A Straight Dope Classic from Cecil's Storehouse of Human Knowledge

Do some people remain alert—but paralyzed—under anesthesia?

February 26, 1999

Dear Cecil:

I've heard of people under general anesthetic who become physically paralyzed but remain mentally alert. They feel the surgeon's scalpel but are helpless and unable even to blink an eye or make a sound. Could you give me the straight dope on this phenomenon?

Cecil replies:

It happens, babe. Get a load of these horror stories from the medical journals:

  • One patient in the UK required an operation that involved cutting open his leg and drilling into the bone. He was anesthetized but awoke in the operating room with a tube down his throat, aware but unable to move. He tried to alert the doctors by wiggling his toes; a nurse noticed this but was told it was "just reflexes" and she should ignore it. Someone then grabbed the patient's leg and began applying a tourniquet to his groin, at which point he realized that (1) the operation was just beginning, (2) he was acutely sensitive to pain, and (3) he could do nothing about it. The patient had to lie there in helpless agony while his leg was sliced open and four holes were drilled into the bone. He felt sick and stopped breathing in another attempt to alert the OR staff, but the ventilator began "breathing for him." Afterward he sued and was awarded 15,000 pounds, pretty modest compensation under the circumstances.
  • A 31-year-old woman with Hodgkin's disease was due to have her spleen removed and other organs biopsied. She was anesthetized but awoke before the operation began, fully sensitive to pain but paralyzed except for some slight ability to move the eyelids. Two observers in the operating room, probably students, pointed out that the patient's pupils weren't dilated, but the anesthesiologist lectured them on how anesthetics worked and shut the patient's eyes. The patient tried to flutter her eyelids later; the operating team eventually decided she was waking up and gave her more muscle relaxant, which made it impossible for her to signal further but did nothing for her pain. The patient suffered for 45 minutes while the surgeons cut her open, removed her spleen, explored the other organs, then stitched her back up. After the patient was wheeled out of the OR the muscle relaxant wore off and she was able to shout, "I was awake in there!" The anesthesiologist rushed back to the operating room and discovered the oxygen flush had been locked in the "on" position during the operation, diluting the anesthetic. The woman subsequently had recurring nightmares and panic attacks and required psychiatric help.
  • A woman having a cesarean section awoke on the operating table, alert but paralyzed. Initially she felt nothing, but eventually the painkiller wore off and the rest of the operation was a nightmare. "The nearest comparison would be the pain of a tooth drilled without local anesthetic — when the drill hits a nerve," she wrote later. "Multiply this pain so that the area involved would equal a thumbprint, then pour a steady stream of molten lead into it." Yikes.

Awareness under anesthesia occurs in perhaps two cases per thousand in general surgery, and at a substantially higher rate in cases involving trauma or cesarean section. (Not all incidents are as horrifying as the ones described; sometimes the patient knows he's being sliced open but feels no pain.) It's usually blamed on faulty equipment or technique, though a few people just seem to be immune to anesthesia, at least the part involving loss of awareness. The underlying problem is that nowadays anesthesia involves not one but several drugs. These include painkillers, sedatives, amnesia-inducing agents, and relaxants that allow the muscles to be pulled aside so the surgeons can do their work. Getting the mix right is tricky. Too much inhaled gas, for example, can cause cardiac instability and possibly snuff the patient; not enough and he suffers the tortures of the damned.

Over the years doctors have used various methods to detect awareness under anesthesia, none entirely satisfactory. You can try keeping one arm unparalyzed so the patient can signal the doctors if he's not unconscious, but this approach is far from foolproof. A promising new technique involves something called a bispectral index monitor, which analyzes brain waves to determine the patient's depth of consciousness. I'm sure it works great. But I'd want my surgeon to leave me with one good arm too, so if all else failed I could strangle the son of a bitch.

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