She was a vicar's wife in her 50s who had developed a sudden agonising headache. Her general practitioner diagnosed a subarachnoid haemorrhage, which was confirmed by computed tomography. Angiography revealed a right posterior communicating artery aneurysm. She remained well, and because of the risk of re-bleeding we decided to operate as soon as possible. My usual consultant anaesthetist was away on holiday, and a relatively junior (but experienced) registrar standing in. (The level of cover provided when seniors were away had long been a source of contention.)
From the outset conditions were difficult: she was tachycardic; the skull, bone edges, and extradural space bled profusely; the brain bulged. I complained that conditions were suboptimal. Response: a grunt. At last, the bleeding came under control, and the dura slackened sufficiently for us to continue. I feared she had re-bled from her aneurysm. Eventually I was able to expose the aneurysm—it looked angry and red, but had not bled during the procedure. My own registrar commented, somewhat unhelpfully, that it looked about to burst. Fortunately, the dissection of the neck proved easy, and I clipped it uneventfully.
Then, a most remarkable change occurred. The brain, hitherto bulging underneath the frontal lobe retractor, became slack, and the tachycardia disappeared. I mentioned this to the anaesthetist, who muttered something about changing the ventilator. Closure was routine.
After 30 minutes in recovery, the patient had recovered her poise and sense of humour. She said, “Mr Choksey, you seem awfully concerned about me.” I explained that I had had a struggle. She said, “I know.” I asked her how. She said, “I heard all of it—I was awake throughout the operation.” She then went on to describe, in graphic detail, the conversations I had had with the anaesthetist and my registrar's remark that the aneurysm looked about to burst (she prayed it wouldn't). Her account of the operation was lucid, and it was obvious that she had been awake until just after the aneurysm was clipped. She remembered that she could just wriggle her right big toe and hoped that someone would notice. Nobody did.
I contacted her husband, the vicar, and explained what had happened. Although clearly furious, his response was humane. He interviewed both the chief executive and the chairman of the Division of Anaesthesia. The main reason for his wife's awareness during anaesthesia had been that the anaesthetic monitoring equipment was inadequate and that she had been given 100% oxygen, with no anaesthetic gas. Her awareness had been manifest by the difficult operating conditions. She only went off to sleep when the ventilator was changed, accompanied by a sudden improvement in the operating conditions.
The vicar insisted that the hospital install all the anaesthetic equipment required in all the operating theatres to ensure that this could never happen again
Footnotes
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