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Awake under the knife: More patients opting to stay conscious during surgery

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As Dr. Abhishek Julka sliced into the base of Mikaela Rueter's palm, the Madison woman, unlike most patients undergoing carpal tunnel surgery, was wide awake.

"It feels numb, with a lot of pressure," Rueter, 38, said while Julka cut a ligament to relieve tension on a nerve as monitors beeped in the operating room at UW Health at the American Center. "I wouldn't call it pain."

More doctors are letting patients remain alert during certain surgeries, for logistical, financial and medical reasons. It's a national trend playing out in Madison.

Regional nerve blocks and local injections of anesthetic have improved in recent years, reducing the need for general anesthesia, in which the patient is unconscious and requires a breathing tube.

Many patients getting hand or arm surgeries, knee or hip procedures and even some breast and urological operations have started receiving regional or local numbing shots instead of general anesthesia. That can mean a quicker recovery, less cost and fewer side effects, doctors say.

Still, most of those patients receive intravenous sedation, similar to what people get during a colonoscopy. They are largely unaware of the procedure and remember little, if any, of it afterward.

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Injecting the wrist

Dr. Abhishek Julka, a UW Health hand surgeon, injects Mikaela Rueter's palm with local anesthetic before carpal tunnel surgery in which she stayed awake. Most of Julka's patients don't use general anesthesia or sedation. "If you do a really good job with the local anesthetic, they don't need that," he said.

A small, but growing, fraction of patients is choosing to stay completely awake, with no sedation. They're joining two groups that have long remained conscious during surgery: many women delivering babies through Cesarean sections; and certain brain patients, such as those receiving deep brain stimulation, who must be able to communicate with doctors during their procedures.

"We are getting more and more requests from patients who say, 'I want to avoid sedation if it's not necessary,'" said Dr. Mike Ford, an anesthesiologist at UW Health. "Some patients don't like the idea of losing complete control."

Rueter opted to forego sedation because Julka said she didn't need it. He pumped her wrist with local anesthetic and finished the carpal tunnel repair in just a few minutes.

Despite being fully aware, Rueter was not able to see Julka's instruments inside her wrist because a surgical drape blocked her view.

"I would have liked to have looked over," she said. "Then again, I might not have liked it."

Don't say "Oops!"

SSM Health St. Mary's Hospital in Madison has started using regional anesthesia, instead of general anesthesia, in many cases in recent years, said Dr. Mark Kruck, a St. Mary's anesthesiologist. But the vast majority of patients want sedation, Kruck said.

"When we propose a regional block, the number one response is, 'I don't want to be aware of anything in the operating room,'" he said.

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Operating inside the wrist

Dr. Abhishek Julka, left, and Dr. Walker Flannery perform carpal tunnel surgery on Mikaela Rueter, of Madison, as she remains awake. Julka prefers having patients stay alert during the procedure so they can tell him if his instruments hit a nerve. "Particularly for people with small wrists, I really want them awake," he said.

Dr. Steve Lagman, an anesthesiologist at UnityPoint Health-Meriter, said many patients worry about becoming anxious if they're awake. "The operating room, being an unknown place, is kind of scary," Lagman said.

Another reason few patients remain alert during surgery, Lagman said, is that some surgeons don't like the idea. "The easiest thing for a surgeon is to have a perfectly still target," he said.

In a study published last year, surgeons whose patients are awake said they have to be more careful about how they communicate, such as avoiding the word, "Oops!"

"They felt like there were two responsibilities: doing the job of the surgery, and tending to the comfort and potential anxiety of the patient," said Dr. Alexander Langerman, a bioethicist and head and neck surgeon at Vanderbilt University Medical Center in Nashville, who led the study.

If a surgeon is performing a challenging part of a procedure, "it becomes very hard to split that responsibility," Langerman said. During one of his procedures, "I had to tell the patient, don't ask me questions right now."

Another obstacle the study identified: Surgeons said it's more difficult to teach residents — doctors in training after medical school — if patients are awake. Plus, some patients don't like knowing that residents are participating in their procedures.

Dr. Geoff Baer, an orthopedic surgeon at UW Health who does knee and shoulder surgeries, said up to 5 percent of his knee surgery patients stay awake.

Teaching residents during the procedures hasn't been a problem, Baer said. "We don't try to hide that... We're a teaching institution."

Many of his surgeries are arthroscopic, with a video camera displaying the work he is doing beneath small incisions. Patients who remain awake can watch the video as Baer describes each step.

He also lets the patients select background music in the operating room. "Otherwise, the environment is pretty much the same" as when patients are unaware, Baer said.

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Mikaela in recovery

Mikaela Rueter, 38, of Madison, said she felt pressure, but no pain, during a carpal tunnel surgery in which she stayed awake. She was hopeful to get relief from her wrist pain. "There were a couple of days when I couldn't even get dressed," she said.

Like pulling a tooth

Dave Knight was fully conscious during his arthroscopic knee surgery last year by Baer. Knight, who works in sports medicine at UW Health, was able to see his knee injury and its repair on the video screen.

"It helps me better understand why my recovery has taken a little longer than I would normally expect," said Knight, 43. "It's the location of the biggest piece of missing cartilage."

Julka, who did Rueter's carpal tunnel operation, said most hand surgery patients in Madison use sedation. But most of his patients don't.

One advantage of avoiding sedation, he said, is safety: If his instruments get too close to a nerve, patients who are awake can feel that and tell him, which can reduce complications. Also, local anesthetic is appropriate for a localized procedure, he said.

"This is like having a tooth pulled," Julka said. "There are thousands of dental procedures done all over the country every day with local anesthetic. Why would this be any different?"

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Julka by door/hallway

Dr. Abhishek Julka, right, said he started encouraging his hand surgery patients to stay awake during the procedures after learning that the practice is common in Canada and England. It's becoming more common, but is still unusual, in most parts of the United States. "You can do this with 5-year-olds," Julka said. In the background, Dr. Mike Ford, an anesthesiologist, checks on patient Mikaela Rueter.

Jay Gavin, 61, of Reedsburg, stayed awake during his carpal tunnel surgery in April by Julka. Gavin said he'd do it again if he needs the surgery on his other wrist.

"You don't feel a thing, but you know what they're doing," he said.

The Rev. Earl Sias, of Evansville, has been awake during three operations, at St. Mary's: carpal tunnel repair and elbow surgery several years ago, and a double knee replacement last year.

Sias, 70, rector at All Saints Church in Janesville, said a friend died shortly after an operation years ago, which made him worry about being put to sleep.

"If the doctor's going to say, "'We're losing him, we're losing him,' I want to know that I'm going," he said.

Surgeons and staff have acted professionally during his procedures, he said, but he did overhear some gossip during his elbow surgery. An unsuspecting nurse entered the room and asked the surgeon if he would introduce her to his friend, who was also single.

"I was just inwardly amused," Sias said.

From his knee replacements, he remembers the sound of the saw. "Obviously, it was cutting through bone," he said.

The buzzing didn't bother him because nurses had told him what to expect. "My fear of being unconscious outweighs a lot of the other normal fears," he said.

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David Wahlberg is the health and medicine reporter for the Wisconsin State Journal.