“Vividly written, candid exploration . . . striking in content and quite moving.” Kirkus

In three minutes, your life is in my hands.

“A rare and thoughtful look behind the scenes of this crucial yet arcane specialization.”
 Publishers Weekly Starred Review


Henry Jay Przybylo, MD

An associate professor of anesthesiology at Northwestern University School of Medicine, “Dr. Jay” also holds an MFA in creative nonfiction from Goucher College. He lives in Chicago.

What compelled you to become an anesthesiologist?

Frankly? $600. In med school, a stipend was offered for an anesthesia rotation. The experience in the OR opened my eyes to the breadth of the field.

Have you ever “been under” yourself?

Yeah. Dumb Turkey Day football game blunder.

“Lethe, the river of oblivion, rolls his watery labyrinth, which whoso drinks forgets both joy and grief.” —John Milton, Paradise Lost

Read an Excerpt

I am an anesthesiologist, I erase consciousness, deny memories, steal time, immobilize the body; I alter heart rate, blood pressure, and breathing. And then I reverse these effects. I eliminate pain during a procedure, and prevent it afterwards. I care for sick people and I have saved lives, but it’s rare that I’m the actual healer. As an anesthesiologist, I do nearly all of my hands-on work behind automatic double doors, sequestered, allowing surgeons to cut, gastroenterologists to probe, cardiologists to stick. The patients I care for place their faith in me, but we’ve usually been introduced only a few minutes before, and they rarely remember my name after their surgery or procedure is completed.

I put people into a coma, and the medications I administer cause paralysis. Yet only a handful of times each year do patients or family members ask how anesthesia actually works. The truth is there is much about anesthesia that even modern science can’t yet explain.

But I know, as sure as the sun rises in the morning, that when I add a gas to the inhaled breaths, loss of consciousness follows; and when I remove the gas, awareness returns. This is a harrowing responsibility, and one I never take for granted.

“Gentlemen, this is no humbug.”

Those words were spoken by James Warren on October 16, 1846 after surgically removing a tumor from the neck of a patient who’d undergone the first public pain-free surgery through the use of ether. The inhaled gas, patented as “Letheon” for anesthesia had yet to be coined, was administered by young Boston dentist William T.G. Morton in a live demonstration held at Massachusetts General Hospital in the medical amphitheater known to this day as “The Ether Dome.”

The renowned New England Journal of Medicine recently polled its readers to select the most important article the magazine had published in its distinguished history. The “resounding favorite” its readers settled on was the NEJM’s 1846 article by Henry Jacob Bigelow about the demonstration. This article, published just a few months after the historic demonstration at Mass General’s Ether Dome in Boston, bested every advance made since then, including the introduction of antisepsis, of X-ray imaging, and of antibiotics.

Ether Day, or The First Operation Under Ether (Robert C. Hinckley, 1882–1893)


on medicine’s most important breakthrough

What does an anesthesiologist do?

The term “anesthesia,” which means “without feeling,” doesn’t adequately encompass all of the goals of care by an anesthesiologist.

The procedure for general anesthesia during a procedure entails a generic recipe: the big syringe (20 mL of a medication that causes a loss of consciousness), the little syringe (5mL of a paralyzing medication), and two clicks to the right (on the vaporizer that adds a gaseous anesthetic). Behind the simplicity of the recipe is a complex mix of aims, drugs, and techniques that extends anesthesia care beyond the actual anesthesia procedure, including pre-anesthesia patient preparation and post-procedure pain relief.

Since the discovery of ether, many adjunct medications have been added to the anesthesia gas to accomplish all-inclusive care. The effects that these side medications produce are what I call the “Five A’s of Anesthesia”:

  • Anxiolysis, relieving stress created by an upcoming surgical procedure
  • Amnesia, preventing memory formation during anesthesia care
  • Analgesia, relieving pain during the procedure, but also considered beyond the procedure room to include post-procedure pain relief, acute (trauma) pain relief, and chronic pain relief
  • Akinesia, preventing a patient’s movement during a procedure
  • Areflexia, stopping adrenaline surge and swings in blood pressure and heart rate while under anesthesia
What is the difference between general and regional anesthesia?

Today’s potent anesthesia gases, the one-stop anesthetic, completely obliterate the presence of pain during a procedure. At some point the procedure is complete and my all-in-one gas must be turned off for the patient to return to consciousness. Another method of continuing analgesia becomes necessary.

Dating back to the Incas and through the nineteenth century, cocaine was used topically and injected into the spine to provide prolonged loss of sensation to the lower body without mental sedation—and thus regional anesthesia was born.

The use of regional anesthesia is expanding, with better and easier imaging techniques making it possible to accurately place current drugs on more nerves.

How does anesthesia provide relief from pain?

Pain starts by activating a receptor at the source of the injury that transmits information to the brain as an electrical signal conducted by nerves. An insulator, the fatty membrane myelin, acts like the plastic coating on an electrical wire, preventing the loss of the signal to adjacent tissue as it travels. Breaks in the myelin called “nodes of Ranvier” enhance the speed of transmission of the pain signal by allowing the signal to jump quickly from node to node along the nerve. This rapid transmission is known as “saltatory conduction.”

Regional anesthesia enters these nodes, blocking the signal jumps and thus the transmission of the pain signal beyond that point. General anesthesia induces a a complete insensibility to pain and all sensation. How exactly the inhaled gases work still remains a medical mystery.

What factors affect a patient's ability to receive anesthesia?

Age and weight are two crucial factors in determining which and how much of the complex mix of drugs and techniques that are used to put someone “under.”

Not all patients are able to tolerate anesthesia gas, and sometimes additional medications must be used. In such cases, amnesia must be a specific goal of the anesthesiologist, with medications for that purpose provided, or redosed if the procedure might outlast the actions of the amnestic drug.

Why can't I eat too close to receiving anesthesia?

Restricting food intake before a procedure isn’t meant to deprive you of comfort food. It is meant to prevent aspiration of any stomach contents into the lungs. The goal prior to anesthesia is to allow enough time to ensure that food exits into the intestines and leaves the stomach empty, eliminating the possibility of aspiration pneumonitis.

The separate paths leading to the stomach and the lungs work on the either/or principle. Only one path may be open at a time, and eating and breathing are kept separate through a series of coordinated actions including muscles and reflexes. The vocal cords at the entrance to the trachea snap shut when food or drink enters the mouth. This reflex, the laryngeal adductor reflex, is beyond our active control and prevents any- thing in the mouth from going down the wrong pipe. To swallow, sphincters made of muscle in the esophagus relax and the contents of the mouth slide down into the stomach.

Acid is the anesthesiologist’s enemy. The stomach is capable of withstanding the acid it produces as an aid in digestion. But other tissue is not immune to this acid. Herein lies the risk of anesthesia, which relaxes muscles and turns off reflexes. The cinched esophageal sphincters relax, allowing the contents of the stomach to flow to the mouth while the laryngeal adductor reflex no longer guards the entrance to the trachea. To prevent aspiration under anesthesia, the stomach must be empty.