When Bart wakes up from his out-of-body experience, he says, "I did go away, Mom! I was miles and miles and miles away, writhing in agony in the pits of Hell! And you were there! And you and you and you," a reference to The Wizard of Oz (1939), when Dorothy awakens from her slumber.
The show's then-script supervisor Doris Grau also appears in the show for the first time. She was used because of her unique voice, and appears as a minor character in this episode, but would later become known for voicing Lunchlady Doris.
Dr. Hibbert pokes Bart's bump and he shouts "Ow! Quit it." two times. This was the second time we hear Bart shout "Ow! Quit it." He first shouted it in The Simpsons: Simpsons Roasting on an Open Fire (1989). Matt Groening claims this reference comes from what his real life siblings (Maggie and Lisa) used to do to him when he was a child.
This is one of the most heavily edited episodes in syndication. The full opening sequence is replaced with the short opening from Season 5's _Rosebud_, and there are 17 cut scenes, none of which are over nine seconds long.
Although the episode was written by John Swartzwelder, a lot of the ending was pitched by executive producer James L. Brooks. He felt that the episode needed a more emotional ending, so some shots were reworked so that voice-overs could be added.