The Introvert, Post-operative Delirium and Goats

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My name is Reyna and I have a goat obsession. It seemed like a harmless eccentricity, so I never mentioned it to the doctors. But I wasn’t always this way. 

It all started in 2011, when I had two surgical procedures separated by a few months. Both procedures required general anesthesia and produced interesting cognitive effects upon waking. Prior to that fateful year, I had had no experience with general anesthesia and had no reason to assume my mental processes would be in any way affected when I came to.

The first time I awoke, I heard Zydeco music playing faintly in the background. I found it odd that someone in a hospital environment would be playing music loud enough to be heard in the patient rooms, but it wasn’t unpleasant, so I lay back and listened. Because I was not familiar with Zydeco, the unusual music held my attention. I distinctly heard fiddle and accordion and I remember thinking that, given my circumstances, it was good that the compositions were upbeat and happy. When I noticed that the music would come and go as the heating system turned on and off, I just figured that the sound was being carried through the vents. Someone in some distant room in the hospital was responsible for the unexpected entertainment. But once the room temperature was steady and the blower was no longer necessary, the broadcast was taken over by the white noise from the equipment in the room. Oh, that ain’t right, I thought.

The second time I went under, I woke up thinking how much I liked goats. I really, really liked goats. I knew I didn’t have this deep affection before the operation, but I was nonetheless unperturbed and just went with it. By this time, the Zydeco music had faded for the most part and I only heard it occasionally when there was a source of white noise, so I figured the goat thing would also go away in time. Didn’t happen.

In the coming weeks, I bought a book on the care and feeding of goats. Fortunately for my husband Rich, we were not zoned for goats, so I was unable to fully indulge in the goat fantasy. When I returned to work, I made a goat screensaver and wallpaper for my computer. Shortly after this, departmental operations moved from the east coast to the west and my team and I were laid off. I worked as scientific director at a major pharmaceutical company, and you might call it paranoia, but I have lingering concerns that the operational transition was somehow influenced by the goat presence on my work computer. Human resources never said anything specific about the goats and, like the others caught up in this disaster, I was sent for re-education at a job transition agency. The re-education was supposed to get me to think more broadly about next steps and future employment. Little did they know…

When Dave, the facilitator at this agency, asked me about my thoughts on what to do next, I brought up goat farming. Dave’s eyes bugged out and he became excited. It turned out that when he lost his job, he cobbled together a collection of employment opportunities to earn an income: facilitating sessions at the job transition agency, teaching at a community college and—wait for it—goat farming. Rich and I ended up visiting Dave’s farm, playing with the goats and buying some very delicious cheese. The reality of goats completely lived up to the fantasy, so I was not cured by this experience. Unable to start my own farm due to zoning restrictions, I went on to write the Zackie Stories, incorporating something about goats into each of the two books in this growing series, and occasionally subverting a blog post with a caprine reference.

Lest you think that brain abnormalities following surgical procedures are rare or specific only to my cognitive processes, Science Magazine, one of the premier journals in the scientific literature, recently published a disturbing article related to this phenomenon. A caveat to keep in mind while considering this report is that the human studies cited lack proper control. Because it’s unethical to withhold necessary surgeries from some people just to create a control group for comparisons to those who had surgery, solid conclusions are a bit iffy for this stuff.

In the summary article “Will surgery sap your brain power?,” the authors examine the potential causes and consequences of cognitive issues following surgery that required general anesthesia. Postoperative delirium involves symptoms of delusion, confusion, and hallucination that usually fade quickly (or not, to wit, my goat obsession). Postoperative cognitive dysfunction (POCD), on the other hand, involves difficulties with memory, attention, and concentration. Again, this can be temporary and last only months, or the deficit can remain for a lifetime. Anecdotal stories imply that the elderly are particularly at risk for dwindling mental abilities following surgery. The elderly, already potentially struggling with mental decline, can be pushed over the edge and enter a postoperative delirium from which they never emerge. The data to support this notion, however, are equivocal.

Trying to get a grip on this phenomenon is difficult for a variety of reasons. As mentioned above, prospective case-control studies in humans are impossible to perform for ethical reasons. Also, the true frequency of these events is difficult to pin down because there is no official diagnostic criteria (but some studies suggest these impairments are disturbingly common). In addition, the type of operation has an effect—heart surgery patients suffer most frequently from cognitive decline, while bariatric surgery patients surprisingly become mentally sharper. Feeding into the type of surgery a patient requires is the effect of their pre-existing condition. For example, heart disease takes its own toll on the brain. Elderly patients, meanwhile, may have mild cognitive impairment (a frequent precursor to Alzheimer’s disease) prior to the operation. In either case, these patients may have declined anyway, with or without anesthesia or surgery. Teasing out these confounding factors is not simple, but the researchers need to do this in order to determine if surgery and/or anesthesia is accelerating mental decline.

There are a few hypotheses to explain why surgery under general anesthesia might cause cognitive decline. One possibility is that surgery reduces blood flow to the brain and deprives this organ of oxygen. But wouldn’t the experience of POCD be universal if this were the explanation, albeit with variations in intensity due to pre-existing conditions that affect blood flow?

Another hypothesis is that anesthesia itself is screwing up the brain. “Awake Under Anesthesia,” a recent article in The New Yorker, delves into how “people can hear things while under anesthesia, and can be affected by what they hear even if they can’t remember it.” If this is the case, it begs the question of what in the world my surgical team was up to while I was under. But back to anesthesia—this substance also has documented biological effects. It’s known that neurons in a culture dish can be killed by exposure to anesthesia and that animal brains will develop abnormally if exposed. Perhaps we awake from surgery with a mild brain damage and it’s not just chemically-suppressed memories of surgical suite antics.

The hypothesis du jour to explain POCD and delusions is that surgery unleashes a body-wide inflammation, which then infiltrates the brain, particularly in the elderly. Evidence from both brain imaging studies in humans and memory studies in animals appear to support this idea.

For me, it could have been worse. I don’t do well on opioids. I’ve never been genotyped, but I suspect I’m a poor metabolizer for these drugs and get all the nausea and dizziness without the benefit of significant pain relief. Once the medical staff saw my impersonation of the possessed little girl in The Exorcist, I got a whole lot of anti-inflammatory drugs instead of the usual opioids. This change in medication might have prevented more serious cognitive problems than hallucinating Zydeco music or developing a goat obsession. Something to consider. With a little more brain inflammation, who knows what I’d be writing? As my brain function inevitably declines with age, maybe we’ll find out. Things could get interesting.

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Photo credit: George Chernilevsky – Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=8002106

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The Introvert, Post-operative Delirium and Goats

2 thoughts on “The Introvert, Post-operative Delirium and Goats

  1. I really enjoyed your fascinating and thought-provoking post. Although whatever cognitive damage you might have experienced from anesthesia could hardly be described as a good thing, you might consider adopting a silver-lining attitude regarding your newfound (or newly implanted) fondness for goats. Goats are wonderful, under-appreciated creatures. Prior to your surgery, you probably never really thought much about them, but a tiny bit of brain damage offered you an epiphany.

    Like

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