anesthesia awareness

Kathleen Labrie woke up to hear her surgeon talking about his new car.

She might have taken an interest under different circumstances, perhaps even joined the conversation, but Labrie couldn't move a muscle or make a sound. She couldn't open her eyes to see.

She could, however, feel and hear everything happening to her at the time, the Nashua woman says.

Exactly what was happening, and at what time, remains a point of dispute between Labrie and her anesthesiologist. Labrie says she was paralyzed, yet conscious and in pain, while a surgeon operated on her sinuses, and that the experience left her traumatized.

Her anesthesiologist, Dr. Bharat Karajgi, and his lawyers argued Labrie remained fully sedated during surgery and began to come around while her doctor was checking her afterward.

Labrie sued, and a jury at Hillsborough County Superior Court heard eight days of arguments and testimony in August before deciding in favor of Karajgi.

The experience Labrie says she suffered is a rare but well-documented risk of surgery. Studies suggest it happens to one to two of every 1,000 patients who undergo general anesthesia.

Researchers at the University of Washington in Seattle are compiling a registry of people who have experienced it in hopes of learning more about the phenomenon.

"Anesthesia awareness, also called unintended intraoperative awareness, occurs under general anesthesia when a patient becomes cognizant of some or all events during surgery or a procedure, and has direct recall of those events," states an article from the Joint Commission on Accreditation in Healthcare Organizations.

"Because of the routine use of neuromuscular blocking agents (also called paralytics) during general anesthesia, the patient is often unable to communicate with the surgical team if this occurs."

"Awareness with recall after general anesthesia is an infrequent, but well described, phenomenon that may result in posttraumatic stress disorder," states the summary of a study published in the Anesthesia & Analgesia journal.

That study concluded Anesthesia awareness happens to about .13 percent of patients who undergo general anesthesia, or about 26,000 people each year in the United States.

"It's a problem that not many people know about, but it happens all the time," said Labrie's husband, Romeo Labrie.

Proving it happened in a particular case is another matter, however. Labrie charged she was traumatized by her experience, and experts agreed she suffers from Post Traumatic Stress Disorder. In the end, however, jurors apparently weren't persuaded by Labrie's recollections of an experience that took place, literally, all in her head.

An 'eternity'

Undergoing surgery without the benefits of anesthesia sounds like something out of a horror film. Labrie said it's worse.

"Nobody can imagine what it's like, not being able to move and in that much pain," Labrie said. "I was hurting, and I was scared and I couldn't do anything."

Labrie's doctor had recommended surgery because of frequent, almost chronic sinus infections, she said. The doctor proposed to fix her deviated septum and ream out her sinus passages.

It seemed like a good idea at the time, Labrie said. She had insurance to cover the cost, and she was tired of repeated trips to physicians and pharmacies.

"I was living at the doctors'," she said.

Her surgery was scheduled and took place Jan. 14, 2002, at the outpatient surgical center at St. Joseph Hospital. Karajgi met with Labrie beforehand to explain the anesthesia, she said. It all seemed routine, and she signed a consent form. She was brought to the operating room and given an intravenous line.

"I was put to sleep," she said. "The next thing that I was aware of was my surgeon talking to the nurses."

"I could hear, word for word, what was being said," she said, adding later, "The surgeon was talking about a new car he'd just gotten; it was a green Subaru."

All the while, the surgeon was doing something inside the right side of her sinus passages. It hurt tremendously, she said.

"I heard talking, and then I could feel the pain," Labrie said. "I tried to talk, but I had a tube down my throat. I tried to open my eyes, but I couldn't."

"When he was widening the passage, I could feel it. . . . I could feel whatever it was, the scraping."

The experience was confusing, on top of terrifying and excruciating, Labrie said. She could feel her hands, arms and legs, but she couldn't move. She could sense her eyes, but couldn't open them or see. She could feel everything � the surgeon's tool, the tube down her throat � but she couldn't respond. Struggling to make sense of her situation at the time, Labrie said she concluded she was dead or dying.

"I thought, 'They've given up, and I'm dying. Why am I dying so slowly? Why am I in this much pain?' " Labrie said. "Waking up and hearing people talk, but not being able to move, I really believed I was dead.

"There's nothing you can do. Everything was black. . . . Nobody could see me move."
Labrie can't say how long the experience lasted, she said.

"It seemed like eternity," she said.

Timing in dispute

Labrie is mistaken, said Karajgi's lawyer, Mark Attorri of Manchester. Karajgi accepts Labrie's account of what she perceived, but disputes her conclusions, Attorri said.

"Our position at trial was that Mrs. Labrie was not awake during her surgery. She may have honestly believed that she was awake, but she wasn't," Attorri said. "We didn't challenge her sincerity at all. The defense didn't claim that she was lying or that it was made up or fabricated."

Karajgi was with Labrie during the operation and afterward as she began to recover, and an anesthesia expert, Dr. Stephen Cohen of Beth Israel Deaconess Medical Center, testified he did everything right, Attorri said.

"He gave good care," Attorri said. "If his own mother had been on the operating table, he would not a have done anything differently."

"He feels nothing but compassion for Mrs. Labrie and wishes her well," Attorri added later.

ON THE NET
Information on Anesthesia awareness.

Anesthesia Awareness Registry

Anesthesia Awareness campaign


Based on Labrie's description of what she heard and felt, Attorri argued her experience was the result of regaining conscious after the operation. For instance, Labrie remembers hearing a nurse remark on her nail polish, but her arms and hands were underneath a surgical drapery during the operation, Attorri said.

Labrie said she heard the surgeon say, "I'm going to pack her now," and then, "I'm going to get a quick lunch and then I'll be back to check on her." Attorri argued those remarks indicate the operation was over, although Labrie counters she had been aware and awake for some time beforehand.

Labrie remembers feeling the tube down her throat, but it's normal for the tube to remain in place until patients can breathe and cough on their own so they don't choke, Attorri said, and it's common for people to be aware of the ventilation tube.

"The patient can't be extubated until they can protect their own airway," he said. "It's unpleasant, but it's not unexpected."

Labrie's surgeon testified he used instruments to check inside Labrie's nostrils while she was in recovery, and Attorri argued that is what she felt, and assumed to be part of the operation, in her post-operative state.

"The things that she said she heard and felt didn't happen while she was under general anesthesia," but later, after the operation was over, Attorri said. "That is, of course, when patients are supposed to be regaining consciousness."

Could it happen?

Labrie said she opened her eyes as soon as she was able. Her husband was with her, waiting for her to come around. She told him what had happened, that she'd been awake during the surgery, and her husband told a nurse, but it didn't go any further, Labrie said.

The nurse made a note documenting Labrie's complaint, court records show, but the nurse later testified she never told Karajgi about it, even after Labrie repeated her complaint as she was leaving the hospital.

Labrie said she was disinclined to make a fuss at the time, however.

"After I was fully awake, I just wanted to get out of there," she said. "I told them I was fine. . . . All I kept thinking was, 'OK, I must be alive, I want to get out of here.' "

Karajgi offered to meet with Labrie after learning what had happened, but she declined. Labrie had already seen her own doctor and had been referred to therapy, she said.

Labrie filed her lawsuit three years after the operation, in January 2005. Her suit named Karajgi and his partnership, and the SurgiCenter, the outpatient surgery department at St. Joseph Hospital. Judge William Groff later dismissed Labrie's claims against the hospital, however, ruling she couldn't show that the hospital was responsible for any harm she'd suffered.

By the time her case came to trial in August, the court's files on her case stacked up to nearly 7 inches thick. Both sides hired anesthesia experts to testify, and both sides were able to review Labrie's medical records from the surgery and virtually every other treatment she'd ever received.

Karajgi testified about the treatment he administered to Labrie before, during and after the operation, and the two anesthesia expert's opinions about it differed only slightly. Karajgi's expert, Cohen, said it was possible � though highly unlikely � that Labrie could have become conscious despite the anesthesia.

"There's no dispute at all that anesthesia awareness does occur," Attorri said. "The studies indicate that it occurs in 0.1 to 0.2 percent of cases."

However, he added, "Most patients who experience intraoperative awareness do not experience pain."

In addition to the sedative and paralytic drugs, Labrie received strong local anesthetics, he said.

"Even if Mrs. Labrie had been awake, it would have been unlikely for her to have experienced the sort of extreme pain that was alleged," Attorri said. However, he added, "Pain is a very subjective thing."

Labrie's expert, Dr. Albert Ferrari of Mount Holly, N.J., testified it would have been impossible for Labrie to be awake, given the levels of anesthesia Karajgi said he administered. Ferrari nonetheless believed Labrie did wake up.

"Awareness during anesthesia is a rare complication," Ferrari wrote in a report on the case. "Of particular concern are patients who are aware, feeling pain, and paralyzed. This is a particularly traumatizing situation. This is what Mrs. Labrie experienced."

Ferrari had an idea of how and why it could have happened, but Groff didn't allow him to share his speculations with the jury. Ferrari opined that "more likely than not" the vaporizer delivering the anesthesia ran dry during surgery.

Although Karajgi's medical records showed the treatment he believes he administered, evidence that could have confirmed it was lost. The equipment used to deliver the anesthesia can create printouts showing the type and amount of drugs being given at each moment. Those readings aren't routinely retrieved, however, Attorri said.

No one told Karajgi of Labrie's complaints after the operation, and no one printed out or saved the records that would have shown the actual levels of anesthesia administered during the operation.

Not faking

Labrie has been diagnosed with Post Traumatic Stress Disorder, and expert witnesses for both sides agreed she isn't faking.

One of Labrie's witnesses, psychiatrist Bessel van der Kolk of Massachusetts, opined that "waking up and being consciously aware while undergoing surgery is one of the worst experiences that a person can have, and if not treated properly, frequently results in PTSD and other psychological problems."

While van der Kolk took the PTSD as evidence of anesthesia awareness, however, Karajgi and his expert argued that was a false assumption. Karajgi cited Labrie's medical history to argue that other factors, including a previous car crash, may have caused her PTSD.

"You can't reason backwards from the syndrome to prove that a trauma must have happened," Attorri said.

"Dr. Karajgi did not dispute the sincerity of Mrs. Labrie's psychiatric injuries. What we disputed was how they were caused. There were other things in Mrs. Labrie's life that could explain her psychiatric symptoms."

Karajgi's medical background was less of an issue at trial. Karajgi has been practicing medicine for more than 25 years in the United States, and until Labrie's case, he had never been sued, Attorri said. His successful record had no bearing on what happened in Labrie's case, however, so jurors didn't get to hear of it.

Similarly, jurors didn't hear of Karajgi's repeated attempts to become certified by the American Board of Anesthesiology. Karajgi testified during a deposition before trial that he has taken the written examination "year after year," for more than 20 years, but has yet to pass.

"Whether Dr. Karajgi failed the examination for board certification numerous times is not relevant to whether he exercised the required standard of care in this matter," Groff ruled.

New Hampshire has allowed Certified Registered Nurse Anesthetists to handle anesthesia during surgeries since 1991, according to the American Association of Nurse Anesthetists. Karajgi is a doctor � an anesthesiologist � if not board certified.

"Dr. Karajgi was more than qualified," Attorri said.

Ultimately, Labrie said she believes jurors were swayed by Karajgi's testimony and the records of his treatment. All she had to offer was her recollections of an event that she alone experienced.

"It was my word against his," she said. "He had more evidence. He had more proof."

Labrie said she has been unable to return to work since the surgery. She and her husband said the lawsuit, medical expenses and lack of income have hurt them. Labrie has been getting therapy, but said she still struggles with PTSD. She and her husband said she has been hospitalized five times for suicidal impulses.

"Before this happened," Romeo Labrie said, "you might say it was night and day. Our whole life changed in an hour or two. We were always the types that were very active . . . always on the go, always doing something."

The couple used to enjoy bicycling, hiking, cookouts and socializing, he said, but they don't get out anymore.

"Kathy just kind of regressed more and more. . . . It got to the point where we wouldn't go out of the house," he said. "She really didn't want to be around people."

Researching the phenomenon and getting in touch with other people who've experienced it has helped, the Labries said. Kathleen Labrie has talked extensively with Carol Weihrer, a Reston, Va., woman who started a Web site to campaign for awareness and prevention of Anesthesia awareness, she said.

She has learned, for instance, that there are devices, including one made by a Massachusetts company, Aspect Medical Systems of Norwood, that can be used to monitor brain waves and detect awareness during anesthesia. The technology is promising, but not proven, Attorri said. Hospitals don't always use them, but patients can ask, Labrie said.

"I know what happened, and I know how it has changed my life and my family's life," she said. "I may not have won my lawsuit, but I'm going to fight to get the word out. . . . People have to know about this."

"Hospitals do a lot of nice things for a lot of people," Romeo Labrie said, "but they need to find a better way to treat people when something goes wrong."