 So in this episode, I wanted to address a topic that has really been a common concern for patients that I've found when you're talking to them about the anesthesia you're going to give them and you know maybe this is the first time they're having surgery and the first time they're having anesthesia. A lot of people are really concerned about waking up and awareness under anesthesia. So I was able to get a couple of episodes from different popular shows that show in a dramatic way how this could happen to someone and I wanted to go through it with you guys and kind of react and then explain like what was going on and what could be the possible things that as an anesthesiologist you know in that setting you could be looking for or make it or clear to you that this is happening to your patient and what you would do in that situation. So let's take a look. So we're going to watch an episode from Grey's Anatomy that came out a while back that depicted a really scary scenario showing a patient having surgery on her abdomen or her belly and she woke up during the middle of the surgery. That's you know one of the most horrifying situations that could ever happen and people are really nervous about that happening to them before surgery. So let's take a look at what happened in this episode. I'm gonna be able to catch the end of Shepard's big speech. Okay so they're in the OR, the patient's heart rate is picking up Tachycardia. It went up to 150 and they don't know what's going on. Nothing is going on in the surgical field. Everything is fine there. No reason other for her to have a high heart rate. So the patient moved a little bit which is usually not supposed to happen when patients are having surgery. They're supposed to be as still as possible and you ensure that as anesthesiologists by giving them certain drugs that are called paralytics and those things make people not respond to any surgical stimulus. Like there's anything going on in the abdomen specifically it's really important for patients to be really relaxed or paralyzed. So when that patient moved a little bit it was very alarming to them because they're already on alert about something bad going on. So that's when they looked up at the anesthesiologist like sir your job is to keep the patient from moving what's going on. So let's see what else they did after that. She's awake. The patient's awake. This is unreal. Like she's looking left and right. Like how did he not notice that? So I mean I watched that for the first time and I saw like the patient moving looking and like shivering like come on like that's like those those things that happened suddenly I feel like like dude are you paying attention? Like what are you doing? I know he was reading a manual or journal or magazine but like come on the surgeon the resident Gray shouldn't be telling you as an anesthesiologist that the patient's awake you should know this you should have already noticed that. Not judging this very fine actor very I enjoy his work all you know I know this is this is drama this is for tv but like come on like these things they're just made to be like very like interesting for for your viewership but I feel like someone would have already noticed this coming to be if they were paying attention to the patient in any way shape or form. Like yeah. What the hell did you do? What the hell did you do? Get her back to sleep right now. And the patient's awake and she's blaming him. Everything is going to be okay. Just try to agree. And then the surgeon uh Dr. Gray the resident is speaking to the patient telling her everything is going to be okay. Like that's what you're supposed to do as an anesthesiologist. You're supposed to be watching the patient making sure that you're catching any little movement any teeny bits of sign that someone is not deep under anesthesia. So you need to be like very vigilant that's actually like the key term for anesthesia. Personnel is vigilant since this is a moniker for like being an anesthesiologist. Vigilance right? So paying attention. Ms. Wilson we're here to update you on the surgery. We completed your tumor resection. I was able to resect the entire thing off of your abdominal wall. So wait now the first thing they did they sent Meredith and resident to talk to the patient to check on her right? They didn't wait for Meredith to come out and tell them like okay the patient is pissed because the patient woke up during surgery and she remembers everything. They went in there starting to talk to her like didn't even ask the patient like the first thing you do you go into a room when you're checking on patients postoperatively is ask them how are you feeling? No one asks this patient how she's feeling like even if she didn't remember the situation what if she was having pain right now? Like this this is very I'm upset because I'm watching this and I'm just like what kind of doctors are these? Really? How about the part when I woke up on the table? How well did that part go? Where I could smell my own burning flesh? When I was lying there unable to speak well I could actually feel you butchering my insides. I couldn't move I was awake and couldn't move and you had no idea. Okay so there's that the patient literally recalls being awake under anesthesia and recalls clearly things that were happening which honestly speaking I don't think would ever be a reality as far as like her vivid recollection of everything. Usually when patients have surgery most often the next day someone from the anesthesia team either the person who did the anesthetic or a colleague of theirs will go into what we call a post-anesthesia evaluation and this is a time that we would have have found out about the patient's recollection how much she remembered from this situation. This is a really really really rare event so it's really actually a small number in comparison to this general group. I'm going to check the anesthetics themselves. You draw CBC, Kim 18 and let's do some genotyping studies. Oh here's what we do we did you not hear her that girl is traumatized so the only thing we are doing is getting sued. That's what she's worried about. Where do you even get off speaking to me like that? You have no idea what she's like don't touch me. Well here's what I know I know that you're new here I know that you probably still have a chip on your shoulder because your parking space in Mercy West was better and I know that you're an anesthesiologist which means you make buckets of money logging reasonable hours sitting on your behind and flipping through architectural digest while somebody on the other side of the curtain does the real work. So he's going to be ordering some tests a CBC is a test of your blood count actually I don't see how that would help I usually test your amount of blood that you have red blood cells that you have and the amount of white blood cells that you have and the amount of platelets you have so really I don't see how that would help because that usually has no bearing on the effect of anesthesia on a patient maybe only in the extreme cases if someone has a very low blood count they may respond more profoundly to anesthesia you know the blood pressure would drop a lot more than someone who had a higher blood count but then he's going to be checking some genetic studies to you know see if there's a genetic difference which actually has some validity because there are people who are known to be rapid metabolizers of anesthesia and those patients have a different enzyme in their bodies that help them to clear like toxins out of their blood and the same enzymes kind of work on clearing off the anesthesia know the perspective that is being given here is really that of like the anesthesiologist is like just sitting out here getting money and not really doing their job well and causing patients harm and and in this situation this particular doctor did cause the patient harm by not recognizing the signs of this patient getting light or coming out of the anesthesia quicker than is intended and get sued for excuse me you have no idea mercy west but here at sea out of grace we expect to be able to trust the gas man trust him to do his job so that we can do ours we expect the gas man to stay awake at the switch no matter how long and boring a procedure might be we expect the gas man to stay focused enough to keep the patient unconscious what can you say that's truth i mean i totally understood her point of view there because that is our one job as anesthesiologists our one job is to keep the patient safe to be vigilant about any changes in the patient's status and to fix them you know so i feel like this particular scene is truth you know she's angry any surgeon would be angry there have been times where surgeons have become angry at me when a patient has woken up during a procedure and no the patient did not wake up during the procedure maybe their muscles became less relaxed because their bodies metabolized the muscle accent that i gave them quickly you know that's something that we're monitoring every 15 to 30 minutes during a procedure always and you know some people are more quick to metabolize but anyhow you know just that like back and forth between them i really enjoyed watching that because it's like so real because that's kind of how it is sometimes in the or settings you know i think this exchange was a very good one i liked watching it um leslie hi uh this will only take a moment we just need to examine and take your care i don't want you to touch me well leslie i mean don't let her touch so this you know your patient was traumatized she told you clearly that she remembered everything and she felt everything and no one not one of them said i'm sorry not one not one of them explained to her what possibly could have happened you know nothing no explanation of any sort you need to you need to face the music you need to address this problem and that is something that you're taught in medical school hurts on a deep level for me because that's not how i practice and i would never want to you know be in that position you know whereas something happened to me and you know my doctors didn't show any remorse i remember i remember you screaming and sergeant you were panicking she's getting techie heartic man it came with their hand inside my body so clearly um you know this patient is not doing well and she remembers the whole scene with the surgeon you know screaming and being you know panicked about the situation showing again her vital signs are elevating you know she's easily stressed she responds very rapidly to the stress by you know hyperventilating or breathing fast becoming tachycardic again the same phrase used before her heart rate is elevated and then now she's bleeding from her incision her body responds to stress in a very dramatic way so that was also happening to her even under the depths of general anesthesia you know this is kind of like reiterated here and i like that they did that she doesn't want dr bailey touching her i understand and um in that situation dr bailey you know kind of steps back from the patient because you're never to touch a patient without their consent that's actually considered as assault in medicine um you know you can physically assault a patient if you're doing something to them without their consent and that patient is considered a competent individual the gas man would like an apology what leslie wilson's cytochrome p450 results so just to kind of like explain what does that mean cytochrome p450 basically cytochromes are enzymes in the liver right so the liver is responsible very much responsible for its eliminating toxins or things that may be harmful to the body anything that's ingested when you eat goes through the liver and the liver kind of checks it out and is like okay this is good it's not good so it also helps with digestion but it mostly rids the body of like toxins or things that are harmful one of the enzyme families is the cytochrome p450 and those enzymes and enzymes are things that kind of like chew up again the toxins break things down one of those enzymes also breaks down drugs that we give in anesthesia so this patient has something going on with that the type she has means she metabolizes anesthetic drugs too fast there's no way we could have known that before surgery so this is why she woke up it is she's gonna need a second surgery her incision site won't stop bleeding she might have internal bleeding okay it's not gonna be easy but now i know how to keep her under she won't let me touch her uh-oh so i wouldn't let you touch me either um Dr. Bailey because you came in here and you never addressed the issue it's great that they found out the reason why she woke up so quickly i'm thinking you know with his knowledge of her being a rapid metabolizer he can actually monitor her anesthetic depth a little bit more closely with um we have additional monitors that we can put on patients to kind of help us understand a pattern or the levels of anesthesia that we're giving them the pattern of their depth it's called a bis monitor it's a bispectral index but basically they check to see like if someone has irregular patterns in their brain waves while they're awake and also while they're sleeping we can also use it figure out kind of a general idea of how deep a patient is under anesthesia i'm good with patients this is true she is they always trust me at i'm never she wasn't good with this patient she won't let me touch her okay okay just check their nostomosis so the first part of that scene the patient is wearing a sticker that goes across her forehead and ends on her temple and that is the bis monitor the bispectral index moses and keep going everything's still good bp stable bis levels 45 like i said just like the last time you asked two minutes ago so she keeps checking in with anesthesiologists to make sure that everything is okay um i think i don't ever get offended by that you know when that happens in the or and i'm you know taking care of the patient if the surgeon is constantly asking me how are things looking up there you know how's it looking up there i think that is great you know as a surgeon you should always be conscious of everything that's going on your patient is a person not just the body part that you're working on and i like and i actually really appreciate when i'm asked this question anastomosis looks clean bowels intact could get a new mesh oh and uh so you know i don't read architectural digested i was a journal of clinical anesthesia in case you're wondering i wasn't ready for ready for the mesh please i'm educating myself i actually don't like the sitting down part of my jobs not great for the back you know and uh i like to keep in shape so i can lift my big buckets of money so in that moment she was addressing you know all those accusations she made earlier he's retorting back to her that look i'm actually reading to get education on anesthesia while i'm in the or which is a great use of time if your patient is completely stable however um you know she'll always be primarily focusing on watching your patient watching the monitor responding to any changes now i kind of like the analogy of delivering anesthesia to driving a car right we know usually when we get in a car the things that we do there's a bit of muscle memory you know brake stop accelerate you know slow down before you turn kind of thing and your car usually responds appropriately and you know that your car is going to be relied upon same thing kind of goes on in the or like you have your anesthesia machine your ventilator you check everything as i showed you guys in a previous video and you can check that video out like how to watch out for things that could go wrong and how to check your equipment before you deliver anesthesia so you expect things to go a certain way however you need to pay attention to like your check engine light or like you know smoke coming out of a muffler if you're driving a gas car like things that are like out of the ordinary that are going on so again when you're giving anesthesia yes you have your muscle memory you're used to the monitor sounding a certain way the tone beeping a certain way with the pulse oximeter and that's telling you about your patient's oxygen level and their heart rate you're used to hearing that used to hearing a certain tone when those things go wrong you need to pay attention to it just like you would go to get your car checked out duck i yell when she woke up it was one of the scariest moments in my life so i yelled and then i yelled some more that's what i do that's what she does what is that apology close this thing you're gonna get basically that's also like like be real so i think you know in the moment right before that video segment cut in you know he made aware that you know as a chief you know the chief of surgery it's really important for you to come through and talk to your patient and discuss with them you know when things go wrong and apologize when you apologize to patients in the setting of things going wrong if that's the first thing that you do there's a lower likelihood that the patient will bring a lawsuit against you and not that we're all practicing to try to protect ourselves from lawsuits but you know it is part of the job it's a part of being a doctor in america potential for getting sued and malpractice you always just want to think about how that patient would feel in the moment and again the empathy part of being a physician like and i think that that's something that should be first and foremost like the medicine secondary like how your patient feels and what they're going through in that moment is like the most important thing that you need to consider when you're treating anyone for any reason so with that i just want to say thank you guys so much for watching and i hope you guys like and subscribe to my channel and i will see you again on the next upcoming episode of 3 anesthesia and me see ya