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Comment by jandrewrogers | Hacker News Reader

The use of amnesiacs like midazolam in conjunction with unpleasant surgery has become common practice because it has been shown to significantly reduce the psychological trauma associated with surgical procedures and related changes in behavior as a result. You will still experience the trauma at the time whether you remember it or not, but the experience is not persistently encoded into your brain.

This is important because the psychological trauma of a surgical procedure will often cause people to avoid future procedures even when procedures are medically advisable. These drugs temporarily prevent strongly negative experiences from becoming a part of who you are mentally, subconscious or otherwise.

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And that makes intuitive sense. I'm still left with the question: is the experience of surgery really that bad?

I'll say yes. For example, sometimes we have to run electrical current through someone's chest to correct an arrhythmia. Depending on the urgency, we will give a medication such as midazolam. Ideally you want the sedation to have taken effect, but you don't always have the time to wait for that before your hand is forced and you have to cardiovert. The amnestic properties will help reduce some of the traumatic memories.

Sure. That makes sense. You gave me enough keywords with that comment to look up electrical cardioversion and pain, and so now there's something new that I'm scared of (kale for dinner tonight!) (thanks!).

But that's actually something different than what I'm asking. I have no trouble understanding why I wouldn't want to remember a pain "similar to that of surgical incision". Similarly: I wouldn't want to remember an unanesthetized incision!

But before learning that surgical patients were routinely given midazolam to zap their memory, my impression was that surgical patients were completely zonked out by general anesthesia, and so there'd be no need to zap their memory, because they weren't going to consciously experience the incision in the first place.

Now I'm like, is all of general anesthesia a scam, and we're all enduring horrible pain, and we just don't remember it? J/K ONLY SERIOUS.

Midaz can be used as premedication before induction of general anesthesia, but it's not an induction agent itself. If you're getting general (as opposed to "twilight") anesthesia, once you're induced, you should be unconscious (to the best of our ability to understand consciousness).

I'm medicine, not anesthesia, so I don't use these agents all day and therefore referred to cardioversion which is more in my domain. Cheers!

I am noting with interest and a small amount of alarm the abruptness with which you've ejected yourself from this thread after my suggestion that all of anesthesia is a huge scam. :)

FWIW, unlikely. I specifically remember being asked to count down from 10, going like 8 7 6 ... 5 wait I feel weird and sleepy. That is, my first thought after being woken up was the next number in sequence.

It seems unlikely that would be the case if the time inbetween was spent thinking 'oh my god this hurts so much' rather than just blacked out.

Were you given a benzo specifically to erase your memory of the events? Because this thread is about the fact that many (maybe most) surgical patients are.

(Let me clear, I'm being deliberately silly about all this. I do not think there is a huge anesthesia conspiracy. I am, at the same time, seriously skeeved out by having my memory deliberately tampered with.)

> Were you given a benzo specifically to erase your memory of the events?

I don't remember! :P

Offering tptacek a dose of midaz: There is no thread.

I asked an anesthesiologist this question and am transcribing from memory (hehe), so I may have screwed some things up.

The answer to your question in is no, you aren't suffering enduring horrible pain while under general anesthesia. That doesn't mean you won't experience things you would rather not remember. Some examples: 1) patient may experience burning sensation from propofol (induction agent) entering the body 2) patient may see something disturbing before general has kicked in (e.g. a big saw before an orthopedic procedure) 3) in certain cases (e.g. emergencies) or due to human error, patient may not be fully under pre-surgery, e.g. patient may remember breathing tube being inserted.

The high level answer for why you are given midazolam (at least in the US) is because anesthesia is a "patient satisfaction" service and giving it increases patient satisfaction.

> is the experience of surgery really that bad?

It varies by person but - Yes, it certainly can be.

My grandma had to undergo hip surgery awake with only local anesthetic. She was too frail and had all these health conditions so she couldn't be put under or given much medication. At the same time they couldn't just leave her hip broken. It was an extremely traumatic event for her.

Of course others would think it wasn't such a big deal.

I can give you some idea. I've had two surgical procedures where something like midazolam was strongly recommend, but opted out for one of them. The one I opted out of was a four hour procedure sawing on bone and soft tissue.

For the procedure on midazolam, I have virtually no recollection of the procedure except for about a minute in the middle where it apparently wore off. It was a completely neutral experience.

For the other procedure, it was extremely unpleasant for two reasons but I got through it like a stoic. First, they had trouble keeping up with the local anesthetic, too many nerves involved, so there was quite a bit of transient pain and it got sloppier over the length of the procedure as the doc got tired. Second, even when you can't feel pain, you can still feel them tearing up your tissues and rearranging your parts, which is disconcerting if nothing else. Overall, I strongly recollect just how unpleasant and painful (even under anesthetic) that procedure was. I probably would not be able to tell you any of this if I was on amnesiacs because I would not remember.

It is really about where your thresholds are. Like you, I find the loss of memory on the amnesiacs disturbing and the alternative, anecdotally, was far more unpleasant than I think some people imagine. The experience that I remember doesn't bother me that much because that is my nature but I can't deny that I have vivid memories of it. I can easily imagine that many people would prefer to not have those memories. That said, I would likely elect to forego an amnesiac again if I thought it would inconvenience me (i.e. by making you useless for several hours). I can deal with the experience.

I've always been afraid of intravenous sedation (="twilight anesthetic" in other English speaking countries) for the same reason.

The only time I experienced it was for an endoscopy. Because I was a heavy drinker at the time (probably the reason for the symptoms that lead the the endoscopy, ironically) the intravenous sedation had little effect, so I was awake through the whole thing. I didn't find it traumatic, merely unpleasant, but I think other people might have. The local anesthetic at the back of my throat wore off after some time, so I was dry retching every few minutes. At one point they pumped air into my stomach so they could take a sample with a needle (which was in itself painless), and that sensation was also unpleasant.

So while I doubt people undergoing intravenous sedation during routine surgery are in extreme pain, they may be in very uncomfortable situations that most people would rather forget. Also if it had been effective, it would alter your state of mind as well, so that the immediate experience was less bad.

I've had an endoscopy before, to push down some food stuck at the top of my stomach, with no sedation or numbing. Being held down by a couple of nurses and the doctor whilst the procedure was done three times - the first two times I pulled the endoscope out after having panic attacks - was the worst medical-related experienced I've ever had, and it still gives me nightmares. Turns out the doctor was known for being a sadistic bastard who enjoyed seeing his patients squirm; I wish I was making this up.

OTOH I regularly have a colonoscopy under heavy sedation, and never remember a thing.I know there are risks with any kind of sedation or anaesthetic, however anecdotally they've saved me a lot of trauma.

A friend of mine had a skin graft done under a local anasthetic. Debriding the wound was worst. Harvesting the skin was unpleasant. Attaching the graft was unpleasant. Dressing it all was not fun.

Given the procedure I was undergoing[1], I can understand the preference of doctors to make sure the patient doesn't remember it.

[1] (let's just say this was moving a camera in a....direction...against traffic)

Can you talk about the use of such meds in ITUs?

As I understand it there's an increased risk of PTSD if people are chemically restrained, which is why some ITUs (but not in England) use physical restraints when needed.

This is a different use case from surgery, where these meds are useful.

A very close relative died after a procedure similar to what had happened to Joan Rivers. I've had that procedure (prior to the death) but now I am really scared to have it done again.

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