The first thing Sidney L. Williams says he heard when he awoke in the operating room during open heart surgery two years ago was the insistent whine of a bone saw cleaving his sternum.
As doctors began discussing his badly damaged heart, Williams wondered whether he was eavesdropping on his own death: The surgeon had warned him before surgery that there was a 50 percent chance he would die on the table. Seconds later, Williams said, he felt jolts of searing pain as the doctor shocked his heart, which had stopped.
“I once almost severed two fingers with a table saw,” Williams, 56, recalled. “This was much, much worse.”
Worst of all, said Williams, who lives in Austin, Texas, was his utter helplessness, his inability to let anyone know he was awake. Williams couldn’t make a sound: A breathing tube had been snaked down his throat. He couldn’t move a muscle: He had been given standard paralytic drugs that rendered him motionless during surgery. And he couldn’t cry: His eyes were taped shut and the drugs he was given stopped tear production.
“I remember just screaming and screaming, `This is killing me,’ but it was only in my head,” Williams recalled. “It was like I was being buried alive.”
Williams, who said he drifted in and out of consciousness during the three-hour operation, is a victim of an uncommon, largely unrecognized and often psychologically devastating experience known as anesthesia awareness, or intraoperative awareness.
Every year an estimated 20,000 to 40,000 of the 21 million patients who receive general anesthesia wake up during surgery because they are under-anesthetized, usually by mistake or because doctors fear too high a dose of anesthesia could be dangerous. Half of them, like Williams, can hear or feel what is going on but are unable to communicate what is happening to them because they have been temporarily paralyzed. Nearly 30 percent feel pain, studies have shown.
Stress disorder
As a result of the experience, about 50 percent of awareness victims develop serious psychological problems, including post-traumatic stress disorder, experts say. Williams said he regularly relives his ordeal in nightmares so vivid that he has cracked several teeth grinding them in his sleep.
Recently the Joint Commission on Accreditation of Healthcare Organizations, which inspects the nation’s hospitals, issued an alert about anesthesia awareness, calling it “a frightening phenomenon” that is “underrecognized and undertreated.”
The commission called on hospitals to educate their staffs as well as high-risk patients about the problem; to take steps to prevent it by properly maintaining equipment and using “appropriate available monitoring technology”; and to devise policies that deal swiftly and compassionately with affected patients, including providing them access to mental health treatment.
Physicians and nurses “must balance the psychological risks of anesthesia awareness against the physiological risks of excessive anesthesia,” said commission President Dennis S. O’Leary.
The commission’s action was prompted in part by three studies published last year about the frequency of intraoperative awareness, which is estimated to affect one or two of every 1,000 patients receiving general anesthesia–and the ability of newer brain wave monitoring devices to detect it. The advisory alert means that the commission will begin collecting data on awareness cases from patients. In the future, the alert could become the basis for new requirements hospitals must meet to retain their accreditation, as have previous warnings about preventing wrong-site surgery.
Unlike wrong-site surgery, which is well-known, few doctors outside anesthesiology had heard of anesthesia awareness until recently, even though the first recorded case dates to 1842.
“Until a year ago I wouldn’t have believed it if a patient had told me it had happened or known what to do about it,” said Robert A. Wise, a psychiatrist and former HMO medical director who is the commission’s vice president for standards.
Wise said he first learned about the problem in 2003, when he received a call from Carol Weihrer of Reston, Va., founder of an advocacy group called the Anesthesia Awareness Campaign. Six years ago, Weihrer said, she woke up in an operating room at Washington Hospital Center while doctors were removing her diseased eye.
“I don’t think surgeons are tuned in to it,” Wise said. Unlike anesthesiologists or nurse anesthetists, surgeons typically see patients for postoperative appointments. A recent study found that recall of awareness is greater seven days after surgery than it is 24 hours afterward.
Not telling doctors
Knowledge of the problem has been hampered by the reluctance of patients to tell their doctors about it, said Peter S. Sebel, a professor of anesthesiology at Emory University in Atlanta.
“Patients often don’t report it because they’re worried about being called crazy by their physicians,” added Sebel, lead author of a study involving nearly 20,000 patients at seven U.S. teaching hospitals. Sebel’s team estimated that about 100 patients wake up every workday in U.S. operating rooms for periods ranging from a few seconds to much longer.
Anesthesiologists in particular have been loath to talk to patients about intraoperative awareness, which one study characterized as “second only to death as a `dreaded’ complication” among anesthesiologists.
Lawyer Douglas Hornsby of Newport News, Va., said he has represented a dozen patients who sued their anesthesiologists for malpractice after they developed post-traumatic stress disorder from waking up during surgery. Two cases that went to trial in Virginia resulted in jury awards of $150,000 and $350,000, he said. But other cases, including one filed by Weihrer, were settled secretly, on the condition that the name of the doctor, the size of the payment and in some cases the entire court file be sealed. (Weihrer said her anesthesiologist paid her a substantial settlement.)
“That means no one ever hears about this problem,” said Hornsby, who represented Weihrer.
Roger W. Litwiller, a Roanoke, Va., physician who is president of the American Society of Anesthesiologists, said that while his group is “very concerned” about intraoperative awareness, he considers the number of cases the commission cites to be inflated.
Who knows best?
“These people are not specialists in anesthesiology,” Litwiller said of the commission, adding that anesthesiologists know best how to handle the problem.
In 33 years of practice, he said, he has never learned he had a patient who was awake, nor have most of his colleagues. Litwiller said he worries that some of the commission’s recommendations, such as holding preoperative discussions about the possibility of awareness with high-risk patients, could scare them into not having surgery.
“Of course,” Litwiller added, “any patient who had an unpleasant experience in the operating room deserves all our compassion.”
“Anesthesiologists think they can measure the depth of anesthesia, but there are times when this is not true,” said Mohamed M. Ghoneim, a professor of anesthesiology at the University of Iowa. “It’s really difficult to measure, especially in light anesthesia such as cardiac cases or trauma with lots of blood loss.”
The best way to detect whether a patient is sufficiently anesthetized is by using a specialized EEG machine that monitors brain waves, Ghoneim said. He predicts such monitoring will become the standard of care in a few years.
Ghoneim said he routinely uses a bispectral index monitor, a device that commission officials consider promising. The Food and Drug Administration, which first approved the device in 1996, in 2003 authorized manufacturer Aspect Medical Systems to market it for awareness reduction. Last year two prospective studies involving more than 7,000 patients found that the monitor, the leading brain wave device on the market, reduced the risk of anesthesia awareness by about 80 percent.
