By Harrison Chow, MD
“A dream is a wish your heart makes when it is asleep” – Disneyland Hotel Pillow
Fear
Dream Survey #174, Kelley #1
In early October 2021 I received a welcome back text from Miranda Shull, a former Stanford CRNA who had just left to go to another hospital 2 months earlier. Before she had left Stanford, we had been investigating a total intravenous anesthesia (TIVA) postoperative nausea and vomiting (PONV) prevention departmental protocol for breast cancer surgery using propofol and remifentanil. Part of a breast cancer Enhanced Recovery After Surgery (ERAS) program, the technique had proven spectacularly successful at Stanford in preventing PONV and post-operative sedation. Awake and alert patients after general anesthesia had a very common and curious side effect – lucid dreams. And I was chasing dreams.
“My patients dream, Dr. Chow,” said Miranda in August. “What’s the big deal?” Then she left Stanford. Now, she was back to work on our lab dream surveys.
I texted her back, “We are working together Wednesday, let’s do the dream surveys on TIVA and breast cancer cases!”
“Smile and thumbs up emoji,” she texted back.
“Mary” from Santa Cruz was the second case of that Wednesday (dream survey #185), undergoing a partial mastectomy for breast cancer. Miranda and I hovered over the processed electroencephalogram (EEG) as she emerged from anesthesia. The familiar EEG patterns appeared and Mary’s eyes opened rapidly. After the laryngeal mask airway (LMA) was removed, Mary asked, clear-eyed, “Where am I?”
“You are at the Stanford OR, where do you think you are?” I asked gently.
“I’m at Henry Cowell Redwood Park, I’m walking with my daughter on the redwood loop.” For the next 5 minutes in the OR, Mary talked about how she walked continuously in a loop at the Redwood Park for hours in her dream, talking with her daughter about life and love. They hugged and cried. “Dr. Chow, I have never been so happy, my daughter is everything to me.”
What a clear and powerful dream! I looked over at Miranda and she just shrugged. “Told you,” her shrug seemed to say.
I called Mary the next day and left a message. Mary called back later because, as you may have guessed, she went to Henry Cowell Park and walked the Redwood loop with her daughter. “I told her, Dr. Chow,” she blissfully cried over the phone, “Absolutely everything, that I had breast cancer and how much I loved her.” I texted Miranda with the “touchdown emoji” as I finished the call.
The next year of relentless dreams from breast cancer patients were at first exhilarating to myself and the staff as we began implementing the departmental TIVA protocol with the dream survey. A pattern began: breast cancer patient after patient, repeating essentially the same dream to the staff. Family, family, family and most particularly, the children. Breast cancer dreams are literally a cliche. Love thy family.
The most poignant of these was dream survey #296, Kelly. A schoolteacher from California Gold Country, she had a partial mastectomy and axillary node dissection for breast cancer. After her 3-hour procedure she rocketed awake after another TIVA, eyes wide open. “Where am I?” she asked sharply. “Where’s Aidan?” I calmly explained (by now in the PACU) that she had had surgery. She spent the next few minutes explaining in her dream that she had made breakfast for her son Aidan (8), brought him to school, taught in her elementary classroom, picked him up, and then gave insulin at home – hours or even a full day of dream time.
“Where’s Aidan?” She wondered out loud as the PACU monitors beeped in the background. Her eyes dimmed with recognition of her situation, “Aidan’s not here, I just had surgery and I have breast cancer.” The PACU staff and myself grew silent.
“Who is going to take care of Aidan if I die?”
*****
Safety
Dream Survey # 429, Kelly #2
Kelly would return soon a few months later, for a full mastectomy. We by now had split our “dream” team into two full operational teams, one consisting of clinical providers headed by myself and one clinical research team headed by Boris Heifets.
Our teams communicated regularly about our patients’ dreams, the nature of dream content, and particularly the EEG signatures observed. We dissected and discussed everything both by text and teleconference. I finally learned how to read the EEG spectrogram (the PhDs forced me too).
“Harrison, when you are looking at the EEG in the OR, you are looking for the red delta-alpha band fade after the split,” said Dr. Pilleriin Sikka, a Swedish-US researcher of dreams who had joined our lab, after analyzing our OR EEGs on our conference call.
“Harrison, there is a green beta band that follows the alpha red band fade,” chimed in Dr. Toru Ishii, a Japanese MD, PHD and sleep medicine fellow, on the same call.
My head was spinning, you guys are ganging up on me!
Kelly’s case was uneventful, full TIVA with a rapid pre-emergence. Red alpha-delta split, alpha band fade, green beta band on spectrogram She woke up with tears and a smile. “Tears of happiness, Dr. Chow, don’t worry,” she soothed. “Aidan is at home with friends. He is playing so nicely.” As we went through her dream survey, she described how Aidan was bullied often and how happy it made her to see him safe at home with friends. “I didn’t have to worry, Aidan was safe.”
“In our dreams, Harrison, patients ultimately will retreat somewhere safe from their fear,” explained Dr. Sikka on our follow-up research call.
*******
Happiness
Dream Survey #596, Kelly #3
Why do these dreams make patients so happy? I was asking on our research call about what was becoming known both at Lane Surgery Center and the Outpatient Surgery (Redwood City), sites of our breast cancer and orthopedic dreams, as the “Stanford Curse”.
In a dream world where patients had relentlessly reported dreaming about their loved ones, Stanford people when waking up from TIVA only kept talking about their work or school projects. I would listen patiently about university projects, efficiency initiatives, statistical analysis, lecture notes, student grades or even scrubbing hands for surgery or seeing patients in clinic. Stanford dreams of work.
“Fear is converted to happiness in the anesthesia dreams; this is the biggest difference between anesthesia dreams and natural dreams”, explained Dr. Sikka.
“So why do Stanford people dream of work, isn’t that stressful?” I asked over our conference call.
“Because they are concerned about their work,” concluded Dr. Sikka, “and we often dream of things we are concerned about. In our dreams patients ultimately will retreat somewhere safe from their fear.”
“Harrison, who is Imbordino?”, asked Dr. Ishii, interrupting our Stanford dream talk.
“Katie Imbordino is one of CRNAs, she probably is the most consistent in doing TIVAs and dream surveys. Why do you ask?”
“Harrison, going through all your data, if Imbordino uses the propofol/remifentanil TIVA technique with EEG pre-emergence at a PSI >50 for at least 10 minutes, we get a 90% reported dream rate on the dream surveys.”
“90%?!” I mused out loud. “90% is Stephen Curry’s free throw shooting percentage.” Everybody on the call grew silent. Nobody knows who Stephen Curry is.
Kelly came back again. This time she seemed happy; she came with a significant other in the pre-operative area. “Maybe she will dream about me?” he joked. Kelly and I looked at each other and giggled. Fat chance.
This time she was getting breast biopsies evaluating for return of cancer. Biopsies all clear. Smooth TIVA wake-up yet again. Smiling in pre-op, smiling going under anesthesia, smiling waking up in her third anesthesia dream.
“Picked up Aidan from summer camp and went to a lake vacation house where we all got together as family,” she readily volunteered in the OR upon wake-up. “We are going there later this week so I guess I was thinking ahead.”
Why can’t Stanford people dream like that?
*******
Triumph
Dream Survey# 786, Kelly #4
“The cancer may have come back,” said Kelly’s breast surgeon, Dr. Frederick Dirbas. “Can you do the case in two weeks?” I was in the pre-op area at Lane Surgery Center on a Wednesday talking with our CRNA team. “Kelly, you remember her, you have done her anesthesia three times before,” he continued. “She has become pretty fond of the anesthesia and the dreams.”
“We’ll do it, Fred. I’ll work with the schedulers,” I reassured.
I had lined up Katie Imbordino, who was fortunately working that day. If there was somebody on this planet at this moment to make somebody dream, it was Katie. We unfortunately had a lot of repeat breast cancer patients, but Kelly would be potentially the only surgical patient to report an induced anesthesia dream 4 separate times.
Two weeks later I would see Kelly in the Lane pre-op area, I hadn’t seen her in nearly a year. I had to bite my lip as I saw her in Pre-op 2; her long hair and eyelashes were gone and she had lost so much weight. I was used to seeing breast cancer patients like this but the shock of her physical appearance was jarring emotionally.
“Kelly, we’ve got to stop meeting like this,” I joked with my best fake smile.
“Well, good morning Dr. Chow, so happy see you,” she said with a giant genuine smile, without a hint of fear. Katie and I went over the anesthesia yet again and of course the dream survey.
“You know the drill, tell us where you are and who you are with when you see me,” I said for the fourth time to her in 3 years. Kelly nodded. “I’m looking forward to it.”
As Katie brought Kelly, head bandana and all, in to the OR and then moved onto to the OR table, Dr. Dirbas stood aside and watched as induction began, EEG stickers and all. I couldn’t help a notice how peaceful Kelly looked, so comfortable with her care team and so unafraid. Where does one find such faith? I was nervous. I moved everything around to be on this case with Katie. Could we pull this off? The Four-Peat! It’s Imbordino, she is going to dream.
Dr. Dirbas looked on, a small platoon of surgical residents, students, fellows, nurses and Katie tending to Kelly. LMA inserted and EEG reading, we were underway.
“Prop/Remi, anti-emesis precautions with red delta-alpha band split, alpha-band fade, green beta band pre-emergence, gentle wake-up 10 minutes with dream survey,” I said to Katie as confidently as I could. Katie calmly nodded as sure as Stephen Curry was lining up for a free throw. I had just went over the anesthesia and dream survey plan with Katie.
Dr. Dirbas looked at us with curious amazement. “Hey Harrison, that sounds like a quarterback calling out plays,” he joked. I explained that I was talking about the EEG spectrogram and the sequence the spectrogram would have to go through to both prevent PONV and generate an anesthesia dream.
“So you guys have broken the anesthesia dream code?” Dr. Dirbas asked.
“Well at least Katie and the lab has,” I admitted, shrugging my shoulders. “That was a lot of PhD EEG talk that we’ve incorporated into our anesthesia. A lot of smarter people than us,” I laughed.
“What do you think she (Kelly) will dream about?” Dr. Dirbas asked curiously.
“She is going to dream about her two sons and particularly Aidan. He has a medical disability and she worries about him always in her dreams.”
“What would you dream about, Fred?” I asked back.
Dr. Dirbas looked at me after a few seconds to think, “Work,” he says emphatically. “And you?”
“Work too,” I admitted. We both just smiled.
Four hours later, surgery was finishing. Katie texted me she has started pre-emergence titration of the propofol and remifentanil as the surgical residents and students slowly start to close the massive wound. Uggh. We had 20 minutes left. As the medication faded from general anesthesia levels, the alpha band split into an alpha and delta band, followed by a solitary red alpha band and then a firm green beta band on both the left and right frontal cortex. EEG waves dampened into a characteristic fast low amplitude signature. Boom – dream time! Timer on.
Despite the medication now turned off, the green beta band maintained its bilateral frontal cortex course. Seven minutes into the EEG dream spectrogram signature the surgical residents were finished. “Can we move the patient to the gurney?” asked the junior resident.
“In 3 minutes,” said Katie firmly. The room then calmed down for what was coming next. At the 10-minute mark, Kelly looked so peaceful even with the eye tape off, we could see her eyes moving slowly, another sign she was probably in a dream. Even now she looks different emotionally than when we first met 3 years ago.
“10 minutes,” called out Katie. “Kelly, wake-up,” I said firmly. No answer, no movement at all. Kelly looked like she could keep napping for hours, LMA, surgery and all. I gently pushed her left shoulder, and her eyes opened suddenly, tracking to me.
“Where are you, Kelly?” I asked. She spitted out the LMA herself.
“Aidan and I are on a train in Europe. My hair has grown back and Aidan is a teenager now.” She stopped and reached up with her left arm (IV and all) and hugged me tenderly. “My cancer is gone and I’m giving a book tour about my story about beating breast cancer.”
Her words faded as she continued to talk about her dream. As Katie began to go though our post-op dream survey, the OR was thoroughly enraptured for the next few minutes of the story.
She looked so calm and so happy. Humanity, Homo Sapiens, never looked so beautiful. We are beautiful at our emotional core.
I looked around as Katie started to move Kelly. One of the surgical technicians was silently crying in the corner of the room, the power of the moment probably recalling a distant loving memory. Dr. Dirbas had left the room but the OR nurse asked me off to the side, “Did any of that really happen?”
I just shrugged, “Does it really matter?”
Swish.
******
At the risk of being accused of being a nagging academic, please call your mother for Mother’s Day. Most likely she has been dreaming of you. Of long walks, dinners together, barbecues, her grandchildren and train rides – all with you in it, happy, healthy and secure. Even if she is at the risk of dying, she has these dreams with you and those she loves, playing on a constant loop in this sugar-sweet-made-for-TV-movie in her mind.
Especially though if you are a medical professional or student, as you plow along on your teaching, school studies, work projects, research or whatever, a note of caution. We apparently dream of the world we can change but not the world of our love – aka our mom. Please put away the laptop. Don’t forget to call your mother, she loves you to her emotional core. Probably until her last night on Earth as she finally sleeps.
We know this because we have the data.
Dr. Harrison Chow is a Clinical Associate Professor of Anesthesia at Stanford Medical School and is a frequent contributor to CSAOF. He is part of the Heifets Lab (https://heifetslab.stanford.edu) and has been writing about and observing anesthesia dreams for 15 years. The Heifets lab has published a case series addressing symptomatic relief of PTSD recently in the American Journal of Psychiatry (https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.20230698) with patient video describing their anesthesia dream experiences, dream surveys #135 and #591, (https://www.youtube.com/watch?v=il0V4lAWGd0).
The Heifets lab has collected nearly 900 anesthesia dream surveys from Stanford Hospital Epic patient database with approximately 600 reporting anesthesia dreams. Some of the data in this story are part of an (accepted) upcoming Methods manuscript describing our research observations. Names of patients changed, their dreams and care described with their permission.