The silent scream

When Barbara Waters went into surgery at Memorial Mission Hospital nearly three years ago, she had no idea how profoundly the experience would alter her life.

The Brevard woman, now 58, says she became conscious during her March 31,1997 gynecological surgery — but couldn’t open her eyes or otherwise alert her doctors because of the paralyzing drugs she’d been given.

“I felt every cut, every burn, every time they sewed. I was screaming as loud as I could, in my brain — but, of course, no one could hear me,” Waters says about the surgery that still haunts her today. “It was just like a red-hot poker burning your insides out.”

The pain was compounded by the horror of her helplessless.

“When I realized I could not move a muscle and was unable to make even a tiny sound to warn them I was awake, a feeling of total helplessness and stark panic came over me that is indescribable,” Waters says in a written account of her surgery she provided for this article. “I had to call on everything in me, that is me, just to survive.”

She and her husband, Ed, sued her anesthesiologist, her nurse anesthetist and their employer, Asheville Anesthesia Associates. Much was disputed at the trial (held last month in Buncombe County Superior Court), including what Waters told her nurse before the surgery about her drug tolerance, whether her anesthesia met commonly accepted standards of care, and how the experience affected Waters psychologically.

A jury found no negligence on the part of her caregivers. But no one at the trial disputed that she had been awake — and in pain — for at least part of the surgery.

According to some estimates, thousands of Americans each year experience what medical professionals term “awareness” during surgery. It can range from hearing voices in the operating room to the searing pain Waters remembers.

Why people wake up during surgery can vary. Medical mistakes are a common cause, though some cases remain a mystery. And the long-term effects of such experiences can be devastating.

But despite major progress in anesthesiology over the past 150 years, there’s still no guarantee for patients that everything will go exactly as planned.

Weighing the odds

Opinions differ as to how many patients wake up during surgery. Emory University anesthesiology Professor Peter S. Sebel has estimated that it happens in at least 40,000 of the nation’s 20 million surgeries each year (about 0.2 percent). Of those, some 400 feel pain, according to Sebel, who has studied the problem and who testified as an expert witness for Waters in court.

Other medical professionals believe those figures are low. Anthony Messina, director of anesthesiology at New York City’s North General Hospital, told U.S. News & World Report that as many as a couple of hundred thousand people a year may awaken during surgery but not report it, according to a 1998 article.

Dr. Steven Roos — an anesthesiologist at Asheville Anesthesia Associates who was not involved in Waters’ case — puts the figure at between 1 and 2 percent of general-anesthesia patients. (Under local and regional anesthesia, the patient is supposed to be awake.)

Roughly 22,800 people had general-anesthesia surgery at Memorial Mission and St. Joseph’s hospitals in fiscal year 1998-’99, according to figures compiled by Roos (the two institutions merged in January 1999). If 1 percent of those had some form of awareness during surgery, that would mean about 228 local people woke up under the knife, that year alone. The 0.2 percent figure translates to 46 people (only a few of whom might actually have felt pain).

Other than Waters, Mission St. Joseph’s Health System has no incidents of patient awareness in its records filed by patients or staff members, says Media and Community Relations Manager Merrell Gregory. But no one questions each patient about whether they’ve had unusual experiences or recollections, either, she says.

“It doesn’t mean it hasn’t happened here,” Gregory admits. “It means it hasn’t been reported. We obviously know it can happen.”

Sometimes, patients may be reluctant to say they’ve been awake during surgery, says Roos — perhaps because they’re embarrassed, they think something’s wrong with them, or they don’t want to criticize their doctor. That may be why studies in which patients are asked more probing questions generally yield a higher number of instances of awareness than studies based on what patients spontaneously report.

“They’ll hold back,” Roos observes. “For a number of reasons, the person won’t report it.”

In the world of surgery, the term “awareness” refers to a patient who has undisputable evidence of being awake, such as memory of a specific conversation or of an incision, says Dr. Jeffrey L. Coston, an anesthesiologist who’s part of Park Ridge Anesthesiology Services in Fletcher. “Recall,” on the other hand, is usually a vague sense that something was wrong, he says.

Different types of surgeries carry different risks for awareness. Cardiac, obstetric and trauma surgeries are likely to have higher incidences of awareness than elective surgeries, experts say.

“Sometimes, you simply cannot give as deep an anesthetic,” Coston notes.

In young women undergoing emergency Caesarean sections, for example, the incidence of awareness may be as high as 7 percent, says Coston. That’s because, in some situations, more anesthetic might cause the mother’s blood pressure to dip, which could harm both the woman and her baby.

In major trauma cases, the incidence of recall may range from 11 to 43 percent, according to a 1993 article in the journal Seminars in Anesthesia. But trauma patients who are being resuscitated may have very low blood pressure — and so may not be able to tolerate the effects of anesthesia.

“In those instances, any anesthesia that you use may have side effects that can kill the patient,” Coston warns.

Do I wake or sleep?

Of all the sensations described by people who report awareness during surgery, actually feeling pain is the least-common experience. But it may be the most devastating.

Jeanette Tracy‘s story has been told in the national media, as well as at anesthesiologists’ conferences. While undergoing hernia surgery in 1991, the Dallas television producer endured pain she described as “a blow torch in my stomach … every tissue tearing like a piece of paper,” according to a 1997 Time magazine article.

Waters describes a similarly terrifying experience.

“Oh, that was the most horrifying, helpless feeling you could have — knowing that you’re completely paralyzed and they’re coming at you with a scalpel and you can’t run,” Waters recalls.

Andrea Thaler — a Nashville, Tenn., HMO executive — felt the excruciating pain of six “slicing, burning” laparoscopic incisions during her gallbladder surgery eight years ago, she told Time.

But experts say it’s more common for patients to hear what’s going on in the operating room than to actually feel pain.

“The number of reported instances of pain as part of recall is a pretty tiny number,” says Roos. “What most people report is what they hear — which is distressing enough, for some patients.”

In Tracy’s case, her physical pain was compounded by hearing her anesthesiologist comment on the size of her breasts.

Even low-level awareness of operating-room conversation can cause problems. Madison, N.J., psychologist Henry Bennett told Redbook about a cancer patient who suffered long-term depression and was convinced that part of her tumor hadn’t been removed. The woman realized the source of her fear years later, when she spoke to her doctor.

“She told him, ‘I heard you say that you didn’t get all the black stuff out,'” recounted Bennett. “To her, that meant there was still cancer in her body. Well, first of all, cancer is not black, although a lot of people imagine it that way. But the surgeon remembered that in the operating room he had said something about the floor tile, and that he couldn’t get all of the black out of his bathroom at home. Obviously, she had heard this comment and it had haunted her. She never accepted that all the cancer was gone until she had this conversation.”

Hearing is one of the most fundamental human defense mechanisms — which helps explain why even anesthetized patients may still hear what’s happening around them, Roos observes, adding, “Hearing is the most difficult sense to put to sleep.”

A waking nightmare

Waking up during surgery can have serious repercussions for patients’ mental health. Up to 70 percent of patients who have suffered awareness during surgery face side effects — including sleep disturbances, dreams and nightmares, as well as flashbacks and anxiety during the day — according to a 1993 article in Anesthesiology. A minority of patients may develop posttraumatic stress disorder, experiencing repetitive nightmares, anxiety, irritability and preoccupation with death. Panic attacks, depression and other problems can also dog such patients.

Waters was diagnosed with posttraumatic stress disorder, according to testimony in her court case. She complains of nightmares and flashbacks and avoids riding in a car, because of the chance she could be involved in a wreck and require surgery. She can’t bear to watch TV programs about doctors, or even visit friends in the hospital.

“You have to deal with this 24 hours a day,” says Waters. “Everywhere you look, you can’t escape it.”

Tracy, the Dallas television producer, also suffered nightmares, as did Jeannie Smith — who won a $150,000 lawsuit against her anesthesiologist in 1998, after being awake during surgery to remove both her ovaries at Riverside Hospital in Newport News, Va. Smith also suffered panic attacks and depression, according to the U.S. News & World Report article.

Boston University psychiatrist Janet Osterman, who researches surgical awareness, says her subjects display symptoms of posttraumatic stress disorder, including flashbacks, irrational fears and insomnia.

“They are afraid to go to sleep,” Osterman told Time magazine. “Letting go feels too much like going under anesthesia.”

Tracy went on to found a support group called AWARE (Awareness with Anesthesia Research Foundation). But Waters says she was unable to find a support group in Western North Carolina.

Mixing it up

At many U.S. hospitals, anesthesia is handled by an anesthesiologist and a certified registered nurse anesthetist. The physician and the nurse decide on an anesthetic-care plan, which is carried out by the nurse under the doctor’s supervision. Doctors may supervise more than one operation at a time, according to testimony at Waters’ trial.

Anesthesia at Mission St. Joseph’s Health System is provided by Asheville Anesthesia Associates, which is made up of 22 board-certified anesthesiologists and 63 nurse anesthetists, Roos explains. When Memorial Mission and St. Joseph’s hospitals were separate institutions, Asheville Anesthesia and WNC Anesthesiology each served one hospital. When the hospitals merged, so did the two anesthesia practices in an effort to avoid scheduling conflicts.

The anesthesia team has several aims: maintaining the patient’s vital functions; rendering the patient unconscious; making sure the operation is pain-free; and ensuring that the patient doesn’t remember the operation, anesthesiologists say.

To that end, a wide array of drugs is available. Each has its specific function and properties that must be suited to the individual patient and coordinated with the others used. There are drugs to induce unconsciousness, to relax the muscles for surgery (which paralyzes the patient), and to control pain.

“You can mix them up according to the situation and what you’re most familiar with,” Roos says.

The anesthesiologists at Asheville Anesthesia, for example, have been trained all over the country and, thus, use a variety of techniques, he notes. But nobody gets “really wild” in experimenting with different drugs, adds Roos.

Preparing anesthesia can be compared to spicing up chili, according to Dr. Fred Spielman, a professor of anesthesiology at UNC-Chapel Hill, who testified for the defense during Waters’ court case. Some doctors may use garlic sauce, others may prefer jalapeno peppers or Tabasco sauce, he said.

“How you make that chili spicy is really up to you,” Spielman testified.

A drug that’s easy on the heart, for example, may have the disadvantage of lasting longer than other drugs, says Roos. And, along with differences in the drugs, the anesthesia-care team must also consider differences in patients. Even the patient’s weight provides no clear guidelines, notes Roos: Effects may vary by a factor of 10 or more in patients of similar weight, because of differences in age, liver function or other circumstances.

Usually, a doctor or nurse will administer an approximate dose of the anesthetic and then watch the patient’s reaction. Because the drugs are mostly short-acting and patients are monitored constantly, adjustments can be made rapidly, Roos explains.

“It’s like flying a plane without an auto pilot,” he says.

Why it happens

There are many reasons why patients wake up during surgery. One study, which analyzed more than 4,100 U.S. malpractice claims between 1961 and 1995, found 79 lawsuits revolving around awareness during surgery, according to a 1999 article published in the journal Anesthesiology. Medical mistakes such as drug-labeling errors and insufficient vigilance were the most common causes.

“Syringe swaps of muscle relaxants with sedative or hypnotic agents remain an important potential source of error in the practice of anesthesia,” the article notes.

At Park Ridge Hospital, anesthesiologists try to avoid that pitfall by having the doctor preparing the anesthesia label the syringes, to indicate what drug they contain.

Coston notes that giving a patient a muscle relaxant without providing an adequate amount of anesthetic can also cause problems. And high-stress hospital environments, he continues, can lead to momentary lapses in attention during surgery.

In Waters’ court case, her lawyers and expert witness claimed that she hadn’t been given enough anesthesia, which was disputed by the defense. She also maintained that her nurse didn’t listen to her before the surgery when she told him a particular drug didn’t work on her. The nurse, however, testified that she had never told him about that particular drug.

In some situations, such as trauma cases, doctors may have to risk patient awareness in order to keep vital functions going, says Roos. And sometimes, the cause of patient awareness remains a mystery.

“It can occur under the best of circumstances,” Roos observes, noting that it doesn’t necessarily mean that someone made an error.

“The patient is listening”

Doctors and nurses rely on certain indicators when assessing whether their patients are truly anesthetized, watching their blood pressure, heart rate and a host of other measures, Roos explains.

Some of the signs that a patient may be at risk for recall include fluctuations in heart rate or blood pressure, watering eyes, and movement, Coston notes.

In addition, many doctors now use a BIS monitor. A kind of modified EEG device, it measures a patient’s brain waves. Hailed by some as the “Holy Grail of anesthesia” when it made its debut a couple of years ago, Roos now sees it more as “one more piece in that puzzle” — and not an infallible one, either.

“There’s no definitive way to measure whether a person is having recall or not, and there is no definitive way to avoid having recall,” Roos asserts.