Awake While Under The Knife

This is a surgical patient's worst nightmare. Frankly it's also an anesthesiologist's worst nightmare too. In July 2020, Matthew Caswell underwent a hernia operation at Progress West Hospital in O'Fallon, Missouri. Unfortunately he was awake for at least thirteen minutes during the operation. The anesthesia team had paralyzed him then forgot to turn on a volatile agent to induce amnesia.

Mr. Caswell said he knew something was off when he could feel his skin being cleaned with the cold prepping agent. Expecting that his anesthesia would kick in any moment, next thing he felt was the knife cutting his skin. He was paralyzed and could not inform the anesthesia team that he was awake. His heart rate jumped from 70 to 115. Meanwhile his blood pressure shot up from 113/73 to 158/113. He could feel three trocars inserted through his abdominal wall and his abdomen being insufflated for the operation.

According to the lawsuit, the anesthesia team at this point should have noticed that something was wrong. Yet no further anesthesia was given for thirteen minutes. In the meantime he could hear and feel everything that was going on in the operating room. Mr. Caswell said he was so scared he thought he was having a heart attack.

The anesthesia records later showed a "Significant Event Note." It said that "review of the anesthetic record demonstrates a delay in initiating inhalational anesthetic after induction of anesthesia." Mr. Caswell and his mother were "immediately informed regarding the delay in initiating the inhaled anesthetic agent until after the start of the surgical procedure." It goes on to say that the hospital provided emotional support immediately after the surgery and they would offer psychological counseling for free. His mother took a video of Matthew immediately after the operation and it's clear he has been traumatized by the entire ordeal.

Mr. Caswell is suing Washington University along with the anesthesiologist, Brian Weber, MD, JD, and Kathleen O'Leary, CRNA. (Though the first page of the complaint says Dr. Weber's first name is Brian, the subsequent pages of the complaint call him Bruce. I can't explain the discrepancy.) I can't think of much defense they can mount against this tragedy. Better just write a big fat check right now. Lucky for them the plaintiff is suing each defendent for only $25,000 each. 

This is going to be an unfortunate black mark on this young anesthesiologist's career. It's the kind of incident that can easily derail a promising new physician and make him question everything he's learned during training. Though not as traumatized as the patient, Dr. Weber is likely to feel enormous guilt for a very long time.

There are various methods to prevent surgical recall. Some have advocated using a BIS monitor to track a patient's level of consciousness. Other's show that making sure enough inhalational agents in the patient will prevent recall just as well as the BIS. Giving the patient midazolam preoperatively can help ensure amnesia in case not enough gas has been given to the patient.

Perhaps the most important thing the anesthesiologist can do is to always be vigilant. Be constantly aware of what is happening to the patient. Just because an operation is likely to be routine and uneventful is not an excuse to stop monitoring the patient scrupulously. If the anesthesia team in this case had been more attentive to the stresses manifested by Mr. Caswell's tortured surgery, maybe they wouldn't have waited thirteen whole minutes before finally giving him his anesthesia.

Anesthesiologists Need Space Too

 

Looks about right for an anesthesia work space.

Anesthesiologists are frequently an afterthought when it comes to designing operating rooms. I've worked in operating rooms so small there was literally just enough space for the patient gurney to get wheeled in and no room to walk around it once the patient was inside. I've worked in rooms that were literally former janitorial storage rooms. I vividly remember administering anesthesia in rooms so tiny that when you went to relieve the anesthesiologist inside, that person had to get out first before you could squeeze yourself into the space. There was just enough room for the anesthesiologist to stand in place, never mind a space for a chair.

A dream space for the anesthesiologist.

All that discomfort and disrespect for the anesthesiologist may be changing. The New York Times has written about a revolution in operating room design. The article follows the OR remodels taking place at the Medical University of South Carolina. Led by Dr. Scott T. Reeves, the chair of the department of anesthesia and perioperative services at the hospital, they are making OR's that are bigger and far more accommodating for all the staff. They even take into account how to future proof the new rooms, deciding where to place bulky equipment like X-rays and robotic surgery that are used with increasing frequency during operations.

This is a far more professional way to design the operating rooms than what I've witnessed in the past. I remember when we were opening a new wing of the hospital and the anesthesia department had its first chance to see how the operating rooms would look. We had absolutely no input into the space during the design phase. They never asked for nor received any input from the anesthesiology department. Needless to say, the placement of the anesthesia equipment was suboptimal, almost dangerously so. 

Upon review of the blueprints, we noted that the rooms were drawn with plenty of space around the operating table for the surgeon. However, the anesthesia machines and carts were not drawn to a realistic scale and were squeezed into the corners of the rooms. Our anesthesia machines were easily twice the width and depth of the models that were used in the blueprints. To this day, we still have problems with placing the machines in the proper locations to ensure patient safety. But the surgeons have plenty of space to do their work though. 

I'm glad hospitals like MUSC, Stanford, and Loma Linda are not forgetting the needs of all the staff in the operating rooms. Surgeons may think they walk on water in the OR, but without consideration for all the other professionals in the OR, they and their patients would sink pretty quickly.