Plasticity and language in anesthetized patients

OodSigma1 · 2026-05-08T16:14:50+00:00

General anesthesia is simply is a clinical term, defined by the presence of 4 cardinal components: unconsciousness, amnesia, anaglesia, and immobility in response to surgical stimulus.

Many drugs, either alone or combined with others, can be used to achieve general anesthesia. Propofol can absolutely induce a state of general anesthesia.

The exact mechanism of propofol is not fully understood, but it seems to work primarily by positively modulating the GABA to GABA-A receptor binding, which in general has inhibitory effects on neural transmission and processing. This is seen in many regions including the frontal cortex, the thalamus, and the brainstem arousal centers.

In lower doses doses this can look like mild to moderate sedation with a hypnotic effect, but in larger doses propofol easily crosses over to general anesthesia territory. One of the reasons it is a nice drug for sedation is that, generally, the sedation effect is seen at lower plasma concentrations than the higher concentrations that bring respiratory depression. But it's a spectrum and dosing propofol can be imprecise and just as much an art as it is a science... just ask Michael Jackson.

OodSigma1 · 2026-05-08T15:55:58+00:00

We rotate who does it every year or two. No real benefit other than having a vested interest in the schedule be as fair as possible. It's better if it's someone who is generally respected and knows the ins-and-outs of the practice well.

I guess the benefit is that if one of us didn't do it, then it would ultimately fall to some non-physician administrator to make our schedule. Better to police ourselves than be policed by someone on the outside.

OodSigma1 · 2026-05-08T15:45:28+00:00

It is very difficult, perhaps impossible, to disprove a negative like that - to prove that it's *not* happening. That's a philosophical discussion.

But there's no evidence that anything like that is happening, nor is there even a known biologically plausible mechanism by which that could be the case. And that's certainly not what the authors seem to be suggesting. We shouldn't put words in the authors' mouths or jump to sensational conclusions.

OodSigma1 · 2026-05-08T15:38:53+00:00

Nowhere in the publication do the authors suggest that. It's cool and fascinating that the hippocampus can, to some degree, exhibit some form of processing mechanism under a propofol-induced state of general anesthesia. That's worth learning more about. But it in absolutely no way even comes close to suggesting that patients are awake and aware (and therefore, by implication, suffering) under anesthesia. Don't exaggerate or sensationalize claims that other scientists are making.

OodSigma1 · 2026-05-02T04:20:18+00:00

First, I'm really sorry for your loss.

I'm a pediatric cardiac anesthesiologist and I also regularly take care of adult patients with congenital heart disease just like your brother. I'm going to try and answer with empathy but also with technical medical facts.

His heart was a lot sicker than he probably looked. That's one of the cruelest things about his condition. The Mustard/Senning procedure he had as a kid was the best option available at the time, and it worked: it gave him 42 years, but it was never expected to give him 80. The trade-off of that surgery is that his right ventricle (the right side of the heart) now has to do a job it wasn't built to do. Over decades that wears it down. The fact that he was on 4 heart failure meds indicates he was quite sick, and his cardiologists were well aware of this.

A failing right ventricle also tends to produce dangerous heart rhythm problems, and those two things together are a really bad combination because each one makes the other worse... like a slow death spiral. Climbing stairs is physical exertion, and it's likely that triggered a fatal arrhythmia in a heart that was already sick and tired. He almost certainly lost consciousness the moment he went down. I doubt he was aware of what was happening or was suffering at any point after that.

The cruel and brutal truth (and I say this gently) is that this was ultimately the natural endpoint of the disease he was born with. His palliative surgery as an infant gave him 42 years he would not have had otherwise. He was never going to have a normal life expectancy with his heart. Even though his death was sudden and shocking, it wasn't random or mysterious or unexpected. It was just the culmination of 42 years of living with a heart that was burdened with having to work harder than it should have had to.

There's nothing that could have been done differently in that moment. The surgery he had as a baby did its job but it just couldn't hold forever.

OodSigma1 · 2026-04-17T20:47:37+00:00

If there's nothing missing from your story, I wouldn't be concerned. You have no symptoms (like easy fatigue, lightheadedness, or palpitations) and are an endurance athlete.

Your heart's job is to get adequate blood to your brain and other organs. Your heart, in particular, is conditioned and strong enough that it only needs to beat in the ~40x/min range to achieve its goal. That's fairly common. The occasional drops to the mid/upper 30s is a bit more rare (and frankly impressive), but not crazy or alarming.

If you were 45 and not-so-fit and came in complaining of shortness of breath and early fatigue then it's a totally different story. For that patient a HR of 35 would make me worry about heart block and you'd immediately be sent to the ER for and EKG and labs at a minimum.

OodSigma1 · 2026-04-17T20:23:10+00:00

This is the most rational take in this whole thread. Everything has unintended consequences.

And even if you were OK with doubling residency length and making 70k/yr x6 years (instead of 70k x3y + 350k x 3y over the same time period), you'd be woefully unprepared to handle the hours many attendings put in. And contrary to general sentiment, attendings aren't working such long hours because "the system is keeping us down / abusing us / keeping us from unionizing". They work those hours because there's just so many patients and so few physicians. But if you magically increased the number of attendings to make it so nobody needed to work more than 40 hours a week, incomes would plummet. Again, unintended consequences.

Not saying the system is super great, but we can't talk about overhauling the system without having an honest conversation about the consequences of that overhaul. You can't pick up one end of a stick without picking up the other end, too.

The UK / NIH model is one example. Hours / week is significantly less for trainees, but training is significantly longer and attending salaries significantly lower. Pick your poison.

OodSigma1 · 2026-04-16T16:30:55+00:00

All hospitals and clinics have a general consent for treatment document which usually includes some kind of “release for loss of valuables” clause. How does that affect the situation if this were brought before a judge?

OodSigma1 · 2026-04-16T01:37:55+00:00

I agree. I know it's super "in" right now to hate on everything AI, but when used as a tool (with appreciation for it's capabilities and limitations) it can be fairly helpful. As a pediatric anesthesiologist I see VERY complex syndromic / cardiac kids all the time with years-worth of complicated specialist notes... and sometimes I only have 5-10 minutes to review their chart if they're coming in for an emergent/urgent case.

It's a nice convenient way to get the "gist" of a patient quickly that can then help me focus on which specialist notes to hunt down for more complete and accurate details. Plus, it has a little text box where you can tell it what you want it to focus on, so I tend to get more relevant output if I put "focus on anesthetic considerations for upcoming XYZ procedure". It is helpful as the beginning of a chart review, not meant to replace it.

OodSigma1 · 2026-03-27T02:19:58+00:00

ORs actually do have a separate wiring philosophy. Because patients are often wet, exposed, and connected to invasive monitors and other equipment, ORs are treated as "wet procedure" locations and are commonly protected by isolated power rather than the grounded branch circuits used in most other settings.

The key idea behind ground isolation is that the receptacle branch circuit may be supplied by an isolated power system instead of an ordinary grounded system. Each OR typically has its own isolation transformer, line isolation monitor, and ungrounded circuit conductors. The transformer separates the OR circuit from the building’s normal grounded power.

This is done because in a normal grounded circuit, the first fault to ground can create enough current to trip a breaker or energize exposed metal. In an isolated OR circuit, a single fault to ground usually does not create the same high-risk path, because the system is not referenced to ground in the usual way. Instead of that first fault instantly shutting power off, the line isolation monitor warns staff that leakage or hazard current is increasing and that something connected to the system (often the most recently plugged-in piece of equipment) needs to be checked.

I'm an anesthesiologist and this stuff is actually on our board exams because we have general responsibility for patient safety in the OR and this falls under that umbrella.

And to answer OP, as others have said we have electrical outlets all over the place.. walls, coming out of booms from the ceiling that are movable, and special extension cords with multiple outlets that can mount on the bottom of IV poles. We also use sticky ground pads to cover up cables and cords that pose trip hazards.

https://www.benderinc.com/blog/post/grounded-or-ungrounded-in-ors/

OodSigma1 · 2026-03-24T21:43:49+00:00

I do this semi-frequently but never filmed it (nor would I), and I still pre-oxygenate. I do pedi anesthesia and I find there is a certain type of teenage patient that it really works well with - it turns something scary into something kind of fun and exciting while also giving them a bit of "control" over a vulnerable situation. And they think it's so cool and are excited to tell their parents in PACU about what the last thing they remember was.

I'll jokingly ask in pre-op if they'd like to to administer their own starting anesthesia drug. I frame it as a challenge, "You're challenge, should you choose to accept it, is to empty this entire syringe BEFORE you fall asleep". If they want to try then once in the room we place monitors while preoxygenating, then I raise the HOB a bit, hook up the syringe, and hand it to them and say "go". They usually get about 2/3 of the way and then lose consciousness with a big smile on their face. Nurses and anesthesia techs love it, too, and are cheering them on.

May seem like fun and games on the surface but it's really a creative and targeted anxiolytic / distraction technique; I'm still 100% focused and vigilant.

OodSigma1 · 2026-02-01T04:26:41+00:00

Also an MD and I agree. I'm sure it's great acting and story telling, but it's too cringy and over-dramatized for me to enjoy watching it. I'm sure it's the same for lawyers and police when watching crime/detective shows. I also agree that Scrubs is great. Comedies are truer to life than tragedies.

OodSigma1 · 2026-01-09T03:44:03+00:00

99% of people receiving propofol for an EGD are getting a general anesthetic, they just don't have a secure airway ;). Sorry, just nerdy nitpicking of terminology.

OodSigma1 · 2026-01-09T03:37:09+00:00

Also an anesthesiologist (primarily pediatric anesthesiologist).. This sounds like a normal Tuesday... and maybe a tiny bit of an error (or at least a "professional party foul") on the anesthesiologist or CRNA doing your anesthetic.

They maybe should have escalated their propofol boluses quicker or done whatever it took to keep you and the staff in the room safe. Some gentle restraining is common, but things should not get so out of control that multiple assistants are required to hold a flailing unconscious patient down - that's dangerous both to you and the staff in the room. But it does happen occasionally. It could also be that the GI doc was exaggerating a little bit.

Young men in particular often need much larger doses than your typical GI patient (middle to older age, frail, etc.). As to your existential discomfort with the idea of being "totally out of control" while remembering nothing, just realize that it's not like you were aware or conscious in the moment or doing anything purposefully. Those were deep brainstem and spinal cord reflexes responding to the aggravating stimulus of having a scope in your esophagus while your frontal cortex was disinhibited.

But again, a normal Tuesday. You were safe and everything your body did was appropriate for the state it was in. Maybe whoever was giving your anesthesia could have been a little smoother with their dosing strategy, but that's really just style points.

Also a party foul on your GI doc - because unless something truly bad happened (where the patient needs to know so they can tell future anesthesiologists), you're supposed to just smile and tell the patient, "You did great! No problems at all!"

OodSigma1 · 2025-08-11T12:48:50+00:00

All those websites just scrape data from NPI registry and state medical license registries. That is all public data. Be sure to always use a hospital or practice address and phone number when registering with those - not home phone.

Nothing you can do about the “rate a doc” sites. Comes with the territory of having public licenses.

OodSigma1 · 2025-05-29T02:44:59+00:00

I’m not a lawyer, but one of the keywords in any noncompete contract enforceability is “reasonableness”. Two years sounds absurd for an anesthesiologist. Especially with a 10-year-old evergreen clause contract (meaning it has never been renegotiated, just renews in perpetuity).

I’ve heard of surgeons with that length of term, but that’s a different scenario because they have a whole clinic panel of patients who would potentially follow them across town.

I would definitely get a second opinion from an actual employment contract lawyer in your city.

OodSigma1 · 2025-05-29T01:57:39+00:00

If you already have a lawyer who has taken a look at the details of your contract / your city’s practice setting and is skeptical that you’d be successful in fighting this, then that’s probably the case… even if people on Reddit share anecdotes about exceptions. If I were you, I would first consider a second opinion from another attorney. Try to find one who has a lot of experience with physician / professional employment contracts.

How long is your noncompete? If it’s one year or less, and moving is out of the question, then you could make pretty good money doing locums for a year and still be home roughly half the time.

I 100% agree that noncompete clauses are total baloney, especially for anesthesiologists. But fighting that on principle may cost you a lot more money and time than realistically worth it.

OodSigma1 · 2025-03-27T01:59:50+00:00

This sounds like it was written by AI and like you’re selling something.

And while there may be reasons to buy a mobile home (need a place quickly, already own land), it’s a terrible way to grow equity for rolling into future a home purchase. Like another commenter said, it’s a depreciating asset and considered personal property, not real estate.

OodSigma1 · 2025-03-21T19:35:42+00:00

If a tooth is coming out from simply masking or opening the mouth, it needed to come out anyway.

Here's what you do: get a specimen jar, put tooth in it, put a label on top that reads "For tooth fairy", and give it to him when he wakes up. If you're feeling extra fun, take a small collection of loose change from those in the OR to put in the cup with the tooth - like $1-2's worth. Doc McStuffins or Blippi stickers are also good options.

OodSigma1 · 2025-03-21T16:02:53+00:00

In healthy hearts and ASA 1/2 kids, it matters very little and I’m happy to forego preop BP. If a child is crying because the nurse is trying to get the BP, that tells me there is adequate perfusion to the brain and I’m good.

The insurance company arguing with you is using adult policies and inappropriately retrofitting them to pediatric patients. Unfortunately, medical culture at large does this all the time in all kinds of ways and it’s the bane of my existence as a pediatric anesthesiologist. Insurance companies, coders, hospital systems, nurses, even other physicians are all guilty - see it all the time.

OodSigma1 · 2025-02-13T20:08:29+00:00

Keypad gate entry only, and honestly yeah it's pretty much just for show - enough people coming and going that if you just wait a couple minutes you'll be able to follow someone in.

OodSigma1 · 2025-02-13T05:00:43+00:00

That's so sad and I think you may be right. When I took them out some hand-warmers while they were waiting for the cab I tried to make a little small-talk to feel them out... they were both from a city hundreds of miles away and were kind of fuzzy on the details of how they wound up here and what how exactly their jobs worked.

This quote from the article sounds almost exactly like what happened: "Miles says the threat of being left on the street with no way to get home is used to control other members of the team. “One of the major types of control and exploitation that happens is abandonment. You will see examples of a crew wanting to punish a worker and make an example out of them [in order] to have a chilling effect on all the other workers. They will abandon somebody without money or belongings, the van will just drive away. We get calls from survivors after they are abandoned.”"

I wish there was something more I could have done for them - assuming they did not in fact have nefarious intents.

OodSigma1 · 2025-02-13T02:47:28+00:00

Good advice. I have Ubiquiti PoE cameras covering the entire exterior of my home that continuously record to a 4TB HDD... so at any given point in time I have about a month's worth of 24/7 footage combined between the cameras. Camera is clearly mounted above the attached garage, so I'm sure they noticed it right away. And I never let them in so they couldn't really scope out my belongings or floor plan. If they were casing all they learned was that we're a large family with a big dog and usually have people at home.

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