Abstract
Theresa is a lady with brittle asthma. She presented to the Emergency Department (ED) with an asthma attack and was rapidly intubated and ventilated. From subsequent blood gas results, ventilator pressures and a chest X-ray it soon became clear that she did require ventilation to be continued. The ICU consultant requested she be ventilated until the relaxant wore off and she was subsequently extubated in the ED. Unfortunately she was fully aware for the time she was ventilated. This is her story.
Keywords: awareness, anaesthesia, asthma, intensive care, post-traumatic stress disorders
Case report
Theresa is a lady with brittle asthma. She presented to the emergency department (ED) with an asthma attack and was rapidly intubated and ventilated. From subsequent blood gas results, ventilator pressures and a chest X-ray, it soon became clear that she did not require ventilation to be continued. The intensive care unit (ICU) consultant requested she be ventilated until the relaxant wore off and she was subsequently extubated in the ED. Unfortunately, she was fully aware for the time she was ventilated. This is her story.
My name is Theresa I am a nurse and a human being. I have three grown up children and nine grandchildren. I am a daughter, sister, niece and cousin. This does not include my partner and best friend.
I was admitted to the resuscitation area of the Emergency Department suffering from an acute asthma attack. I was given various medications in an attempt to bring my symptoms under control. The decision was made that I needed an anaesthetic to manage my breathing as at that time nothing appeared to be helping.
It was only a short time after been given the anaesthetic that I became aware that things had gone badly wrong. I could hear people around me and in the next cubicle. I became terrified thinking that I had died. That was traumatic enough but what came next was complete devastation; the thought that I would never be able to hold or kiss my children again. This was the worst thing in my world. These three people are my life.
I know now I had been given paralysing drugs so I could not move. However because I could not move I thought that I was in the metal box that the porters take to the mortuary. There was a lovely outreach nurse who was with me throughout this whole time and she was stroking my hand. I was trying with all the power I could muster to make my hand or even a finger move with no result. My eyes were taped shut. I tried to move an eye lash or eye brow but nothing would move. I thought ‘Dead bodies don’t move’.
Your brain is a great tool but it can also be a scary place when it makes up stories to fit in with what one hears around oneself. I heard someone say ‘If they find out about this I will be in trouble’. This brought another wave of fear and then dread because as this was said a heat rose from my feet to my head slowly, very slowly, and I thought that I was being put into an oven. I had had enough by this point and I willed my brain to die because I thought that I was drowning, although I could hear the oxygen going into my lungs. I did not want to be left locked in my brain. There is only so much our brains can deal with.
When I was extubated, I at once became very tearful and kept saying almost to anyone that would listen that I had been awake but at that point everyone left me alone. Of course why would anyone stay with a dead body or do observations on a dead body? For about ten minutes I relived the fear that I was dead. In fact I was given midazolam just prior to being extubated so there is a time window of about another hour that I have no recollection of. I was later informed by my daughter that I had tried to phone my dad, my son and finally my daughter in law. I must have been speaking nonsense. All my daughter in law could glean from our conversation was that they had put me to sleep. She then called my daughter (at around 2.00 am) who was told when she phoned the hospital that I was very sick but was OK now. I cannot emphasise enough how much the harm would have been reduced by having my family around me at this very traumatic time.
While in the ED resuscitation bay a doctor came and told me that she knew what had happened and that she was going to take me somewhere safe (the acute medical unit). It was the next day when my children arrived. They became very angry and demanded to see a doctor. The ICU consultant on duty came but he was not involved in the events of the previous evening and could not offer much help. My children live with the guilt of not coming to the hospital that night especially my daughter who, even now a year or so on, is struggling to cope with the guilt. There is also a ripple effect on friends and family, I am the centre and as the ripples move out you have my children, grandchildren, parents, siblings, then aunts and uncles, then friends. All of these people have been affected in one way or another by what happened to me. My parents and friends worry about me all the time, my sister and brother panic, my friends are watching me all the time.
I did not meet with the ICU consultant involved until three whole days after the incident. At this time no one had really acknowledged what had happened. I felt that they did not believe me and that I was going mad. The rational, fun loving person that I was prior to this had become a quivering, crying wreck; in fact a person that I did not recognise as me. I do feel that at this time I should have had some psychological input and medication that would have reduced the harm which continued after leaving hospital. I became suicidal and could not live with this new person who I did not recognise as me or with the harrowing night terrors and day terrors that I was now suffering.
Now, looking back I can see there was good and bad practice and I would like to finish this on a good note as I feel it is important and will give understanding to how I have got to where I am today.
When I did finally meet the duty ICU consultant, he sat with me for a long time listening to me recount the thoughts and feelings and was visibly very upset. At last someone understood what I was trying to say. WOW, this felt good. He validated everything I was experiencing and most of all he apologised to me. He put me in touch with an ITU sister who became my rock in the early days. She also listened to me and cried with me as a mother and gave good constructive advice. She explained that if someone made a mistake that they would cover their tracks so the feeling that I was being put in an oven was not the thought of a mad woman but of a person who would naturally deduce this. Both gave me their mobile numbers so that on discharge if I had any problems I could call them and I did.
I was then put in touch with a gentleman who had spent many weeks in ITU and had experienced similar problems as myself. It was great to talk to someone whose thoughts at times had seemed worse than my own. I was also referred to the PTSD team and they have helped me to file the incident away but I don’t think that you ever really get over something like this; I think you just learn your own ways of coping. I still have mild memory problems which manifest as not being able to remember simple words and at times my grammar is not too good. I still cannot go into the resuscitation area of the ED but I hope with time and work this hurdle will be overcome. I will never be me again but I hope I can make what happened to me a point of learning for others; if I can save just one person from having my experience then I am better for it.
Discussion
The National Audit Project 5 (NAP5) published in 2014 examined 308 cases of accidental awareness but only 7 of these originated from the ICU.1 The report acknowledged the numbers were small (ICU/ED accounted for 1% of the anaesthetics given and 2.3% of the cases of awareness). Nevertheless, these data suggest awareness to be more common in the ICU setting than in theatre and that more research into this area is needed. NAP5 commented that florid cases of awareness as described by Theresa are the tip of the iceberg in intensive care since they rely on patients volunteering that they had experienced awareness. However, in patients who are on the ICU for many days or weeks, episodes of awareness may occur long before the patient finally recovers. Memory of such events will therefore be incomplete and not be recognised for what they are. Most powerfully the report gave patient accounts of what they had experienced whilst being aware and highlighted a number of risk factors. Theresa’s case illustrates many of these features, how the awareness arose, how it was subsequently managed and how this impacted on her recovery.
Induction was performed using a rapid sequence induction with propofol and rocuronium. This was performed skilfully by the anaesthetic trainee and Theresa did not remember the intubation. However, she was not obtunded prior to induction and was subsequently maintained with a single agent (a propofol infusion at about 50 mg/h). Midazolam was only given towards the end. The reliance on a low-dose fixed-rate propofol infusion without opiates occurred in a number of the cases reported to NAP5, and awareness also occurred in patients who were obtunded prior to intubation. NAP5 emphasised the importance of giving adequate anaesthesia to all patients, supporting the blood pressure if necessary by using vasopressors rather than giving low doses of anaesthetic agents. Human factors also played a major part. There was inadequate communication between the ED and ICU consultants both before the intubation and in her subsequent management in the ED. The trainee anaesthetist looking after Theresa was left unsupported as the ICU consultant had been urgently called elsewhere. There was also no guidance available in the department to guide the trainee how to sedate ventilated patients in the ED, as is now recommended by NAP5, nor is there an anaesthetic machine with vaporisers available in ED.
Theresa’s experience is similar to those described in the report with feelings of terror and being convinced she had died. She reported paralysis without pain (Michigan 4D) and suffered severe psychological sequelae. There was a significant delay before the duty consultant became aware of what had happened which increased the risk of post-traumatic stress. Once the relevant staff became aware of the problem management was in line with that recommended by NAP5, but Theresa herself notes that the delay significantly increased her stress and that of her family. Of relevance, NAP5 notes that
In several cases, early support and empathy after the occurrence of accidental awareness appeared to influence the nature of longer-term reactions. In contrast, in a minority of cases patients were reported to have become angry or upset by an apparently unsupportive reaction by staff and in some cases this engendered greater unhappiness than the actual experience. (NAP5 para 7.53)
Support for staff involved after the event is also important, although in this case it was not formalised and relied on existing mentoring arrangements. A root cause analysis was undertaken by a senior anaesthetist. This identified the human factors above and made similar recommendations to NAP5. The report was shared with Theresa who was very much in favour of a checklist, similar to the intubation checklist of NAP4, which is routinely used in our ED. This could detail, amongst other things, how to continue sedation and undertake safe transfer.
In summary, a patient has described her experiences of awareness and the sequelae after she was ventilated for an asthma attack. The case is typical of the severe ones described in NAP5. It highlights the importance of guidance to prevent awareness, and of early recognition and prompt action if it occurs. For many staff a patient describing their experience of awareness is a very powerful learning tool, and far more memorable than figures and facts. We hope that this case report will ago some way to fulfilling Theresa’s wish and help prevent further cases of this avoidable and potentially devastating iatrogenic complication.