Awareness followup

Sorry I haven't posted in a while, I've been busy at work. I got the following email from someone who came across this blog. I asked her if I could post it so others could share her experiences. Here it is edited (minimally) and posted with her permission.

Hi there,

I stumbled across your blog today and enjoyed reading your post about BIS monitors. I agree -- they DO NOT always work. I experienced awareness during anesthesia just last month, and my doctor was using the monitor.

I lost my baby during my pregnancy and needed a D&C. Unfortunately, my uterus was perforated during the D&C, and so the surgeon performed an emergency laparoscopy to repair the tear. I "woke up" feeling like I couldn't breathe, experiencing intense pain in my naval from the scope, and hearing parts of conversation in the OR around me. I was paralyzed, so I couldn't tell anyone what was happening. But I knew that if my belly was cut, something serious had gone wrong. I honestly thought that I was going to die. I eventually blacked out again for the remainder of the surgery, but have memories from pretty early after extubation (while still in the OR), and have much more recall of the recovery room than seems typical.

It had never occurred to me that something might go wrong with the anesthesia on top of everything else. (I figure that in the "Bizarro universe," my double has just won the lottery.) The only bright spot in this is that I ended up writing the anesthesiologist a letter describing what I experienced. He called me right away and said he was sorry, which was surprisingly helpful for me. He also said that when the perforation occurred, he'd had to quickly switch from using a mask to intubating me. From the details I described, he felt I woke up during that process. He said the BIS monitor lags real-time by at least a minute, and that while they are helpful, they obviously can't prevent all problems.

I do have a question for you: In future surgeries, how detailed does my description of what happend need to be to ensure I don't have awareness while under general anesthesia again? Any tips would be helpful.

My reply:

Sorry about your awful experience, and sorry about the loss of your child. From what I know, the experience you had was one that is typical of people that suffer recall. Generally an emergency happens and anesthetic techniques need to be changed in a hurry, or things are so tenuous, that the risk of recall is weighed against keeping a patient alive. Trauma situations and obstetric situations are classic. I'm glad you had a positive conversation about this with your anesthesiologist. Still must have been a traumatic experience.

As for future surgeries, I think the mention that you had awareness during a D&C converted to a general anesthetic for a laparoscopy, (Just the description you gave me) should be sufficient to avoid any problems. They will probably have you go through your experience so that they can be a better picture of what happened. Some may request a copy of the previous anesthesia record to see exactly what medications you received, but I'm guessing most won't.

I cannot of course promise that this won't ever happen again(you may be resistant to some of our medications) but I'm guessing the urgency of the situation was the main cause of your period of awareness.

Hopefully your future experiences will be more pleasant.

I hate to ask this, but would you mind terribly if I posted an edited redition of your experience on my blog, so that I can post the advice.

Good luck with everything. I'm happy to answer any other questions, sorry for my delay in reply.

Her response:

Hi again,

Thanks for the extra information. And yes, you can post my email(s) to your blog, in whatever edited version you want. I just request that you leave out my name.

The anesthesiologist for my surgery called me back again since I emailed you. He pulled my chart, and what he said matches up closely with what you surmised: Shortly after the lap began, my BP dropped. He administered ephedrine and lightened the anesthesia (propofol, I think he said?) to stabilize me. He believes this is when I initially became aware. He said that BIS readings remained in the 60s throughout the incident, which meant that I should have been out. I guess it just shows how hard it is to categorize levels of consciousness, even with a monitor. As a secondary
issue, he also wonders if I might metabolize Versed faster than normal, which would allow me to remember what happened.

It was a God-awful experience. I honestly thought I was dying, and you don't just immediately shrug off that sort of event afterwards. But, I don't really see how it could have been avoided. After doing some research and talking to both the surgeon and the anesthesiologist about what happened, I'm satisfied I got good care, despite my complications. So I am choosing to lump everything that happened to me -- the baby having trisomy 18 and dying, the uterine perf, and the anesthesia problems -- into the same category, which can be summed up as "sometimes you're lucky in life, and sometimes you are probability's bitch." I wish I'd been lucky.

Anyway, I'm hoping that this was a one-time bad event for me. For any planned surgeries, I'll follow your advice and explain my history as best I can.

Thanks again

This woman has had an awful experience, and has had the heart to share it with us. I think it illustrates that good communication between patients and physicians is of critical importance. It is especially important when "bad" things happen, though it should exist when things go well also.

Questions

Lately I've gotten some questions from readers and I thought I'd take the chance to answer some of them. I've been rather delinquent.

Some questions from some one beginning premed studies...

1)Any opinions regarding DO vs MD training particularly as it applies to anesthesiology?

Hmmm... interesting question. I think both avenues are good approaches to medicine, and they don't differ as much as you would thing, allopathic and osteopathic classes are almost the same with a few exceptions. I think in general MD programs give you more choices when you are choosing a what type speciality you want to practice in. I've trained with DOs and done a fellowship with a DO and find so generalities applicable. I will say in particular reference to anethesiology is that it seems to be becoming more competitive as a residency. Thus we are seeing less DO physicians meet the rigorous requirements for interview selection in my facility, but those we do see are amazing candidates. So I would have to say that doing well in school and getting high board scores are the most important requirements.

2) What is your experience with physicians who were non-traditional students (i.e. older -- I am already 30), again with particular reference to anesthesiology?

First of all, I do suggest to all my friends who are considering medicine as a career to reconsider it. It is a tough road with long hours of work and study. It is physically as well as mentally taxing. There are better ways to earn money, influence, and/or respect. Saying all that, if you are one that really wants to be a medical professional, who am I to stop you? I do love my job, but the road to where I am now has been a rough one. I would however do it again.

Next, I don't think being a non-traditional/older student necessarily puts you ate any sort of disadvantage in being selected for a residency program. I think it provides an interesting perspective in the field of medicine. Being older, I think the physical demands of medical training may be more difficult. Also there is more likely to be a family involved. And that has needs of its own. All that is fine though, many people train in the medical field with large families. It just requires more juggling.

Just think though if you're considering anesthesiology at age 30 and start medical school in the next few years you may be 40 or older before even starting to have the opportunity to practice on your own. That time is valuable and it is quite a commitment. In reference to anesthesiology, there are plenty of older residents, some have completed all or a significant portion of another medical residency (anesthesia is a field that is highly switched into), some have just gotten a late start as you have. Also anesthesia is demanding, but may require less time commitment in residency some places, then say other residencies such as surgery (although there are wide spread work hour limitations)


Another question from an electrical engineer.
3) How accurate are the new monitors that are supposed to indicate depth of anesthesia in a patient?

That also is an interesting question. The device you're most likely referring to is the Bis monitor. It's gotten quite a lot of press lately. It's basically a transcutaneous monitor that picks up electric activity from the brain (EEG), performs a complicated "black box" calculation and spits out a number ranging from 100 (awake) to 0(No electrical activity). We do not use this device at our institution. There are several problems that I see. First of all there are plenty of other ways to measure consciousness clinically. The device and disposables are not inexpensive. Also what bothers me the most is that the calculations that are performed by the devices are a proprietary formula, and we are not privy to those aspects. I'm not sure how accurate thes e devices are, but regardless I'm not sure they're necessary. (just one man's opinion)

Picture taken without permission from Aspect Medical Systems, Inc. website

If I missed your question, let me know I'm trying to keep up.