UW seeks to prevent 'awareness' in surgery

UW seeks to prevent ‘awareness’ in surgery

By CHERIE BLACK
P-I REPORTER
http://seattlepi.nwsource.com

Soon after being put under anesthesia to undergo a hysterectomy, Diana Todd began hearing voices. As she tried to listen to what the voices were saying, she felt the first cut.

The pain was indescribable.

She stopped counting after the fifth time her surgeon’s scalpel sliced into her body.

Lying on the operating room table, the anesthesia drugs had her paralyzed. She was screaming on the inside, but no one in the room knew she was fully aware of the surgery being performed on her.

It’s been nearly four years since Todd experienced what is called awareness — being awake and able to hear or feel what is happening during a surgery when one is supposed to be unconscious.

Similar accounts from patients nationwide (about 28 percent say they experience physical pain when aware of their surgery) prompted the University of Washington to create an anesthesia awareness registry to understand how and why it happens and come up with ways to prevent it. Launched in October, the registry is a forum for patients from around the country to share their stories of awareness. Physicians then look at their medical records, from which names and locations have been removed, to try to determine if mistakes were made.

“The goal is to teach anesthesiologists how to do our jobs better,” said Dr. Karen Domino, a neuroanesthesiologist at the University of Washington Medical Center and lead researcher at the registry.

Domino said awareness occurs in about one out of every 1,000 surgeries. That’s more than 20,000 of the 21 million people undergoing surgery each year, according to the Joint Commission on Accreditation of Healthcare Organizations, which certifies hospitals.

But others question the numbers.

Awareness is becoming a “buzzword,” said Dr. John Dombrowski, much like attention deficit hyperactivity disorder and chronic fatigue syndrome were when they first were identified — everyone thinks they’ve experienced it.

The recent Hollywood movie “Awake,” about a man who awakens during heart surgery to find he is paralyzed and can’t signal the surgical team, also put awareness into the mainstream, promising in its ads to “do for surgery what ‘Jaws’ did for swimming.”

“It’s a very defined, very horrific, very real event, but we have to make sure we’re talking about what awareness really is,” said Dombrowski, district director of the American Society of Anesthesiologists in Washington, D.C.

He said hearing voices while going to sleep, or while waking up or while undergoing a colonoscopy (where you’re not fully under anesthesia) is not awareness, and often patients become confused about what they experienced.

“Does this happen? Yes,” Dombrowski said. “Does it happen every day? No. You take one or two grains of truth and turn it into a full-blown fact. We want to deal with science, not sensationalism.”

There’s higher risk for awareness during open-heart surgery, Caesarean sections and trauma cases because anesthesia is given in smaller doses to decrease side effects. Trauma patients are critically ill, Dombrowski said, and giving them too much anesthesia could kill them. The effects of anesthesia also could be blunted in alcoholics, drug users and those on some blood pressure medications, he said.

Most patients the American Society of Anesthesiologists has studied during the past five years haven’t experienced any pain during awareness, he said.

Carol Weihrer, 56, isn’t one of them. Last week, the Virginia resident marked the 10-year anniversary of her experience in which she awoke while having her right eye removed in a Washington, D.C., hospital. She likens it to a rape or kidnapping minus the ability to kick and scream.

“I woke up screaming, ‘I was awake, I was awake, I was awake,’ as soon as I was unparalyzed and kept saying it for the next three days,” she said. “I told them every word that was said during surgery.”

She unsuccessfully sued her anesthesiologist, founded the Anesthesia Awareness Campaign Inc., has talked with about 4,000 people about their experiences and has appeared on numerous television programs.

“People lose their jobs, their sanity, their friends, their homes because of the post-traumatic stress that happens after awareness,” she said. “I haven’t been able to sleep in a bed in 10 years. I sleep on a recliner.”

Using a brain activity monitor is a simple way to let anesthesiologists know when patients are awake, Weihrer said, even if the patient can’t speak.

Monitors generally cost $4,000 to $6,000. She said there is no excuse not to use them. When she found out her local hospital had none, she switched to one that did for a surgery scheduled for this week.

Domino said monitors should be used selectively on high-risk patients. One small study has been done in Australia in which a monitor was used on one group of patients during surgery and wasn’t used on another group. While using the monitors reduced cases of awareness, the numbers were small and the monitors didn’t prevent awareness completely, Domino said.

“We need more than one study performed in a different country on a small number of people to mandate this,” she said.

Dombrowski said anesthesiologists still are trying to figure out which monitor is best.

“Carol is a very good advocate, but she may be jumping on a bandwagon,” he said. “We don’t want to treat machines, we want to treat patients. This is where the judgment and medical training comes into play. We’re not necessarily going to believe the machine against our better judgment.”

The Joint Commission on Accreditation of Healthcare Organizations wrote in 2004 that “anesthesia awareness is underrecognized and undertreated in health care organizations.” It recommended that hospitals using general anesthesia develop policies on using anesthesia monitoring techniques and educating staff about awareness.

Todd, 47, who lives in Manteca, Calif., describes her awareness as the “single most difficult experience” in her life. She contemplated suicide because of her trauma. She hopes her story helps others realize it wasn’t “all in their head,” as she was told. She said the experience changed her, and she now suffers from claustrophobia, can’t sleep without a light and finds it hard to make decisions.

“I’ve always been a person who believes good things come out of bad,” she said. “This one has been a challenge.”

ANESTHESIA AWARENESS

Multiple studies show anesthesia awareness occurs in 0.1 percent to 0.2 percent of the 21 million people undergoing surgery in the United States each year — about 20,000 to 40,000 cases. Some physicians say it can happen in as many as 1 percent to 2 percent of cases.

Of patients studied who said they were aware during surgery:

# 48 percent remember hearing conversations

# 48 percent had sensations of not being able to breathe

# 28 percent experienced pain

# More than 50 percent experienced mental distress after surgery, including post-traumatic stress syndrome.

Sources: American Association of Nurse Anesthetists, The Joint Commission on Accreditation of Healthcare Organizations, American Society of Anesthesiologists
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