Patient with awareness

DutchgirlRN, ASN, RN · Feb 16, 2005

WHAT IS ANESTHESIA AWARENESS?

Anesthesia Awareness, or intra-operative awareness, is perhaps the most helpless and terrifying feeling in the world. It occurs when one is supposed to be completely asleep under full general anesthesia, but the brain is not asleep. Usually your body is paralyzed; you have a tube down your throat; you can't speak or move to alert the doctors that you are awake. If you do manage to move, as I did, the usual response from the anesthesiologist is to simply administer another dose or doses of paralytic drug; not considering the possibility that the patient is awake.

I'VE NEVER HEARD OF ANESTHESIA AWARENESS. WHY NOT?

It's one of the best-kept secrets in anesthesia, and one of the least-known phenomena in the medical or legal fields in general, yet recent studies indicate awareness is reported 100 times per working day, and we know that under-reportage may be as much as a third. Pediatric cases may occur 4-6 times as often. Those figures work out to 20,000 - 40,000 times per year! The anesthesia community is in deep denial of the number of times intra-operative happens, denies patient reports of the problem, fails to make the occurrence known to the surgeon or other hospital caretakers, and grossly underestimates extent and the length of the after-effects of anesthesia awareness.

WHAT CAUSES ANESTHESIA AWARENESS?

In my opinion, the most prevalent cause of anesthesia awareness is lack of care and attention on the part of the anesthesiologist. In a 1999 syndicated radio interview the President of the American Society of Anesthesiologists admitted that "drugs are sometimes mislabeled or administered in the wrong order, and tanks do run dry."

Patients seldom get to meet their anesthesiologist more than five minutes before surgery; they have no choice of doctors or any chance to check out credentials or even know whether the person administering anesthesia is an M.D. or nurse anesthetist; or whether he/she will be monitoring only your surgery, or several other surgeries at the same time. Patients are rarely told whether they will be paralyzed, or if and what type of monitors will be used to determine the level of consciousness of the patient.

yoga crna · Feb 16, 2005

Again, I don't have an answer for you, however this discussion is useful in pointing out several relevant issues. First, the anesthesiologist was sloppy in preparing the anesthesia record and recording pre-operative information. This obviously gives you reason to question his overall ability. But, in my opinion none of those facts, including your normal vital signs are relevant in your recall. Administration of anesthesia is a very dynamic process, with the patient's response changing moment to moment, according to many factors which include pre-anesthesia condition, the surgical procedure, physiological changes inherent with anestheia and surgery and the preferences of the individual practitioner. I have had to turn down my anesthesia agents to almost nothing when the patient is hypotensive. Those patients have never complained of recall--and I am not sure why. I have heard of patients with documented recall (able to give a verbatim account of OR converstations) when there was a brief period of time when the vaporizer was off to be refilled. Each patient's response to anesthesia and surgery is different. That is what makes it stimulating for those of us in the profession and why we can never do recipe card anesthesia. I am not defending your recall--I can't think of anything worse to happen to a patient, but understand that you may never know what happened.

My other point has to do with monitoring. I am a better practitioner because I learned anesthesia before we did any monitoring except blood pressure, heart rate and respiratory rate. I can and do watch my patients carefully and try to anticipate changes before they happen. It is important to use your senses (including common sense) and not totally rely on technology that may not function properly.

Yoga CRNA

Home Health Columnist / Guide · Feb 16, 2005

I can understand your concerns as had an experience last year with unsucessful intubation with multiple attempts and aware of what was happening. Analayzing the anesthesia record did little to relay my fears and concerns over need for future anesthesia/surgery.:crying2:

I'm positive that if I had a follow-up visit by anesthesia upon return to my room discussing my failed intubation, would have helped in processing incident and maybe avoid the panic feeling I had after hospital discharge.

What greatly helped was writing a letter to the hospital involved expressing my concerns and having a frank discussion with the Chief anesthesiologist regarding the event on several occasions. Discussing what happened, what should have been done and having an understanding of what my individual anesthesia needs were helped process the event and prepare for future sugery. Intubation and anesthesia given by the chief went smoothly second time and I have no recall of surgery.

:Melody: Carrying the Chief's beeper number with me for future need is added piece of mind.

Mana_Tangata · Feb 16, 2005

I can understand your concerns as had an experience last year with unsucessful intubation with multiple attempts and aware of what was happening. Analayzing the anesthesia record did little to relay my fears and concerns over need for future anesthesia/surgery.:crying2:
I'm positive that if I had a follow-up visit by anesthesia upon return to my room discussing my failed intubation, would have helped in processing incident and maybe avoid the panic feeling I had after hospital discharge.
What greatly helped was writing a letter to the hospital involved expressing my concerns and having a frank discussion with the Chief anesthesiologist regarding the event on several occasions. Discussing what happened, what should have been done and having an understanding of what my individual anesthesia needs were helped process the event and prepare for future sugery. Intubation and anesthesia given by the chief went smoothly second time and I have no recall of surgery.
:Melody: Carrying the Chief's beeper number with me for future need is added piece of mind.

Thanks for all of your support on the board. You know, this is the first time anyone would talk to me openly about it (and without a person from risk management in the room).

kmchugh · Feb 16, 2005

I first saw this thread yesterday, and decided that I'd better take a little time away from it before responding. Now that I have cooled a bit, I think I can get my points across, yet be calm and reasonable.

First of all, to Mana Tangata, I am truly sorry that you experienced this. I cannot imagine what a horrific experience awareness under anesthesia must be. I understand your need to look for "answers," but unfortunately, there may not be good answers out there. As with all human endeavors, there are occasionally bad outcomes with anesthesia. Cases where things go wrong, sometimes owing to the error of the anesthesia provider, sometimes owing to factors beyond the control of anesthesia. To be perfectly honest, presented with the same situation, I cannot say that I would have done anything significantly different from what your anesthesia provider did. In any event, I don't think you will find your answers here. And looking for answers here, and in the fashion you did, can generate a great deal of ill feeling and anger. Allow me to explain why.

To begin with, you cannot understand what it is to be in a field like anesthesia until you experience it for yourself. Ours is one of the most frequently sued fields in nursing and medicine. We deal with it every day. No, we don't dwell on it, or none of us could ever do an anesthetic. On the other hand, we must be aware of it, and we must factor that into every clinical decision we make.

When you started this thread, you were initially misleading about your reasons for asking the question. All disclaimers about not wanting to "muddy the waters" notwithstanding, you were not direct and up front about who you were and why you were asking. That alone is guaranteed to generate some anger. As other anesthetists here have said, we cannot and should not sharp shoot your anesthesia provider based solely on the brief description you provided here on the board. And by misrepresenting yourself, you put us in a very untenable position.

There is a degree of animosity in the anesthesia community right now towards Aspect, the company that makes and markets the BIS monitor. Those outside of anesthesia have a hard time understanding this, so let me explain. I've said elsewhere, the BIS monitor is a good monitor for a select few types of cases. Aspect isn't happy with that, however. They want the BIS monitor to become a standard of care for every anesthetic given. Never mind that the monitor itself is expensive. Never mind that the disposable monitor pad attached to the patient is expensive. They want it to become a standard of care, very much like the ECG or pulse oximeter. Nearly all anesthesia providers believe it simply isn't a necessary monitor to be used in every case.

Most anesthesia providers do not believe that the BIS monitor is the next pulse oximeter, period. Aspect disagrees. They don't like what the professionals in the field have had to say, so in my opinion, they have decided to use the uneducated public to achieve what they cannot. Aspect went out and found people like yourself who have had intra-operative awareness, and used you to strengthen their sales pitch. In my opinion, they have blown the problem of awareness all out of proportion to its actual dimensions along the way. I'm not trying to minimize your experience, or the horror that people who have awareness suffer, but it isn't the all-pervasive problem that Aspect has tried to tell the public it is.

In my opinion, Aspect has used you and people like you to get exactly what they wanted. The popular press heard the "awareness drum" Aspect has been beating so hard. And the popular press never lets facts get in the way of a sensational story. That is exactly what BIS was hoping for.

And suppose Aspect got their way, and the BIS monitor became a standard of care. Would the monitor actually eliminate awareness? Probably not. Would that relieve anesthesia providers of liability for awareness in the event it occurred with proper use of the BIS monitor? Absolutely not. Aspect has been careful to caveat the use of their monitor as only part of awareness prevention. So, in the wonderful world of Aspect, we anesthesia providers are liable for cases of awareness that occur when we don't use their monitor. We are also liable for cases that occur when we do use their monitor. And they wonder why anesthesia providers hold them in such contempt.

The one thing Aspect has accomplished along the way is to make the public more frightened of a very rare occurrence. While awareness in the OR is a problem that all anesthesia providers need to be aware of, it isn't the biggest problem we face. I know that for someone who has had awareness, this is difficult to understand, but it's the truth.

I'm sorry this has gone so long, but you touched a nerve. Again, I am genuinely sorry for what happened to you. Without doubt, you have issues that you need to sort out. Counseling may help, and I strongly encourage you to seek counseling out. PTSD is a real danger after awareness under anesthesia. That said, you wouldn't find your answers here.

This board is for CRNA's and other anesthesia providers, and for those who wish to become anesthesia providers. It isn't a place where we can sharpshoot other health care providers for any reason. Not because we are closing ranks against you, but because it is impossible in this forum to ever present all the facts. Therefore, all we would be doing is shooting from the hip. It isn't fair to us to come in, misrepresent who and what you are, to ask us to second guess another provider based on a couple of short paragraphs. And our answers wouldn't help you in any case, because they would be based in incomplete information.

Kevin McHugh, CRNA

loisane · Feb 16, 2005

I think Kevin's description of our state of knowledge regarding awareness, BIS, Aspect and its marketing are dead on. I think his expressed opinion is shared by many (maybe most) anesthesia professionals.

I also agree with him that this is an unfortunate thing to have happened to any patient, including the original poster.

I would offer a slightly different insight about these discussions on this forum. Most of us who are here regularly, see this as a professional area. But this board is housed on an open forum. Anyone can post, there are no criteria for admission. The nature of discussions here are neccessarily different than those that would take place on a forum which is only open to anesthesia professionals.

This thread is a good illustration of why we all need to be aware of the difference. What we post here can be read by anyone. Similarly, what is posted here could have come from anyone, and motivated by any number of intentions.

As long as this is an open forum, we are bound to be discovered by the lay public in search of information and answers regarding many aspects of anesthesia.

loisane crna

CRNAsoon · Feb 16, 2005

... I would offer a slightly different insight about these discussions on this forum. Most of us who are here regularly, see this as a professional area. But this board is housed on an open forum. Anyone can post, there are no criteria for admission. The nature of discussions here are neccessarily different than those that would take place on a forum which is only open to anesthesia professionals.
This thread is a good illustration of why we all need to be aware of the difference. What we post here can be read by anyone. Similarly, what is posted here could have come from anyone, and motivated by any number of intentions.
As long as this is an open forum, we are bound to be discovered by the lay public in search of information and answers regarding many aspects of anesthesia.
loisane crna

Well said, Loisane!

Mana_Tangata · Feb 16, 2005

Wow, I've obviously hit a nerve here and offended a lot of people. I am so sorry. As far as intentionally misleading people about who I am, you are right, I did not let you know my position up front, but I did not lie about it either.

The increadible emotional response I get from people is part of the reason I hide what happended to me. They are either horrified, don't believe me, want to kill my anesthesiologist....I've just stopped telling people. I'm so sorry.

As far as not knowing what all of you go through and the stress that you are under to do a good job, you are right I will never really understand it. In looking in to what happended to me, however, I do have a new appreciation for how hard your job is. But I do have a huge amount of anger towards MY anesthesiologist. I think that he was very sloppy. I think that 99.99% of people in the profession are not.

I really don't know whether to post here anymore or not. It was so nice to find a safe forum to discuss my experience, but I'm really don't want to piss people off. Also, frankly I'm not up for taking the brunt of the backlash.

deepz · Feb 16, 2005

.......frankly I'm not up for taking the brunt of the backlash.

Please don't take the harsh remarks about Aspect Medical, etc, etc, as directed at you personally. If you have not yet had counseling to help deal with your aftermath of this episode, as has been previously advised, you truly should, IMHO. Now that we know who you are and why you are here, could you perhaps go on to help us to better understand the nature of your recall?

Could you give us -- in-depth, with as much specific detail as possible -- a description of what you experienced while under general anesthesia?

TIA

deepz

jwk · Feb 16, 2005

WHAT IS ANESTHESIA AWARENESS?
Anesthesia Awareness, or intra-operative awareness, is perhaps the most helpless and terrifying feeling in the world...............

No offense DutchGirl, but cutting and pasting this piece from Carol Wieher's website will not earn you any points here. Do you think we haven't seen it before? It adds nothing to the discussion, just fans the flames.

And do you really think that everyone in this section of the board isn't aware of monitors that claim to prevent awareness under anesthesia? And no offense to Centennial Medical Center - I know nothing about them, but that really sounds like a marketing claim, pure and simple. (Perhaps you work there?)

There are several different manufacturers making these types of monitors, and to date, NONE OF THEM have been shown to reliably predict awareness under anesthesia. Again, you're just fanning the flames.

jwk · Feb 16, 2005

Wow, I've obviously hit a nerve here and offended a lot of people. I am so sorry. As far as intentionally misleading people about who I am, you are right, I did not let you know my position up front, but I did not lie about it either.
The increadible emotional response I get from people is part of the reason I hide what happended to me. They are either horrified, don't believe me, want to kill my anesthesiologist....I've just stopped telling people. I'm so sorry.
As far as not knowing what all of you go through and the stress that you are under to do a good job, you are right I will never really understand it. In looking in to what happended to me, however, I do have a new appreciation for how hard your job is. But I do have a huge amount of anger towards MY anesthesiologist. I think that he was very sloppy. I think that 99.99% of people in the profession are not.
I really don't know whether to post here anymore or not. It was so nice to find a safe forum to discuss my experience, but I'm really don't want to piss people off. Also, frankly I'm not up for taking the brunt of the backlash.

Mana - You may have hit a nerve (unintentionally) but I don't think you've offended anyone.

Obviously there was a problem. The cause is unknown. It's obvious that you have contacted someone at the hospital since you have a copy of your records and have mentioned risk management in your postings. Has anyone, either through the anesthesiologist or their group, or the hospital, offered to help you with the after-affects you are or may experience? If not, they should be. Refer them to the JCAHO Sentinel Alert on Awareness in Anesthesia published in October, 2004. They should know what this is, and if they are not using this as a guideline in their dealings with you, I'm surprised.

Please understand that anesthesia professionals are acutely aware of this issue at the present time. We are asked questions every day about this because of intense media coverage, including an oft-repeated program on the Discovery Channel. If there is a monitor out there that can be shown to reliably measure awareness under anesthesia, we would all love it. There is no such monitor at the present time.

The strong reactions you'll get from some is simply because we have been inundated on this issue for the last couple of years. Sensational news stories and media events, often sponsored by manufacturers of awareness monitors, makes this a difficult issue to deal with. Websites such as the one DutchGirl cut and pasted a section from don't help either. The woman who sponsors this particular website now offers her story in person, for a price, and wants to use her experience, again for a price, and call herself a "consultant" on anesthesia awareness. These are all blatant conflicts of interest. These companies and individuals have a profit-motive.

We want to make sure that whatever system is used to prevent awareness under anesthesia actually works. If it doesn't work, why use it?

Mana_Tangata · Feb 16, 2005

No offense DutchGirl, but cutting and pasting this piece from Carol Wieher's website will not earn you any points here. Do you think we haven't seen it before? It adds nothing to the discussion, just fans the flames.
And do you really think that everyone in this section of the board isn't aware of monitors that claim to prevent awareness under anesthesia? And no offense to Centennial Medical Center - I know nothing about them, but that really sounds like a marketing claim, pure and simple. (Perhaps you work there?)
There are several different manufacturers making these types of monitors, and to date, NONE OF THEM have been shown to reliably predict awareness under anesthesia. Again, you're just fanning the flames.

Hi,

I'm sorry if this is not the place, but I think that my experience has a lot to be learned from. There seems to be a war going on around anesthesia awareness, and I feel I have been caught in the middle. Common sense seems to have been lost. Do I think that I was given negligent care, or that a monitor would have prevented what happened? I don't know. Do I think that if my experience did not initiate such a defensive and denial reaction I would be in such bad shape? I don't think so. I was cut lose without any couseling, completely unprepared for the psychological consequenses. If I had experienced some kind of complication that did not elicit such a defensive reaction, I think that I would have been given the care I needed.

It seems to me that anesthesia awareness has been touted as being equivalent to inadequate care. I do not agree with this, and think that that type of thinking is detrimental to patient care. I have two friends who also experienced this, both trauma cases. Do I think that they received substandard care? No. I don't think in either case the anesthesia providor knew about the awareness. This was a good ten years ago, so before all the press.

I feel like a nail that has stood up and gotten very hammered down. Earlier I posted that i did not know if I would continue to speak up. But you know what, I exist. It seems to me that there are might be some people on this board who would want learn something from me.