Anesthesiology/bad prior experience with anesthesia---facing more surgery
Hi. I am a semi-retired MD who missed my own appendicitis symptoms 7 years ago and underwent general anesthesia as an add-on case for a ruptured appendix. Immediately post extubation, I developed POPE and had severe resp distress causing the appendix drain to retract into my abdomen, and I required oxygen, Lasix IVs and antibiotics and had a 7 day hospital stay instead of 3-4 days as initially planned. I had a breast Bx under MAC a year later, and the anesthesiologist in pre-op area was confrontational instead of reassuring when I specified that I would not want to be intubated unless a life-threatening complication arose that made intubation necessary. (the only good thing about the initial event was that I had a sleep study afterwards (my idea) and undiagnosed sleep apnea was recognized. I have done GREAT on CPAP since (I am not fat and have a small neck, but I have mild benign familial hyperextensibility (EHlers Danlos III) and my tissues sag, I guess). I am now facing elective over-due surgery to correct a foot deformity ---Hallux valgus and a hammer toe that rubs the top of my shoe. The surgery will be done by a very good orthopod at the same hospital, and it will be done under spinal, which should be safe. As the op date nears, I find that my BP rises and I get emotionally labile even talking about anesthesia. I think, that with my luck, I might encounter one of the 2 anesthesiologists with which I had trouble, and I do not feel I could let either of them tap me. During the first event, the anesthesia doc who dealt with me NEVER came by the floor to explain what had gone so wrong, and, when the resp distress started, I have a sharp memory of the anesthesia person at the foot of the bed, waving arms and imploring me to breathe, as I wheezed and peed on myself (the Versed was apparently not re-dosed in time to prevent the memory. ) I have requested a pre-surgical date anesthesia appt. I am afraid (even tho my internist and I went up on BP meds to hopefully prevent it) that I will arrive in pre-op with BP of 180/120 and the procedure will be cancelled. My original training was in Pediatrics, and I never really dealt with patients with PTSD, but I am beginning to think I may have a case of it. The hospital has become a teaching hospital now, and that may add to potential problems. So many of the anesthesia people I have met have been imperious and dismissive, that I am worried. I have thought about writing a first-hand account for the anesthesia journal about how problems in the OR can lead to very difficult future interactions with the patients who experience them. The original anesthesia doc patted me on the shoulder before the OR< and said"You are going to be in one of my rooms, and I am going to take really good care of you!" If that is ever said to me by anyone, I will run to the parking lot. I am not worried about pain but do hope that enough Versed or Benzos can be used to prevent much recall. Thank you for any input you may have. Thanks for letting me vent.
There are a couple of issues here that I will try to address. The first is the POPE (which is more often called NPPE or negative pressure pulmonary edema). It is generally caused by biting on the endotracheal tube during emergence while trying to breathe in. it is a relative rare complication but often not picked up without an x-ray. So the fat that the anesthesiologist did not pick up on it does not necessarily mean they were incompetent or ignoring you. It is usually self limiting and is treated conservatively with oxygen, Lasix and time. As for the breast biopsy issue, I think part of the problem may have been how you phrased your wishes. The biopsy could have been done under local or general with an LMA and I don't think the anesthesiologist would have a problem with that, but if you pin him to "only if I am about to die can you intubate me..." might put him on the defensive. As for the foot deformity problem, these are often done under an ankle block or a spinal and there is no reason to do them under general so there is no reason why the anesthesiologist will take issue with that. Finally the anesthesiologist who told you "You are going to be in one of my rooms...". While that sounds terrible, it really is full disclosure. Many anesthesia practices run with an anesthesiologist covering between 1 and 4 rooms staffed with CRNAs. The CRNAs are trained to perform the anesthetics under the physicians oversight and you are in good hands. While it would probably be better if he didn't say anything to you, it is better than lying and saying that he will be with you the whole time.
Now to the more important issue and that is the PTSD-like symptoms. These are definitely real and I have heard this complaint before. When you have your preoperative evaluation, sit down with the anesthesiologist and quietly explain the issues that you have had and the anxiety your are currently experiencing. Have he/she discuss the anesthetic options and agree in advance on that plan. That way, when you come in, your BP should be reasonable as there won't be the fear of the unknown. I am sorry that you had a bad experience with anesthesia in the past but the majority of anesthesiologists really do care about making the experience a positive one. The fact that the hospital is now a teaching center may actually work in your favor because you still get the expertise of the faculty while getting the interpersonal interactions with the residents.
Ronald Levy, MD
Professor of Anesthesiology