This article originally appeared in The Skeptic, Volume 18, Issue 2, from 2005. It is the second part of a two-part series – read the first part here.
Having examined the background to the Pam Reynolds case, we can now turn to her experience itself. I will begin with the effects of anaesthesia on the body of Pam Reynolds. She underwent a major neurosurgical procedure in 1991. I have considerable experience of neurosurgical anaesthesia, and the technique of anaesthesia in all Western countries at this time was very standard. Pam would have undergone a standardised form of balanced anaesthesia with three different types of drugs – a technique that is still in use today.
Sleep-inducing and sleep-maintaining drugs: These may be the same or different drugs. After injecting a short-acting drug to induce unconsciousness, other drugs are administered to keep the patient asleep, or a continuous infusion of the same sleep-inducing drug could be used.
Powerful pain-killing drugs: Sleep does not mean a person does not feel, or react to pain – so powerful painkilling drugs are administered to reduce involuntary nervous system responses to pain.
Muscle-paralysing drugs similar to curare (deadly Amazon Indian arrow poison): Persons rendered unconscious, and who have been administered powerful painkilling drugs at dosages sufficient to prevent bodily nervous system responses to pain, are in a particular medical condition; they do not breathe because of the combined effects of the sleep-inducing and the painkilling drugs. Pain-killing drugs cause their muscles to stiffen, rendering even the remaining breathing insufficient. Furthermore, this combination of drugs still does not prevent bothersome reflex movements in response to pain. All these effects can be eliminated by paralysing every body muscle of these patients with curare-like drugs. This makes the work of the surgeon easier, and in some situations even possible when it would otherwise not be.
There is only one problem with such a combination of drugs: breathing stops totally. So the standard technique is to pass a 1-2 centimetre diameter tube through the mouth, through the vocal cords into the trachea (windpipe). An inflatable cuff around the tube within the windpipe ensures an airtight fit, and this tube is connected to a machine called a ventilator which performs the act of breathing for the patient. This is a perfectly normal and standard anaesthetic technique employed for many millions of operations all over the world each year. A person undergoing such a technique of anaesthesia does not breathe, does not move, looks and feels ‘absent’ – such a person at that moment is no more than a biological mechanism undergoing repair by a surgeon. It is the task of the anaesthesiologist to induce and to maintain this situation until the surgeon is ready, as well as to keep the patient alive in spite of all the effects of the operation performed by the surgeon.
Sometimes the concentration of sleep-inducing drugs within the bodies of patients undergoing such a form of anaesthesia is insufficient to maintain unconsciousness. So these people are awake – they hear what is going on around them, they feel the touch of the surgeon and others, and if their eyes are open, they actually see what is happening. But because of the powerful pain-killing drugs they feel no pain, and because of the muscle-paralysing drugs they cannot move, speak, or breathe. They lie still and unmoving while observing all that happens to them and around them. Subsequently, after recovering the ability to speak, they can give very detailed reports of what happened to their bodies and about their bodies during their periods of awareness.
This may sound amazing to some people, but everyone can test for themselves the quality of observations made by a person lying still with their eyes shut. Lie blindfolded on a bed. In such a situation you can quite clearly visualise what people are doing and saying in your immediate surroundings, as well as clearly visualise what is happening to your body. This is the situation in which Pam Reynolds found herself when she awoke at the beginning of her operation.
There is another fact that all students of the experience of Pam Reynolds should realise and understand with great clarity. Pam Reynolds could tell no-one about her experience until after the tube was removed from her windpipe after she awoke in the recovery room subsequent to the successful completion of her operation. During the period of anaesthesia and operation, until after the tube was removed from her windpipe, she could not speak. So her report of her experiences was a report of remembered experiences. This does not mean she did not undergo these experiences, simply that she had time to process and associate her sensations and experiences with her existing knowledge and expectations. An experience reported at the time it is undergone is sometimes quite different from a remembered report of the same experience.
Furthermore, the mental processes of Pam Reynolds were certainly affected by the pain-killing and sleep-inducing drugs when she underwent these experiences. After all, she was conscious during her experience, but felt calm, and felt no pain due to the operation – facts proving that her mental processes were affected by anaesthetic drugs during her experience. So an examination of the details of her experience reveals observational facts mixed together with the effects of the anaesthetic drugs, her own expectations and extrapolations, all welded together into a coherent and wonderful story.
Knowing these things gives background and perspective to her story, making it possible to begin with a step by step analysis.
Pam Reynolds was first put under anaesthesia, and the positioning and preparation of her anaesthetised body for surgery was commenced. This can sometimes be a time-consuming procedure for neurosurgical operations, but here there was also the necessity to prepare her for cardiopulmonary bypass. During this long preparation time, the effects of muscle-paralysing, pain-killing drugs, and sleep-inducing and maintaining drugs can decrease below what is needed to maintain sleep. Regular doses of these drugs need to be administered to maintain sleep, total muscle paralysis, and adequate pain treatment.
I commenced my career in anaesthesiology as a junior resident in 1977, and have seen medicines, techniques, and fads come and go. So the fact that Pentothal was used as a sleep-inducing drug for the anaesthesia of Pam Reynolds during 1991 indicates to me that the anaesthesiologist used a perfectly standard combination of anaesthetic drugs for that time. I used exactly the same drug combinations at that time too. The dosage of Pentothal used by anaesthesiologists to induce sleep keeps people asleep for about 5-15 minutes, after which sleep is maintained with other gases in the mixture of air pumped into the lungs by the ventilator. Her anaesthesiologist would have maintained sleep with nitrous oxide (laughing gas), perhaps together with a vapour such as isoflurane or enflurane which were in common use at that time. But Pam Reynolds was conscious at various times during her operation, indicating to me that neither isoflurane nor enflurane vapours were used to keep her unconscious.
The neurosurgeon began first. He made an incision in her head, and then began to saw the bone of her skull open with a pneumatic saw shaped like an electric toothbrush. The high pitched whining of the idling motor of this saw caused Pam Reynolds to awaken – this was the “natural-D” that she heard. She was awake but partially paralysed due to muscle paralysing drugs, and had a tube in her windpipe. So she could neither move nor speak. The powerful pain-killing drugs ensured she felt no pain, she heard people speaking and moving around her, she felt the touch and movements of the surgeons on and in her body, and she registered all these things in her mind. The effects of anaesthetic drugs caused her to feel calm. Malfunction of her brain caused by these same drugs, possible reflex minuscule twitching of her limb muscles, together with abnormal functioning of her muscle spindles induced the out-of-body experience. Chapters 10, 11, and 12 of Mortal Minds contains a detailed discussion of the physiology of out-of-body experiences, including those occurring under anaesthesia (Woerlee, 2003; see also Blanke et al., 2004).
The usual monitoring of her vital signs was used by the anaesthesiologist, in addition to which her electroencephalogram was monitored, as well as the response of her brain to clicking sounds in two earplugs (VEP = vestibular evoked potentials). (N.B. VEP measurement is a very useful indication of the depth of anaesthesia and the level of consciousness.) Some authors make much of the fact that she could hear everything, in spite of the fact she had earplugs feeding clicking sounds into her ears. My reaction to this is that of course she could hear what happened about her – proof of this is seen all about us. There are simply enormous numbers of people all around the world, wandering around, listening to loud music played through earplugs, who at the same time are able to hear and understand all that happens in their surroundings. And people under anaesthesia can hear things; otherwise this perfectly standard VEP monitoring technique would be useless as a measure of the depth of anaesthesia. So being able to hear, despite the insertion of earphones making clicking sounds, is nothing wondrous.
Some people also make much of the fact that the VEP monitoring did not signal that she was conscious. The truth about all monitoring such as VEPs, is that while such monitoring is generally very accurate, it is not 100% accurate. This is realised and appreciated by all experienced anaesthesiologists, who understand and must work with this humbling fact. So they always keep a sharp eye on their patients for other signs of awakening.
The story of Pam Reynolds also provides features allowing precise timing of some events. For example, the time of one period of awareness was given very accurately by what she heard one of the surgeons saying:
Someone said something about my veins and arteries being very small. I believe it was a female voice and that it was Dr. Murray, but I’m not sure. She was the cardiologist. I remember thinking that I should have told her about that…Sabom, 1998
She was not on cardiac bypass at the time of her out-of-body experience, because the cardiothoracic surgeon was having trouble introducing the cardiac bypass machine tubing into the blood vessels of her right groin – the blood vessels in her right groin were too small for the size of the tubing and the blood flow needed for cardiac bypass. This means the cardiac bypass apparatus was not even connected to her body at this time. The cardiothoracic surgeon eventually used the blood vessels in her left groin. So at that time, Pam Reynolds had a normal heartbeat and body temperature, as well as the normal responses of a paralyzed person who was awake while supposedly under general anaesthesia.
Then we come to Pam Reynolds’ description of the pneumatic saw she observed during her out-of-body experience. Here again, it cannot be emphasized enough that her description of this episode was a description of a remembered event. After all, she could not describe these things at the time they occurred.
Furthermore, she knew no-one would use a large chain saw or industrial angle cutter to cut the bones of her skull open. She was 35 years old in 1991, the year of her operation. This means she was born in 1956, meaning she was a member of a generation of Americans blessed with excellent dental care. Pneumatic dental drills with the same shapes, and making similar sounds as the pneumatic saw used to cut her skull open, were in common use during the late 1970s and 1980s. Because she was born in 1956, a generation whose members almost invariably have many fillings, Pam Reynolds almost certainly had fillings or other dental work, and would have been very familiar with the dental drills. So the high frequency sound of the idling, air-driven motor of the pneumatic saw, together with the subsequent sensations of her skull being sawn open, would certainly have aroused imagery of apparatus similar to dental drills in her mind when she finally recounted her remembered sensations.
There is another aspect to her remembered sensations – Pam Reynolds may have seen, or heard of, these things before her operation. All these things indicate how she could give a reasonable description of the pneumatic saw after awakening and recovering the ability to speak.
Pam Reynolds’ mental processes were certainly affected by the anaesthetic drugs coursing though her body. This is proven by her absence of pain sensation during her operation, together with her sensations of mental calm. And while her mind was under the influence of these drugs, she described her mental state as more awake and aware than normal, with better than normal sensations. But her statement is no more than a typical statement made by a person whose brain is affected by medications, toxins, body waste products, or the effects of oxygen starvation. Observers see that the mental processes of such people are foggy, clouded,illogical, and disoriented – yet those affected by medications, toxins, body waste products, or oxygen starvation feel their thoughts and mental processes are clearer, that their minds function better, and that their perceptions are more acute than normal. In fact, they often feel wonderful. The mental effects of the anaesthetic drugs used on Pam Reynolds are similar to those of oxygen starvation:
Hypoxia (oxygen starvation) quickly affects the higher centers, causing a blunting of the finer sensibilities and a loss of sense of judgement and of self-criticism. The subject feels, however, that his mind is not only quite clear, but unusually keen. (Liere & Stickney, 1963)
This is why Pam Reynolds experienced her mental processes as better than normal, even though no-one else would say they were normal.
After exposure of the aneurysm, she was put on cardiac bypass and subjected to hypothermic cardiac arrest (her body temperature was lowered and her heartbeat was stopped). Her body temperature was lowered to 15º Celsius (60º Fahrenheit). This is a temperature at which all people are unconscious. So she was unconscious, and could therefore have no conscious experience during this period. Even so, she was able to remember some of what happened before her period of hypothermic cardiac arrest, because she was able to remember her “out-of-body experience” prior to the period of cardiac arrest.
Many people may consider this technique of hypothermic cardiac arrest as a wonderful and unusual technique. Yet it was one of several standard techniques for performing open heart surgery during the 1960s and the 1970s. If the body and brain are cooled to 15º Celsius and lower, it is possible to stop the heart and breathing, perform the necessary surgery, subsequently re-warm the patient, restore normal heartbeat, and the patient will suffer no brain damage, provided the duration of cardiac arrest is less than 45 minutes. The fact that the brain cooled to a temperature of 15º Celsius can survive a period of absent circulation for 45 minutes is not miraculous. Cooling reduces the speed of all chemical reactions, enormously reducing the metabolism of the brain and body, enormously reducing the requirement of the brain and body for oxygen and nutrients. This is a situation similar to keeping meat in a refrigerator – the cooler the refrigerator, the better the meat is preserved.
Was Pam Reynolds ‘dead’ during the period her heart was stopped? Very definitely not! Her body metabolism had simply been reduced to a minimal level. After all, cessation of breathing and cessation of heartbeat are manifestations of death, but are not death. True death is irreversible failure of all brainstem functions. For example, heart-lung bypass is a situation where people do not breathe and have no heartbeat, yet are very much alive, and may even be conscious (Woerlee, 2003, see chapter 2).
After successful removal of the aneurysm, the body temperature of Pam Reynolds was gradually increased to normal, and her heartbeat was restored. Blood flow and brain function returned during this period. Nonetheless, even though brain function was restored, Pam Reynolds’ brain did not immediately return to normal function. To begin with, her brainstem function recovered enough to restore consciousness – otherwise she could not have consciously perceived the dark vortex through which she passed to undergo a typically American near-death experience (NDE) during which she was guided and aided by deceased relatives (Osis & Haraldsson, 1986). Furthermore, the visionary content of her NDE was a product of her knowledge that the operation could possibly cause her death. I say this because during her NDE she saw deceased relatives who aided her, and guided her in the realm of the dead – features typical of NDEs undergone by people who expect to undergo a potentially lethal experience (Greyson, 1985).
Restoration and normalisation of normal brain function restored normal perceptions, and she awoke to the accompaniment of ironically appropriate music:
When I came back, they were playing Hotel California and the line was “You can check out anytime you like, but you can never leave.” I mentioned [later] to Dr. Brown that that was incredibly insensitive and he told me that I needed to sleep more. [laughter] When I regained consciousness, I was still on the respirator.Sabom, 1998
She was awake, but paralysed by a muscle-paralysing drug – so she still could not move, breathe, or talk. She was indeed locked inside her body – she could not leave. Furthermore, she could not talk because of the muscle-paralysing drugs and the tube passed through her windpipe that was attached to the respirator.
She awoke later in the recovery room. Only then was the tube removed from her windpipe, and only then was she able to speak and tell all who would listen of her wondrous experience. And it was indeed a profound personal experience, but it was an experience whose roots lay in the functioning of her body, complemented by imagery nestling in the deepest reaches of her psyche, as well as the fact that she was awake for several periods of time during her operation.
What is very evident throughout this whole story of Pam Reynolds is the fact that she was conscious at several periods during her operation. This is likely a reflection of an interaction of her undoubted anxiety about the operation with the anaesthetic technique used. Anxious people are more difficult to keep asleep than are calm and relaxed people (Woerlee, 1992). Her mental functioning during her periods of awakening was very evidently influenced by anaesthetic drugs, her anxieties, as well as by the residual effects of low body temperature. And lastly, her story is a remembered account of experiences undergone while under anaesthesia. This last point is the most important aspect of this story. It means that her story is a product of her socio-cultural upbringing, her prior conscious and unconscious knowledge of the operation she was to undergo, her prior knowledge of all things medical, that which she consciously and unconsciously observed during her periods of awareness, the effects of anaesthetic drugs, low body temperature, surgery, her anxieties, and finally, her personality. All these things were unconsciously combined and integrated into a coherent story of a wondrous experience.
Nonetheless, experiences such as that of Pam Reynolds are experiences teaching each of us how little we know of ourselves and the functioning of our bodies. Careful and critical study reveals their true nature, each experience revealing more and more about the true and complex nature of the human behind the mask of normal consciousness.
- Blanke, O., Landis, T., Spinelli, L., & Seeck, M. (2004). Out-of-body experience and autoscopy of neurological origin. Brain, 127, 243-258.
- Greyson, B. (1985). A typology of near-death experiences. American Journal of Psychiatry, 142, 967-969.
- Liere, E. J. & van Stickney, J. C. (1963). Hypoxia. Chicago: University of Chicago Press.
- Osis, E., & Haraldsson, K. (1986). At the Hour of Death. New York, USA: Hastings House.
- Sabom, M. (1998). Light & Death. Michigan, USA: Zondervan Publishing House.
- Woerlee, G. M. (2003). Mortal Minds: A Biology of the Soul and the Dying Experience. Utrecht, The Netherlands: de Tijdstroom.
- Woerlee, G. M. (1992). Kinetics and Dynamics of Intravenous Anaesthetics. Dordrecht, Netherlands: Kluwer.