Not that Sort of Eye Disease in Research

You’d think that a humble anaesthetist would be happy. A really big study on anaesthesia and awareness gets released in the media and gets people talking. About time. No more of people asking to “See the Doctor” when you go for the preoperative review. Less Sudoku jokes. Except then I read this coverage in The Guardian.

Shock. Horror. Calamity. People are sometimes aware when they should be super unconscious during surgery.

Except that reporting is sort of baloney. The report has been messed up by another example of “I” disease, where a very clever research team have let it be about them and not the problem of interest. It’s a problem in other branches of medicine. You can usually spot it when a medico uses the word “I” too much when discussing a story that should be about a patient.

Here is my reaction in snow leopard form. [Credit: Tambako the Jaguar, CC 2.0]

Here is my reaction in snow leopard form. [Credit: Tambako the Jaguar, CC 2.0]

Why the snarl?

There’s a particular section of that report that really did it. It’s around the point where the lead author quoted comes up with this:
He said: “For a long time it has been a discussion on the periphery. This is real. We need to understand it and tackle it.”

I get it. You run a big and impressive study. You want to get word out there. It’s a chance to say something. It’s hard not to try and make it sound that little bit more seductive. After all, you wouldn’t want to get trumped by surfing dogs on the news. It’s so tempting to make sure the release sounds that little bit more sensational.

Then you end up with a whole lot of misrepresentation.

The thing is, awareness is not at all a peripheral topic in anaesthesia. Generations of anaesthetists have sweated over it. It is a core part of what anaesthetists offer patients when they deliver general anaesthesia. It’s a topic that has been researched extensively (both the protocol and summary paper under discussion have more than 40 references at the back, though not every one is specific to awareness). There are a variety of monitors that have been trialled as a means of preventing awareness. Sounds like the sort of behaviour of those trying to ignore the whole thing, right? (It’s even inspired blog posts from obscure people.)

Read that report and you’d think the profession hadn’t realised this was a thing that was a thing. After the opening we hear about a string of things that have been “recognised officially for the first time”. Apparently patients can be aware (not news). Some patients are traumatised and some are not (not news). Having medicine on board that prevents you moving increases your risk (not news). Drug errors are implicated (not news).

It’s hardly the first time there’s been a bit of the sensational in a bit of coverage on something related to anaesthesia. It certainly isn’t as extreme as this special effort from 2005, where one of the commonly used co-agents was fingered as somewhere between cyanide and arsenic. A few years later the follow-up study showed that all the earlier stuff claimed was actually not an issue.

Excellent. The self-correcting virtuous circle of research strikes again, right? Slight pity about the impact on all the doctors and patients in between times of course.

Why the mankini?

So why try to dress it up as something memorable? Maybe they were misrepresented and really just wanted to stress that it is a problem that needs addressing (it is). Maybe they wanted to be able to say “I” just a few extra times.

The thing is there’s lots of interesting stuff in the study they could have focussed on. They sampled a period including nearly 3 million anaesthetics, utilising 296 local site co-ordinators with a 100% response rate. That’s a pretty astonishing effort and makes it about as big as you could hope for when it comes to sample size.

They chose to include only self-reported cases of possible awareness which is a slightly different method to that frequently used in other awareness research. Often an interview technique is used where patients are specifically quizzed over a bit of time which might well influence people’s recall of events. This may partly explain the overall lower reported incidence of awareness here, which for this study is around 1 in 20 000 anaesthetics (down from the oft quoted 1-2 per 1000). Even on a pessimistic interpretation, you’d only have a rate of about 1 in 6000 anaesthetics.

They confirmed that having an anaesthetic to deliver a baby or for heart surgery can still be considered high risk situations, but kids having surgery were a lower risk group using this study methodology. All of these things are worth a chat. So why make it sound like no researchers came before and anaesthetists didn’t really give a damn?

It’s not just sleepy doctors

Maybe there are bigger issues here. A recent excellent piece on the risks of blowing your own trumpet in research appeared over at The Conversation. It covers a bit on BICEP 2 and improbably fast neutrinos (there’s a whole series on Understanding Research at The Conversation which is well worth a read). It makes the very fair point that a bit of circumspection can save a lot of confusion for all.  A bit more reserve might have other benefits.

The temptations to claim big results are obvious. In an environment where funding is hard to come by and it is easy to feel your work is invisible there is a push on at many levels to make a big splash whenever possible. The problem is that framing all research findings as bold new discoveries is a disservice to the public we’re trying to inform. Surely the story of research is one of small revelations not sudden bolts of lightning. Isn’t it more honest to let the public know that research tends to be a lot of work to reveal sometimes obscure details in a complex picture?

Then maybe when we try to explain that new knowledge takes decades to fully understand, or that making the step from first insight to clever thing that changes your life is actually thousands of shuffles it would make more sense. The argument that science needs a long-term strategic plan with consistent commitment from supporters would be more obvious. The need to have lots of different people looking at a puzzle from a variety of angles would be far easier to explain too.

Whether it’s a case of “I” disease, or a desire to bring sexy back to (or even just to) your patch of research it might just be time to communicate a bit more honestly. If there is a time and place to put on a mankini, I’m pretty sure it doesn’t involve researchers.*

 

 

* In the spirit of logical consistency, it should probably be said that the time and place for a mankini cannot involve researchers because there is no time and place that should involve a mankini.

 

Total (Embellished) Recall and Anaesthetic Nightmares

We all have memories that we hold onto very hard. There’s also a few we’d like to shed. It might be that time you thought your dancing was way better than it actually was or a bout of food poisoning on a 16 hour plane flight. For me it’s the whole of the 18 months I thought I’d give my hair a chance to grow down to my shoulders. (Tangentially, this episode also tells me I can’t trust anyone I know to act when an intervention is required.)

Well every one of those memories isn’t even the memory you thought it was. All those memories are actually about you right now more than they reflect you back then. And that fact also has me thinking about one of the more commonly mentioned fears in anaesthesia – being aware of the operation while you’re supposed to be deeply unconscious.

Huh?

Let me add some detail here because that was a bit opaque. Growing up I used to view memories as my personal museum exhibits. Curios encased in glass and placed haphazardly on dusty shelves for me to pick up and examine as required on rainy weekend afternoons. At the time the theory was that after initial establishment and consolidation your memories were filed away in spots around the brain to be drawn on at will. This knowledge had been around since the early stages of the 1900s.

Over some decades mechanisms for memory consolidation were slowly uncovered. So it has been known for decades that at the time of initial memory formation, proteins need to be produced in the memory areas. More recent rodent research has shown that this protein formation is also a feature of retrieval of that memory, and that blocking that protein formation at the right time (close to the point of memory retrieval) alters the previously established memory associations. (There’s an excellent if long article on this stuff here.)

A progress edit of Sylvia Plath's "Stings" [via www.english.illinois.edu.au]

Just one of the revisions of Sylvia Plath’s “Stings” [via http://www.english.illinois.edu.au]

This is profound stuff. If memory is rewritten continuously what does that mean for the way you incorporate your recollections into your current actions and thoughts?  We use our memories of people and behaviour to govern our interactions with the world. What emerges is not a static history informing our progress but a constant revision and re-examination of how we relate our present and past.

Since the emergence of this concept of rewriting the whole process of memory only becomes more intriguing. In addition to further work demonstrating our constant ‘White Out’-wielding ways (with more here and here) there’s early evidence of the ability to artificially manipulate memories. A team at UC Irvine have demonstrated that they can create an enhanced response to the memory of a sound  by manipulating cerebral cells (more rodent work, but interesting).

So if it’s true we both continually revise our memories and that we’re starting to see ways to manipulate them, maybe Eternal Sunshine of the Spotless Mind  (the rather brilliant movie where a guy takes up the offer to erase the memories of a recent failed love and then realises he wants to keep them after all, even attempting trickery to protect and rewrite them) is not so abstract.

Rewriting Awareness

This new understanding also has implications for one of the common fears expressed by patients undergoing anaesthesia – that they’ll be aware of what is happening during the operation while everyone thinks they are asleep. Called awareness, it’s easy to see why this would be something that causes some concern. After all, the whole purpose of the anaesthetic is to make sure you don’t know what’s going on, right?

The thought then that you’d feel the full extent of a surgery with no ability to respond sounds pretty horrifying. The experience can be scarring. In adults there’s studies including follow-up on small numbers of patients who have experienced explicit recall (the classic story of knowing everything that is going on while apparently asleep) which suggest a reasonably high rate of post-traumatic stress disorder and anxiety symptoms. I suspect most people would assume that’s almost inevitable.

Interestingly in kids the rate of awareness appears to be higher (anywhere between 0.2-1.2% of operative cases under general anaesthesia compared to 0.1-0.2% in adults). You might assume kids would be more likely to find that incredibly scary, but there’s at least one study (see 6 in the bibliography) suggesting no difference in apprehension about future surgery or differences in the post-operative phase. There’s even been some work suggesting that a proportion of kids experiencing awareness expected to be aware of their operation (not exactly selling the skill of the anaesthetists, there).

In the anaesthetic literature awareness was once described as an issue of conscious perception. It’s actually an issue of memory formation. Being aware alone isn’t enough to have the patient retelling theatre jokes – there has to be a stage of establishing and consolidating a memory. It’s probably then true that the individual keeps remodifying that memory each time they retrieve it. The question of why some people are more likely to end up with an episode of awareness than others (and a prior history has been suggested to increase your chance of a subsequent event 5 times  over) could relate to personal differences in the way individuals revise the manuscript of their operative awareness.

As we’re still trying to figure out exactly how anaesthetics work (but getting there, as discussed here) it’ll be a while before we figure out how to guarantee that patients won’t be left with the distress of experiencing awareness, or any of the surgeon’s jokes. Perhaps more achievable is finding therapeutic options to apply just after the event so that any memories are no longer scary. This would be more like convincing the friendly lab rat that grabbing the cheese won’t lead to a nasty shock and that stuff has already been done.

The appeal of being able to intervene on day one to prevent a memory turning into a trigger for long-term PTSD is immediately apparent and could prevent a lot of long-term distress. And if science could rapidly deliver a way to help me forget this ever happened (while delivering back that 3:31 thanks Hasselhoff) I’d be even more impressed.

 

Some reading on anaesthetic awareness for the curious:

1. Ghoneim MM, Block RI, Haffarnan M, Mathews MJ. Awareness During Anesthesia: Risk Factors, Causes and Sequelae: A Review of Reported Cases in the Literature. Anesth Analg 2009;108:527-35.

2. Pryor KO, Hemmings HC. Increased Risk of Awareness under Anesthesia: An Issue of Consciousness or of Memory?  Anesthesiology 2013;119:1236-8.

3. Aranake A, Gradwohl S, Ben-Abdallah A, et al. Increased risk of intraoperative awareness in patients with a history of awareness. Anesthesiology 2013;119:1275-83.

4. Mashour GA. Post-Traumatic Stress Disorder After Intraoperative Awareness and High-Risk Surgery. Anesth Analg 2010;110:668-70.

5. Davidson AJ, Smith KR, Blussé van Oud-Alblas HJ, et al. Awareness in children: a secondary analysis of five cohort studies. Anaesthesia 2011;446-54.

6. Malviya S, Galinkin JL, Bannister CF, et al. The Incidence of Intraoperative Awareness in Children: Childhood Awareness and Recall Evaluation. Anesth Analg 2009;109:1421-7.