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NB: Please scroll down for archive correspondence:

Who started the Anaesthetic Network - and WHY?

Sally Pearson:

Sally underwent an awareness experience during an emergency caesarean
for the birth of her son. The anaesthetist responsible for
the operation hadn’t noticed that the tube giving Sally the nitrous
oxide gas had become disconnected at the beginning of surgery. Sally had
been paralysed with a muscle relaxant, intubated and had her eyes taped
shut. She was totally aware of what was happening to her for the entire
operation. As the surgeon’s knife sliced across her stomach, she tried
to scream her terror and distress to the medical staff, but was unable
in any way to indicate that she was awake. She remained conscious
throughout the delivery of her son until the wound was stapled
together, at which point the anaesthetist realised what had happened,
and connected the anaesthetic gas again.

A ‘VERY RARE EVENT’?

One of the things Sally and her husband David were told all those years
ago was that Sally’s experience was a ‘very rare event’, that was
unlikely to happen in the future because of new technologies that were
becoming available.

HOW DID THE HOSPITAL RESPOND?

In Sally’s case, a series of fortunate events following the operation
meant that the mistake was acknowledged and admitted by the hospital.
She received support rather than the ‘closing of ranks’ that sometimes
follow medical accidents. The hospital’s open and constructive response was one of the reasons why Sally and David chose not to take legal action. Recent research in relation to awareness experiences indicates that the hospital’s openness was a significant factor in Sally’s recovery, as was the fact that James was born fit and well, and has grown up to be a healthy
young man. The way the hospital responded was highlighted by the BBC through the ‘Rough Justice’ series presented by Helen Alexander in 1990, which was the first time Sally spoke publicly in the media to ‘raise awareness of awareness’.

‘IT WON’T HAPPEN IN FUTURE!’

Sally and David were assured by several medical experts that, with the advent of new technologies,
future patients undergoing surgery would be protected against awareness
during surgery. Eventually, she and David decided to do their best to
put the experience behind them, in order to pour their energies into the
joy of parenthood.

WHY START AN ANAESTHETIC NETWORK (UK & Ireland)?

Upon reading Ian Sample’s account (Guardian Weekend 19th February 2005) of how Carol Weihrer had founded the Anesthesia Awareness Campaign, Inc. in America,following her own terrible experience whilst undergoing eye surgery,
Sally received a great shock. 17 years after her own experience it was clear that the refusal, by many medical professionals, to change attitudes towards the introduction of consciousness monitoring techniques and use the new technologies available, meant that at least as many as 1 to 2 in 1000 patients may have experienced some form of awareness, and possibly 4 to 6 times higher in paediatric cases.

Now Sally has joined Carol and many others who are working together to
raise awareness… of awareness.

Archive correspondence

Letter to Roberta Blackman-Woods MP

25th June 2005

Mrs Roberta Blackman-Woods
House of Commons, London, SW1A 0AA/
26 Market Place
Durham
DH1 3NJ

Dear Mrs Blackman-Woods

Thank you for your letter of 24th June, enclosing the reply from the
customer service centre on behalf of Patricia Hewitt, Secretary of State
for Health.

I e-mailed Ms Hewitt to congratulate her on her new appointment, and
also to draw her attention to the horrific ongoing problem of
anaesthetic awareness. I received the reply from customer services (as
enclosed by you) on the 7th June. I was initially granted permission to
display this reply on the Anaesthetic Awareness Network UK & Ireland (AANUK&I)
website, although this permission was retracted by the Department of
Health shortly afterwards, pending further internal discussions.

Other victims of anaesthetic awareness have also been in touch with
their MPs to strongly express their concerns over the frequency of
incidences. As a result, Mr Roger Williams, MP for Brecon and Radnorshire, tabled three
Parliamentary Questions requesting further information from the Secretary of State for Health.
Mr Williams was acting on behalf of Mrs Meryl Davies, who went through
this experience not once but twice - at the hands of the same anaesthetist.

The questions were responded to on 16th June and are
displayed on the website (Hansard).

Through contact with the Royal College of Anaesthetists and the
Association of Anaesthetists Great Britain and Ireland, I am aware that
there are on-going discussions underway regarding the future of
consciousness monitoring during anaesthesia. This may result in the
introduction of expensive new brain-monitoring equipment being used in
future to assist anaesthetists in the detection of awareness during
surgery. I am also in regular contact with a consultant anaesthetist in
the North-East of England whose research and practice involves an
inexpensive and ‘low-tech,’ yet possibly more reliable, form of
consciousness monitoring. There is still as yet no agreement among
anaesthetists as to the most appropriate way to try to find a solution
to this complex problem.

It is, therefore, my sincere hope that the search for effective ways to
monitor, report and follow-up incidences of awareness will be kept high
on the anaesthetic agenda, especially as it is possible that these occur
as frequently as 2-3:1000 (and perhaps even more often during paediatric
surgery). The consequences of this trauma on the well-being of victims,
as well as resources for appropriate aftercare, also deserve the full
attention of all the professional personnel involved.

I am now in contact with the National Patient Safety Agency (NPSA), in
an attempt
to ensure that the issue of anaesthetic awareness remains a priority for
those with responsibility for delivering a quality healthcare service to
the public.

The Anaesthetic Awareness Network (UK & Ireland) will continue to act as
a catalyst, as well as provide support and information for victims and
healthcare professionals alike. Please do not hesitate to contact me if
the Network can be of any further assistance.

Thank you again for your attention to this matter

Yours sincerely

Mrs Sally Pearson
Facilitator
(AANUK&I)

cc Mrs Meryl Davies
Mr Roger Williams, MP
Professor Michael Wang (Advisor, AANUK&I)

Reply from Prof. Michael Harmer, President of the Association
of Anaesthetists of Great Britain and Ireland (www.aagbi.org)
in response to Sally’s contact and raising of concerns about current
practice:


“Thank you for
your Email and I am grateful to you for contacting me over this
matter. As someone who has undergone anaesthesia but has never
suffered awareness, it is impossible for me to comprehend the effect
such an event would have on a person’s life. I realise that it is
all too easy for me to make reassuring sounds about the rarity of
awareness under anaesthesia, without perhaps giving full weight to
the seriousness of the event. The incidence overall may be very low
but for the victim such as yourself, the incidence is 100%.

I hope that I might be able to reassure you on some matters. It
would be wrong to a say that nothing has changed since your episode
of awareness. The problem in your case was a disconnection matter;
these have been all but eliminated by the introduction of a range of
monitors for routine use: disconnect monitors with alarms, carbon
dioxide analysers with alarms, anaesthetic agent monitors with
alarms, pulse oximetry with alarms. These combine together to
virtually guarantee that disconnection is rapidly detected. The
widespread introduction of these monitors followed a campaign by the
Association of Anaesthetists to ensure a Minimum Standard for
Monitoring (the latest version is available on our website:
aagbi.org). Such monitors will also detect problems with the supply
of anaesthetic gases and vapours and sound an alarm. These monitors
have had an impact in reducing the incidence of awareness and the
number of new cases each year is reducing.

The Holy Grail of awareness monitoring though has proved more
difficult to achieve. It would seem a simple thing to have a monitor
to show whether you are asleep or not. Research in this area has
been going on for many years and many different techniques have been
used. All have pros and cons but the real problem has been in the
reliability and accuracy of the recordings produced. In effect, the
latest generation of monitors look at brainwaves and produce a
figure of depth of anaesthesia. Ther have still been anecdotal
experiences of the monitor giving spurious results that would miss a
case of awareness but these monitors are being introduced gradually.
In the US, they are used in about 10% of anaesthetics and are not
yet widely available, though some companies claim a much greater use
(this is information from the President of the American Society of
Anesthesiology).

In the UK, we are organising a joint working group of the
Association and the Royal College of Anaesthetists to look at this
specific problem and see if we can come up with some specific and
reliable advice.

I very much appreciate your positive approach to this matter and if
you would like to meet up sometime, I would be pleased to try to
arrange such. I hope that in the near future we will be in a better
position to give you more positive news but I would like to
reiterate that things have changed quite a bit since your problem -
but we still have to strive for perfection.

Kind
regards

Mike Harmer

President
AAGBI“