For Anesthesiologist, Easing Pain And Erasing Memories Is All In A Day's Work
TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. Here's how my guest describes his work. He writes, (reading) I am an anesthesiologist. I erase consciousness, deny memories, steal time, immobilize the body. I alter heart rate, blood pressure and breathing, and then I reverse these effects. I eliminate pain during a procedure, and I prevent it afterwards. I care for sick people, and I have saved lives, but it's rare that I'm the actual healer.
That's from the opening of Dr. Henry Jay Przybylo's new memoir, "Counting Backwards: A Doctor's Notes On Anesthesia." He specializes in pediatric anesthesiology and estimates he treats about 1,000 children a year from micropreemies (ph) to teenagers. He's dealt with benign conditions, like the removal of a skin mole, as well as potentially fatal ones, like clipping a cerebral artery aneurism and heart transplants. He's also an associate professor at the Northwestern University School of Medicine.
Dr. Przybylo, welcome to FRESH AIR. Your book is called "Counting Backwards." So why do anesthesiologists ask patients to count backwards from 100?
HENRY JAY PRZYBYLO: You know, I'm not sure. I searched the Internet and everything to try and find the answer to that, and the closest I can come to is that around 1940s, we came up - medicines were developed to induce anesthesia that were given through veins - IV - and they were extremely quick-acting. And I think sometime, some anesthesiologist somewhere just wanted to see how long it would take and asked the patient to start counting backwards from a hundred, realizing they never made it out of the 90s before they were anesthetized, and I think that just stuck.
GROSS: Why not count from one, two, three, four, five, as opposed to 100, 99, 98?
PRZYBYLO: Because I think you have to think a little bit. You can slur the counting upwards, but counting backwards is a little more difficult. And I even make it a little bit more problematic and difficult for the patient because I say, OK, count backwards from a hundred by sevens. They might make it to 93. They never make it to 86.
GROSS: Wow, OK. But you have children who you're working with.
PRZYBYLO: The children to go to sleep by mask, so they're breathing, and I talk to them about my piggy gas story and - you know, when we're slowly going to sleep. And in the mask, usually, there's some odor, some bubble gum or cherry to start with and a little bit of laughing gas to try and take the edge off, and then we introduce the sevoflurane, the anesthetic gas.
And I tell them, the smell is changing, and we're taking an imaginary trip to the zoo, and my favorite animal of all time is the piggy, but piggies are a little bit stinky and then ask them how many they count, and are they big or little, and do they have straight tails or curly tails? By the time we get to curly tails, they're fast asleep.
GROSS: So you write in your book, I put people into a coma, and the medications I administer cause paralysis. I read that, and I was thinking, please don't tell me that right before you put me under.
PRZYBYLO: I don't. I never tell them that.
GROSS: So are you - you're putting patients in a coma. What's the difference between the anesthesia-induced coma and sleep?
PRZYBYLO: We go right through the sleep patterns. And that - if you were to check the electrical activity in my anesthesia, there's very, very little electrical activity, where, in sleep, you have different phases of which includes dreaming. So while you're asleep, your brain is still functioning, and you're still having dreams. In anesthesia, that doesn't happen.
GROSS: So you're not having dreams, but did you say your brain isn't functioning?
PRZYBYLO: Well, it's doing the basic functions from the lower parts of the brain that are giving you heart rate and blood pressure and breathing, unless I have given the paralysis. But in terms of the upper brain functions, no, you have no sensibility for anything that's going on.
GROSS: So what is it that causes the paralysis, and what degree of paralysis are we talking about, and why are you even doing that?
PRZYBYLO: It's a complete paralysis, and it goes way back, hundreds of years ago, to the poisons discovered in Central and South America - the curare, wurare, I believe it was when it was first discovered. And for instance, if you're doing a very, very delicate procedure, the best that comes to mind right away is if a neurosurgeon is clipping a brain aneurysm, there cannot be a millimeter of movement, otherwise the outcome could be dramatically changed. So to prevent that patient moving under any circumstances, you give them a drug that paralyzes them for a period.
GROSS: Do you worry that they won't come out of it?
PRZYBYLO: Oh, never, never. The - and while I can't fully explain how a lot of my anesthetics work, you know, 40 million times a year, people receive anesthetics, and they wake up. It's a rare one who doesn't wake up. It's a rare one who doesn't come out of the medications that I give them.
GROSS: And you also give a drug that prevents people from remembering anything that happened during the anesthesia.
PRZYBYLO: Correct. You know...
GROSS: So what kind of drug is that?
PRZYBYLO: You know, it's mother's little helper. I think the Rolling Stones wrote the song about it. It's a Valium-like drug. But there's a little bit of a difference here. And let me pull back just a moment for you - that when I give my gas anesthetic, it's an all-in-one anesthetic. It does everything. It - include inducing the coma, preventing the memories, stealing time - when you're not necessarily going to give that gas anesthetic, when you want to use a different technique, then I can go to the benzodiazepines, the Valium-like drugs, and I can use that to prevent memory.
GROSS: But people who take Valium for anxiety - is that killing their memory?
PRZYBYLO: Well, it depends what dose they're taking. You know, this - there's the one sleeping drug called Ambien that has had a lot of following in the press over the years, and it has the ability to prevent memory so that you can - the people are sleepwalking and sleep driving. So that patient gets into an accident or gets stopped, and the police are saying, what's going on? And that person will never remember doing the driving, doing the sleepwalking. It just doesn't register.
GROSS: I see. I remember when I had my tonsils removed - and this was a long time ago. And it was back when all children had their tonsils removed.
PRZYBYLO: Yeah, we're still doing a lot of that today.
GROSS: Are you? OK. So I had ether.
GROSS: And I still remember the smell.
GROSS: And, in fact, I really believe this. I may be wrong, but I lived in an apartment building when I was growing up, and one of the kids at the other end of the floor - after I had my tonsillectomy, that kid had their tonsillectomy. And I remember smelling the ether in the hallway. Is that even possible?
PRZYBYLO: Oh, you sure did. The gases - the ether - the beauty of it is that it worked. I mean, in the 1840s, they fell out...
GROSS: But I mean, in the hallway of my apartment building, after the patient came home...
PRZYBYLO: Absolutely. What happened was - the first ether that was used was what we call very soluble. It just got into every part of the body, and it took a long time for it to get out. On the other hand, the sevoflurane that I'm using today is very insoluble. It goes straight from the lungs to the brain, does its work, and so that - it doesn't take long before that smell is gone. And by the time the kids leave the hospital, there's no issue. But I can understand why you have that.
GROSS: Hmm, OK. So one of the developments you write about is ultrasound, which can target specific nerves. So how do you use that as an anesthesiologist?
PRZYBYLO: The ultrasound is like a pack of cards - the probe that you take. And you put a gelatin on the end of the probe, and then you just rub it along the skin, and it gives sound waves to give you pictures of what's beneath the skin. So you can see from the skin to the deepest of bones, and you can identify different structures within that picture. So I use it for a combination of things. I use it for identifying nerves.
So for instance, if somebody's going to have a procedure around the knee, right behind the knee and a little bit above it in the back are a pair of nerves that come down, and they're easily seen on the ultrasound screen. And you can watch your needle get right up next to them, inject your local anesthetic on it so you can have much more accuracy with the block that you're placing. But I use the ultrasound for other things too because it's also great for seeing blood vessels.
So I do a tremendous amount of cardiac anesthesia. So we're always looking for big veins to put IV catheters in, and we're also looking for the more difficult - the artery - arteries, excuse me, that we're trying to put a catheter in there so that we have moment-to-moment blood pressure readings, and we can also access blood for any sampling that we want to do during it.
GROSS: So you specialize in pediatric anesthesiology. You estimate that you anesthetize about a thousand children in an average year, and you also work with preemies - premature babies. Like, what's the smallest that you've had to administer anesthesia to?
PRZYBYLO: Six hundred and forty grams is my memory. It's 1 1/2 pounds. The most recent was 2 1/2 pounds. So yeah, we're - pretty tiny.
GROSS: Oh, that's, like, the definition of fragility. I mean, what are your concerns?
PRZYBYLO: Oh, everything is so tiny.
GROSS: ...That you have to deal with when you have to - yeah.
PRZYBYLO: It's just so tiny. The - you know, sometimes, I'm asked, what's the difference between the pediatric care and adult care? In the pediatric care, so much of it is similar, but it's like, you take a bull's eye, and you shrink that bull's eye from the - what? - 2 and a half feet or 2 feet it is across over, and you just shrink it down to tiniest, tiniest. So you have to be much, much more precise. The other thing is that the smaller the child, the less forgiving they are. You have to be very, very quick with all your responses, otherwise you're going to get into trouble very, very quickly.
GROSS: You must have to administer a microdose.
PRZYBYLO: We use the tiniest syringes. That's absolutely right. The gas, interestingly, isn't as much of a difference. The gas doesn't matter across - it does a little bit but not a whole lot across ages and not across species either. So I can anesthetize a goldfish with my gas at about the same amount. But when you start talking about the medications that you give them by IV, it changes very much so.
GROSS: Well, let me reintroduce you here. If you're just joining us, my guest is Dr. Henry Jay Przybylo. He's an anesthesiologist who's written a new memoir called "Counting Backwards." We'll be right back. This is FRESH AIR.
(SOUNDBITE OF TODD SICKAFOOSE'S "TINY RESISTORS")
GROSS: This is FRESH AIR and if you're just joining us, my guest is Dr. Henry Jay Przybylo. He's an anesthesiologist who's written a new memoir called "Counting Backwards." He's also an associate professor of anesthesiology at Northwestern University School of Medicine.
So you're not supposed to eat before anesthesia. Everybody who's ever had any form of anesthesia knows that. I think it's usually, like, midnight the night before is the latest. And you're supposed to have - what? - like, a light meal? You tell me.
PRZYBYLO: The whole issue - whenever you put something in a stomach, you generate acid. And that acid - while the stomach is built to withstand it, none of the rest of the body is. So when you have something that, you know, doesn't sit well with you and you burp a little bit, you feel that burning sensation in your chest, that's the acid coming out of your stomach and up into the esophagus.
Well, under anesthesia, I drop the tone of all the muscles throughout the body. So the tone keeping the volume in the stomach is dropped. And the other thing that's dropped is the action of the vocal chords. So the vocal chords will not close when something happens. So if you have something come up into your mouth, the vocal chords close right away, and they prevent anything from going from the esophagus down into the - past vocal chords down to the lungs. So that's what happens under anesthesia. So we want to have no acid in that stomach as much as possible. So that's what NPO is called - nil per os in Latin.
We're not so strict as the 12 o'clock midnight because if you're going at 2 in the afternoon, that's a long time to go without anything. And we also know that if you have clear fluids, things that you can see through that don't have any fat in them, they don't tend to produce a lot of acid. As a matter of fact, they may actually clear the stomach a little bit - so two hours before an anesthetic, a little bit of clear fluids. Six hours, eight hours - nothing solid, and life will be OK.
GROSS: So you write that the first time you saw a human heart, it was a religious experience. Tell us about that experience.
PRZYBYLO: When the chest is opened, you know, the heart lies deep to the sternum - that hard bone, the breast bone. And when you open it up, the first thing you see is a covering, the pericardium. And the heart is deep to that. So you get a sense to it. But when that pericardium is open and you see that organ just moving, just beating so rhythmically, it's not like a lot of other parts of the body. You don't see them moving, actually. This is one that you should never see, but I did. And that's just the way it is. It was very, very moving.
GROSS: Now, I saw a beating heart in a movie recently. And I have to say I found it a little upsetting (laughter) because - well, let me explain why.
PRZYBYLO: Yes, please.
GROSS: I didn't want to think about how hard that muscle has to work every second in order for me to stay alive. Like...
PRZYBYLO: It sure does.
GROSS: You kind of don't want to be thinking about that.
PRZYBYLO: No, you don't want to be thinking about it. But when I see the heart, there's a very good reason. And that's because that heart isn't going to be beating much longer unless I do see it.
GROSS: So you see hearts beating on the table during transplants.
PRZYBYLO: Oh, yes, oh, yes. The most - the emptiest feeling that you get is at the transplant time when they take the heart out and you look into their chest cavity where something should be and it isn't there. And that is just a feeling you never get over - just seeing that empty chest cavity. And then when the new heart goes in, you know, it needs a moment of reflection, you know, because somebody else gave up that heart for this person to get it. So you know, there's two lives on line minimally. So it is a very, very moving experience. It's one that never goes away.
GROSS: So you've had to calm a lot of parents who are basically handing their children over to you to be anesthesized (ph) before surgery. You were in that position of being a parent yourself when your son at the age of 30, I think was, was anesthetized before a very major procedure. What was the surgery your son was having?
PRZYBYLO: He had a vascular malformation in his brain that needed to be taken out.
GROSS: And so what was the experience like for you of not doing that anesthesia yourself and handing your son over to the anesthesiologist and overriding your impulse to, like, watch (laughter) the anesthesiologist over his shoulder while he or she worked?
PRZYBYLO: It was absolutely horrible because every second that you sit in that waiting room, you know, you're picturing exactly what's going on right behind the walls that you're trying to peer through. And you're trying to be the one doing the controlling. You know, the anesthesiologist has control of the body during the procedure and all the functions. And I so desperately wanted to be the person controlling all of my son's functions, and so it was intensely nerve-wracking.
GROSS: How come you didn't do it yourself?
PRZYBYLO: It was at a different hospital. I would have done it if I could have. I would have given anything to do it. I did procedures on my wife. So you know, I would have if I could have. But he needed to go to a different hospital.
GROSS: You write that you were overcome by waiting room paralysis. Describe what that is.
PRZYBYLO: That's when you plunk yourself down in a chair, and you're afraid to move a millimeter because you're afraid that in that time, somebody is going to come and announce something to you. And so you just sit there. And you wiggle a little bit, and you watch the clock no matter - I told tens of thousands of families, you know, don't watch the clock; it has no bearing in the operating room. It takes what it takes. The No. 1, 2 and 3 goal is to get your person, your family member, whatever back to you in better condition than coming to me, and time is inconsequential. And I tell them all the time, and I know that. But when you're in that waiting room, it's completely different.
GROSS: I think I've had that kind of waiting room paralysis, but I didn't have a name for it. Is that your expression, or does everybody use that?
PRZYBYLO: That's my expression.
GROSS: Yeah, that's a good one. So how did your son's procedure turn out?
PRZYBYLO: It it turned out well. I mean, we were very, very grateful. The (laughter) silly thing about it is that at the end of the procedure, which went longer than it was anticipated, they didn't have a intensive care unit bed ready. And he spent I think about two hours in the operating room awake waiting for his room, and they actually - the anesthesiologist was a friend of mine and actually sent me a picture of Jason from the operating room with the thumbs up that everything was OK.
GROSS: Your book is dedicated to your wife...
GROSS: ...Who you write left me far too soon.
PRZYBYLO: She had a brain aneurysm.
GROSS: When did that happen?
PRZYBYLO: She was pregnant with my last daughter. It was right during the pregnancy, and she wasn't supposed to survive and miraculously she did. She was in the single-digit survivor risk rate. And she managed to walk out of the hospital, but she had a brain injury that consumed her and took many years. But it did consume her, and she's the reason I turned to writing.
GROSS: What's the connection between that and writing?
PRZYBYLO: Well, first of all, it was - she had a lot of mental changes. And so we were searching for years for different things and different causes and different help. And we went through dozens of psychiatrists, psychologists and sociologists and social workers, and they couldn't help. And it came to the point where I just said to myself, you know, if they couldn't help her, they certainly weren't going to help me. So I just said, you know, I - people were coming up to me and saying, where are you getting help? And I turned to writing because it was a way to try and rationalize everything that you couldn't rationalize.
And so then as that progressed, I - a secondary benefit came out of it because I thought sitting with my wife, which is all I wanted to do, what could I do that would be productive? And so I started writing about her, and I started thinking about writing seriously. And so then I went to get my master's degree, and I went to a college in Maryland in Baltimore, Goucher College - fabulous place for me. And I went there writing about my wife. My first mentor, Diana Hume George, said to me - and said something, by the way, that Mary Karr I think said to you in an interview - that you can't write through tears. And they were absolutely right. So they asked me to write about something else and "Counting Backwards" got a genesis.
GROSS: With your wife's brain changes, was that cognition or mood, memory?
PRZYBYLO: It was everything. It was everything. But she was very, very unpredictable. She had a frontal lobe injury called dysexecutive function disorder. And for anybody who doubts how great psychiatry is - and I'm not picking on them, but any disease process that you name dysexecutive function disorder, you know, you just don't understand it.
GROSS: What does that mean?
PRZYBYLO: It means pretty much she lost her soul, that at - given any time alone, she would do something bad. And so we had to keep a constant eye on her.
GROSS: Bad to herself or to just in general.
PRZYBYLO: Bad to herself. It was very difficult.
GROSS: How long did she live after that?
PRZYBYLO: She passed away two years ago, so she made about 16 years.
GROSS: I'm so sorry. It must have been so hard for you during that whole period, let alone after it.
PRZYBYLO: Still is.
PRZYBYLO: Still is.
PRZYBYLO: But, you know, you try and look at the bright side of things and you try to go forward. And the comments that I've had about the book have all been spectacular, and they give me pause to, you know, give another day. Let my world revolve one more day.
GROSS: My guest is Dr. Henry Jay Przybylo, author of the new memoir "Counting Backwards: A Doctor's Notes On Anesthesia." We'll talk more after a break. And Jesmyn Ward will talk about her novel "Sing, Unburied, Sing," which won a National Book Award this month. I'm Terry Gross, and this is FRESH AIR.
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GROSS: This is FRESH AIR. I'm Terry Gross, back with Dr. Henry Jay Przybylo, a pediatric anesthesiologist who's written a new memoir called "Counting Backwards: A Doctor's Notes On Anesthesia." He's also an associate professor at the Northwestern University School of Medicine.
So from your perspective as an anesthesiologist, what are some of the most worrisome things happening now in health care and health insurance just in terms of people getting what they need and being able to afford what they need?
PRZYBYLO: Well, there's the one section about the boy with the transplant, and it's a very problematic, bothersome, very hurtful thing that you go through - the point of getting a transplant to a patient and the patient is thriving, and then for whatever reason, they stop taking the drugs. And the particular reason in the book is that the coverage, the state coverage, for the drug ran out. And you just think to yourself, how silly. Why should bureaucracy get in the middle of health care? But it did in a big way.
GROSS: In this case, it was a boy who had been on Medicaid. And the Medicaid for children runs out at age 18 or 19. Do I have that right?
PRZYBYLO: You know, I'd have to look it up myself. I think it's on the 30th day of the month of their 19th birthday the bill sunsets. And so then he no longer received money for his medication. And I think it was around $20 a day. And he was choosing to save the money for something else and stopped taking it. And nine days later, he's back in our care.
GROSS: And that costs a lot of money.
PRZYBYLO: Not only does it cost a lot of money, these people kick into a non-retransplant list because they've caused their own issue. And there's so many people waiting for transplants before them that they don't even make it to the list again. And so he passed away.
PRZYBYLO: It was horrible.
GROSS: How would you change that if you could?
PRZYBYLO: You know, if the state would have had the foresight to, say, spend the $20 a day then you would have stopped 50, 60, 70 days in the intensive care. You could have paid for 20 years of his medications. You know, it was just poor hindsight.
GROSS: So when you were just starting out as an anesthesiologist, were you nervous that you would do something wrong? And if so, how did you kind of mask that and present a kind of calm surface to the people who you had to calm?
PRZYBYLO: The very first day of being a physician - July 1 - after receiving lectures on you better do all your medical charts or you're never going to get paid, and the sheriff will come and deliver your malpractise summons here, and how to act respectfully during cardiac arrests, then they say, OK, go off. And you're on your own now. Go to your service. Report to your service. And it was just by serendipity that my very first service was anesthesiology.
So I walked up to the front desk. And at the front desk the person running the schedule, the anesthesiologist in charge of running the schedule that day, said, you know, I remember your name being on a schedule when you were a student doing the rotation here - couldn't put the face. Now I remember who you are. Your first patient is waiting outside room six.
And so I was thrown into it deep like you could never believe. I had never set up a room before. I had never actually pushed the syringes before. I had never managed an airway before. And I had never intubated on my own without somebody showing me where the vocal cords were. And there I was all by myself. And the attending anesthesiologist covering me that day just kind of stood off to the side and said OK. And, you know, I pushed the medications in. And I put the mask on her face. And I got a seal. And I watched their chest rise.
And I said, oh, boy, this is good and then went to look for the vocal cords. And they were staring me in the face. And I put that endotracheal tube through. And it built a confidence that I kept from there on - not that I would do it right all the time, but that I could do it. And so that was a very, very interesting first day of being a physician.
GROSS: So no offense, but I think a lot of patients really do live in fear that they're going to get, like, the new doctor or the new resident (laughter) and that you're going to be a kind of practice patient and not have really experienced hands working on you.
PRZYBYLO: One way to look at it is every patient is a practice patient for me because I'm always trying to get better. I'm always looking for better ways to do things, more successful ways to do things.
GROSS: Yeah, but you're really skilled.
PRZYBYLO: But - yeah, I can't argue. I am. And, you know, I would like to be nice and humble on that one, but I am. But whenever anybody touches a patient in my stead, if I'm the one directing it, that's an extension of my hands. And my hands are right next to that patient. I'm never going to let them do anything dangerous. They're never going beyond my range. So anything happens with a patient because a resident of mine did something, it's my problem. And I will respond like my problem.
GROSS: You said that you use anesthesia all the time, but you don't really understand how it works.
GROSS: Must be kind of odd for you to administer medications when you don't know how they work.
PRZYBYLO: You know, I ask the patient to have faith in me as I have faith in my anesthetic. And it just works. Healthy patients go in. Healthy patients come out. It's just my statistics, but I'm very proud of them. So it works, but I can't tell you why.
GROSS: It's been a pleasure to talk with you. Thank you so much.
PRZYBYLO: Thank you. I've enjoyed this very much.
GROSS: Dr. Henry Jay Przybylo is the author of the new memoir "Counting Backwards: A Doctor's Notes On Anesthesia." After we take a short break, Jesmyn Ward will talk about her novel "Sing, Unburied, Sing," which won a National Book Award this month. It's about a boy growing up with a black mother and white father in rural Mississippi. This is FRESH AIR.
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