything that was going on during the procedure.
And perhaps the most amazing thing about anaesthesia? Is that it so rarely causes problems. Such problems as are likely to arise are well-studied and standard practices for dealing with them have been long established. Essentially, a well-organized, meticulous and non-panic-prone anaesthesiologist can practice for many decades and only really break a sweat a handful of times in their careers.
This is wonderful news for patients, but a bit less wonderful for readers of this book. I didn't really learn much more about how these drugs actually work -- nobody really seems to know. There's no active research going on, because the current drugs work so well and people aren't developing immunities to them. Not to say there weren't moments of drama in this book -- one kid went into conniptions because he had requests orange-scented gas and got bubble-gun scented. Another kid lost his St. Christopher medal. Once he had to deal with a Mom who was a total bitch. The most interesting story didn't even have a human patient.
Yawn.
I'm grateful for Dr. Pysybylo's career -- as a doctor. I am 100% grateful to live in the Age of Anaesthesia and hope the practioners I encounter are as dull, plodding, methodical and error-proof as he is.
Okay, carefully snipped out of one's chest, but you get the idea.
One thing I learned in this book is that the amnesia is not a freebie with anaesthesia. A separate drug is induced to produce the amnesia; it isn't strictly necessary, but it's generally considered preferable for the patient NOT to overhear and remember everything that was going on during the procedure.
And perhaps the most amazing thing about anaesthesia? Is that it so rarely causes problems. Such problems as are likely to arise are well-studied and standard practices for dealing with them have been long established. Essentially, a well-organized, meticulous and non-panic-prone anaesthesiologist can practice for many decades and only really break a sweat a handful of times in their careers.
This is wonderful news for patients, but a bit less wonderful for readers of this book. I didn't really learn much more about how these drugs actually work -- nobody really seems to know. There's no active research going on, because the current drugs work so well and people aren't developing immunities to them. Not to say there weren't moments of drama in this book -- one kid went into conniptions because he had requests orange-scented gas and got bubble-gun scented. Another kid lost his St. Christopher medal. Once he had to deal with a Mom who was a total bitch. The most interesting story didn't even have a human patient.
Yawn.
I'm grateful for Dr. Pysybylo's career -- as a doctor. I am 100% grateful to live in the Age of Anaesthesia and hope the practioners I encounter are as dull, plodding, methodical and error-proof as he is.
November 14, 2017
Summary: The sections on history and philosophy of anesthesiology weren't my favorite, but the fascinating, moving patient stories were fantastic.
In his career of more thirty years, anesthesiologist Dr. Henry Jay Przybylo has administered anesthesia more than 30,000 times. His patients have included everyone from "newborn babies, screaming toddlers, sullen teenagers, even a gorilla." (source). As he shares his experiences with these patients, he also explores the nature of consciousness and the history of anesthesiology.
The author led with some history of anesthesiology and his philosophy of how anesthesiology should be done. In these parts, he came across as somewhat self-important. For example, describing the gases he uses as 'my anesthesiology gases' instead of as 'the anesthesiology gases'. These little things that bothered me completely disappeared when he started talking about his patients. He clearly cares deeply for the well-being of his patients and told their stories with care and comparison. He's had some incredible experiences in his career, which were a pleasure to read about.
His stories about his patients were delightfully varied. Some were funny, others heartbreaking. All were incredibly interesting. Topic transitions could be a little rough and I think I'd have enjoyed this book more had it been exclusively patient stories. These were the bulk of the book though and I'd definitely recommend picking this up for that reason. It was a quick, easy read and I think the engaging patient stories would make this a great pick even for someone who doesn't often pick up nonfiction.This review was originally posted on Doing Dewey
In his career of more thirty years, anesthesiologist Dr. Henry Jay Przybylo has administered anesthesia more than 30,000 times. His patients have included everyone from "newborn babies, screaming toddlers, sullen teenagers, even a gorilla." (source). As he shares his experiences with these patients, he also explores the nature of consciousness and the history of anesthesiology.
The author led with some history of anesthesiology and his philosophy of how anesthesiology should be done. In these parts, he came across as somewhat self-important. For example, describing the gases he uses as 'my anesthesiology gases' instead of as 'the anesthesiology gases'. These little things that bothered me completely disappeared when he started talking about his patients. He clearly cares deeply for the well-being of his patients and told their stories with care and comparison. He's had some incredible experiences in his career, which were a pleasure to read about.
His stories about his patients were delightfully varied. Some were funny, others heartbreaking. All were incredibly interesting. Topic transitions could be a little rough and I think I'd have enjoyed this book more had it been exclusively patient stories. These were the bulk of the book though and I'd definitely recommend picking this up for that reason. It was a quick, easy read and I think the engaging patient stories would make this a great pick even for someone who doesn't often pick up nonfiction.This review was originally posted on Doing Dewey
November 19, 2017
I'm always interested in medical history and autobiography, so I was very excited to read about an anesthesiologist's history and views on his profession. Too many of us take anesthesia for granted without a real understanding of what the practice entails.
I found the historical background very interesting, especially how little really changes in the field. And I do admire his commitment to his patients.
There were a few off-putting things for me. Parts of it felt like it had been written 20 or 30 years ago- he makes a repeated assertion that anyone in the U.S. has top-class healthcare available to them at any time, which we certainly know isn't true. And he seems to think that the U.S. is a world leader in access to healthcare for everyone, while ignoring that most of the developed world actually has some form of universal health care. And although the book was recently published, there was very little about the current opioid epidemic in the U.S., which for a doctor who deals with pain seemed very distant from reality. I was very glad to read of his journey towards understanding non-verbal patients.
Overall I enjoyed it- please, let's have more anesthesiology memoirs!
I found the historical background very interesting, especially how little really changes in the field. And I do admire his commitment to his patients.
There were a few off-putting things for me. Parts of it felt like it had been written 20 or 30 years ago- he makes a repeated assertion that anyone in the U.S. has top-class healthcare available to them at any time, which we certainly know isn't true. And he seems to think that the U.S. is a world leader in access to healthcare for everyone, while ignoring that most of the developed world actually has some form of universal health care. And although the book was recently published, there was very little about the current opioid epidemic in the U.S., which for a doctor who deals with pain seemed very distant from reality. I was very glad to read of his journey towards understanding non-verbal patients.
Overall I enjoyed it- please, let's have more anesthesiology memoirs!
May 28, 2019
I highly recommend this book! It tells about medicine yet is written for non-medical people. The author explains what we know and what we have yet to learn about anesthesia, with just the right amount of medical description. I learned about the history of anesthesia and how it made modern surgery possible, and how the anesthesiologist is in charge of the operating room even more so than the surgeon.
The author's personal dedication to being the best doctor possible and his care for his patients shines through in his descriptions of his interesting cases. His writing style is friendly and understandable; I think that he would be very interesting to sit and talk with.
This book is excellent for anyone interested in medicine, science, or what happens when we undergo anesthesia. I think it will be great for students who are considering a career in medicine -- and may make some aspiring surgeons decide to become anesthesiologists instead!
The author's personal dedication to being the best doctor possible and his care for his patients shines through in his descriptions of his interesting cases. His writing style is friendly and understandable; I think that he would be very interesting to sit and talk with.
This book is excellent for anyone interested in medicine, science, or what happens when we undergo anesthesia. I think it will be great for students who are considering a career in medicine -- and may make some aspiring surgeons decide to become anesthesiologists instead!
May 3, 2025
I am a recovery room nurse in a pediatric hospital and have been recovering kids after surgery for the past 27 years. As I read this book it makes me appreciate what a pediatric anesthesiologist goes through to assure their patient is well covered from the beginning to end of their case. You can feel
Dr. Jay really is caring and compassionate about his job. I enjoyed his story -
Dr. Jay really is caring and compassionate about his job. I enjoyed his story -
December 31, 2024
Amazing read that started a little slower (maybe just bc it’s non fiction) but got better and better! Has me considering pediatric anesthesiology as a specialty now…
November 28, 2017
I won this book in a Goodreads giveaway, and an honest review was requested. Thank you to W.W. Norton for providing me this engrossing memoir! I absolutely love a good medical memoir, and this one delivered all of what I love: a smart, committed person with a real passion for medicine to narrate, a window into a new medical field I know little about, many interesting stories about patients (Tabibu was my favorite!) and excellent writing. I would recommend this book to anyone who has enjoyed memoirs by Atul Gawande, Paul Kalanithi, or Damon Tweedy. I will say I don't agree with Dr. Przybylo's conviction that we all have a right to be completely pain free at all time in any circumstance -- I think that idea was invented and sold by opiate manufacturers and has been a big factor in the current opiate addiction epidemic -- but that's a minor quibble and it did not interfere with my enjoyment of this book at all. It is a very quick and engaging read, and it actually made me feel a lot better about the prospect of any future surgical procedure or hospital stay, which medical memoirs, quite honestly, rarely do.
March 29, 2019
I've been under anesthesia twice this week, so it was finally time to read this memoir. Dr. Jay recounts his experience working in one of the least understood (and under the radar) medical specialties. He blends engaging patient stories with history and science, and helped me understand all that goes into a safe, unremarkable anesthesia experience.
He's absolutely right that the anesthesiologist is so crucial to your care, yet you meet them just a few minutes before you go into a procedure. They must build trust so quickly, particularly in his sub-specialty of pediatric anesthesiology where he must balance worried parents with children who may not be old enough to fully understand. You can research your surgeon and the hospital, but rarely do patients think about the anesthesiologist who will guide them through everything.
I thoroughly enjoyed this memoir and would recommend it for anyone curious about what happens when we're unconscious.
He's absolutely right that the anesthesiologist is so crucial to your care, yet you meet them just a few minutes before you go into a procedure. They must build trust so quickly, particularly in his sub-specialty of pediatric anesthesiology where he must balance worried parents with children who may not be old enough to fully understand. You can research your surgeon and the hospital, but rarely do patients think about the anesthesiologist who will guide them through everything.
I thoroughly enjoyed this memoir and would recommend it for anyone curious about what happens when we're unconscious.
April 7, 2018
3.5 stars. I’m a sucker for a physician memoir and this was everything it needed to be.
February 10, 2018
This book is a quick easy read, which was not what I expected. It was a mix of medical science/history and anecdotes, which is fine. But the science was science lite, and the patient stories were either inspirational (thankfully in a non-religious way) or had morals like Aesop's fables. The author specializes in pediatric anesthesia, so his patients are cute kids, and he seems to have a good rapport with them. He paints a pretty picture: Anesthesia, when done expertly (e.g., by him), on fairly healthy people who follow instructions, is perfectly effective, with only occasional and mild side effects. I would definitely want him to do anesthesia for anyone in my family, as he's meticulous, experienced, and also concerned with post-operative pain relief.
The book is well written. I am rounding down from 3 1/2 stars to 3 on his content. He mostly ignores anything on the dark side of anesthesia effects. He skims by the side effect of tooth damage (from intubation? he doesn't say) as insignificant. I don't think patients would think so! He mentions post-anesthetic delirium but says a sedative and sleep cures it. Sometimes yes, but sometimes (in the case of my father) it's permanent. He also says that it's questionable that post-anesthetic cognitive loss exists, which I think is not true (again, my father). He writes as if no patient is ever conscious during anesthesia if it's given properly, and maybe he is such an expert that it never happens to his patients. I recently read Anesthesia: The Gift of Oblivion and The Mystery of Consciousness by Kate Cole-Adams, which focuses on such incidents, which are not all that uncommon.
The other reason I'm rounding my rating down is that I thought it was kind of creepy that he asks his preteen (!) and teen patients about their girlfriend or boyfriend to distract them on the way to surgery. He tells fondly of harassing two of them for the names, which they didn't want to tell. (Not to mention he's assuming they're heterosexual.)
The book is well written. I am rounding down from 3 1/2 stars to 3 on his content. He mostly ignores anything on the dark side of anesthesia effects. He skims by the side effect of tooth damage (from intubation? he doesn't say) as insignificant. I don't think patients would think so! He mentions post-anesthetic delirium but says a sedative and sleep cures it. Sometimes yes, but sometimes (in the case of my father) it's permanent. He also says that it's questionable that post-anesthetic cognitive loss exists, which I think is not true (again, my father). He writes as if no patient is ever conscious during anesthesia if it's given properly, and maybe he is such an expert that it never happens to his patients. I recently read Anesthesia: The Gift of Oblivion and The Mystery of Consciousness by Kate Cole-Adams, which focuses on such incidents, which are not all that uncommon.
The other reason I'm rounding my rating down is that I thought it was kind of creepy that he asks his preteen (!) and teen patients about their girlfriend or boyfriend to distract them on the way to surgery. He tells fondly of harassing two of them for the names, which they didn't want to tell. (Not to mention he's assuming they're heterosexual.)
March 29, 2018
If you’ve ever been to the hospital for a surgery or long-term care, you may remember your doctor or a certain nurse, but your anesthesiologist? Probably not. That isn’t the case for me. When I had to go in for an emergency c-section for my second son, I was terrified, screaming not to let me lose another child. My husband by my side…and my anesthesiologist. He obviously HAD to be there, at least at first. But after our child was born early, my husband rushed to the NICU with our son while I was still in surgery. I was overwhelmed, I was nauseous, and still scared out of my mind when the anesthesiologist said: “I know you are here by yourself. I know you are scared. I promise I will stay here with you as long as you need.” And he did…even when I vomited rainbow colors all over him (thanks to all those popsicles I was given in the hospital to stave off my 48 hours of not eating) and even after his primary job was done. Even 3.5 years later, I can’t tell you much about my 2 week stay in the hospital – the doctors, the surgeons, the nurses. But I can tell you about that amazing man who comforted me when no one else would or could.
I’ve read several medical memoirs, but I was excited to finally see one on an anesthesiologist. The author, Dr. Jay, realizes he is not in the most remembered of professions and he’s not wrong. He goes through a quick history of anesthesia, prominent people, and his own stories. The beginning was sort of slow going. I did enjoy his personal stories and thoughts. It was a quick read. So even with the slow bits, it only took me a couple days to get through. Not the best memoir I’ve read but a pleasant book.
I’ve read several medical memoirs, but I was excited to finally see one on an anesthesiologist. The author, Dr. Jay, realizes he is not in the most remembered of professions and he’s not wrong. He goes through a quick history of anesthesia, prominent people, and his own stories. The beginning was sort of slow going. I did enjoy his personal stories and thoughts. It was a quick read. So even with the slow bits, it only took me a couple days to get through. Not the best memoir I’ve read but a pleasant book.
April 17, 2017
Anesthesiologist/author Przybylo takes readers beyond the forbidden operating room doors into the O.R. itself. In a calm, warm tone, the author details how patients are given anesthesia prior to medical procedures and the myriad of ways in which they differ. He deftly includes the history of anesthesia, from the discovery of ether to more modern ways of blocking pain and alleviating pre-surgery anxiety. Wonderful book for those skittish about undergoing surgery.
I read an advance copy and was not compensated.
I read an advance copy and was not compensated.
January 24, 2022
I've had one minor surgery in my life, and I don't even think I know who the anesthesiologist was. I'm a bit of a needle-phobe, and I remember being absolutely wigged out about the idea of an IV in my arm. A "bit of a pinch" is an understatement, but I remember the person administering the IV was super nice and encouraging. I remember getting wheeled away, and then I remember waking up and being told I had to leave because it was like 5:30pm and these people had to get home (it wasn't at a hospital, more like a specialized clinic, I guess, not a 24/7 operation). I'm assuming things went smoothly, but after listening to this audiobook I regret not learning more about the whole "going under" portion.
Dr. Przybylo specializes in anesthesiology, putting people under, keeping them there during the operation, and bringing them back out again. He's a bit proud of his profession (as I would be too, were I in his shoes), and this book explains his practice and the history of it through example cases he's encountered. I learned a lot about the early days of being put under for painful operations, the drugs used, the changes in the field. As with many things taken for granted in the medical industry, there's a lot more going on here than I knew about. I particularly liked the story involving the gorilla, and the exchanges between him and various kids throughout the book.
Super interesting stuff that I'm glad I took some time to read about. I'm hoping to keep some of this stuff in the back of my head, just in case I'm put in that position. Not necessarily to pick their brains, but maybe give my anesthesiologist something better to work with to ease my anxiety rather than the mundane chitchat they have to come up with on the fly. "Hey, I read a book once...."
Dr. Przybylo specializes in anesthesiology, putting people under, keeping them there during the operation, and bringing them back out again. He's a bit proud of his profession (as I would be too, were I in his shoes), and this book explains his practice and the history of it through example cases he's encountered. I learned a lot about the early days of being put under for painful operations, the drugs used, the changes in the field. As with many things taken for granted in the medical industry, there's a lot more going on here than I knew about. I particularly liked the story involving the gorilla, and the exchanges between him and various kids throughout the book.
Super interesting stuff that I'm glad I took some time to read about. I'm hoping to keep some of this stuff in the back of my head, just in case I'm put in that position. Not necessarily to pick their brains, but maybe give my anesthesiologist something better to work with to ease my anxiety rather than the mundane chitchat they have to come up with on the fly. "Hey, I read a book once...."
March 11, 2018
Counting Backwards: A Doctor's Notes on Anesthesia
by Henry Jay Przybylo
I have to disclose first that I am a surgeon's daughter, so this may give me a different slant on this book than the general reader. When I was growing up in the 1960's & 70's, medicine was an old boy's club, more interested in forming a supportive line of protection when someone screwed up than truly focusing on the patient's well-being.
For me it was refreshing to read a book by a medical professional who holds himself to such high standards. He gives the reader a look into the difference between a teaching hospital and an ordinary hospital, something that many readers do not understand clearly. He discusses individual cases of interest (I'm sure the names were changed to protect the patient's privacy). He does an excellent job of conveying the crucial attention to detail it takes to have a successful result. I also enjoy his asides on the history of anesthesia very much.
He is honest about what the field doesn't yet understand, and what advances would be most useful. In fact, I found his candor and humility a wonderful structure upon which his tale hangs.
This is a very readable book for the lay reader, with suggestion how you as a patient can help yourself receive the best possible care. I recommend it whole heartedly.
by Henry Jay Przybylo
I have to disclose first that I am a surgeon's daughter, so this may give me a different slant on this book than the general reader. When I was growing up in the 1960's & 70's, medicine was an old boy's club, more interested in forming a supportive line of protection when someone screwed up than truly focusing on the patient's well-being.
For me it was refreshing to read a book by a medical professional who holds himself to such high standards. He gives the reader a look into the difference between a teaching hospital and an ordinary hospital, something that many readers do not understand clearly. He discusses individual cases of interest (I'm sure the names were changed to protect the patient's privacy). He does an excellent job of conveying the crucial attention to detail it takes to have a successful result. I also enjoy his asides on the history of anesthesia very much.
He is honest about what the field doesn't yet understand, and what advances would be most useful. In fact, I found his candor and humility a wonderful structure upon which his tale hangs.
This is a very readable book for the lay reader, with suggestion how you as a patient can help yourself receive the best possible care. I recommend it whole heartedly.
October 19, 2017
This was a fun and fast read. Dr Przybylo is clearly a guy who is conversant in a very technical, high-stakes field of medicine but his writing isn't a thicket. It was darn clear. Anesthesia isn't a forgiving area, I suppose, and Dr Jay (as he calls himself) wasn't able to forgive himself for some earlier goofs in his career until those patients themselves showed some grace. High expectations are important, and yet they also can lead to painful moments after mistakes. This is what we want as patients, though, right?
Now, if I had Dr Jay by my side I'd ask for some more nuance regarding removal of pain (one of the five A's, as he says, of anesthesia). Isn't some pain a helpful thing--a messenger of sorts? Perhaps there was some subtlety that I missed when he mentions that he wants to eradicate pain from patients.
The sections about CP and the ways by which he endears himself to patients were very touching. How we relate & communicate with those around us is important, especially for those of us in positions of power. You never know who is listening, or who can understand, despite outward appearances.
I'd recommend this book. I'm grateful I rec'd an ARC.
Now, if I had Dr Jay by my side I'd ask for some more nuance regarding removal of pain (one of the five A's, as he says, of anesthesia). Isn't some pain a helpful thing--a messenger of sorts? Perhaps there was some subtlety that I missed when he mentions that he wants to eradicate pain from patients.
The sections about CP and the ways by which he endears himself to patients were very touching. How we relate & communicate with those around us is important, especially for those of us in positions of power. You never know who is listening, or who can understand, despite outward appearances.
I'd recommend this book. I'm grateful I rec'd an ARC.
February 4, 2020
I really enjoyed this book! The concept of erasing time, pain and memories is fascinating and explained very well by this doctor. His anecdotes gave you an inside view of what happens behind the scenes with the dr that no one ever really sees or remembers spending any time with. I knew the job was obviously complex and complicated, but after some of the chapters, I was really wowed by how much these doctors do. I especially liked his interactions with his pediatric patients and their families.
I read this when headed to surgery #3 in the past 4 months and it actually made me feel much more relaxed about being under anesthesia (not that it ever really bothered me). He did make me question why I do trust my anesthesiologist so much without even knowing or researching them.
But, hands down, I still think it's the best sleep you will ever experience!
I read this when headed to surgery #3 in the past 4 months and it actually made me feel much more relaxed about being under anesthesia (not that it ever really bothered me). He did make me question why I do trust my anesthesiologist so much without even knowing or researching them.
But, hands down, I still think it's the best sleep you will ever experience!
January 12, 2018
In the ever growing genre of reality medical texts for non medical readers, this book is a very well crafted view of the critical role played by the anaesthesiologist. Our .ives depend upon their calculations, attention to vitals and their interventions to prevent consciousness an post operative pain. The writer’s craft is on view throughout, asking this book an enjoyable and engaging “read.”
July 18, 2020
Meh. This was not what I was hoping for. My too-many (eight??) experiences with anesthesia are a source of personal interest and fascination and this just didn’t go in a productive/useful direction. Oh well.
March 14, 2018
Too much medical terminology for me. I think I'd rather be in the dark about how some medical procedures work. If you are interested in this topic, you'll probably enjoy it.
July 6, 2018
Part memoir, part medical history, the book provides an interesting peak behind the surgery curtain and into the mystery world of the anesthesiologist. As someone who as undergone anesthesia over half a dozen times, "Doctor Jay" is correct that the anesthesiologist is often an overlooked part of the process. You choose your doctor, surgeon, and surgical center, but you meet the anesthetist the day of the procedure, often for just a few minutes, before you hand your consciousness over to them.
It's an unnerving feeling - getting heavier and going completely blank and out of your control, knowing that in what feels like an instant you'll be groggily and painfully awaking again, disoriented (and in my case freezing cold, shaking uncontrollably, and often on the verge of puking my guts out). But I'm grateful to these mystery doctors who dedicate their professions to keeping us safe, relatively pain free, and blissfully unaware as our teeth are pulled, our orifices scoped, bones scraped, and organs removed. The alternatives prior to the invention of safe anesthesia are too horrifying to imagine (and people did have surgery without them, which makes me shudder).
It's an unnerving feeling - getting heavier and going completely blank and out of your control, knowing that in what feels like an instant you'll be groggily and painfully awaking again, disoriented (and in my case freezing cold, shaking uncontrollably, and often on the verge of puking my guts out). But I'm grateful to these mystery doctors who dedicate their professions to keeping us safe, relatively pain free, and blissfully unaware as our teeth are pulled, our orifices scoped, bones scraped, and organs removed. The alternatives prior to the invention of safe anesthesia are too horrifying to imagine (and people did have surgery without them, which makes me shudder).
August 7, 2018
Gave me a peek into my dad's work world. I get why he's such a control freak. ;)
June 1, 2021
This book gave a comprehensive review of the life of an anesthesiologist through many unique and interesting patient cases. It was an easy, engaging and informative read.
December 16, 2017
I initially heard about this book while listening to Terry Gross interview the author on NPR. The interview (worth listening to!) persuaded me to seek out the book. It is a fascinating look into the mostly invisible, somewhat mysterious yet absolutely critical world of anesthesiology.
If you ever need anesthesia, you want someone with this doctor's skill and compassion taking care of you.
If you ever need anesthesia, you want someone with this doctor's skill and compassion taking care of you.
December 8, 2018
After my last, lengthy review of At The Edge of the Orchard, you might actually be in need of some anesthesia so, how fitting that this book is next in my backlog of reviews waiting to be written?! Unfortunately for you, I highlighted 35 notes from this book because it contains so many interesting tidbits, so you may still be in need when you’re finished.
I first heard Dr. Jay (whom I’ll call DJ for the sake of brevity) on NPR and remember him saying that nobody knows where you go when you’re under anesthesia. I found this fascinating to consider and here’s what I learned by reading it about that: “The state of anesthesia is far different from sleep, but every day I find myself commenting to my patients and families on the process of “going to sleep.”… “Anesthesia is lost time. There is no memory. From the moment anesthesia is induced until that point in emergence that awareness returns, a gap in time forms in the existence of the patient. If memories enter the brain during this time—debate exists as to whether the anesthesia experience prevents memory formation or memory retrieval—they never come to mind when awareness returns. The benzodiazepines help form that time hole. The drugs I use deny the formation of new memories but leave past memories intact.”
As someone who’s delivered 7 babies, I’ve had more than my share of interactions with anesthesiologists. I’ve had 6 inductions, 4 with epidurals and 1 ending in a C-section, and I’ve also had 2 D&C’s and 1 D&E. All told, I’ve therefore had more than my share of experiences on the L&D floor, each of which is a tale in and of itself. But because DJ works mostly with children, one of the stories this book brought mostly to mind was when my youngest, Bella, had her adenoids out at age 2 because, as DJ describes: “A clump of tissue with the consistency of jam, the adenoids, blocked the breathing path through her nose.”
In fact, Bella’s surgery came to mind time and again as he described his techniques, like here, “I pointed out the bees, butterflies, and birds painted on the walls and talked about her favorite colors. In the operating room, I continued to talk about breathing bubblegum, the scent she had chosen for the mask.” Before they put Bella under, they were asking her that very thing as she sat in my lap in the surgery room. “What’s your favorite color, sweetie?” they said with syrupy voices as they inserted a needle someplace I’ve forgotten. But before she could say “pink”, she slumped down into me like an analogy I refuse to consider and they all sprang into action, swiftly extracting her from my arms and pushing me out the door so fast my head was spinning. I, myself, could barely breathe as they gave me what my mom would call “the bum’s rush” and I found myself standing in the hallway with the door shut firmly between me and my baby thinking, “Don’t you want to know what my favorite color is?”
But let’s get started on these notes because this book drops a whole lot of interesting knowledge. I’ve never been happier to meet anyone than the 4 docs who gave me an epidural, all of whom were godsends in stage 3 transition labor but are mostly remembered by their crotches, since that’s the part of their body that presented itself to me as I lay there while my pain was erased. As DJ confirms, “Forty million people in the United States undergo anesthesia every year. It is the most frequently performed medical procedure that entails risk to the patient. The anesthesiologist is ubiquitous but largely invisible. Before the slash of the scalpel, the insensibility to pain is taken for granted. More people, up to a hundred million per year, seek relief from pain, both acute and chronic. Pain is the most common human health issue.”
Here are some of the historical notes, all of which I found fascinating. First of all, harken back to “the late 1600s when opium added to alcohol (laudanum) was introduced in the Western world.” Fast forward 2 centuries: “On October 16, 1846, Morton conducted his demonstration on a patient named Edward Gilbert Abbott in the operating room of the Massachusetts General Hospital….A month later, the term “anesthesia,” Greek for “without sensibility,” was coined in a letter to Morton by Oliver Wendell Holmes Sr.—the Boston poet, physician, and professor—and it stuck.”
I’ve long considered myself lucky to live in a time when we can be “without sensibility”, for which I give thanks every single time I go to the dentist. “Over 170 years ago, inhaling a gas was shown to render a person senseless and thereby allow invasive medical procedures.” I had an impacted permanent tooth, so my childhood was filled with what Dr. Moody called “sweet air”, as DJ describes: “Nitrous oxide, although not potent enough to use alone, is added because it provides a boost to the loss of sensation, and it does so without an unpleasant odor.” I can still conjure the taste and smell of that fun gas.
Further along, when my fifth baby, Jonah, was found to have no heartbeat after my placenta abrupted, I still had to labor and deliver him, a horrific experience. I was hemorrhaging internally while waiting for my cervix to dilate sufficiently to deliver a 7 pound baby and at one point during those too-many hours, my husband noticed that my blood pressure had dropped to 60/40 and I was looking like I was about to join Jonah. He sprinted out to the nurse’s station and they all rushed in along with a cardiologist who stuck a long needle into my broken heart, delivering this next drug appropriately lauded here by DJ, for which I probably owe my life today. “There’s one last item in my setup: the mother of all drugs, the resuscitator extraordinaire, the last-ditch effort to retrieve a life trying to end—epinephrine. It deserves a special place in my anesthesia nest—a place I call the “Oh Shit Shelf.” It’s on top of the anesthesia machine, immediately to the right of the flat-screen monitor. Whenever anyone in the room says “Oh shit,” I reflexively reach high and to my right, and grab the only syringe ever placed there, the epinephrine. I am the ultimate patient advocate, and my first thought jumps to a patient in jeopardy. Epinephrine is the single strongest heart-kicking drug I have. It bumps a slowing heart rate and increases a sagging blood pressure. Along with oxygen, epinephrine is the anesthesiologist’s life preserver.” A life trying to end. Sigh.
On a lighter note, this next bit reminds me of the 5 D’s in Dodgeball, from the movie of the same name which you should watch if you haven’t. “The term “anesthesia,” which means “without feeling,” doesn’t adequately encompass all of the goals of care. Since the discovery of ether, many adjunct medications have been added to the anesthesia gas to accomplish all-inclusive care. The effects that these side medications produce are what I call the “Five A’s of Anesthesia”:
• Anxiolysis, relieving stress created by an upcoming surgical procedure
• Amnesia, preventing memory formation during anesthesia care
• Analgesia, relieving pain during the procedure, but also considered beyond the procedure room to include postprocedure pain relief, acute (trauma) pain relief, and chronic pain relief
• Akinesia, preventing a patient’s movement during a procedure
• Areflexia, stopping adrenaline surge and swings in blood pressure and heart rate while under anesthesia
And here’s another A you should know about, “Today, there are over thirty Azepams to choose from, including the sleep-inducing—and sometimes sleepwalk-inducing—Ambien and Rohypnol, street-named “roofie,” otherwise known as a date rape drug.” I am certain this happened to me one night which shall not be named and I was suddenly and completely incapacitated, which was not good. Here, DJ discusses the complexities of consciousness. “We form memories while asleep, but not while anesthetized by volatile gas, and we lose awareness while we’re awake during daydreams, as well as under the influence of azepams. There’s always a risk that a patient will retain awareness somewhere along the process of anesthesia.” Which seems to contradict our first paragraph premise but there are exceptions to every rule, particularly in the practice of medicine.
Because I wrote a book called Breathe, I’m always interested in that very topic and here are some fun facts DJ imparts, “The average body contains over sixty thousand miles of conduit, blood vessels, that carry nutrients to and waste from all the cells of our bodies. The heart beats on average 115,000 times per day, transporting ninety-two hundred gallons of blood. In a day’s time, the average person takes over twenty-three thousand breaths.” 23,000. Woah.
And lest you think history has not been made in your own lifetime, consider this, “Although the call for standardized anesthesia records began in 1923, not until 1985 did standards for monitoring, including use of the ECG, become accepted by the American Society of Anesthesiologists.”
This seems like a good time for a vocabulary building interlude: “Iatrogenic”—derived from the Greek iatros (“physician”) and genic (“to be produced by”)—is a word that was developed less than a century ago to indicate something caused by a physician that has adverse effects.”
Burying two children is like being hit by lightning. Twice. When Bella was only months old, she had to have an MRI to check her brain for what was happily just fine but as I’ve already mentioned, to witness your baby being anesthetized is traumatic, regardless of what your favorite color is or the following comparisons DJ relates, “It is more probable to be struck by lightning than to die while under anesthesia. The risk of dying from anesthesia is less than one in a hundred thousand cases. It’s about the same risk as dying as a result of skydiving, participating in a triathlon, or riding a bike. Anesthesia is very safe. But anesthesiologists can never, ever let their guard down.” And neither can parents.
I have hypertension and have been on meds for about 2 decades. And now I know that I’m a PS2 patient. Huh. “A PS1 patient is healthy. A PS2 has a compensated health problem not impacting everyday life—high blood pressure controlled with medications, for example. Eighteen holes of golf presents no problem. A PS3 suffers from a life-altering condition, such as heart disease that makes it difficult to function normally—for instance, to walk up a flight of stairs. PS4 and PS5 patients are at risk of dying or are expected to die. Anesthesia risk rises as the PS number does.” Hoping I don’t need it any time sooner than never.
I found his discussion of heart transplants so very interesting. Consider these three:
“The heart is the most inspirational organ to observe, to touch, to feel. Nothing stirs my medical emotion more than watching the heart deep in the chest, lurching with every beat. Unlike any other organ, it’s always in motion, never resting. Its beat defines life.”
“In a twisted sense of the balance of life, for John to live, someone had to die. A viable, undamaged organ for transplant requires a quick strike to life, causing rapid brain death. The scenario almost always involves violence. The optimist views it as making the best of a horrible situation—saving one life instead of losing two.”
“The longest-surviving transplanted heart to date has beat a little over a billion times, or thirty years. Eight out of ten heart transplant recipients survive the first year. Most will survive for twenty years, or 750 million heartbeats. That’s a very large number, but it is far less than three billion, the number of heartbeats in a normal life. So, the transplanted heart is not a guarantee into old age. It is a lease on life that will need to be renewed. This is especially true for young recipients. The transplanted heart gradually develops narrowed blood vessels—a vasculopathy—a perverse injustice resulting from the same medications that prevent organ rejection. Heart failure eventually recurs.” A good reminder of the many areas of research and development we still need, like a better medication for this.
It’s also always good to be reminded that our teens and young adults have brains that are still developing, aptly described here: “Teens have pedal-to-the-metal accelerators, but they lack competent brakes. Subtle changes to the brain continue into the twenties, gradually containing the twitchy impulse control—or lack thereof—and the emotional volatility of the teen years.”
And this, about our pathetic health care system, directly contributing to the early death of this transplant recipient, Bandul, “The politicians decided that their generosity ended when kids were no longer kids. They defined that moment as the last day of the month of a child’s nineteenth birthday. So, Bandul was no longer provided his medications.” And tragedy struck.
I was heartened to read this next statement, an imperative cultural change that we in the stillbirth community are constantly striving to impart, “Mothers always know best. I was surprised by how blindly I had acted up to this point. When moms say something’s wrong, it’s true until proven otherwise. This is a belief I was taught early on.” Amen. It should be taught in medical school.
Shout out to Malcolm Gladwell here, “One day early in my career, he pulled me aside and advised me that it would take ten thousand anesthesia cases before I would understand the limits of my ability. To paraphrase Donald Rumsfeld: There are known knowns, and known unknowns, and then there are unknown unknowns. Frank taught me the value of recognizing and limiting the unknown unknowns.” Indeed. This is why medical research and development is imperative.
Having endured a medical malpractice lawsuit for Jonah’s death, I found this interesting, “Two times I have been accused of medical negligence, and both anger me. In both cases I was part of a team that tried to preserve a life, and both times I was soon dropped from the suit. But the accusation is enough to hurt, and regardless of the lack of proof, I still must list both cases when I apply for privileges anywhere.”
And when the shoe is on the other foot, I appreciated his candor regarding his own surgery when, as he writes, “a midcareer anesthesiologist became one of the forty million who receive anesthesia every year.” “I was caught on the unfamiliar side of an all-too-common scene, one that repeats itself across the country 150,000 times on an average day. Spouses, mates, parents, children, and friends exchange hugs and kisses with a loved one who is about to enter into an unknown, sequestered space—where senses are reversibly altered to allow a body to undergo an invasive and painful procedure out of medical necessity.”
And lest you think that Botany is for losers, consider this, “A large portion of my anesthesia tool chest is filled with pain relief drugs derived from plants. The poppy, the coca plant, birch bark, cannabis (as an anti-inflammatory), and coffee (for me, good effects on multiple organs and the downside not obvious).
I have long stated that the absence of pain is a beautiful thing, relief I was granted by the blessed epidural. So I echo DJ’s sentiment here, “Freedom from pain should be an undeniable human right in all places, under all conditions, and at all times.” Amen. Ditto for good health in general, but, sadly, we have a long way to go on both fronts. And, as a result of our inability to treat mental health in the same way we do physical health, we find ourselves in the midst of an opioid epidemic here in the land of the free and the brave. DJ pens, “And this is a craze, an epidemic: every eleven minutes a death by overdose occurs. More people die by overdose each year than by falls, car accidents, or gunshots.” That is a horrifying statistic. It has taken me many 11 minutes, many deaths by overdose, to write this review.
And while on the topic of this epidemic, DJ describes this: “Propofol provides two of the Five A’s: anxiolysis and amnesia. It provides no analgesia and actually burns on injection. Painful procedures require additional medications and techniques. Despite its short action, propofol is a dangerous drug, as evidenced by Michael Jackson’s death by overdose, a reminder that vigilance when altering alertness remains a necessity. The biggest advantage of this drug is that it speeds reentry. All the other drugs I use to treat anxiety and amnesia entail a hangover period, in which the patient feels altered and unable to perform normal tasks. With propofol, there is no hangover. Propofol allows consciousness to return rapidly and intact, with the added benefit of reducing postanesthesia nausea and vomiting.” Unless you’re in a hospital, just say no.
Okay. Read it.
K3
I first heard Dr. Jay (whom I’ll call DJ for the sake of brevity) on NPR and remember him saying that nobody knows where you go when you’re under anesthesia. I found this fascinating to consider and here’s what I learned by reading it about that: “The state of anesthesia is far different from sleep, but every day I find myself commenting to my patients and families on the process of “going to sleep.”… “Anesthesia is lost time. There is no memory. From the moment anesthesia is induced until that point in emergence that awareness returns, a gap in time forms in the existence of the patient. If memories enter the brain during this time—debate exists as to whether the anesthesia experience prevents memory formation or memory retrieval—they never come to mind when awareness returns. The benzodiazepines help form that time hole. The drugs I use deny the formation of new memories but leave past memories intact.”
As someone who’s delivered 7 babies, I’ve had more than my share of interactions with anesthesiologists. I’ve had 6 inductions, 4 with epidurals and 1 ending in a C-section, and I’ve also had 2 D&C’s and 1 D&E. All told, I’ve therefore had more than my share of experiences on the L&D floor, each of which is a tale in and of itself. But because DJ works mostly with children, one of the stories this book brought mostly to mind was when my youngest, Bella, had her adenoids out at age 2 because, as DJ describes: “A clump of tissue with the consistency of jam, the adenoids, blocked the breathing path through her nose.”
In fact, Bella’s surgery came to mind time and again as he described his techniques, like here, “I pointed out the bees, butterflies, and birds painted on the walls and talked about her favorite colors. In the operating room, I continued to talk about breathing bubblegum, the scent she had chosen for the mask.” Before they put Bella under, they were asking her that very thing as she sat in my lap in the surgery room. “What’s your favorite color, sweetie?” they said with syrupy voices as they inserted a needle someplace I’ve forgotten. But before she could say “pink”, she slumped down into me like an analogy I refuse to consider and they all sprang into action, swiftly extracting her from my arms and pushing me out the door so fast my head was spinning. I, myself, could barely breathe as they gave me what my mom would call “the bum’s rush” and I found myself standing in the hallway with the door shut firmly between me and my baby thinking, “Don’t you want to know what my favorite color is?”
But let’s get started on these notes because this book drops a whole lot of interesting knowledge. I’ve never been happier to meet anyone than the 4 docs who gave me an epidural, all of whom were godsends in stage 3 transition labor but are mostly remembered by their crotches, since that’s the part of their body that presented itself to me as I lay there while my pain was erased. As DJ confirms, “Forty million people in the United States undergo anesthesia every year. It is the most frequently performed medical procedure that entails risk to the patient. The anesthesiologist is ubiquitous but largely invisible. Before the slash of the scalpel, the insensibility to pain is taken for granted. More people, up to a hundred million per year, seek relief from pain, both acute and chronic. Pain is the most common human health issue.”
Here are some of the historical notes, all of which I found fascinating. First of all, harken back to “the late 1600s when opium added to alcohol (laudanum) was introduced in the Western world.” Fast forward 2 centuries: “On October 16, 1846, Morton conducted his demonstration on a patient named Edward Gilbert Abbott in the operating room of the Massachusetts General Hospital….A month later, the term “anesthesia,” Greek for “without sensibility,” was coined in a letter to Morton by Oliver Wendell Holmes Sr.—the Boston poet, physician, and professor—and it stuck.”
I’ve long considered myself lucky to live in a time when we can be “without sensibility”, for which I give thanks every single time I go to the dentist. “Over 170 years ago, inhaling a gas was shown to render a person senseless and thereby allow invasive medical procedures.” I had an impacted permanent tooth, so my childhood was filled with what Dr. Moody called “sweet air”, as DJ describes: “Nitrous oxide, although not potent enough to use alone, is added because it provides a boost to the loss of sensation, and it does so without an unpleasant odor.” I can still conjure the taste and smell of that fun gas.
Further along, when my fifth baby, Jonah, was found to have no heartbeat after my placenta abrupted, I still had to labor and deliver him, a horrific experience. I was hemorrhaging internally while waiting for my cervix to dilate sufficiently to deliver a 7 pound baby and at one point during those too-many hours, my husband noticed that my blood pressure had dropped to 60/40 and I was looking like I was about to join Jonah. He sprinted out to the nurse’s station and they all rushed in along with a cardiologist who stuck a long needle into my broken heart, delivering this next drug appropriately lauded here by DJ, for which I probably owe my life today. “There’s one last item in my setup: the mother of all drugs, the resuscitator extraordinaire, the last-ditch effort to retrieve a life trying to end—epinephrine. It deserves a special place in my anesthesia nest—a place I call the “Oh Shit Shelf.” It’s on top of the anesthesia machine, immediately to the right of the flat-screen monitor. Whenever anyone in the room says “Oh shit,” I reflexively reach high and to my right, and grab the only syringe ever placed there, the epinephrine. I am the ultimate patient advocate, and my first thought jumps to a patient in jeopardy. Epinephrine is the single strongest heart-kicking drug I have. It bumps a slowing heart rate and increases a sagging blood pressure. Along with oxygen, epinephrine is the anesthesiologist’s life preserver.” A life trying to end. Sigh.
On a lighter note, this next bit reminds me of the 5 D’s in Dodgeball, from the movie of the same name which you should watch if you haven’t. “The term “anesthesia,” which means “without feeling,” doesn’t adequately encompass all of the goals of care. Since the discovery of ether, many adjunct medications have been added to the anesthesia gas to accomplish all-inclusive care. The effects that these side medications produce are what I call the “Five A’s of Anesthesia”:
• Anxiolysis, relieving stress created by an upcoming surgical procedure
• Amnesia, preventing memory formation during anesthesia care
• Analgesia, relieving pain during the procedure, but also considered beyond the procedure room to include postprocedure pain relief, acute (trauma) pain relief, and chronic pain relief
• Akinesia, preventing a patient’s movement during a procedure
• Areflexia, stopping adrenaline surge and swings in blood pressure and heart rate while under anesthesia
And here’s another A you should know about, “Today, there are over thirty Azepams to choose from, including the sleep-inducing—and sometimes sleepwalk-inducing—Ambien and Rohypnol, street-named “roofie,” otherwise known as a date rape drug.” I am certain this happened to me one night which shall not be named and I was suddenly and completely incapacitated, which was not good. Here, DJ discusses the complexities of consciousness. “We form memories while asleep, but not while anesthetized by volatile gas, and we lose awareness while we’re awake during daydreams, as well as under the influence of azepams. There’s always a risk that a patient will retain awareness somewhere along the process of anesthesia.” Which seems to contradict our first paragraph premise but there are exceptions to every rule, particularly in the practice of medicine.
Because I wrote a book called Breathe, I’m always interested in that very topic and here are some fun facts DJ imparts, “The average body contains over sixty thousand miles of conduit, blood vessels, that carry nutrients to and waste from all the cells of our bodies. The heart beats on average 115,000 times per day, transporting ninety-two hundred gallons of blood. In a day’s time, the average person takes over twenty-three thousand breaths.” 23,000. Woah.
And lest you think history has not been made in your own lifetime, consider this, “Although the call for standardized anesthesia records began in 1923, not until 1985 did standards for monitoring, including use of the ECG, become accepted by the American Society of Anesthesiologists.”
This seems like a good time for a vocabulary building interlude: “Iatrogenic”—derived from the Greek iatros (“physician”) and genic (“to be produced by”)—is a word that was developed less than a century ago to indicate something caused by a physician that has adverse effects.”
Burying two children is like being hit by lightning. Twice. When Bella was only months old, she had to have an MRI to check her brain for what was happily just fine but as I’ve already mentioned, to witness your baby being anesthetized is traumatic, regardless of what your favorite color is or the following comparisons DJ relates, “It is more probable to be struck by lightning than to die while under anesthesia. The risk of dying from anesthesia is less than one in a hundred thousand cases. It’s about the same risk as dying as a result of skydiving, participating in a triathlon, or riding a bike. Anesthesia is very safe. But anesthesiologists can never, ever let their guard down.” And neither can parents.
I have hypertension and have been on meds for about 2 decades. And now I know that I’m a PS2 patient. Huh. “A PS1 patient is healthy. A PS2 has a compensated health problem not impacting everyday life—high blood pressure controlled with medications, for example. Eighteen holes of golf presents no problem. A PS3 suffers from a life-altering condition, such as heart disease that makes it difficult to function normally—for instance, to walk up a flight of stairs. PS4 and PS5 patients are at risk of dying or are expected to die. Anesthesia risk rises as the PS number does.” Hoping I don’t need it any time sooner than never.
I found his discussion of heart transplants so very interesting. Consider these three:
“The heart is the most inspirational organ to observe, to touch, to feel. Nothing stirs my medical emotion more than watching the heart deep in the chest, lurching with every beat. Unlike any other organ, it’s always in motion, never resting. Its beat defines life.”
“In a twisted sense of the balance of life, for John to live, someone had to die. A viable, undamaged organ for transplant requires a quick strike to life, causing rapid brain death. The scenario almost always involves violence. The optimist views it as making the best of a horrible situation—saving one life instead of losing two.”
“The longest-surviving transplanted heart to date has beat a little over a billion times, or thirty years. Eight out of ten heart transplant recipients survive the first year. Most will survive for twenty years, or 750 million heartbeats. That’s a very large number, but it is far less than three billion, the number of heartbeats in a normal life. So, the transplanted heart is not a guarantee into old age. It is a lease on life that will need to be renewed. This is especially true for young recipients. The transplanted heart gradually develops narrowed blood vessels—a vasculopathy—a perverse injustice resulting from the same medications that prevent organ rejection. Heart failure eventually recurs.” A good reminder of the many areas of research and development we still need, like a better medication for this.
It’s also always good to be reminded that our teens and young adults have brains that are still developing, aptly described here: “Teens have pedal-to-the-metal accelerators, but they lack competent brakes. Subtle changes to the brain continue into the twenties, gradually containing the twitchy impulse control—or lack thereof—and the emotional volatility of the teen years.”
And this, about our pathetic health care system, directly contributing to the early death of this transplant recipient, Bandul, “The politicians decided that their generosity ended when kids were no longer kids. They defined that moment as the last day of the month of a child’s nineteenth birthday. So, Bandul was no longer provided his medications.” And tragedy struck.
I was heartened to read this next statement, an imperative cultural change that we in the stillbirth community are constantly striving to impart, “Mothers always know best. I was surprised by how blindly I had acted up to this point. When moms say something’s wrong, it’s true until proven otherwise. This is a belief I was taught early on.” Amen. It should be taught in medical school.
Shout out to Malcolm Gladwell here, “One day early in my career, he pulled me aside and advised me that it would take ten thousand anesthesia cases before I would understand the limits of my ability. To paraphrase Donald Rumsfeld: There are known knowns, and known unknowns, and then there are unknown unknowns. Frank taught me the value of recognizing and limiting the unknown unknowns.” Indeed. This is why medical research and development is imperative.
Having endured a medical malpractice lawsuit for Jonah’s death, I found this interesting, “Two times I have been accused of medical negligence, and both anger me. In both cases I was part of a team that tried to preserve a life, and both times I was soon dropped from the suit. But the accusation is enough to hurt, and regardless of the lack of proof, I still must list both cases when I apply for privileges anywhere.”
And when the shoe is on the other foot, I appreciated his candor regarding his own surgery when, as he writes, “a midcareer anesthesiologist became one of the forty million who receive anesthesia every year.” “I was caught on the unfamiliar side of an all-too-common scene, one that repeats itself across the country 150,000 times on an average day. Spouses, mates, parents, children, and friends exchange hugs and kisses with a loved one who is about to enter into an unknown, sequestered space—where senses are reversibly altered to allow a body to undergo an invasive and painful procedure out of medical necessity.”
And lest you think that Botany is for losers, consider this, “A large portion of my anesthesia tool chest is filled with pain relief drugs derived from plants. The poppy, the coca plant, birch bark, cannabis (as an anti-inflammatory), and coffee (for me, good effects on multiple organs and the downside not obvious).
I have long stated that the absence of pain is a beautiful thing, relief I was granted by the blessed epidural. So I echo DJ’s sentiment here, “Freedom from pain should be an undeniable human right in all places, under all conditions, and at all times.” Amen. Ditto for good health in general, but, sadly, we have a long way to go on both fronts. And, as a result of our inability to treat mental health in the same way we do physical health, we find ourselves in the midst of an opioid epidemic here in the land of the free and the brave. DJ pens, “And this is a craze, an epidemic: every eleven minutes a death by overdose occurs. More people die by overdose each year than by falls, car accidents, or gunshots.” That is a horrifying statistic. It has taken me many 11 minutes, many deaths by overdose, to write this review.
And while on the topic of this epidemic, DJ describes this: “Propofol provides two of the Five A’s: anxiolysis and amnesia. It provides no analgesia and actually burns on injection. Painful procedures require additional medications and techniques. Despite its short action, propofol is a dangerous drug, as evidenced by Michael Jackson’s death by overdose, a reminder that vigilance when altering alertness remains a necessity. The biggest advantage of this drug is that it speeds reentry. All the other drugs I use to treat anxiety and amnesia entail a hangover period, in which the patient feels altered and unable to perform normal tasks. With propofol, there is no hangover. Propofol allows consciousness to return rapidly and intact, with the added benefit of reducing postanesthesia nausea and vomiting.” Unless you’re in a hospital, just say no.
Okay. Read it.
K3
January 4, 2018
Fun listen (audiobook version), some interesting stories, and a good book on the generalities of Anesthesia and the practice thereof. Its a bit short, slightly under 6 hrs of audio. And it never goes very deep.
To me, the book was similar to if a younger person had gone up to this very knowledgeable doctor and asked to tell the story of what it is like to be an Anesthesia doc. It sums up the main points very nicely, and very digestable, but never goes super deep. In contrast to books by Marsh, Kalanthi, etc this book is more surface level. It is still very very good at it, and was a fun listen (especially the story regarding his non-human patient), and I can't say it is the wrong move for this book. It just seems a bit different in that regard.
To me, the book was similar to if a younger person had gone up to this very knowledgeable doctor and asked to tell the story of what it is like to be an Anesthesia doc. It sums up the main points very nicely, and very digestable, but never goes super deep. In contrast to books by Marsh, Kalanthi, etc this book is more surface level. It is still very very good at it, and was a fun listen (especially the story regarding his non-human patient), and I can't say it is the wrong move for this book. It just seems a bit different in that regard.
September 7, 2017
3.5 rounded up.
November 30, 2017
Personal memoir of the professional life of an academic anesthesiologist. I think it provides good insights from my standpoint as a non-anesthesiologist physician. It is truly your anesthesiologist hold your life in his hands during surgery, but in fact it is the surgeon who gets the recognition and credit for a successful procedure. In addition to the general reading public, I think this book would be particularly useful for someone considering going into that specialty.
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