Films, facts and fiction
2008; Wiley; Volume: 63; Issue: 7 Linguagem: Inglês
10.1111/j.1365-2044.2008.05586.x
ISSN1365-2044
Autores Tópico(s)Intensive Care Unit Cognitive Disorders
ResumoA movie depicting awareness during anaesthesia was recently released in the UK [1] and has elicited coverage from the media and reaction from some anaesthesia organisations. Contrary to the synopsis described on the movie website, this was not a ‘psychological thriller about a common occurrence called anaesthesia awareness’; it was a predictable murder mystery with a pointless subplot about the hero being awake whilst having a heart transplant [2]. Along practically identical lines, a short film called ‘Anesthesia’ won best Student Film at the San Fernando Valley International Film Festival in 2006 [3]. A woman who is wheeled into a surgery room for heart surgery is supposedly given anaesthesia, but although she is paralysed she remains awake and able to feel everything. Tension in the film mounts quickly as the surgeons get closer and closer to operating. The tag line of the film was ‘Try to remember it’s only a movie’… When ‘Awake’ was released in the UK, Radio 4’s ‘Today’ programme and ITV’s ‘This Morning’ carried emotive interviews with two women who had experienced awareness during Caesarean section – events which had occurred 20 and 38 years ago and the Times published an article called ‘Awake under the knife’ [4]. These were clearly harrowing experiences, with long-term psychological sequelae, and also frightening to listen to for those about to undergo surgery under general anaesthesia. There are many other equally disturbing accounts of similar experiences available on the internet and self help organisations such as Anaesthetic Awareness Network UK and Ireland and Anesthesia Awareness Inc., in the USA provide further access to media coverage and anecdotal testimonies. The Anaesthesia Awareness Network in the UK has information for patients worried about awareness provided by a psychologist, Professor Michael Wang [5]. He says that the incidence of awareness is one in 600 and that there is a higher risk in longer operations. There have been many studies of awareness during general anaesthesia but the incidence figures cited vary widely. The figures appearing at the start of the movie ‘Awake’ are ‘21 million surgeries and 30 000 episodes of awareness’, which is 0.14%. The usual overall incidence quoted comes from a study where 25 awareness cases among 19 575 patients were found at a rate of 1–2 cases per 1000 patients at each of seven sites, giving an overall incidence of 0.13% [6]. However, another study from the USA last year reported only six instances of awareness from a total of over 87 000 patients, across eight sites, giving an awareness incidence of only one per 14 560 patients [7]. Awareness in children may occur more frequently than in adults [8]. An increased risk of recall after surgery for trauma was reported in a study from 25 years ago with 6/51 patients having recall [9]. Cardiac surgery has also been associated with a higher risk of awareness, although recent studies quote incidences of only 0.3% and 0.5% [10, 11]. In a study of 3000 patients undergoing emergency Caesarean section under general anaesthesia, the incidence of awareness was 0.4% [12]. The video sharing site ‘YouTube’ has 3.9% of the share of internet visits a day worldwide and claims an incredible 4 million video plays per day. One video clip shows Dr Richard O’Leary, an American anesthesiologist, saying ruefully that ‘“Awake” has done for anaesthesiology what “Jaws” did for swimming in the ocean’ [13]. In fact, the American Association of Anesthesiologists was so concerned that the movie ‘Awake’ would generate a significant amount of adverse publicity for anaesthetists and anxiety and apprehension on the part of patients, that they produced a pamphlet on awareness, notified their members and put their own video on YouTube [14]. They have taken the reassuring approach, advising that awareness is ‘quite rare’ and state: ‘Patient awareness occurs very infrequently. This remote possibility should not deter you from having surgery’. The self-help organisation Anesthesia Awareness Inc. [15] clearly has little common ground with the American Society of Anesthesiologists, replying ‘“Rare” is a word viewed differently by different people. Is 100–200 cases per day (not including the unreported cases) of anaesthesia awareness in the US alone “rare?” Is 20 000–40 000 times per year in the US “rare?” Is the occurrence of anaesthesia awareness being about equal with auto accident deaths “rare?”’ Again it is not clear where these figures are from. The Australian Society of Anaesthetists in turn issued a members’ statement in anticipation of the release of ‘Awake’ in Australia [16]. Again the patient information leaflet, entitled ‘The facts about anaesthesia awareness’, contains no actual facts, although the Australians are more up front about higher risk situations. Ontario’s Anaesthesiologists in Canada issued a lengthy media release claiming that the film distorted the facts relating to anaesthesia awareness in an irresponsible manner and went on to list the inaccuracies in the movie in detail [17]. They said ‘The movie presented an anaesthesiologist who was inattentive and intoxicated. This would obviously not be an acceptable level of care in Ontario hospitals’. The Royal College of Anaesthetists launched their patient information leaflet about awareness risks long before ‘Awake’ came along [18]. It states that one or two people per thousand experience some degree of awareness, but only a third of these feel pain. The leaflet then goes on to tell patients that the risk for Caesarean section is four in 1000; for cardiac surgery one in 100 whilst those undergoing emergency surgery for major trauma have a one in 20 risk of being aware. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) does not have its own specific information on awareness for patients; a tab on their website entitled ‘Patient Info’ has a link ‘Your anaesthetic’ and takes you the Royal College's patient information webpages, to which the AAGBI contributed. However, specific information on awareness is found only in the patient information leaflet described above [18], without reference to the AAGBI. AAGBI did issue a position statement about the time that ‘Awake’ was released in the USA, which addresses the issue of awareness and reiterates the professionalism and training of anaesthetists in the UK [19]. If this article is intended for patients it is hard to find and the cited risk of awareness given (one in 10 000) is at odds with information provided via the Royal College of Anaesthetists’ website. Public perception of anaesthetists has been consistently shown to be distorted and ‘Awake’ will have done little to improve confidence in anaesthesia in general. Previous reports from several countries have shown that the public generally do not know very much about anaesthesia and anaesthetists, with only around half of people surveyed even knowing that anaesthetists were medically qualified [20–23]. Movies with anaesthetists in key roles are few and far between and, although medical drama is popular on television, accurate portrayal of anaesthetists is limited [24]. Surveys have revealed that many members of the public get information about medicine from the media and the internet. Many of the video clips available on-line depict anaesthesia and anaesthetists in ways which are at best flippant and at worst, inaccurate, unprofessional and sensationalised. For example, the Amateur Transplants, a pair of tuneless singing doctors, are undeniably funny, but their song ‘Blips of the Heart’– to the tune of Bonnie Tyler’s ‘Total Eclipse of the Heart’ has lyrics which would not exactly convince a would-be patient that anaesthetists are fully trained doctors with a wealth of skills and unquestionable professionalism [25]. Many people who have watched ‘Awake’ will assume that the film is true to real life since it appears realistic enough, although several facts are distorted and there are inaccuracies. ‘Awake’ will have made large numbers of patients justifiably concerned, although the incidence of awareness is variable and most patients are at low risk. Anaesthetists may well be faced with very worried patients as a result of the movie itself and the associated media coverage and it may be helpful to be aware (pardon the pun) of what information is available to patients. Do most anaesthetists know exactly what figures about awareness are freely available to patients? It should be noted that there is no evidence that discussion about awareness before surgery leads to a increase in the numbers of reports of actual awareness events. The movie ‘Awake’ may have done little for the public perception of anaesthetists and will certainly have raised fear levels, but it has at least highlighted the issue of what patients are told before their operations and several anaesthesia organisations around the world are now looking over their shoulders. Thanks to ‘Awake’ patients may now be aware about awareness, but are anaesthetists aware of what patients are aware of?
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