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手术麻醉失效留下的极端痛苦记忆

更新时间:2019/4/13 8:48:14 来源:纽约时报中文网 作者:佚名

What happens when anaesthesia fails
手术麻醉失效留下的极端痛苦记忆

It can be the smallest event that triggers Donna Penner’s traumatic memories of an operation she had more than ten years ago.

最微不足道的小事,也可能引发彭纳(Donna Penner)10多年前一次手术所造成的创伤记忆。

One day, for instance, she was waiting in the car as her daughter ran an errand, and realised that she was trapped inside. What might once have been a frustrating inconvenience sent her into a panic attack.

比如有一天,她在车里等女儿办事,发现自己被困在了车里。换作过去,这不过是个讨厌的麻烦,而今却导致她惊恐发作。

“I started screaming. I was flailing my arms, I was crying,” she says. “It just left me so shaken.” Even the wrong clothing can make her anxiety worse.

“我开始尖叫。挥舞双臂,连哭带喊,”她说。“我感到非常害怕。”甚至衣服不合适都会加重她的焦虑。

“Anything that’s tight around my neck is out of the question because it makes me feel like I’m suffocating,” says Penner, a 55-year-old from Altona in Manitoba, Canada.

彭纳55岁,来自加拿大马尼托巴省(Manitoba)的阿尔托纳(Altona),她说:“我的脖子绝对不能缠东西,那会让我感到窒息。”

Her panic attacks began after a small medical procedure that she had before her 45th birthday. She was working in the accountancy department of a local trucking company and had just celebrated the wedding of one of her daughters. But she had been having severe bleeding and pain during her period, and her family physician had suggested that they investigate the causes with exploratory surgery.

在45岁生日前夕,她做了一个小手术,之后就会出现惊恐发作。当时她在当地一家汽车运输公司的会计部工作,一个女儿刚刚结婚。她在经期一直伴有严重的出血和疼痛,家庭医生建议进行探知手术来查找病因。

It should have been a routine procedure, but, for reasons that are far from clear, the general anaesthetic failed. Rather than lying in peaceful oblivion, she woke up just before the surgeon made the first cut into her abdomen. With her body still paralysed by the anaesthetic drugs, she was unable to signal that anything was wrong.

这本是个常规手术,但不知何故,全身麻醉失效了。她并没有毫无知觉地平静躺在那里,在外科医生划向腹部第一刀前,她就醒了。由于身体仍然被麻醉药物麻痹,她无法示意出了问题。

She remained helpless on the operating table, in indescribable agony, as the surgeon probed her body. “I thought, ‘This is it, this is how I’m going to die, right here on the table, and my family will never know what my last few hours were like because no one’s even noticing what’s going on.’”

医生手术检查她的身体时,她一直无助地躺在手术台上,那种痛苦难以形容。“我想,我就这样死了,死在这张台子上,家人永远不会知道我最后几个小时是怎么过的,因为都没人注意到发生了什么。”

The lingering trauma still causes her to have “two or three nightmares each night”. Having been put on medical leave from her job, Penner has lost her financial independence. She suspects that she will never fully escape the effects of that day more than a decade ago. “It’s a life sentence.”

创伤依旧挥之不去,她“每晚都要做两、三场噩梦”。由于病休,彭纳失去了经济独立。她怀疑自己永远无法完全摆脱10多年前那天的影响。“这是一场无期徒刑。”

For years, anaesthesia awareness has been shrouded in mystery. Although extreme experiences like Penner’s are rare, there is now evidence that around 5% of people may wake up on the operating table – and possibly many more.

多年来,麻醉清醒一直是个未解之谜。虽然像彭纳这样的极端情况很少见,但现在有证据表明,大约5%的人可能会在手术台上醒来,数量也许还要更多。

Thanks to the amnesiac effects of the drugs, however, most of these people will be unable to remember anything about the event – and whether or not that is something we should be concerned about is both a practical and a philosophical question. It is all the more significant given just how often general anaesthesia is now used.

但好在麻醉药有遗忘作用,绝大多数人之后什么都不记得,但我们该不该关注麻醉清醒既是一个现实问题,也是一个哲学问题。全身麻醉现在很常见,这个问题因而显得愈发重要。

“Almost three million general anaesthetics happen each year in the UK alone,” says Peter Odor, a registrar at St George’s Hospital in London. “As a consequence, it is more probable than not that someone, somewhere in the world, right now is aware during their surgery.”

“仅在英国,每年就有近300万例全身麻醉,”伦敦圣乔治医院(St George's Hospital)的专科住院医生欧多尔(Peter Odor)说。“因此,在世界的某个地方,很可能当下就有病人正在清醒着做手术。”

We once knew surprisingly little about why anaesthesia works. Now, however, researchers are striving to understand more about the nature of going under and the circumstances in which anaesthesia doesn’t work, in the hope of making advances that might reduce the risk of anaesthesia awareness. And, with a greater understanding of the anaesthetised state, we may even be able to turn a rudimentary awareness to our advantage – in the form of medical hypnosis.

过去,我们对麻醉原理知之甚少。现在,研究人员主要是去了解失去知觉的本质,以及麻醉失效后的情况,希望能够取得进展,降低麻醉清醒的风险。而且,随着对麻醉状态的了解更加深入,我们甚至可以对人最基本的意识通过医学催眠的方式加以利用。

Let’s be clear: anaesthesia is a medical miracle. Since at least the time of the Ancient Greeks, physicians and medicine men had hunted for a good way to ease the pain of medical procedures. While drugs such as alcohol, opium and even hemlock could act as sedatives, their efficacy was unreliable; most patients did not escape the torture.

让我们明确一点:麻醉是个医学奇迹。至少从古希腊时代起,医生和药师就一直在寻找减轻手术疼痛的好方法。虽然酒精、鸦片甚至毒芹等药物都可以起到镇静剂的作用,但效果并不可靠,大多数病人手术时还是备受疼痛折磨。

By the 1840s, scientists had discovered various gases that appeared to have sedative effects. One of these, sulphuric ether, had attracted the particular attention of a dentist based in Boston who put it to the test in a public demonstration at the Massachusetts General Hospital in 1846. Although the patient was still able to mutter half-coherent thoughts, he reportedly felt no pain, just the faint sense of his skin being “scratched with a hoe”.

到了19世纪40年代,科学家们发现许多气体似乎有镇静作用。硫醚就是其中一种,它引起了波士顿一位牙医的关注,并于1846年在麻省总医院公开进行了实验。尽管病人仍然能够不太清晰地作出并不完全相关的应答,但不觉得疼,只是轻微地感到皮肤在被“锄头铲”。

The news of the demonstration soon spread throughout the medical establishment, heralding the start of the anaesthetic era. With the subsequent discovery of even more effective anaesthetic agents such as chloroform, the agony of the surgical knife seemed to be a thing of the past.

这次公开手术的消息很快就在医学界传开了,它预示着麻醉时代的到来。后来又发现了氯仿等更有效的麻醉剂,手术刀的痛苦似乎成了过去。

General anaesthesia creates a controlled unconsciousness that is deeper and more detached from reality even than sleep. Today, anaesthetists have a wide range of pain-killing and consciousness-reducing drugs at their disposal, and the exact choice will depend on the procedure and the patient’s particular needs.

全身麻醉会产生一种可控的无意识状态,比睡眠更深层、更远离现实。今天,麻醉师可以选用各种各样止痛和模糊意识的药物,究竟怎么选择则取决于手术和病人的特殊需要。

Often, the aim is not to produce a loss of consciousness but simply to remove the sensation from a particular part of the body. So-called “regional anaesthetics” include spinal and epidural anaesthetics, both of which are delivered between the bones of your back to numb the lower half of your body. These are commonly used during childbirth, bladder operations and hip replacements.

通常,麻醉不是为了完全丧失意识,而仅仅是消除身体特定部位的感觉。所谓的“局部麻醉”包括脊髓麻醉和硬膜外麻醉,都是在背部的骨头之间给药,麻痹下半身。这两种麻醉方法通常用于分娩、膀胱手术和髋关节置换。

You may also be given a sedative, which produces a relaxed, sleepy state. However, it does not fully eliminate your awareness.

也有可能用镇静剂,让你放松昏昏欲睡,但不会完全消除你的意识。

General anaesthesia, in contrast, aims to do just that, creating an unresponsive drug-induced coma or controlled unconsciousness that is deeper and more detached from reality even than sleep, with no memories of any events during that period. As Robert Sanders, an anaesthetist at the University of Wisconsin–Madison, puts it: “We’ve apparently ablated this period of time from that person’s experience.” (During the operation, the patient may also be given painkillers to ease their recovery when they wake up from surgery.)

而全麻就是要让人意识全无,用药物引起毫无反应的昏迷,或是可控的无意识状态,甚至比睡眠更深层、更远离现实,病人对麻醉期间的所有事情都没有记忆。正如威斯康星大学麦迪逊分校(University of Wisconsin-Madison)的麻醉师桑德斯(Robert Sanders)所言:“我们显然是从病人的经历中摘除了这段时间。”(手术中可能还会给病人用止痛药,以减轻术后醒来时的疼痛。)

We still don’t know exactly why anaesthetic agents dim our consciousness, but they are thought to interfere with various brain chemicals called neurotransmitters. These chemicals turn up or turn down the activity of neurons, particularly the widespread communication between different brain regions.

我们仍不清楚麻醉剂为什么会使我们意识模糊,但据信它们会干扰大脑中被称为神经递质的各种化学物质。这些化学物质会增加或者减少神经元的活动,尤其是影响大脑不同区域之间的广泛交流。

Propofol, for instance – a milky-white fluid used in general anaesthetics and some types of sedation – seems to amplify the effects of GABA, an inhibitor that damps down activity in certain areas of the brain, as well as communication between them.

以异丙酚为例,这种乳白色的液体用于全麻和某些镇静功效,似乎会增强γ-氨基丁酸的作用——这是一种抑制剂,能阻碍大脑某些区域的活动以及区域之间的交流。

Sanders’s colleagues recently used a form of non-invasive brain stimulation to demonstrate this principle in action, with propofol silencing the waves of activity you would normally see spreading across the brain in response to the stimulation.

桑德斯的同事们最近利用一种无创的大脑刺激实际证明了这一原理,使用异丙酚抑制了大脑在应对这些刺激时通常会形成的波动。

“It’s very possible that anaesthesia interferes with that ascending transmission of information,” he says. And without it, the mind temporarily disintegrates, becoming a blank screen with no ability to process or respond to the body’s signals.

“麻醉很可能会干扰信息从身体向大脑的传递,”他说。没了这种自下而上的信息传递,大脑就会暂时死机,成了一个空白的屏幕,无法处理或回应身体的信号。

In the clinic, there are many complicating factors to consider, of course. An anaesthetist may choose to use one drug to induce the temporary coma and another to maintain it, and they need to consider many factors – such as the patient’s age and weight, whether they smoke or take drugs, the nature of their illness – to determine the doses.

当然,在临床中还有许多复杂因素需要考虑。麻醉师可能会选择一种药物来诱导暂时性昏迷,但用另一种药物来维持,考虑因素还有许多,例如患者的年龄和体重,是否吸烟和使用毒品,还有疾病的性质等等,以此来决定剂量。

Many procedures also use muscle relaxants. For example, nearly half of general anaesthetics administered in the UK included neuromuscular blockers. These drugs temporarily paralyse the body, preventing spasms and reflexes that could interfere with the surgery.

许多手术也会使用肌肉松弛剂。比如,英国近一半的全麻会用到神经肌肉阻滞药。这些药物会暂时麻痹身体,防止出现痉挛和反射现象干扰手术。

Neuromuscular blockers can also ease the insertion of a tube through the windpipe, which can be used to ensure the airway remains open as well as to deliver oxygen and drugs, and to prevent stomach acid from entering the lungs. If the paralytic agents also stop muscles in the diaphragm and abdomen from moving, however, the patient’s breathing must be assisted artificially with a ventilator.

神经肌肉阻滞药还可以减轻气管插管的难度。插管可以确保气道畅通,输送氧气和药物,同时防止胃酸进入肺部。然而,如果麻醉剂也停止了膈肌和腹部肌肉的运动,则必须上呼吸机,人工辅助病人呼吸。

This all makes anaesthesia as much art as science, and in the vast majority of cases, it works astonishingly well. More than 170 years after its first public demonstration, anaesthetists across the world plunge millions of people each year into comas and then bring them out safely. This doesn’t just reduce patients’ immediate suffering; many of the most invasive lifesaving procedures would simply not be possible without good general anaesthesia.

这一切都使得麻醉既是艺术也是科学,而且在绝大多数情况下效果都很好。自从第一次公开展示麻醉的使用后,170多年里,全世界的麻醉师每年将数百万人送入昏迷状态,然后又将他们安全唤醒。这不仅减轻了病人手术时的痛苦,全麻还令许多大创面的救命手术得以实施。

But as with any medical procedure, there can be complicating factors. Some people may have a naturally higher threshold for anaesthesia, meaning that the drugs don’t reduce the brain’s activity enough to dim the light of consciousness.

但与所有的医疗操作一样,麻醉存在一些复杂因素。有些人可能天生麻醉阈值较高,也就是说,麻醉药对大脑活动的减少程度还不足以使他们失去意识。

In some cases, such as injuries involving heavy bleeding, an anaesthetist may be forced to use a lower dose of the anaesthetic for the patient’s own safety.

在某些情况下,比如受伤后大量出血,麻醉师为了保证病人安全,可能得少用一些麻醉剂。

It may also be difficult to time the effects of the different drugs, to ensure that the so-called induction dose (which gets you to sleep) doesn’t fade before the maintenance dose (to keep you unconscious) kicks in.

不同药物起作用的时间也很难确定,要确保诱导计量(让你入睡)不会在维持剂量(让你保持无意识状态)起作用之前失效。

In some situations, you might be able to raise or lower your limb, or even speak, to show the anaesthetic is not working before the surgeon picks up their scalpel. But if you have also been given neuromuscular blockers, that won’t be possible. The unfortunate result is that a small proportion of people may lie awake for part or all of their surgery without any ability to signal their distress.

有些时候,在外科医生拿起手术刀之前,你也许还能抬起或放下手脚,甚至能说话,来表明麻醉没有发挥作用。但如果你同时上了神经肌肉阻滞药,那就不可能了。如此一来,很不幸会有一小部分人在手术部分或是整个过程中是清醒地躺在那里,却无法表达自己的痛苦。

Penner talks about her own experience, during a lengthy telephone conversation from her home in Canada.

彭纳在加拿大的家中与我用电话谈了很久,讲述了她的经历。

She says that she had felt anxious in the run-up to the operation, but she had had general anaesthetic before without any serious problems. She was wheeled into the operating theatre, placed on the operating table, and received the first dose of anaesthesia. She soon drifted off to sleep, thinking, “Here I go.”

她说在准备手术时就感到焦虑,但以前做过全麻,没什么大问题。她被推进手术室,被放在手术台上,打了第一剂麻醉。她很快就睡着了,心想:“开始了。”

When she woke up, she could hear the nurses buzzing around the table, and she felt someone scrubbing at her abdomen – but she assumed that the operation was over and they were just clearing up. “I was thinking, ‘Oh boy, you were anxious for no reason.’” It was only once she heard the surgeon asking the nurse for a scalpel that the truth suddenly dawned on her: the operation wasn’t over. It hadn’t even begun.

当她醒来时,能听到护士们围着手术台说话,感觉到有人在擦洗她的腹部——她以为手术已经结束了正在清理。“我当时想,‘哎呀,之前的焦虑真是没理由。’”直到听见医生找护士要手术刀时她才恍然大悟:手术还没结束。甚至还没开始。

The next thing she knew, she felt the blade of his knife against her belly as he made his first incision, leading to excruciating pain.

接着,她感觉到医生划下第一刀,刀刃抵住了她的肚子,然后是一阵剧疼。

She tried to sit up and to speak – but thanks to a neuromuscular blocker, her body was paralysed. “I felt so… so powerless. There was just nothing I could do. I couldn’t move, couldn’t scream, couldn’t open my eyes,” she says. “I tried to cry just to get tears rolling down my cheeks, thinking that they would notice that and notice that something was going on. But I couldn’t make tears.”

她试图坐起来说话,但由于用了神经肌肉阻滞药,她的身体动弹不得。“我感到如此……如此无力。什么都做不了。动也动不得,叫也叫不出,眼睛也睁不开,”她说。“我尝试去哭,想让眼泪从脸颊滚下来,这样他们就会注意到,就会发现问题。但我无法流泪。”

The frustration was immense. “It felt like someone was sitting on me and holding me down and there was absolutely nothing I could do.”

那种挫败感犹如泰山压顶。“像是有人坐在我身上,压着我,我却束手无策。”

Eventually, she tried to focus all her attention on moving one foot, which she managed to wiggle very slightly – and felt astonishing relief when one of the nurses placed his hand over it. Before she could move it again, however, the nurse had let go. She tried a total of three times, all with the same result. “It was very frustrating for me knowing that was the only way to communicate and it wasn’t working.”

最后,她试着把全部注意力集中去移动一只脚,并稍微晃动了一下,一个护士把手放在了她脚上,她大感欣慰。可还没等再动,护士就松开了手。她总共试了三次,结果都一样。“我知道这是唯一的沟通方式,但却行不通,这让我非常灰心。”

Penner’s torment should have finished after the surgeon had ended his work. But as the neuromuscular blockers began to wear off, she started to move her tongue around the tube stuck down her throat; it was a way, she thought, of signalling to the staff that she was awake.

医生做完手术后彭纳的痛苦应该结束了。但随着神经肌肉阻滞药逐渐失效,她开始用舌头绕着卡在喉咙里的管子动,想以此向医生护士示意她在醒着。

Unfortunately, the staff misread her attempts at communication, and began to withdraw the tube prematurely, before the paralytic agent had faded enough for her lungs to be able to operate on their own. “So here I was lying on the table and he took away my life support, my oxygen, I could not take a breath,” Penner says. She assumed she would die.

不幸的是,医生护士误解了她的意思,过早地取出了管子,当时麻醉还有一定作用,她的肺还不能自行工作。“我躺在手术台上,医生拿走了我的生命保障,我的氧气,我无法呼吸,”彭纳说。她以为自己必死无疑。

At this point, the operating room began to feel more distant, as she felt her mind escape in an out-of-body experience. A committed Christian, she says she felt the presence of God with her. It was only after the staff restored her oxygen supply that she drifted back into the operating room, to wake, crying.

这时,手术室变得愈发遥远,她感到自己灵魂出窍。身为一名虔诚的基督徒,她说感到上帝与她同在。直到医务人员恢复了她的供氧,她才飘回手术室,哭着醒来。

That pain, the fear, the sense of absolute helplessness, all still linger to this day.

那种痛苦,那种恐惧,那种彻头彻尾无助的感觉,直到今天仍然挥之不去。

“It’s hard to sit at home here and watch all the neighbours hurrying out of their house in the morning, jump in their cars, and go off to work, and I can’t.”

“坐在家里,看着邻居们早上匆匆走出家门,跳上车去上班,自己却做不到,真的太难受了。”

Various projects around the world have attempted to document experiences like Penner’s, but the Anesthesia Awareness Registry at the University of Washington, Seattle, offers some of the most detailed analyses. Founded in 2007, it has now collected more than 340 reports – most from North America – and although these reports are confidential, some details have been published, and they make illuminating reading.

世界各地有许多项目都在记录彭纳这样的经历,西雅图华盛顿大学(University of Washington)的麻醉清醒登记项目有一些案例分析最为详细。这个项目始于2007年,目前已收集了340多份报告,大部分来自北美。报告都是保密的,但公开了一些细节,很有启发性。

Nearly all the patients included said they heard voices or other sounds under general anaesthesia (patients’ eyes are typically closed during surgery so visual experiences tend to be less common).

几乎所有患者都表示,他们在全麻状态下听到了人说话的声音或者其他声响(患者的眼睛在手术期间是闭上的,所以往往不会看到东西)。

“I heard the type of music and tried to figure why my surgeon chose that,” one patient told the registry.

“我听到了音乐,在想医生为什么选了这种类型,”一位病人向该项目表示。

“I heard several voices around me,” another reported. “They seemed to be panicking. I heard them say they were losing me.”

“我听到周围有很多声音,”另一个病人说。“他们似乎很慌张。我听到他们说我不行了。”

As you might expect, a large majority of the accounts – more than 70% – also contain reports of pain. “I felt the sting and burning sensation of four incisions being made, like a sharp knife cutting a finger,” wrote one. “Then searing, unbearable pain.”

正如你所料,绝大多数报告——超过七成都提到了疼痛。“我感到有四刀,那种刺痛和灼烧感,就像一把锋利的刀子在割手指,”一个病人写道。“然后是灼热,难以忍受的痛苦。”

“There were two parts I remember quite clearly,” wrote a patent who had had a wide hole made in his femur. “I heard the drill, felt the pain, and felt the vibration all the way up to my hip. The next part was the movement of my leg and the pounding of the ‘nail’.” The pain, he said, was “unlike anything I thought possible”.

一名在股骨上钻了个大洞的病人写道:“有两部分我记得很清楚,我听到钻子的声音,感到疼痛,一直到臀部都能感到震动。另一部分是腿在动,以及感到在敲‘钉子’。” 他说那种痛苦“超出想象”。

It is the paralysing effects of the muscle blockers that many find most distressing, however. For one thing, it produces the sensation that you are not breathing – which one patient described as “too horrible to endure”.

但令很多人最痛苦的,是肌肉阻滞药造成的瘫痪。一方面,它让你觉得没在呼吸——有位患者形容这种感觉“可怕得难以忍受”。

Then there’s the helplessness. Another patient noted: “I was screaming in my head things like ‘don’t they know I’m awake, open your eyes to signal them’.”

其次是无助感。另一名患者指出:“我在脑海中大喊,像是‘他们不知道我醒着吗,睁开眼睛让他们知道’。”

To make matters worse, all of this panic can be compounded by a lack of understanding of why they are awake but unable to move.

更糟糕的是,因为他们不知道自己为什么醒着却动弹不得,因此更加恐慌。

“They have no reference point to say why is this happening,” says Christopher Kent at the University of Washington, who co-authored the paper about these accounts. The result, he says, is that many patients come to fear that they are dying. “Those are the worst of the anaesthesia experiences.”

“他们没有参照,不知道为什么会发生这种情况,”华盛顿大学的肯特(Christopher Kent)与人合著了相关的论文,他说,许多患者担心自己快要死了。“那些都是最糟糕的麻醉经历。”

Estimates of how often anaesthesia awareness happens have varied depending on the methods used, but those relying on patient reports had tended to suggest it was very rare indeed.

评估方法不同,对麻醉清醒发生的频率估算也就不同,但基于患者报告进行的估算认为这种情况非常罕见。

One of the largest and most thorough investigations was the fifth National Audit Project carried out by British and Irish anaesthetists’ associations, in which every public hospital in the UK and Ireland had to report any incidents of awareness for a year. The results, published in 2014, found that the overall prevalence was just 1 in 19,000 patients undergoing anaesthesia. The figure was higher – around 1 in 8,000 – if the anaesthesia included paralysing drugs, which is to be expected, since they prevent the patient from alerting the anaesthetist that there is a problem before it is too late.

其中规模最大、最彻底的一次调查,是英国和爱尔兰的麻醉师协会开展的第五次全国审计,一年内,英国和爱尔兰的每家公立医院都必须报告所有的麻醉清醒事件。调查结果2014年发表,发现在接受麻醉的病人当中发生的概率为1.9万分之一。如果麻醉包括瘫痪药物,这个数字会更高,约为8000分之一。这很正常,因为瘫痪药物令患者无法及时提醒麻醉师出了问题。

These low numbers were comforting news. As the media reported at the time, you were more likely to die during surgery than to become aware during the operation, confirming many doctors’ suspicions that this was a very remote risk.

比例不高是个令人欣慰的消息。正如媒体当时所报道的,你在手术中死亡的风险比醒过来的风险要高得多,许多医生认为麻醉清醒的风险微乎其微,数字也证明了这一点。

Unfortunately, these figures are probably underestimates, as Odor explains to me at St George’s Hospital in London. For one thing, the National Audit Project relied on patients themselves reporting directly to the hospital – but many people may feel unable or unwilling to come forward, and would instead prefer to just put the experience behind them.

但可惜,正如伦敦圣乔治医院的欧多尔向我所说,数字很可能被低估了。一方面,全国审计是靠患者自己直接向医院报告,许多人可能感到无法或者不愿意站出来,宁愿把这件事抛到脑后。

There are also the amnesiac effects of the drugs themselves. “Anaesthetic drugs disrupt your ability to encode a memory,” said Odor. “And the dose that you give to obliterate memories is lower than that you need to obliterate consciousness. So memory goes well before consciousness goes.”

此外还有药物本身的遗忘作用。“麻醉药会破坏记忆能力,”欧多尔说。“消除记忆所需要的剂量比消除意识要少。因此,在意识消失之前,记忆就已经没了踪影。”

This suggests many more people might be conscious during surgery, but they simply can’t remember it afterwards.

这表明,在手术过程中有更多的人是有意识的,只是他们不记得了。

To investigate this phenomenon, researchers are using what they call the isolated forearm technique. During the induction of the anaesthesia, the staff place a cuff around the patient’s upper arm that delays the passage of the neuromuscular agent through the arm. This means that, for a brief period, the patient is still able to move their hand. So, a member of staff could ask them to squeeze their hand in response to two questions: whether they were still aware, and, if so, whether they felt any pain.

为了研究麻醉清醒,研究人员正在使用一种名为前臂孤立的技术。在麻醉诱导期,医务人员给患者的大臂戴上一个袖套,延迟神经肌肉阻滞药物通过手臂的时间。在一小段时间内,患者的手依然能动。医务人员可以让患者通过握拳的方式来回答两个问题:是否仍然清醒,如果还清醒,是否感到疼痛。

In the largest study of this kind to date, Robert Sanders at the University of Wisconsin–Madison recently collaborated with colleagues at six hospitals in the US, Europe and New Zealand. Of the 260 patients studied, 4.6% responded to the experimenters’ first question, about awareness.

在迄今为止规模最大的相关研究中,威斯康星大学麦迪逊分校的桑德斯最近与美国、欧洲和新西兰六家医院的同行合作,在参与研究的260名患者中,4.6%的人对测试者第一个关于意识的问题有所回应。

That is hundreds of times greater than the rate of remembered awareness events that had been noted in the National Audit Project. And around four in 10 of those patients who did respond with the hand squeeze – 1.9% across the whole group – also reported feeling pain in the experimenters’ second question.

这比全国审计中对麻醉清醒有记忆的发生率高出了数百倍。而在有握拳反应的人中,约有四成(占所有被试对象的1.9%)的人对第二个问题表示感到了疼痛。

Ethical quandaries

伦理难题

These results raise some ethical quandaries. “Whenever I talk to the trainees I talk about the philosophical element to this,” says Sanders. “If the patient doesn’t remember, is it concerning?”

这些结果引发了一些伦理难题。桑德斯说:“每当我和实习生谈起都会聊到其中的哲学问题,如果病人不记得,还要考虑吗?”

Sanders says that there’s no evidence that the patients who respond during the isolated forearm experiments, but fail to remember the experience later, do go on to develop PTSD or other psychological issues like Donna Penner. And without those long-term consequences, you might conclude that the momentary awareness is unfortunate, but unalarming.

桑德斯说,如果患者在前臂孤立反应中有反应但事后会遗忘,没有证据表明他们之后会出现创伤后应激障碍或类似彭纳那样的心理问题。如果没有这些长期后果,似乎表示手术中短暂有意识是不幸的,但也不用太担忧。

Yet the study does make him uneasy, and so he conducted a survey to gather the public’s views on the matter. Opinions were mixed. “Most people didn’t think that amnesia alone is sufficient – but a surprisingly large minority thought that as long as you didn’t remember the event, it’s OK,” Sanders says.

然而,这项研究确实让他感到不安,于是他又调查收集了公众对此事的看法。大家的意见不一。“大多数认为只是因为不记得就不去考虑理由并不充分——只有很少一部分人认为不记得就没关系。”桑德斯说。

“My view is that the patient is expecting to be unconscious, and, as a researcher who wants to understand the mechanisms at play, but also a clinician who wants to deliver high-quality care and meet the expectations of the patient, we are duty-bound to understand this balance and to find out the true rates and the true impact of those events, whether they have any impact or not, and the ways we can curtail them.”

“我认为,患者的预期是失去知觉,而且,作为一名想要了解其中机制的研究者,以及希望提供高护理质量并达到病患期望的临床医生,无论麻醉清醒有没有影响,我们都有责任去弄懂麻醉和清醒的关系,确定真实的发生率,真正的影响,以及如何减少这种情况的发生。”

Given that the vast majority of patients will emerge from general anaesthesia without traumatic memories, there is the danger that reports of anaesthesia awareness – including this one – will needlessly increase anxiety before operations.

鉴于绝大多数病人全麻苏醒后都没有创伤记忆,有关麻醉清醒的研究报告(包括本文)可能将不必要地增加患者在手术前的焦虑。

In the worst-case scenario, those fears could even prevent someone from having an essential medical procedure. Certainly, anaesthetists such as Sanders have emphasised that the risks of explicit recall are small, but if you are anxious you should talk to the hospital staff about your concerns.

最严重时,这些焦虑担心甚至可能让人不愿意去做必要的手术。当然,包括桑德斯在内的麻醉师都强调,能够记得在麻醉中有意识的风险很低,但如果你感到焦虑,就应该和医务人员交流你的担忧。

But there are, nevertheless, strong arguments for making this phenomenon more widely known. For instance, as the reports from the University of Washington’s registry show, some patients’ distress was amplified by their lack of understanding of what was happening. They assumed that their awareness was a sign that they were dying. Perhaps if they had known the risk beforehand, that panic might have been assuaged.

但是,也有充分的理由要让麻醉清醒更加广为人知。正如华盛顿大学麻醉清醒登记项目的报告所显示,一些患者因为对所发生的事情缺乏了解因而更加痛苦。他们认为清醒是即将死亡的标志。如果他们事先知道风险,也许就不会那么恐慌。

A better understanding of anaesthesia awareness might also help medical staff to deal with patients who have experienced this trauma. Many – including Penner – have felt that their accounts were misunderstood or simply dismissed by medical professionals.

更好地理解麻醉清醒也能帮助医务人员去处理经历过这种创伤的病人。包括彭纳在内的许多人认为,他们的说法被专业医学人士所误解,或者干脆被忽视。

The Washington registry, for instance, found that 75% of those who had reported awareness were unsatisfied with the response from medical staff, with 51% saying that neither the anaesthetist nor the surgeon expressed sympathy for their experience. Overall, just 10% received an apology, and only 15% were referred for counselling to help them to deal with the trauma.

比如该登记项目发现,有麻醉清醒经历的人当中,75%的人不满医务人员的处理,51%的人说麻醉师和外科医生并没有对他们的经历表示同情。总共只有10%的人接到了道歉,仅仅15%的人被转介给咨询医生接受心理创伤的治疗。

Penner says that many of the staff at her hospital seemed completely bewildered by her trauma. As she came around, she tried to explain to the nurses what had happened to her, but they just stood in silence, she says.

彭纳说,她做手术的那间医院,许多医务人员似乎完全不理解她的创伤。她说,苏醒后,她曾试图向护士们说明发生了什么,但他们只是一言不发地站在那里。

“I’ll never forget their expressions – it was like they were in shock.” She puts this down to a lack of education and understanding of the phenomenon. “They don’t know how to handle this kind of a situation.”

“我永远不会忘记他们的表情,像是受到了惊吓。”她将此归因于缺乏对这一现象的学习和理解。“他们不知道要如何处理这种情况。”

Having gained strength in the years following the trauma, Penner is now trying to remedy the problem. She is working with Canadian universities to educate doctors about the risks of anaesthesia awareness and the best ways to treat patients. “I want them to be prepared, because when things go wrong you need to know how you are going to react to the patient, because that is crucial to the patient’s recovery process.”

创伤后的几年里,彭纳逐渐坚强起来,现在正尝试着解决这个问题。她正在与加拿大的大学合作,告知医生麻醉清醒的风险,以及处理这种病人的最佳手段。“我希望他们能做好准备,出问题的时候需要知道如何处理病人,这对于病人的康复至关重要。”

The ultimate goal, though, is to prevent these traumatic experiences from occurring in the first place, with studies using the isolated forearm technique helping to identify the best procedures to ensure unconsciousness. “There could be specific combinations of drugs that could produce the right blend of anaesthesia to insulate people from the external sensory world a bit better,” Sanders says.

最终的目标是让这些创伤性经历根本不要出现,使用前臂孤立技术进行的研究有助于找到最适合的方式,确保病人是无意识的。桑德斯说:“可能会有特定的药物组合能搭配出正确的麻醉剂,更好地将病人与外部感官世界相隔离。”

There is even a chance that, as our understanding of the anaesthetised state deepens, we might be able to turn rudimentary unconscious responsiveness during surgery to our advantage. Certain forms of medical hypnosis have been found to have a real effect on patients’ experiences in controlled clinical trials – and the anaesthetic state could be the perfect time to put it into practice.

随着不断加深对麻醉状态的理解,我们甚至有可能对手术过程中最基本的意识反应加以利用。在对照临床试验中,已经发现某些形式的药物催眠对患者的体验有实际影响,而麻醉状态可能是实施催眠的最佳时机。

Although widespread signalling across the brain appears to be impaired when people are under general anaesthesia, there is evidence that certain areas – including the auditory cortex – remain responsive, suggesting that medical staff might be able to send suggestions and encouragement, while a patient is unconscious, to reduce their pain after surgery.

尽管在全麻状态下,大脑中的许多信号传递都会受损,但有证据表明,某些区域——包括听觉皮层——还有反应,这表明医务人员可以在病人无意识的状态下给予建议和鼓励,以减少术后疼痛。

Studies investigating this possibility are few, but Jenny Rosendahl, at Jena University Hospital in Germany, and her colleagues have attempted to gather all the evidence to date. Their meta-analysis showed a small but significant improvement in the patients’ ratings of post-operative nausea and vomiting, and less use of morphine after the operation.

这方面的研究还很少,但德国耶拿大学医院的罗森达尔(Jenny Rosendahl)和同事们已经收集了迄今为止所有的资料。他们的荟萃分析显示,这样做能够改善患者术后恶心呕吐的情况,也可以减少吗啡的用量,改善虽不明显但却意义重大。

Clearly, no one is suggesting that you would keep a patient fully aware on purpose, but perhaps one day more anaesthetists will be able to make use of the brain’s ability to absorb information on the operating table. It is an exciting thought that the words we hear during this mysterious twilight zone could have a lasting effect on our recovery.

当然不是故意要让病人保持完全清醒,但或许有一天,更多的麻醉师能够利用大脑在手术台上吸收信息的能力。在这个神秘朦胧地带听到的话可能会给病人的康复带来持久性影响,想想就兴奋。

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