How do I choose an anaesthetic when suffering from anxiety?
December 5, 2016 1:26 PM   Subscribe

Unpleasant female medical procedure + phobic-level anxiety + having to choose an anaesthetic = Horror, anxiety and meltdown. Do you have experiences/information/tips that can help?

I have to go into hospital (UK, NHS) for a hysteroscopy + biopsy. I am prone to anxiety, nulliparous (never had children) and menopausal which has made previous tests hurt and fail. As a result I’ve started to get a bit phobic about gynaecological treatment. The specialist said I could get this done under general anaesthetic. Unfortunately during a preliminary visit, an anaesthetist talked me through the dangers of death from a general anaesthetic and then insisted on talking me through the possibility of a spinal anaesthetic and sedation which unexpectedly reduced me to floods of tears. I was left badly shaken.

I was terrified of being in something like a rape situation where people are doing something invasive and terrible to my body but because I am drugged I can’t stop them. I was coping better with the notion of the general anaesthetic because being knocked out, I wouldn’t get distressed and upset. Complication - I know GAs do carry a small risk of death and I am very overweight (though my health is otherwise fine and I am still under 50).

So now I feel terrified about the whole thing, and wonder if by having a General I am making a terrible mistake and risking my life unnecessarily, and if the spinal plus sedation would be fine, but on the other hand, if I go with the spinal, there’s the danger of a major phobic reaction on my part and ending up hysterical and traumatised - previously I’ve bolted from a wisdom teeth extraction using local anaesthetic after the injections, and had to get that done later under a GA.

The worst part is that I get to choose, and the medical professional’s explanation, far from helping, made both options seem terrifying. Have you experience of spinal anaesthetics plus or minus sedation you can share? How does that work if you are terrified/phobic/highly anxious? Might the general be the better idea after all? Are there other gynaecology-phobes out there who’ve been in similar situations? How did you cope?
posted by highanxiety to Health & Fitness (16 answers total) 3 users marked this as a favorite
Have you asked who will be present at your procedure? Would you be allowed to bring someone whom you trust to actually go into the procedure with you (said person would sit at your side and a sheet would block any overly-intimate view)? If so, that seems like something that would reduce your anxiety about having things done to you that you don't want. If that's not an option, would a female nurse sitting with you (i.e. whose job is to sit with you), being present ease your fears? I've definitely had nurses in procedure rooms whose entire job was to just hold my hand and make distracting small talk the whole time.

That said, the risk of death from general anesthetic is very very very small.
posted by If only I had a penguin... at 1:34 PM on December 5, 2016 [11 favorites]

A friend was informed that the spinal option has a more rapid recovery time back to full alert status.
She chose this option in response to issues similar to yours.
She went through surgery and woke up quickly with no anxiety or issues.
Is there a mental health professional that you might consult on these issues?
posted by calgirl at 1:35 PM on December 5, 2016

I'm sorry you're so anxious - I suffer from crippling anxiety and I know how awful it can be.

Two things that struck me - you had a general for your dental procedure. I'm assuming you would be ok with another general (obviously IANAD), so you might query with your specialist why the team anaesthetist is suggesting a spinal anaesthetic.

Second point - I've had procedures involving sedation and it is much easier than having a local anaesthetic; I was essentially asleep or in and out of a pleasantly relaxed state and had no anxiety during or afterwards.
posted by Martha My Dear Prudence at 1:42 PM on December 5, 2016 [2 favorites]

Do they offer "twilight" anesthesia? This would be sedation meds administered via IV that make you basically unaware of what's happening but don't knock you out completely. This is done for a variety of in-office procedures in the US (including hysteroscopies and D&Cs) and usually it's monitored/administered by a nurse (not an anesthesiologist). It's possible they could prescribe you an oral anti-anxiety med to take before you get to the office to help you through the pre-op and IV-insertion phase, but I would make sure to get that from them so everyone is aware of everything you've taken.
posted by melissasaurus at 1:43 PM on December 5, 2016 [1 favorite]

I am very very anxious as well and have had to get twilight sedation as well as GA for some otherwise minor procedures. The risk of death from GA to me is smaller than the risk that I will freak out or be traumatized by the procedure. That's a decision you'll have to make, but for me? I tell my doc/anesthetist that I don't want to "be there," and so far, all has gone well.

Do ask if you can take something for anxiety BEFORE you come to the clinic. You'll have to have a driver to and from of course. Just going into a hospital or surgery center starts up the anxiety for me.
posted by fiercecupcake at 2:20 PM on December 5, 2016 [1 favorite]

I just had cataract surgeries (two of them!) and have issues with being restrained and out of - not control, but something like it.

I had to be mostly awake. But I told the docs ahead of time that I was likely going to have a panic attack. And worried I would move and my eye would get messed up and I would be blind for life.

So when I was in surgery - I would say "I'm feeling anxious!" And they would give me a little more sedation. Repeat.

Either one you choose, you are going to be fine. The worst thing that can happen is that you'll have a panic attack. That is the absolute worst possibility. If you alert the docs as you go into surgery, they'll be able to work with you and reassure you and take the steps you need.

I also am super photosensitive and wake up from anesthesia queasy, which sets off another stupid panic attack. I told them all of this while I was there, so they knew and took the measures needed.

It's totally normal to have anxiety. You're not going to be the only person that day that will have slightly higher needs.

Instead of going in circles about which to choose, flip a coin. It matters that little. Within an hour of waking up, it will be over.

I will repeat, the absolute worst thing that will happen is that you will have a panic attack. You might even definitely have one.

They pass. They cannot kill you. They suck. But they pass.

(This is what my former shrink taught me when I first started getting them. Talking myself through it works better than any med has. "You're having a panic attack. OK. You're not going to die. It's going to suck for a while. I wonder how long. But it's cool, it'll pass. Nope, still there. OK. It'll pass." They always do and we will never die of one.)
posted by crankyrogalsky at 2:23 PM on December 5, 2016 [4 favorites]

Hi, I am a nurse and midwife with a lot of experience in sedation and anesthesia for ob/gyn procedures. (This is not medical advice/IANYNM/etc.). My experience is in the US, so YMMV in the UK. Here are a few thoughts:
1. The risk of a major adverse event (death, brain damage, etc.) from GA
Is vanishingly small. Even for patients that are slightly more risky (say, overweight or smokers), it's still extremely low. We usually tell pts that the risk of you getting hit by a bus while walking in a big city is higher than the risk of serious complication from the anesthesia, and it's true for most people. (NB: I am
referring to relatively short procedures, which it sounds like you're booked in for).
2. For the spinal vs GA, you should consider that you will be conscious during the procedure with a spinal and if you have anxiety, that might not be the best option for you. Placing a spinal can also be a scary and uncomfortable event for many people. As to GA, is it a true GA where you are unconscious and intubated, or a heavy sedation with something like Propofol? It sounds like Propofol would be a great drug for you for this purpose. That said, if moderate (conscious) sedation is an option, that also seems like a good choice for you. I agree that you should have good communication with whoever provides he anesthesia and let them know about your anxiety.
3. For patients who are highly anxious, we often offer pre-medication with an oral benzo (e.g., lorazepam) before even placing an IV for sedation. This can make a world of difference.
4. I am so sorry to hear about your fears of rape. It makes me think you don't feel comfortable with the staff/hospital/doctor/etc. it might be worth asking if someone can come in the OR with you. Or if there is a nurse you like, ask if (s)he can be in the OR with you. Being conscious with a spinal will of course allow you to be aware during the procedure, but the feeling of numbness (and awareness of the procedure, seeing the dark room, hearing OR noises, etc.) can be scary for some people. (Though others much prefer that...)

So, ultimately it's what you feel most comfortable with, which I guess is why you asked this question! Feel free to MeMail me if you'd like to chat a bit more. I have been working in the OR on and off for 10+years. Sending good thoughts.
posted by stillmoving at 2:51 PM on December 5, 2016 [7 favorites]

I am sorry that the anethestist scared you with the rist of death stuff. I find some of that 'informed consent' stuff just too overwhelming. There's risk in everything but we don't have to listen to a lecture on it before getting a car, on a place, walking down the street.

Sedation is great, if you can chose that. I don't remember anything and actually woke up with the most fabulous sense of well-being, apparently that was the propofol.

do they offer "twilight" anesthesia? This would be sedation meds administered via IV that make you basically unaware of what's happening but don't knock you out completely. This is done for a variety of in-office procedures in the US (including hysteroscopies and D&Cs) and usually it's monitored/administered by a nurse (not an anesthesiologist).

I think in the UK it would probably be administered by an anaesthetist. It is in Australia and I know that UK and Australian anaesthetist training is similiar and US training wasn't recognised (was a bit of a drama when we were recruiting overseas docs to work in the UK. The US docs were understandably offended).
posted by kitten magic at 2:56 PM on December 5, 2016 [2 favorites]

Glad to see stillmoving's recommendation of propofol too - I was still writing when they posted.
posted by kitten magic at 2:58 PM on December 5, 2016

Given your past experience with dental surgery, it seems pretty clear that you shouldn't be conscious for this.
posted by metasarah at 3:01 PM on December 5, 2016 [1 favorite]

There is a sedation plus spinal anaesthetic option but the anaesthetist didn't say what drug was to be used for sedation, or how it would be administered, just that I'd remember nothing. I didn't find this re-assuring - as I didn't know if I'd be traumatised and then my memory effectively wiped and if it would still be terrible at the time. I somehow don't quite trust this option.
posted by highanxiety at 3:06 PM on December 5, 2016

Forgot to add in answer to stillmoving ''It makes me think you don't feel comfortable with the staff/hospital/doctor/etc.

You're correct I don't feel comfortable, because twice now I've been told a procedure is fine, nothing to worry about and it hasn't been true - the procedure has been painful and uncomfortable and upsetting - once by a nurse and once by the gynaecologist, so I no longer trust them to tell me whether something will hurt or upset me or not. I have to factor in whether they're completely wrong about how tolerable procedures are.
posted by highanxiety at 3:14 PM on December 5, 2016 [1 favorite]

Do ask more questions. I've had gynaecological surgery with spinal anaesthetic and sedation -- at first I was put out; I had been expecting general -- but I've had general a number of times, and I experienced no difference at all. I was awake while my bottom half went numb. They looked at my medical records and noticed I was a bit bombproof sedation-wise (I remember the doctor telling a student 'See, that's a dosage that might work for some, but look; she's sitting up talking!') but the dosage escalated and eventually I got not the sleepy feeling one gets from, say, benzodiazepines, but the 'you're going unconscious in about two seconds' feeling that comes with general anaesthetic. After that moment I was every bit as unconscious as I would have been with general anaesthetic, or at least I was as far as my brain was concerned. I would definitely do that again, despite my initial misgivings.

That said, some caveats:

-- it might have been preferable, if possible, to have the sedation kick in somewhat sooner after I went numb from the waist down; that part is not a delightful feeling. I've had a child, with an epidural, and was grateful for the epidural then, but found being partially paralysed in the OR somewhat unnerving

-- with warning/permission, a nurse loosely tied my arms to little...arm-rest thingies. This is the sort of thing that, if I had had a lot of anxiety over the procedure, I would have wanted to know about beforehand.

One advantage:

-- I had GA for a surgical abortion following a miscarriage. I woke up in unbearable pain (and am still very annoyed at the idiots who let that happen) -- it took a few minutes for the person with me to track a nurse down, and then a few more for the IV painkillers to kick in. Apparently I was just waking from GA post-surgery with balls all else in my system? That was over a decade ago and I'm still a little traumatized just thinking about it. Anyway, when I woke up from the surgery with the spinal, the spinal had some time to go before it wore off, so I woke up entirely pain-free, and the transition from "spinal still in effect" to "wearing off, need painkillers" was very slow and gentle.

(This is in Canada, for what that's worth.)

In re. "twice now I've been told a procedure is fine, nothing to worry about" -- I think this is a bit of badly-trained doctor's gentle bullshittery to try to de-stress patients. My GP told me the surgery was "nothing to worry about, some Tylenol and a week off." My surgeon was more honest, said I was looking at around six weeks for recovery, made with the prescriptions, etc. Reality was over two months of exhaustion recovery and two trips to the ER worrying about the low fever I kept running. There probably is a patient out there who had a week and some Tylenol and bounced back, and there are probably patients who were worse off than me. Which see childbirth recovery stories, which wobble all over the map. I think some types of doctors like to tell you about the easy end of the scale to try and relax you -- and some types of doctors like you to be 'fully informed' and go around telling you about stuff like, well, the risk of death from GA. (Obesity is a consideration there; you may want to ask if there's a notably greater safety margin in spinal vs general if overweight?)

I have had a couple of surgical procedures in private offices and a few in hospitals. In hospitals, without fail, the OR has been a busy place and there is no way anybody would be able to get away with doing "something invasive and terrible," I feel -- there are just too many witnesses.
posted by kmennie at 3:53 PM on December 5, 2016 [2 favorites]

Once I had a similar decision (for a different surgery) and what brought clarity for me was to ask the surgeon "Which choice makes your job easier?"

He said "Oh, it's much easier for me if we use Propofol so you are unconscious - I can do a better job with less trauma and the healing is usually quicker as well."

I chose Propofol. It was more expensive, but I had a great outcome and absolutely zero memory of the procedure.
posted by soylent00FF00 at 4:57 PM on December 5, 2016 [3 favorites]

I have had lots of hysteroscopies, while nulliparous. Have the GA - the risks are very low, they only give you a light sniff of anaesthetic (I was awake, dressed and ready to leave less than an hour after I went to sleep), and you won't be aware of the procedure at all. I have no idea why they discussed spinals with you - longer to insert, longer to wear off, and the indignity of being awake while a group of people rummage around in your uterus. Everyone has a moment of "what if I don't wake up" panic as they start to drift off - you will wake up. This is daycase surgery. People do not die during daycase anaesthetics.

In terms of pain afterwards, in my experience it depends on what they've done. The simple quick-look hysteroscopies didn't hurt at all post-op, and I just had a bit of spotting that evening. The ones where they resected things did hurt - not agony, just a constant dull pelvic ache. I couldn't run for about a month afterwards, strenuous exercise caused sharp stabby pain. I bled quite heavily for the first few days, and had ongoing period-level bleeding for a few weeks. It wasn't fun, but it was completely manageable.

I've had an unexpectedly agonising hycosy - the pain was due to my existing gynaecologist probs. When they were sorted out, the subsequent hycosy was indeed painless (I had been terrified beforehand because of my previous experience). So when they told you it wouldn't hurt, they were probably basing that on the fact that it isn't supposed to hurt, not minimising it or lying.
posted by tinkletown at 12:38 AM on December 6, 2016 [1 favorite]

Sorry, that should be "gynaecology" problems not "gynaecologist" - the gynaecology team were all lovely.
posted by tinkletown at 1:18 AM on December 6, 2016

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