Through and beyond anaesthesia awarenessBMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c3669 (Published 12 July 2010) Cite this as: BMJ 2010;341:c3669
- Anne-Marie Aaen, specialist psychologist1,
- Kirsten Møller, specialist in anaesthesiology and intensive care2
- Correspondence to: A-M Aaen , K Møller
- Accepted 4 June 2010
On the morning of 2 January 2004, I gave birth to my second son when I was less than 26 weeks pregnant. The delivery was by emergency caesarean because the umbilical cord had prolapsed, cutting off the blood and oxygen supply to my tiny baby. It was a shock to realise that my son was in grave danger, but I was very thankful to the healthcare staff for responding immediately and doing their utmost to save his life.
Because of the acuteness of the situation, the caesarean was to be carried out under general anaesthesia. Frankly, this was a relief—I was terrified my son might already have died and, therefore, preferred not to witness him being delivered. I had been under general anaesthesia before without any problems and was not too anxious about going through it again.
The experience itself
Unfortunately, something went terribly wrong. The drug that should have put me to sleep worked only partially, but nobody registered this. Instead, the anaesthetists proceeded to give me a muscle relaxant. I was partly drugged, which made me forget the context: that I was giving birth through a caesarean. Otherwise, however, I was wide awake, with no soothing effect of painkillers. I experienced how my muscles twitched then became totally paralysed so I could not breathe, and how a flat metal blade that felt like a knife was put into my mouth and jammed down my throat, followed by a thick wire-like thing that I thought further obstructed my breathing. I then felt an arm being thrust into my vagina (this was to keep my child from advancing into the pelvis, but felt as if I was being raped) and the cool feeling of liquid on my tummy, followed by agony when the obstetrician cut my abdomen open. Because I had forgotten about the caesarean, I thought that I was being raped, strangled, and cut up by some evil force. For a few seconds, I would black out in terror, then wake up again, only to realise that I was dying and unable to fight for my life.
After a few minutes my son was delivered, which was when I received a large dose of opioids and finally drifted away, not realising that I had just become a mother for the second time.
The months after
When I woke after the anaesthesia to learn that my child weighed only 751 g but had survived, I remembered none of the dramatic events surrounding his birth; I was in control and acted rationally. The next few days, however, I reacted very strongly. I cried and was terribly frightened without understanding why. Everybody, including my husband and myself, believed that it was because I was afraid my son would die, which made perfect sense because he was seriously ill. When his condition ultimately improved and he was discharged to go home, my symptoms failed to cease.
During the first few months after his birth, the recollection of how my son was delivered slowly re-emerged as nightmares and uncontrollable flashbacks. I would wake in the middle of the night scared to death about choking, with the memory of a sharp, shiny metal thing being thrust into my throat without me being able to lift a finger to defend myself, or with a strong impulse to vomit or an urge to pee, without any physical cause.
To start with, I refused to relate my nightmares to the anaesthesia—they were too horrifyingly brutal to be true. I finally told first my husband (more than six months later, when my son had stabilised), then my general practitioner about the nightmares. They suggested that there might be a link with the anaesthesia, so I contacted the hospital where my son was born to arrange a meeting with the anaesthetist who had taken care of the anaesthetic on that morning.
Coming to terms with the experience
Meeting the anaesthetist was a scary experience because the anaesthetic drugs had made me lose the context of what was happening. Emotionally, the person I was meeting represented those people who had conspired to rape, strangle, and kill me that morning, and I had spent some time before the meeting being very angry and wishing to avenge what had happened to me. My husband commented that my experience must be similar to that of a torture victim, and that being horrified was a very understandable reaction. Nonetheless, I shook with fear when I finally sat opposite the doctor who had anaesthetised me. At the same time, my rational self realised that she had not intentionally hurt me, and that I needed her help to understand what had happened.
During the following six months, I met with the anaesthetist on a regular basis, underwent therapy from a psychologist, and addressed my emotions from the awareness experience. The anaesthetist explained how my nightmares were related to the events that had taken place when I was anaesthetised and underwent surgery. Understanding what had happened helped me a lot, and I slowly learnt not to be afraid of the anaesthetist. She taught me how to intubate a resuscitation manikin, which helped me work through my own memories of being paralysed and intubated. After half a year of therapy, I voluntarily entered the operating theatre again, lay on the operating table, and let the anaesthetist stand behind me and hold my head. That was a proud and exhilarating moment.
The anaesthetist had also been affected by my awareness experience, but our meetings helped us both to get over the event. I know that several of her colleagues advised her to stop seeing me, but she continued even though it was tough for her. In some ways, my role in our mutual experience was less complicated than hers—I was the injured party, which earned me sympathy and support from people around me, whereas she was the one who was responsible for my suffering, even though it had been impossible to detect during the anaesthesia.
I have learnt a lot from my awareness experience. First of all, I have learnt how strong you can be when you have something very important to fight for. During the first months after my son’s birth, I had my premature baby to fight for, and I did that very well. I also learnt that it is important to ask for help if you cannot handle a problem yourself, and I’ve learnt about trusting somebody again and forgiveness. I am less afraid to die because I believe that dying will be a lot less painful and terrifying than being killed slowly on an operating table. I am also now open to the possibility that a person might need to die simply because they are suffering so much that life becomes worthless.
The anaesthetist and I have become friends, and we still see each other six years after I thought that she was going to kill me. Today, I would trust her with my life without hesitation. I consider myself 95% cured from the severe post-traumatic stress disorder I experienced. I have returned to work as a psychologist and am doing well. I have written a book about having a premature baby, published a few months ago, that includes a description of the awareness experience. It helped me a lot to write it all down. My husband and friends think I have changed, mostly in a positive direction. I personally feel that I have grown less able to sense my emotions; fortunately, I strongly sense my love for my family and my gratitude to all those who helped me heal.
Things that helped me get over my awareness experience
1) My family, friends, and, not least, my doctors listening to me and believing in me
2) People understanding that even though I had not undergone torture or an attempted killing, this was how I had perceived the anaesthesia and surgery
3) The anaesthetist explaining the technicalities of my experience to me and teaching me how to intubate. And finally learning to trust her enough to let her hold my head again and help me to lie on the operating table again
4) The anaesthetist telling me that my experience was intolerable and unacceptable from a professional point of view, and apologising for it
5) A psychologist helping me work through my experience
A doctor’s perspective
When I first heard of Anne-Marie’s experience, some ten months after the event, I had no problem remembering what had happened on the morning in question or accepting that she had suffered an awareness experience. Then, I was an anaesthesia trainee with about four years’ experience.
Two other experienced anaesthetists had been present at the scene: a specialist anaesthesiologist and a nurse anaesthetist. We had been working a long, busy shift, and the pager calling us to Anne-Marie’s case went off ten minutes before hand over. A general anaesthetic was planned because of the urgency and the risk that the baby might have died in utero.
Several things went wrong, however, which was annoying to us but might have added to Anne-Marie’s suffering. The anaesthesia apparatus repeatedly failed the electronic self test, which precluded us from using sevoflurane (an inhalation anaesthetic); instead, we decided to use propofol to maintain the anaesthesia. Next, after the usual crash induction sequence of thiopental sodium and suxamethonium chloride, which we thought had put Anne-Marie to sleep, I intubated the oesophagus instead of the trachea. Although we realised and corrected the error immediately, I have no doubt that the sensation of air deprivation, as well as being intubated twice, aggravated the nightmare that Anne-Marie was experiencing. Additionally, the peripheral intravenous catheter supplying the propofol infusion was displaced during the induction and had to be replaced.
My previous understanding of anaesthesia awareness was thorough but theoretical—I knew that it happens for one to two individuals out of a thousand people undergoing anaesthesia; that the risk can be especially high in women who undergo general anaesthesia for emergency caesarean; and that severity can vary from a vague recall of intraoperative events to catastrophic, agonising post-traumatic distress syndrome. However, to my knowledge I had never before anaesthetised a patient who subsequently turned out to have been aware during the procedure. Hence, I had no idea of the extent of the suffering that Anne-Marie had been through and was unprepared for the shock that it was to meet with her.
As a doctor, I have been taught skills that are supposed to help others, so I found it deeply distressing to learn how Anne-Marie had perceived me as a cold blooded, evil torturer and murderer. Professionally, I had second thoughts about my choice of specialty and considered resigning from my anaesthesia residency. Personally, I developed post-traumatic distress syndrome, which was nothing like as severe as what Anne-Marie had been through but was nonetheless quite painful. Some of my colleagues questioned my approach and suggested that I pull out of the contact with Anne-Marie to protect myself, which sounded very appealing. On the other hand, I had promised to help her out, and, curiously, working together provided a “cure” for both of us.
Like Anne-Marie, I have learnt a lot from this incident, first and foremost about the potentially traumatising personal consequences that an awareness experience might have. I also got a taste of what post-traumatic distress syndrome is like, on a small scale. Moreover, I was forced to reflect on my obligation as a doctor to assume responsibility, and I realised that I had to make my own moral choices.
Finally, Anne-Marie helped me as much as I helped her. Maybe it would have been more “professional” of me not to get as deeply involved as I did, and others might find that our approach won’t work for them. Even so, today I am sure that Anne-Marie and I found the optimal solution for us to our mutual problem.
Kirsten Møller, specialist in anaesthesiology and intensive care
Cite this as: BMJ 2010;341:c3669
This is one of a series of occasional articles by patients about their experiences that offer lessons to doctors. The BMJ welcomes contributions to the series. Please contact Peter Lapsley () for guidance.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any company for the submitted work; no financial relationships with any companies that might have an interest in the submitted work in the previous 3 years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; not externally peer reviewed.