When I started reading this book, I thought it was going to be a story about anesthesia. Instead, it is a book mostly about the lack of anesthesia among patients undergoing surgery; that is, it is a story of intraoperative awareness. The author lives in Melbourne, Australia, and has described her visits and the studies of some of the individuals around the world who have investigated anesthesia recall, including: Kate Leslie, M.B.B.S., M.D., M.Epid., M.Hlth.Serv.Mt., F.A.N.Z.C.A., F.A.H.M.S., of the University of Melbourne (Melbourne, Victoria, Australia); J. Edmond I. Eger, II, M.D., since deceased, labeled by the author as the “most famous anesthesiologist in the world,” who introduced minimum alveolar concentration and how it possibly relates to recall; and George Mashour, M.D., Ph.D., of the University of Michigan (Ann Arbor, Michigan). She also interviewed, and described the horrible observations of, some patients who experienced intraoperative awareness.

The author makes the point that there are risks in paralyzing patients without making sure they are also anesthetized, and the majority of patients who do have recall during anesthesia were paralyzed during their anesthetic. She notes that if a patient remembers their surgery, the patient probably would be more relieved if they are told what actually happened, rather than if the anesthesiologist were to avoid an explanation due to the fear of being sued. The author notes that operating rooms should have a sign on the door saying “The patient can hear,” and that we should be kind to patients. And finally, hypnosis has been shown in some studies to relieve preoperative stress; it is an inexpensive technique that may improve the perioperative experience by reducing distress, and may even help patients after surgery, including those who have distress due to unexpected recall.

The majority of the book is like a stream of consciousness as it relates to the author’s life and her upcoming scoliosis surgery. The book starts with a description of the author’s need for scoliosis surgery, and more than 300 pages later, she finally undergoes surgery. Throughout the book, different studies are summarized that relate mostly to recall or why it might happen. Most books that discuss different studies reference the studies in the body of the text. That doesn’t happen in this book. It was not until this reviewer got to the end of the book that references were viewed. Most of the references are incomplete. Take, for example, a reference in the text: “Take that Swedish study: Sandin et al., 2000.” There are 14 articles that include Sandin as an author, and four with Sandin as the first author. (The referenced article was probably: Sandin RH, Enlund G, Samuelsson P, Lennmarken C: Awareness during anesthesia: A prospective case study. Lancet 2000; 355: 707–11.) Earlier in the book, the author describes Levinson’s study where a mock code was simulated to determine if recall after anesthesia was likely.¹  However, no reference was provided. In that same chapter there’s a reference to the book Poison Arrows, though the actual title of the book is Poison Arrows: The Amazing Story of How Prozac and Anaesthetics Were Developed from Deadly Jungle Poison Darts.

The author is not an anesthesiologist and makes certain statements that do not ring true. “Certain types of anesthetics (those delivered into your bloodstream rather than those you inhale) raise the risk (of anesthesia recall) if used alone”—no evidence supports this. “Certain types of people, too, are more likely to wake during surgery: women, fat people, redheads, drugs abusers…”—the studies that include these descriptors are either small or anecdotal, studies that are mostly not proven true in subsequent large trials. There is reference to William Morton and Charles Jackson, the ones who first discovered anesthesia, without also mentioning Crawford Long. “Few will be aware…eyes will be taped shut”—to eliminate corneal abrasion; “…they may be tied down…”—so they will not fall off the operating room bed, much like a seatbelt used in a car; and “…they will have a plastic tube maneuvered into their reluctant airway…”—for safety purposes for the purpose of ventilation. “It is not unusual for patients, just before passing out, to tell surgical staff how attractive they are…”—in fact, this more commonly happens when patients awaken from anesthesia, particularly when propofol is used. Then, “…nitrous oxide (still among the most widespread anesthetic drugs in use today)”—that’s not true: though difficult to quantify, throughout the world, its use has dramatically decreased.²  “Hallucinations after surgery are remarkably common, particularly in older patients.”—though older patients might have hallucinations after surgery, the evidence to show they are common is not there.

Despite the book’s inaccuracies and its stream of consciousness style, it is nicely written. The book is excellent for residents if only to meet those who study intraoperative awareness and to realize the harm to patients who experience awareness. Anesthesia: The Gift of Oblivion and the Mystery of Consciousness serves as a nice review also for those who practice anesthesia.

J. Lance Lichtor, M.D., Yale University School of Medicine, New Haven, Connecticut.llichtor@me.com