Tuesday, August 24, 2010

Mental Fortitude

David Brooks in yesterday's New York Times wrote a column about mental fortitude, or lack of it in today's society.  He used the excruciating radical mastectomy experience of Fanny Burney, a 19th century English author, to illustrate mental courage. This was the state of surgery before the invention of anesthesia.  Ms. Burney didn't even have the benefits of alcohol for sedation; the surgeon simply placed a piece of cloth over her face to shield her eyes from the horror her body was about to suffer.  She could feel every slice as the scalpel cut through living tissue.  Just when she thought the worst was over as the surgeon finished cutting through skin, she had to undergo more torture when the surgeon cut her tissue down to the bone, literally feeling the knife scrape against her ribs.  It is amazing Ms. Burney lived through this. 

Could anybody today tolerate such torture?  Of course not.  First of all it would be completely unethical to knowingly conduct surgery on a conscious patient, unless of course you were some mad scientist performing some sort of fiendish human experiment.  Can this happen undetected by the surgeon or the anesthesiologist? Unfortunately, the answer is yes.  While extremely rare it's not out of the question that patients have undergone surgery while paralyzed but awake.  It is probably the number one fear among patients about to have an operation.  That's why there is much research into preventing surgical recall and the American Society of Anesthesiologists has established a registry to document any cases of recall in order to understand its etiology.

What's acceptable in advanced Western society today is radically different from the attitude of two centuries ago.  This was before the advent of anesthesia, narcotic pain relievers, or post traumatic stress disorders.  People acquiesced to the fates dealt to them by the gods.  Doctors had little to offer other than cutting and bleeding. No amount of whining would have changed their outlook.  Life was accepted as harsh and unforgiving.  You can still see this kind of compliance when treating patients in less medically advanced societies.  Even their children are less apt to complain about the pain they feel postoperatively. To these people they are just gratified that anything was done at all.  Sometimes it seems to me the more we offer our patients, the less satisfied they are with our care. I think if people understood how far we've come in treating medical diseases they might be more thankful for what they have instead of complaining about how miserable they feel.

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