Health: The waking nightmare

If you come round during an operation, you can feel everything, but you can't scream. What happened to June Blacker could happen to you. By Roger Dobson

It must be the worst nightmare possible; waking up during an operation, feeling the pain of the surgeon's scalpel and being too paralysed to move a finger. "It was torture and there wasn't a thing I could do about it," says 45-year-old June Blacker, in the news last week after the NHS accepted liability for the pain she suffered. She was completely paralysed yet totally aware as the operating team cut away at her abdomen. "I was trying to shout, move, do anything, but they started to probe my insides and I could feel the knife, everything."

For June, the horror of her sterilisation operation at the Prince Charles Hospital in Merthyr Tydfil continues; she still has flashbacks. "I wouldn't wish what happened to me on my worst enemy,'' she says. "I realised something was wrong when I didn't go straight off to sleep, but I couldn't tell them I wasn't asleep because I couldn't move. It was like looking at everything through a foggy haze, but I really started panicking when they were cutting me."

June is the latest of the so-called awareness cases where the patient is conscious of what is happening during an operation but unable to do anything about it. Some of the victims have been counselled and others have received treatment for post traumatic stress as a result of their experiences in the operating theatre. Unsurprisingly, many have gone on to develop a phobia of surgery or hospitals.

In most awareness cases, the patient is only really conscious of what is happening, but sometimes they feel the full pain of the surgery, too. No one really knows just how prevalent awareness is - estimates vary wildly from 30,000 cases a year in the UK to one in 3,000 operations, or up to 3,000 or so a year.

The issue of awareness has arisen largely because of the increasing sophistication of anaesthesia. In the old days, life was simple, albeit more hazardous, and patients were knocked out with a high dose of drugs, which was increased if they started to come round. "In the early days of anaesthesia when you only had ether or chloroform, the only way to make a patient more relaxed was to give them more and more ether. Such high doses did relax the muscles, but they also depressed heart and breathing, and therein lay a lot of problems,'' says Diana Brighouse, consultant anaesthetist at Southampton University Hospital.

Nowadays, anaesthetists juggle with a combination of drugs that each do one of three separate things - keep the patient asleep, keep them pain free and relax their muscles. It's a technique that is said to be safer, and patients don't take so long to get back to normal.

As far as awareness goes, the potential villain is the neuro-muscular blocker, or muscle relaxant, a family of drugs whose effect is total paralysis. These drugs paralyse the body to the extent that even breathing has to be mechanically aided.

Not all patients get these muscle relaxants, and its main use is as part of a general anaesthetic for surgery involving the abdomen, chest, or brain, as well as some keyhole surgery where the patient needs to be motionless.

The art of this kind of anaesthesia is getting the balance right. The problem with awareness arises when this balance is lost and the patient gets too little anaesthetic or too little pain killer, or in some cases too little of each.

"Awareness is usually because inadequate amounts of drugs have been given and a muscle relaxant has been used so the patient can't move, can't respond in the normal way, and if they haven't been given enough to relieve pain, it is an extremely unpleasant experience,'' says Professor Leo Strunin, president of the Royal College of Anaesthetists.

He says that the drug combinations do work for most people, but that for some there will be problems. "Getting it right is matter of judgment and experience, and if something does go wrong it is not necessarily a case of making a mistake. Even the most experienced people can get it wrong,'' he says.

In June's case, the effects were devastating. "I could feel everything that was going on and I'm told that it probably lasted for 10 to 15 minutes but it seemed like a lifetime. I was crying out to tell them and I thought my body was moving but it wasn't, I was completely paralysed. My brain was working but my mouth and body wouldn't move. I felt the knife going and I tried to wriggle away but couldn't move. It was unbelievable pain.

"During the operation I had a cardiac arrest and I could hear the alarm on the machine and the doctors and nurses were suddenly shouting and hands being pressed up and down on my chest."

Since her ordeal, June has discovered that she is by no means alone in her awareness experience. Agnes McKeown, 46, who was fully conscious during an operation to sever nerves around her kidney, was awarded pounds 5,500 and vividly describes what happened to her: "There was a burning pain as they cut my back open from my shoulder to my waist. I could feel something like meat tearing. I wanted to scream but I couldn't, so I prayed.''

Shropshire mother, Evelyn Cooper, aged 35, was awarded pounds 18,000 for her pain and suffering when she was awake during a caesarian section, while Margaret Ashton, aged 30, from Doncaster, was given damages of pounds 21,000 for her suffering during a similar operation.

A confounding problem both for anaesthetists and patients is that there is no way of monitoring awareness. There are clues, such as sweating and increased blood pressure associated with anxiety and panic.

Attempts have also been made to tourniquet one arm so it is unaffected by the muscle relaxants, thus allowing a conscious patient to raise the alarm. There have also been experiments using responses to soundwaves or to electrical impulses to check on the conscious or unconscious state of the brain.

But despite the research and concern about the reported cases of awareness there is no sign yet of a foolproof method of knowing if that inert and apparently sleeping body on the table is conscious, and listening in terror to every word, and feeling every cut and thrust of the scalpel. Not much comfort for June, who is still traumatised by the event. "I have had counselling but I really do need help because I would like to get my life back to normal. How am I going to handle having another operation in the future? How will I cope? The problem is that you can never put something like that completely behind you - it's always there.''

Anaesthetic Types

IN SOME cases patients can be given a choice of anaesthetic, and surveys of anaesthetists have shown that if they were having an operation with a choice they would opt for local or regional anaesthetics. In the US, local and regional anaesthetics are far more widely used than in the UK.

"Patients in the US are much more accepting of being awake and having a local or regional, whereas here patients often say they would rather be asleep,'' says Professor Strunin.

Local anaesthetic: commonly used to block nerves locally when operating on limbs.

Regional or Epidural: inject one or multiple shot of drugs into the back, outside the membranes around the spinal cord. The injected anaesthetic then goes through the membrane.

General anaesthetics: made up usually of a mix of nitrous oxide gas plus other drugs, as well as an analgesic for pain relief and sometimes a muscle relaxant.