Solution to 'Devastating' Surgical Awareness Remains Elusive

Cheryl Clark, August 25, 2011

Two articles in last week's New England Journal of Medicine reminded me of these occasional, nightmarish stories about hospital surgeries gone torturously wrong.

An insufficiently anesthetized patient wakes during the procedure, and feels pain. She senses the surgeon working on her body, and even hears the OR staff talking and the music playing overhead.

But the patient is paralyzed, unable to cry out to let anyone know. It's extremely rare, but it happens.

I recall writing about three patients who underwent gynecologic procedures on the same day in 2008 at Pomerado Hospital in Poway, CA. They told investigators horrifying stories of their intraoperative awareness, cases that resulted in state health officials calling immediate jeopardy and imposing a $25,000 fine on the hospital, which of course, put procedures in place to assure it never happened again.

According to state documents, Patient 104 said she "woke up in the middle of her surgery, felt cutting, smelled burning, felt intense pulling down and towards her right side." She told investigators, "I could feel the tears coming down my cheek..why didn't they see my tears, I tried to talk..the pain was horrendous...heard the surgeon saying she had a lot of scar tissue..remembered them taking the tube out. [being extubated]." The report said that weeks later, Patient 104 said "she was still having a lot of pain and was afraid to go to sleep."

Patient 106 remembered feeling "horrible pain between her being raped," as a Foley catheter was being inserted during the procedure, state documents say.


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