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 legs...like being raped," as a Foley catheter was being inserted during the procedure, state documents say.
"I tried to tell my body to wake up, but I could not move, I could not open my eyes...remembered gagging feeling, like I could not breathe," recalled Patient 105, the documents say. At the end, she told the anesthesiologist "I felt every...[expletive deleted]...thing you did. I was awake the whole time."
The problem was a malfunctioning anesthesia machine that was not replaced, despite concern expressed by an anesthesiologist who reportedly questioned its functionality several days before, state documents say.
"The facility failed to have a system in place to ensure that anesthesia equipment that had not been functioning correctly was removed from service and not used for any further surgeries," the documents say.
Other cases surface quick with a simple Google search. Last year, a 73-year old Baptist minister reportedly committed suicide in West Virginia after feeling psychological distress after he found himself awake after his surgery, but was unable to cry out.
Yes, it's horrifying whenever it happens, which could be between 20,000 to 40,000 patients a year in the U.S., or as high as 1% of those who, for a variety of reasons are at greater risk, published studies say.
"How often it happens is a tough question," Jeffrey Apfelbaum, MD, Chairman of the American Society of Anesthesiologists Standards and Practice Parameters Committee, acknowledged. They are extremely rare, although "we know not all of them are reported," he said.
He emphasized that such cases, where a patient has complete or partial unintended awareness during a surgical procedure, "is a devastating complication, and one that can be associated with post-traumatic stress syndrome" years later.
"It's something I can say with confidence, even one case of this is too many," he said.
Apfelbaum explained that in certain patients, easing back on anesthesia for brief periods during surgery to minimize the medication's depressive impacts on essential body functions is necessary to keep the patient alive. For example this can occur "in open heart surgery or a major trauma procedure or during a Caesarean, where the life of the patient or the fetus was endangered and the margin between life and death is extraordinarily slim."
In those patients, said to be at higher risk for surgical awareness, moments of cognition and comprehension may be more common. But that's somewhat different than the completely unintended intraoperative awareness cases described at Pomerado, he said.
The issue is complicated further, Apfelbaum emphasized, because every patient is different. The patient's age, level of disease and brain activity, type of anesthetic drug used, patients' medication history, prior alcohol consumption or other drugs regularly used, general sensitivity, and body mass index can all play a role in determining how much anesthesia is necessary to do the job. And how much might not be quite enough.
Determining it for each patient might be described as anesthesiologist's art as well as a science.
Apfelbaum told me that anesthesiology researchers are trying to get a better handle on when certain surgical patients are at greater risk of waking and being aware of what's happening. But unfortunately, there is no way to detect the degree of a patient's consciousness during surgery. At least not yet.
Last week, researchers published in the New England Journal of Medicine the results of one such effort, which failed to show a distinction between two commonly used measurement methods.
Researchers at Washington University School of Medicine, the University of Chicago and the University of Michigan, led by Professor of Anesthesiology Michael Avidan, compared two methodologies used by some hospitals to detect patients' surgical awareness in 6,041 randomized patients, all at high-risk of surgical awareness.
The standard method, which monitors end-tidal anesthetic agent concentration or ETAC, was compared with a newer and more expensive bispectral index or BIS, which detects brain electrical activity through the use of a commercially available sensor and an EEG. The BIS had been touted as superior.
Patients were interviewed within 72 hours after their surgery and at 30 days after extubation to determine their memory of the period between "going to sleep" and "waking up."
"Contrary to expectations," the researchers wrote, "the superiority of the BIS protocol was not established," as fewer patients in the ETAC group than in the BIS group experienced awareness.
In an accompanying editorial Gregory Crosby, MD, of the Department of Anesthesiology at Brigham and Women's Hospital in Boston, wrote that the findings "are disappointing but not surprising.
The key variables – consciousness, memory, and general anesthesia – are obscure, and tools to assess them intraoperatively are rudimentary. The nature of consciousness is a metaphysical problem that has challenged philosophers for centuries and neuroscientists for decades."
He added, "the astonishing thing is not that awareness occurs but that it occurs so infrequently."
These aren't exactly reassuring sentences.
Apfelbaum said that sometimes anesthesiologists give patients medications to dim their memory of what happened during their surgeries. Then, patients can't recall what they were or weren't aware of.
A few months after I wrote about Pomerado hospital's three patients, I received a phone call from one of them.
She wanted to thank me for the story, but as she did, she broke down in tears. She was still unable to sleep, still having nightmares about that day. Worse than that, she told me, she didn't know when it would ever end.