It's every surgery patient's nightmare: you're awake enough to feel the knife but not enough to scream

By JAMES WILLWERTH

heryl McCobb called the London-based Association for Improvements in the Maternity Services with a chilling story. She said she'd been conscious during her caesarean section operation at Billinge Hospital in Wigan, in northwest England, despite receiving a general anesthetic. "I lay there trying desperately to open my eyes and scream, but I couldn't," she said. "I heard them say it was a girl and then they began to put the stitches in. I felt every one." Alarmed, AIMS chairwoman Beverley Beech placed ads in local papers that elicited 13 similar stories.

The women had experienced what anesthesiologists delicately call "awareness" during a time when they should have been blissfully unaware. In most cases the pain-killers keep working, and all the patient feels is the unnerving pressure of a scalpel cutting and scraping. But sometimes pain breaks through the veil of drugs. No one knows how often awareness occurs worldwide, but one American researcher estimates 40,000 incidents for every 20 million U.S. surgeries annually.

The cases Beech uncovered date back to 1981, a time when such things as surgical awareness and post-traumatic stress disorder were not widely understood--and when, in any event, medical authorities seemed unwilling to acknowledge that there had been a traumatic event in the first place. When the frightened women had gone to medical officials their complaints were either ignored or doctors suggested they had been dreaming. "What made me angry," says Beech, "was that every single woman had reported her experience to someone."

Today, the subtle science of anesthesiology is more high-tech and more precise, and practitioners are more sympathetic to such tales. Still, an unknown number of patients continue to suffer during surgery, and for a variety of reasons most never tell the anesthesiologist about it. One study suggests that only 35% ever say anything. But such studies are rare, and many anesthesiologists don't know how much their patients suffer. "I used to think people who talked about this were flakes," admits Texas A&M anesthesiologist Charles McLeskey, who became a believer after a patient told him what he had overheard while he was under.

Boston University psychiatrist Janet Osterman is having trouble recruiting survivors for a research project on awareness at Boston Medical Center because so many refuse to be interviewed. Osterman says patients show all the symptoms of post-traumatic stress disorder, including flashbacks, irrational fears and, particularly common, severe insomnia. "They are afraid to go to sleep," she says. "Letting go feels too much like going under anesthesia."

Diagnosing awareness isn't easy. Some patients may exaggerate, and others experience not awareness but "emergence." As they wake up they become aware of the pain of the surgical wound even though they were fully unconscious during the operation. But Phil Hopkins, a lecturer in anesthesiology at the University of Leeds, says the incidence of true awareness can be "dramatically" reduced. "It should be something we can avoid with well-trained anesthesiologists," says Hopkins. That's no small task. The anesthetic cocktail is mixed with several factors in mind, from age to weight to sex to the invasiveness of the surgery. "What might be enough anesthetic for one person is not enough for another," he says. "And the ultimate consequence of an overdose of anesthetic is death." For certain surgical procedures, the patient is paralyzed as well as knocked out, which, by restricting body movement, limits the information available to surgeons. "The best monitor of consciousness is lack of patient movement," says Hopkins. When a patient is paralyzed, anesthesiologists must rely on such vital signs as heart rate and blood pressure, which rise if the patient is insufficiently anesthetized. But those are "non-specific" signs, meaning they could have other causes.

Anesthesiologists are investigating more reliable means of detecting awareness, and the focus is on brain waves. On display at the recent annual meeting of the American Society of Anesthesiologists in San Diego, Calif., was a toaster-sized device called the Bispectral Index Monitor, which can reduce or even eliminate surgical wake-ups. A specialized EEG machine, the system monitors the patient's brain waves and then translates them into a single "depth of consciousness" figure that operating-room staff watch like a number on a digital clock. Zero is an induced coma; 100 is fully awake; the ideal sleep state is 60. Anything higher represents a potentially dangerous state of awareness. Anything lower, and the patient could be oversedated.

"This is anesthesia's Holy Grail," says Nassib Chamoun, the machine's inventor, and the device seems to be catching on. Chamoun's company, Aspect Medical Systems of Natick, Mass., won U.S. government clearance last year and has already sold 711 systems.

Cheryl McCobb won $35,000 from Billinge Hospital in a 1986 settlement, and the resulting publicity led some 70 other women to call AIMS with similar stories. "Listening," says Beech, "is one of the things that professionals do not do." Now, at least some frightened patients are being heard.

--With Reporting by Nina Planck /London