The Distress of Waking Up Under Anesthesia

The largest report ever on the topic finds that half of patients who are accidentally aware during surgery suffer long-term psychological effects.

In a foreward to a new report published by The Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland, a woman identified only as “Sandra” describes being conscious during an orthodontic operation, while under anesthesia.

Suddenly, I was aware something had gone very wrong. I could hear what was going on around me, and I realized with horror that I had woken up in the middle of the operation, but couldn’t move a muscle. I heard the banal chatter of the surgeons, and I was aware of many people in the room bustling about, doing their everyday clinical jobs and minding their own business, with absolutely no idea of the cataclysmic event that was unfolding from my point of view.

Nearly four years of research into every hospital in the U.K. and Ireland, as well as 300 anecdotal reports, resulted in this, the largest survey of “accidental awareness during general anesthesia” (AAGA) to date. The editors of the report explain in their introduction that both anesthesia and human consciousness itself are not well-understood, and so, "historically, when faced with a report of AAGA, there was a tendency to disbelieve the patient’s account." And when the phenomenon does occur, there's only one person who really knows what happened—the patient. This project was an attempt to deepen understanding about when and how AAGA happens.

The report estimates that these incidents occur about once in every 19,000 uses of anesthesia. (In a feature for The Atlantic, Joshua Lang reported a higher number—one or two per 1,000, in the U.S.) Different surgeries have different risks—C-sections, for some reason, were the most common, with an incident rate of one in 670.

Being awake and paralyzed during surgery is the stuff of nightmares—and the stuff of movies. The 2007 film Awake starred Hayden Christensen as a heart transplant patient who wakes up during surgery and discovers his doctor is planning to let him die and steal his wife. But the reality, according to this report, is thankfully not quite that dramatic, though the experience seems scary enough without someone stealing your spouse afterward. The “vast majority” of AAGA instances lasted less than five minutes, it found. There was also a wide variety of experiences—only 18 percent of people reported feeling pain. Some of the other experiences patients reported include:

• An inability to move (42%)
• Hearing noises or voices (37%)
• Feeling non-painful touches (21%)
• An inability to breathe or suffocation (11%)
• “Dreamlike experiences” (5%)

Half of the patients who experienced AAGA felt distressed; the other half felt “neutral.” Distress was most common when patients were awake but unable to move, as Sandra was, and 41 percent of patients who woke under anesthesia had moderate to severe long-term psychological effects afterward. (Half of patients suffered some kind of long-term effect.)

For those who suffer post-traumatic stress disorder as a result of AAGA, “Some may only be troubled by PTSD symptoms for a matter of weeks,” the report says. “Others will be disabled for many years, possibly for the rest of their lives.”

The survey found that 85 percent of patients who experienced AAGA told someone afterwards, but only 50 percent reported it to hospital staff. One-third of those who told hospital staff or their families were met with a skeptical response, including Sandra. "When I related surgically-related conversations to the theatre team, they went a little white, but continued to deny what had happened," she writes.

The report recommends “active early support” from physicians and other healthcare workers after a patient reports one of these experiences, and notes that patients who received reassurance often had better outcomes, and that unsympathetic doctors can make things even worse. Troublingly, in spite of this, only 12 of the 360 U.K. hospitals surveyed had any protocol for dealing with a case of AAGA.

In her foreward, an understandably disgruntled Sandra writes:

“I am left feeling that all those years ago, it would not have been difficult for the surgical team to show a human face and apologize. That won’t happen now, but this NAP5 Report, and the reflective practice that will be engendered by it, goes a long way to making up for any lack of an apology at the time.”