Am I awake?

From time to time, patients ask if they may experience awareness as depicted in the movie Awake, which was released almost seven years ago. In it, the protagonist, patient Clay Beresford (Hayden Christensen), is partially paralyzed by a medication but is not asleep and feels surgical pain and manipulation. He dreams of his new wife Sam Lockwood (Jessica Alba) to distract himself from the pain and then comes to realize she poisoned his donor heart to kill him and collect on his life insurance. The movie is fanciful and takes liberal creative license to describe the work of anesthesiologists and surgeons. Fortunately, the events and many facts, including the anesthetic techniques, are works of fiction.

Awareness is thought to occur 0.0069 to 0.1% of the time, with the higher number reported by the movie. To be sure, awareness is more common with cardiac surgery and the use of muscle relaxants (neuromuscular blocking agents). When these medications are not used, patient movement during surgery can be a sign that the patient is not deeply asleep–but still not aware–and the attentive anesthesiologist can give additional medication to keep the patient comfortable. For less involved procedures performed in the office, muscle relaxants are not required and can make awareness less likely to occur.

Another problem is that anesthesia and surgical teams are made to look unprepared. In fact, teams are typically prepared well in advance and communication is of critical importance. The preoperative evaluation is usually performed by the anesthesiologist prior to entering the operating room to, among other things, ensure that chronic conditions are optimally controlled prior to surgery, tailor an anesthesia plan, explain risks, obtain informed consent, and answer questions. The anesthesiologist also performs airway management, maintains life support, administers pain control, and manages the post-operative course.

The anesthesiologist is Dr. Larry Lupin (Christopher McDonald) and is shown drinking from a flask during a break. Substance use among physicians is wholly unacceptable just as it is in most professions. Within the profession, there is a responsibility to confront physicians who are impaired, and the consequences they face are severe, including loss of privileges to administer anesthesia, disciplinary actions by a medical board, criminal charges, and reporting to the National Practitioner Data Bank (NPDB).

Even in the absence of substance abuse, anesthesiologists are taught early on in their careers to adhere to the American Society of Anesthesiologists’ motto, which is “vigilance”. In order to address the needs of the patient while he or she is asleep, the anesthesiologist must also be continuously present, which means not leaving the room without another person assuming care of the patient. An exception that was not clearly noted in the film is cardiac surgery when a perfusionist has the patient on cardiopulmonary bypass, where the patient is being maintained on a pump. In such a case, the anesthesiologist may leave the room, but the patient was not on bypass when Dr. Lupin left the room. A perfusionist and this medical device are not used in outpatient surgery.

Anesthesiologists are also responsible for administering cardiopulmonary resuscitation (CPR) during an emergency, such as the one that occurred near the end of the film when Mr. Beresford’s mother (Lena Olin) overdoses on medication. Techniques that could be performed in such an instance includes supplementation of oxygen, insertion of an endotracheal, or breathing, tube, compression of the chest, and administration of life-saving medications.

My answer to my patients’ question of encountering awareness is very unlikely. There are other things that can be said about this movie but commenting on them falls outside our scope of practice.

References

1. Barash P, Cullen B, Stoelting R, et al., eds. Clinical Anesthesia. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

2. Hughes PH, Brandenburg N, Baldwin DC, Jr., et al: Prevalence of substance use among US physicians. JAMA 1992; 267: 2333.

3. Miller RD, Eriksson LI, Fleisher L, et al., eds. Miller’s Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone.

4. Ontario’s Anesthesiologists (2007-11-30). “Ontario’s Anesthesiologists Criticize the Film Awake”. CNW Group. Retrieved 2014-10-06.

5. Sandin RH, Enlund G, Samuelsson P, et al: Awareness during anaesthesia: A prospective case study. Lancet 2000; 355: 707.

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We are physician anesthesiologists (medical doctor / MD) who provide anesthesia to individuals with a phobia, fear, and anxiety for outpatient procedures in fields such as dermatology, plastic surgery, gastroenterology (upper gastrointestinal endoscopy, esophagogastroduodenoscopy, EGD, colonoscopy, otolaryngology (ear, nose, throat / ENT), and dentistry (deep cleaning, implant, all-on-four, root canal, and wisdom teeth extraction).

We provide various levels of anesthesia–from monitored anesthesia care (MAC) to general anesthesia. MAC is often used interchangeably with conscious sedation and twilight anesthesia. As it relates to dentistry, it is referred to as sleep dentistry, sedation dentistry, dental anesthesia, and intravenous, or IV, sedation.

We practice in Northern (Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma counties) and Southern (Los Angeles, Orange, San Bernardino, Riverside, Ventura, and San Diego counties) California.

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