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Wake-Up Call

Awareness During Surgery, Once Dismissed as Imaginary, Is Real -- and Potentially Devastating. While It Is Rare, Doctors and Hospitals Are Starting to Take It Seriously

By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, November 23, 2004; Page HE01

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, 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.


Jodie Stanley awoke from anesthesia during an operation on her right hand. (Steve Gates - For The Washington Post)

_____From The Post_____
It Knows When You're Awake (The Washington Post, Nov 23, 2004)
_____Transcript_____
Robert Wise, M.D., vice president at the Joint Commission on Accreditation of Healthcare Organizations, was online to discuss patients who wake up during surgery.

"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.

As a result of the experience, about 50 percent of awareness victims develop serious psychological problems, including post-traumatic stress disorder (PTSD), experts say. Williams said he regularly relives his ordeal in nightmares so vivid that he has cracked several teeth grinding them in his sleep. Last month the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which inspects the nation's hospitals, issued an alert about anesthesia awareness, calling it "a frightening phenomenon" that is "under-recognized and under-treated."

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 JCAHO president Dennis S. O'Leary.

JCAHO's action was prompted in part by a trio of studies published earlier this 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 alert, which is advisory, means that JCAHO 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 back 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 JCAHO's vice president for standards.


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