“This Is What It’s like Waking up during Surgery: General Anesthetic Is Supposed to Make Surgery Painless. But Now There’s Evidence That One Person in 20 May Be Awake When Doctors Think They’re Under”, David Robson2019-03-12 (, )⁠:

One day, for instance, she was waiting in the car as her daughter ran an errand, and realised that she was trapped inside. What might once have been a frustrating inconvenience sent her into a panic attack. “I started screaming. I was flailing my arms, I was crying”, she says. “It just left me so shaken.” Even the wrong clothing can make her anxiety worse. “Anything that’s tight around my neck is out of the question because it makes me feel like I’m suffocating”, says Donna, a 55-year-old from Altona in Manitoba, Canada.

…The lingering trauma [of anesthesia awareness] can resurface with the slightest trigger, and still causes her to have “two or 3 nightmares each night”. Having been put on medical leave from her job, she has lost her independence. She suspects that she will never fully escape the effects of that day more than a decade ago. “It’s a life sentence.”

…When she woke up, she could hear the nurses buzzing around the table, and she felt someone scrubbing at her abdomen—but she assumed that the operation was over and they were just clearing up. “I was thinking, ‘Oh boy, you were anxious for no reason.’” It was only once she heard the surgeon asking the nurse for a scalpel that the truth suddenly dawned on her: the operation wasn’t over. It hadn’t even begun. The next thing she knew, she felt the blade of his knife against her belly as he made his first incision, leading to excruciating pain. She tried to sit up and to speak—but thanks to a neuromuscular blocker, her body was paralysed. “I felt so… so powerless. There was just nothing I could do. I couldn’t move, couldn’t scream, couldn’t open my eyes”, she says. “I tried to cry just to get tears rolling down my cheeks, thinking that they would notice that and notice that something was going on. But I couldn’t make tears.”

…Various projects around the world have attempted to document experiences like Donna’s, but the Anesthesia Awareness Registry at the University of Washington, Seattle, offers some of the most detailed analyses. Founded in 2007, it has now collected more than 340 reports—most from North America—and although these reports are confidential, some details have been published, and they make illuminating reading.

As you might expect, a large majority of the accounts—more than 70%—also contain reports of pain. “I felt the sting and burning sensation of 4 incisions being made, like a sharp knife cutting a finger”, wrote one. “Then searing, unbearable pain.” “There were two parts I remember quite clearly”, wrote a patient who had had a wide hole made in his femur. “I heard the drill, felt the pain, and felt the vibration all the way up to my hip. The next part was the movement of my leg and the pounding of the ‘nail’.” The pain, he said, was “unlike anything I thought possible”. It is the paralyzing effects of the muscle blockers that many find most distressing, however. For one thing, it produces the sensations that you are not breathing—which one patient described as “too horrible to endure”. Then there’s the helplessness. Another patient noted: “I was screaming in my head things like ‘don’t they know I’m awake, open your eyes to signal them’.” To make matters worse, all of this panic can be compounded by a lack of understanding of why they are awake but unable to move. “They have no reference point to say why is this happening”, says Christopher Kent at the University of Washington, who co-authored the paper about these accounts. The result, he says, is that many patients come to fear that they are dying. “Those are the worst of the anesthesia experiences.”

…The result is that many more people might be conscious during surgery, but they simply can’t remember it afterwards.

To investigate this phenomenon, researchers are using what they call the isolated forearm technique. During the induction of the anesthesia, the staff place a cuff around the patient’s upper arm that delays the passage of the neuromuscular agent through the arm. This means that, for a brief period, the patient is still able to move their hand. So a member of staff could ask them to squeeze their hand in response to two questions: whether they were still aware, and, if so, whether they felt any pain. (Read more in this short on how doctors are trying to detect anesthesia awareness.) In the largest study of this kind to date, Robert Sanders at the University of Wisconsin-Madison recently collaborated with colleagues at 6 hospitals in the US, Europe and New Zealand. Of the 260 patients studied, 4.6% responded to the experimenters’ first question, about awareness. That is hundreds of times greater than the rate of remembered awareness events that had been noted in the National Audit Project. And around 4 in 10 of those patients who did respond with the hand squeeze—1.9% across the whole group—also reported feeling pain in the experimenters’ second question.

These results raise some ethical quandaries. “Whenever I talk to the trainees I talk about the philosophical element to this”, says Sanders. “If the patient doesn’t remember, is it concerning?” Sanders says that there’s no evidence that the patients who respond during the isolated forearm experiments, but fail to remember the experience later, do go on to develop PTSD or other psychological issues like Donna. And without those long-term consequences, you might conclude that the momentary awareness is unfortunate, but unalarming. Yet the study does make him uneasy, and so he conducted a survey to gather the public’s views on the matter. Opinions were mixed. “Most people didn’t think that amnesia alone is sufficient—but a surprisingly large minority thought that as long as you didn’t remember the event, it’s OK”, Sanders says.

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This Is What It’s like Waking up during Surgery: General Anesthetic Is Supposed to Make Surgery Painless. But Now There’s Evidence That One Person in 20 May Be Awake When Doctors Think They’re Under