Editor’s Introduction: This series is based on a number of patient observations and personal inquiry by Dr. Chow between 2007 and 2009, Dr. Chow has filed a patent with the US Patent and Trade Office regarding the use and application of propofol-based sedation in the production of patient dreams and rapid eye movement or REM sleep.
A question I frequently get in my practice environment—where patient-reported dreams often occur—is whether patients have “nightmares” during surgical anesthesia. By nightmares, I mean dreams that produce negative anxiety (my definition). My usual response is “not really,” which truthfully, is hedging a complicated answer to a simple question, but when pressed, I usually confess that the answer is not straightforward. In my experience, propofol dreams can often start as “nightmares” but typically end up as happy, reconciled dreams through the dream sequence, as described in Part 2 of this series. I usually joke to my colleagues that propofol dreams almost always produce the emotional equivalent of the sappy “Hollywood ending,” no matter how badly the dream starts.
“Jared” is a skinny, twenty-something engineer in perfect health, who underwent a propofol-based sedation anesthetic for a hernia repair. Jared is a very typical patient in my practice: relatively young, in good health and well-educated. In my pre-operative telephone call and visit before surgery Jared really was only concerned about being “starved” before surgery.
Jared’s hour of propofol –based sedation anesthesia, was uneventful. As he was being wheeled back to recovery, Jared revealed he was no longer hungry. Recognizing Jared had been dreaming (one learns to recognized the emotionally satisfied look of a propofol dreamer with experience), I asked Jared why he was no longer hungry, and if he had any dreams under anesthesia.
In Jared’s dream he was at work, but hungry for a snack. His favorite snack then appeared, in the form of a ten-foot tall Oscar Mayer hot dog in a bun. In his dream, Jared was initially so fearful of the oversized, cartoonish hot dog, that he ran for his life, with the snack pursuing him through the office and out onto the street. As Jared described his dream to me I cringed at the possibility (despite the general amusement of the staff) that I had created a nightmare for Jared.
“What happened next?” I asked anxiously.
“Well, I was swallowed up in the buns of the hot dog, and I felt so warm and FULL. I wasn’t hungry anymore,” Jared revealed with a satiated smile.
Ah, relief. Jared revealed that in his dream he was fearful as he was being chased by the giant hot dog for about 20 minutes and then swallowed by the vengeful Oscar Mayer’s bun. Afterwards, he described the pleasant feelings of warmth and gastric fullness, as he lay tucked in the hot dog buns for hours later.
In retrospect, Jared’s dream was very much a nightmare in the beginning. One can imagine if Jared was sleeping at home, perhaps he would have woken up in bed, feeling anxious about his nightmare. Under titrated propofol sedation though, his nightmare converted from a “bad dream” to a “good dream,” at least emotionally. Being swallowed by a giant hot dog did not elicit terror in Jared, but a pleasant feeling. Jared’s anxiety about his hunger was reconciled in his propofol dream.
“Peter” is a fifty year old software project engineer, who was scheduled for a knee arthroscopy. Although Peter requested to be “awake” to watch the procedure, the orthopedic surgeon and I decided sedation anesthesia was best, given Peter’s high level of anxiety. .
The case was uneventful under propofol–based sedation anesthesia, and Peter woke up quickly after surgery. Afterwards, our previously anxious patient appeared relaxed and smiling. In recovery Peter revealed that he had been “awake” the whole time, to my initial horror (Despite propofol sedation, did he have OR recall?)
Peter described being in an operating room as surgery begins. He describes resting peacefully and watching, fully awake, as the details of his surgery unfold.
“You were fully awake in the operating room?” I queried, alarmed about the unplanned alertness and possibility of OR recall. “I was watching you. You never opened your eyes, “ I explained.
“Well kind of awake,” admitted Peter. “I think I was doing the surgery too.”
“You were dreaming you were doing surgery on yourself!?” I exclaimed with relief.
“That’s right,” Peter proudly offered, “and I was good too!”
In Peter’s dream he was wearing scrubs and performing arthroscopic knee surgery on a patient (himself!) As he described it there was apprehension at first, until he realized he was the surgeon and the patient. As he performed surgery on himself (apparently no anesthesiologist present), Peter felt a sense of relief and control over the situation, and his anxiety faded. The surgery went on for hours and didn’t end in his dream.
A Peter was getting ready to go home, his wife added some more detail: Peter had been anxious about the procedure for weeks, reading up on arthroscopic knee surgery, to the point where she thought he was obsessed. He had often joked at home that he could even do the surgery himself! In Peter’s dream he reconciled his anxiety by doing just that.
Jared and Peter’s dreams were both potential nightmares that were converted into dreams that had pleasant emotional endings as their primary anxieties were reconciled. Both followed the dream syntax I described in Part 2 of this series. Both dreams had an imagery set (office and OR), an emotional conflict (hunger and fear of surgery) and primary actors (Jared running from Oscar Mayer, and Peter as the surgeon/patient), with emotional reconciliation (Jared eaten by Oscar Mayer, and Peter performing surgery on himself).
Dream researchers have hypothesized that nightmares occurring in natural sleep stages are just incomplete dreams, in which the dreamer is awoken by the intensity of dream conflict. In propofol dreams, in my experience, these potential nightmares are converted into dreams with pleasant endings, as the anesthesia blunts the ability to awaken and interrupt the dream’s conclusion. When my children wake up at home from nightmares, I tell them not to fear their dreams, that their “bad” dreams will turn into “good” dreams in time...and that’s what I tell myself in the OR as well.
Part 1: A Personal Perspective
Part 2: Of Motherly Love and the Syntax of Propofol Dreams
Part 4: Déjà vu Memories