Awareness
2007; Elsevier BV; Volume: 370; Linguagem: Inglês
10.1016/s0140-6736(07)61825-x
ISSN1474-547X
Autores ResumoAt 1415 h precisely on June 26, 2005, I awoke from general anaesthetic, just as Mr Thomas Weatherley FRCS began to slice off my appendix. These days I have recurring nightmares. People are trying to bury me alive. From time to time, I wake with the crushing feeling of a ton weight on my chest, an incubus prone on top of me. But I'm a comfortable man now, and I can afford life's compensations. So it goes.They say the system's strapped for cash, that the paint falls off the walls and pathogens rage through the hallways, while the whole sorry mess is organised and reorganised, and slimmed, and strengthened, till we don't know if we're coming or—like half the patients—going. Personally, I'm a big fan: free(ish) health care is more of a boon than most people realise. And, contrary to the zeitgeist, I'd rather an aged lady's finger remained sore an extra fortnight than that less sympathetic people like me died of rotten guts.We're very casual about the reality of a stranger cutting away bits of our insides. ‘Operations’ are a feature of the environment. Until, that is, our adenoids make a nuisance of themselves, or our appendices explode, and then we find out for ourselves, often in the most uncomfortable and graphic fashion. Being assisted to relieve myself was profoundly embarrassing. I was also rather taken aback by all the bruising. But in the end we successful cases are grateful, and it's an easy matter to find out all the names of your surgical team—in order the better to express your gratitude.When you tell people your anaesthetic wore off while you were under the knife, they respond neatly in two camps: horrified or sceptical. The first is gratifying, the second troubling. In my case, it's irritating. I'm not given to hyperbole, but at the time it was rather horrible. I had a tube down my throat and a knife scraping away in my belly. Weatherley chatted away, slicing and suturing. I charted the stinging course of a paralytic round my body, trying to ignore the strange tugging that shadowed the screaming pain, conscious of the happy activity in the unholy cavity they'd made, which of course I couldn't see, because I couldn't look at anything other than the solitary ceiling tile that briefly became my universe—every fissure, feature, and flaw of which I can cheerfully reproduce nowadays for anyone with a napkin, a pencil, a few free minutes, and a strong enough stomach to listen to me talking about context.An awful lot of patients like me get very agitated when they come round. I kept my counsel. It wasn't all bad. In fact, I was very lucky to have Mr Weatherley assigned to my procedure.I'm ashamed to admit it, but I was a little starstruck. Consultant GI surgeon and slicer to the stars. The hands of a Swiss clockmaker on the body of an Irish inside centre. As in demand as a private surgeon could conceivably be, and yet—the saint—sufficiently principled to work on cases like mine for a number of hours per month that would have cost better-upholstered patients sums I'd almost hesitate to imagine. He pops up on television from time to time, always to the unrestrained delight of the fairer sex, with a tongue as adept as his fingers. Naturally he refuses to name the appendices he's removed, but it's safe to assume their pedigree is faultless. And I can vouch for a certain grace in those rare moments he drifted across the outer reaches of my field of vision. Which was, at the time, fixed.I went to see a lawyer afterwards. Mr Dominic Roberts, an ambulance-chaser of the old school with a plummy accent, a shabby office, and shiny college cufflinks. He was a sceptic. He made a joke. I informed him he'd probably have split my sides, had they not sewn the abdominal muscles back together so particularly well. For all my many flaws, however, I don't seem mad. I won him round. He researched so-called ‘anaesthesia awareness’ for me; in fact, he became fascinated by it. It was a little ghoulish of him, but he worked hard. I could tell he was genuinely intrigued and not putting on a show for my benefit; I'm sensitive to people's moods and foibles. I used to be a teacher.Nowadays, I have my own lawyer. I've never seen his office because he visits me. His cufflinks are of a level of discretion that comes only at astronomical cost.Roberts knew who Weatherley was, of course. It only underlined his reluctance to press on. Not only was I complaining of an event routinely scoffed at by surgeons and denied by anaesthetists (Roberts said), but I'd been blessed enough to undergo a procedure carried out by a man whose reputation it'd be hard to taint with an 80% mortality rate, let alone with an accident that you couldn't prove and most people didn't realise could happen. He was widely rumoured to pick his own team, regardless of whether or not that was procedure, and it was said that this and certain other freedoms were the price he exacted for his good works. There might, Roberts conceded, be a case for suing the anaesthetist, but this, he reminded me, wasn't America. If you spilled coffee down your lap while driving in the UK, he quite reasonably pointed out, the fault was habitually assumed to be yours and not that of the drive-through restaurant you'd just visited for failing to print a sufficiently enormous warning on the cup.I asked him, eventually rather forcefully, to state the basis of a possible case. It would have been as follows: that the anaesthetist had, by failing to advise me in advance of the risk of this freakish horror show occurring, therefore failed properly to inform me fully of the risks of general anaesthesia, and thus not properly obtained my informed consent for the operation. Ergo, she had “negligently provided medical treatment”. Speculative, at best. There wasn't a trace of negligence in that woman.Warming to his subject, Roberts also pointed out his failure to see how we were going to be able to provide expert testimony that the risk of ‘awareness’ needed to be disclosed in the first place. I had no answer to that either. Without such testimony, he informed me, any such case would almost certainly be dismissed. Frankly, I don't care whether it's part of informed consent procedure. Perhaps it should be. One or two cases in a thousand isn't as rare as all that, after all. But it no longer concerns me directly. I've had mine, and I'm not going to live through another 998 operations.There are campaigns out there, believe it or not, of people who have made it their job to care. Ridiculous and desperate people, whose response to trauma is to make anaesthesia-awareness websites and print stickers, in the forlorn hope that every patient going to a preoperative meeting will wear one to show “solidarity” and “awareness”. Awareness awareness, presumably. I feel solidarity with no one. My experience was intensely personal. My response has been measured. Luck smiles upon me now.Weatherley does pick his own team, as it happens. Don't ask me how he gets to do it in a public hospital. Mine not to reason why. They got on like a house on fire while I was in there; the only person he wasn't openly chummy with as he sliced and diced was the anaesthetist herself. She, I discovered (after several weeks diligently nursing the grievances of, and supplying the drinks for, a desperate and motley collection of impoverished house-officers) was picked because she was super-competent. A touch obsessively compulsive, even. Entirely dysfunctional socially. At 1415 h on June 26, 2005, she was indeed—ironically—so deeply absorbed in her task as to be able to ignore anything not directly relevant. A good pick, I thought: Weatherley has a brand to protect, after all. It wouldn't do for routine procedures to go wrong on his watch.I learned also, as I lay there, that “on my watch” was in fact precisely the sort of phrase that Thomas Weatherley liked to use. I must say I liked him a touch less for that.He played rugby with the operating department practitioner, who clearly idolised him, and who had scored a rather good try the previous weekend. Weatherley tends also to have on his team at least one house-officer or student, invariably young and nubile and often groggily approaching the end of a 90-hour week, picked primarily on aesthetic grounds. This case was no exception. The privileges of office.To me, through the haze of chemicals and the smell of warm plastic and blood, there was something in the surgeon's manner of the benevolent landlord joshing his salt-of-the-earth estate staff, a whiff of charity as testimony to his own generosity of spirit as he picked away precisely at the corruption in my insides. As I said, I'm sensitive to people. Surgeons—the ‘charming’ ones rather than the stereotypically aggressive and dismissive ones—can be very slick. But perhaps I'm being uncharitable. I felt particularly sensitive while they were removing my guts.I often reflect, though, at the end of another leisurely, empty afternoon wandering the capital's museums or sleeping off its excesses, that it pays to be sensitive.Roberts had had another possible approach for me, even more tenuous than the first. This was to sue on the basis that the operating team hadn't used a so-called consciousness monitor to check that I was unconscious (would that I had had one or two of those, back when I was teaching). Elementary research on my part revealed a chronic lack of medical consensus on whether or not this was accepted good practice. Apparently, most devices sold as consciousness monitors hadn't been studied for effectiveness in reducing the incidence of anaesthesia awareness anyway. The furthest informed opinion seemed able to stretch was a conclusion by the American Society of Anesthesiologists that “the decision to use brain function monitors should be made on a case-by-case basis by the individual practitioner for selected patients”.I'm well aware that I presented no elevated risk when I showed up (not of that type, anyway). There was nothing special or non-standard about me whatsoever. Grist to the health-service mill: quiet, unassuming, unquestioning, with a nice line in deferential and self-deprecating humour, which I found years ago appeals strongly to the medical profession.So in the end, Roberts was useless to me. No reasonable case against hospital or anaesthetist, no chance of a successful lawsuit, no point. It was honourable of him, in a way, to admit it; he was excited by the prospect of pursuing this one, and after 10 or 20 years suing local councils for uneven paving stones, I'm not altogether surprised. He was positively itching to get stuck into something that would let him stretch his mind (which from the outside appeared fast-contracting, profoundly frustrated, and unhappy). No concern of mine, though, sadly. I had something else in mind. I'd been looking for something rock-solid from Roberts, and there was nothing there.No win, no fee; and yet no case, you pay for the consultation. He was a threadbare man treading water in a grubby firm, but I didn't mind. You takes your choice, you pays your money. You have to speculate to accumulate. Et cetera.Mr Weatherley doesn't sign the cheques. That would be absurd. They come through someone else. It's rather old-fashioned in these days of broadband and internet banking and titanium implants and robot surgery, but just as they went in with a knife, so did I, and there's something so pleasing about a signed piece of paper. Just as in teaching, the key notion is to pitch your expectation properly; excess ambition is invariably punished either by abject failure on your part or by a negative (in my school, occasionally violent) reaction from your subject.Every couple of months they come, the cheques. It's enough for me not to work, enough for me to keep paying off my mortgage, and enough for me to engage one or two absolutely first-class people on the legal and financial side. I wouldn't say my needs are modest, but they're not extravagant. I have no family—20 years of teaching in London put me off that notion absolutely. I have no partner. Probably the teaching as well, but I don't seem to be able to muster the necessary enthusiasm for other people.Weatherley could talk all four legs off a donkey, no doubt while removing half its intestine at the same time. His callow young house-officer was no match for him at all. Through the pain I even managed to take a few mental notes for myself, and I like to think these days I'm that touch more persuasive for it.I couldn't see her, of course, locked rigid and staring at the ceiling, but she sounded like she was exhausted, no doubt coming to the end of a horrific shift tacked on to the end of an equally horrific week. Something in her voice reminded me a little of one or two of my old students. In a class of thirty-plus, you'd usually have a couple unfairly written off, either as problem children or as slackers; but if you took that extra time to look, engaged with them that touch more sensitively, you'd notice the bags under the eyes, the shadows on the faces, and from time to time the faintest suggestion of a bruise expertly covered with foundation, like the edge of a raincloud far away. So far away you know it'll be spent before it ever rains on you.This young house-officer's name—they only used her first name—was Venetia, and she was from one of the tiny handful of remaining families in the country that could still actively have cared about its reputation. It was the most ridiculous of situations. No doubt they'd questioned her choice of profession, and no doubt she, like Weatherley, had been driven by a perverse and unnecessary need to do something for the common weal. Now, briefly, they shared a problem.No doubt he had on some previous occasion been very persuasive. Or perhaps—let's not jump to conclusions—perhaps she'd been the persuasive one. It matters not; what was without question was that he was in the driving seat now. Thoroughly in command. His hands danced inside me with a precision that was reassuring even through dizzying pain, and his mind was working efficiently away at something else entirely. He was truly an impressive man. A few choice comments here and there, the name of a very discrete colleague at a nondescript but reassuringly expensive Chelsea address, a choice of three or four dates. No doubt the chumminess of his team meant he felt safe enough, and of course there was meant to be no one else there. Nothing was explicit. But you can't survive as a teacher in a school like mine without a very sharp ear for throwaway comments and an ability to put two and two together with your mind distracted. In fact, I rather think the pain and the tugging and that mesmeric ceiling tile—and who knows, perhaps the drugs—helped me think even more quickly than usual. Or, let's say, to be that bit more sensitive.Weatherley, too, was a sensitive man. Nothing he said was harsh, nothing brutal, nothing forceful. Within his field he must be an excellent teacher. He was measured, precise, persuasive, effective.The better he had kept his counsel. At 1415 h precisely on June 26, 2005, I awoke from general anaesthetic, just as Mr Thomas Weatherley FRCS began to slice off my appendix. These days I have recurring nightmares. People are trying to bury me alive. From time to time, I wake with the crushing feeling of a ton weight on my chest, an incubus prone on top of me. But I'm a comfortable man now, and I can afford life's compensations. So it goes. They say the system's strapped for cash, that the paint falls off the walls and pathogens rage through the hallways, while the whole sorry mess is organised and reorganised, and slimmed, and strengthened, till we don't know if we're coming or—like half the patients—going. Personally, I'm a big fan: free(ish) health care is more of a boon than most people realise. And, contrary to the zeitgeist, I'd rather an aged lady's finger remained sore an extra fortnight than that less sympathetic people like me died of rotten guts. We're very casual about the reality of a stranger cutting away bits of our insides. ‘Operations’ are a feature of the environment. Until, that is, our adenoids make a nuisance of themselves, or our appendices explode, and then we find out for ourselves, often in the most uncomfortable and graphic fashion. Being assisted to relieve myself was profoundly embarrassing. I was also rather taken aback by all the bruising. But in the end we successful cases are grateful, and it's an easy matter to find out all the names of your surgical team—in order the better to express your gratitude. When you tell people your anaesthetic wore off while you were under the knife, they respond neatly in two camps: horrified or sceptical. The first is gratifying, the second troubling. In my case, it's irritating. I'm not given to hyperbole, but at the time it was rather horrible. I had a tube down my throat and a knife scraping away in my belly. Weatherley chatted away, slicing and suturing. I charted the stinging course of a paralytic round my body, trying to ignore the strange tugging that shadowed the screaming pain, conscious of the happy activity in the unholy cavity they'd made, which of course I couldn't see, because I couldn't look at anything other than the solitary ceiling tile that briefly became my universe—every fissure, feature, and flaw of which I can cheerfully reproduce nowadays for anyone with a napkin, a pencil, a few free minutes, and a strong enough stomach to listen to me talking about context. An awful lot of patients like me get very agitated when they come round. I kept my counsel. It wasn't all bad. In fact, I was very lucky to have Mr Weatherley assigned to my procedure. I'm ashamed to admit it, but I was a little starstruck. Consultant GI surgeon and slicer to the stars. The hands of a Swiss clockmaker on the body of an Irish inside centre. As in demand as a private surgeon could conceivably be, and yet—the saint—sufficiently principled to work on cases like mine for a number of hours per month that would have cost better-upholstered patients sums I'd almost hesitate to imagine. He pops up on television from time to time, always to the unrestrained delight of the fairer sex, with a tongue as adept as his fingers. Naturally he refuses to name the appendices he's removed, but it's safe to assume their pedigree is faultless. And I can vouch for a certain grace in those rare moments he drifted across the outer reaches of my field of vision. Which was, at the time, fixed. I went to see a lawyer afterwards. Mr Dominic Roberts, an ambulance-chaser of the old school with a plummy accent, a shabby office, and shiny college cufflinks. He was a sceptic. He made a joke. I informed him he'd probably have split my sides, had they not sewn the abdominal muscles back together so particularly well. For all my many flaws, however, I don't seem mad. I won him round. He researched so-called ‘anaesthesia awareness’ for me; in fact, he became fascinated by it. It was a little ghoulish of him, but he worked hard. I could tell he was genuinely intrigued and not putting on a show for my benefit; I'm sensitive to people's moods and foibles. I used to be a teacher. Nowadays, I have my own lawyer. I've never seen his office because he visits me. His cufflinks are of a level of discretion that comes only at astronomical cost. Roberts knew who Weatherley was, of course. It only underlined his reluctance to press on. Not only was I complaining of an event routinely scoffed at by surgeons and denied by anaesthetists (Roberts said), but I'd been blessed enough to undergo a procedure carried out by a man whose reputation it'd be hard to taint with an 80% mortality rate, let alone with an accident that you couldn't prove and most people didn't realise could happen. He was widely rumoured to pick his own team, regardless of whether or not that was procedure, and it was said that this and certain other freedoms were the price he exacted for his good works. There might, Roberts conceded, be a case for suing the anaesthetist, but this, he reminded me, wasn't America. If you spilled coffee down your lap while driving in the UK, he quite reasonably pointed out, the fault was habitually assumed to be yours and not that of the drive-through restaurant you'd just visited for failing to print a sufficiently enormous warning on the cup. I asked him, eventually rather forcefully, to state the basis of a possible case. It would have been as follows: that the anaesthetist had, by failing to advise me in advance of the risk of this freakish horror show occurring, therefore failed properly to inform me fully of the risks of general anaesthesia, and thus not properly obtained my informed consent for the operation. Ergo, she had “negligently provided medical treatment”. Speculative, at best. There wasn't a trace of negligence in that woman. Warming to his subject, Roberts also pointed out his failure to see how we were going to be able to provide expert testimony that the risk of ‘awareness’ needed to be disclosed in the first place. I had no answer to that either. Without such testimony, he informed me, any such case would almost certainly be dismissed. Frankly, I don't care whether it's part of informed consent procedure. Perhaps it should be. One or two cases in a thousand isn't as rare as all that, after all. But it no longer concerns me directly. I've had mine, and I'm not going to live through another 998 operations. There are campaigns out there, believe it or not, of people who have made it their job to care. Ridiculous and desperate people, whose response to trauma is to make anaesthesia-awareness websites and print stickers, in the forlorn hope that every patient going to a preoperative meeting will wear one to show “solidarity” and “awareness”. Awareness awareness, presumably. I feel solidarity with no one. My experience was intensely personal. My response has been measured. Luck smiles upon me now. Weatherley does pick his own team, as it happens. Don't ask me how he gets to do it in a public hospital. Mine not to reason why. They got on like a house on fire while I was in there; the only person he wasn't openly chummy with as he sliced and diced was the anaesthetist herself. She, I discovered (after several weeks diligently nursing the grievances of, and supplying the drinks for, a desperate and motley collection of impoverished house-officers) was picked because she was super-competent. A touch obsessively compulsive, even. Entirely dysfunctional socially. At 1415 h on June 26, 2005, she was indeed—ironically—so deeply absorbed in her task as to be able to ignore anything not directly relevant. A good pick, I thought: Weatherley has a brand to protect, after all. It wouldn't do for routine procedures to go wrong on his watch. I learned also, as I lay there, that “on my watch” was in fact precisely the sort of phrase that Thomas Weatherley liked to use. I must say I liked him a touch less for that. He played rugby with the operating department practitioner, who clearly idolised him, and who had scored a rather good try the previous weekend. Weatherley tends also to have on his team at least one house-officer or student, invariably young and nubile and often groggily approaching the end of a 90-hour week, picked primarily on aesthetic grounds. This case was no exception. The privileges of office. To me, through the haze of chemicals and the smell of warm plastic and blood, there was something in the surgeon's manner of the benevolent landlord joshing his salt-of-the-earth estate staff, a whiff of charity as testimony to his own generosity of spirit as he picked away precisely at the corruption in my insides. As I said, I'm sensitive to people. Surgeons—the ‘charming’ ones rather than the stereotypically aggressive and dismissive ones—can be very slick. But perhaps I'm being uncharitable. I felt particularly sensitive while they were removing my guts. I often reflect, though, at the end of another leisurely, empty afternoon wandering the capital's museums or sleeping off its excesses, that it pays to be sensitive. Roberts had had another possible approach for me, even more tenuous than the first. This was to sue on the basis that the operating team hadn't used a so-called consciousness monitor to check that I was unconscious (would that I had had one or two of those, back when I was teaching). Elementary research on my part revealed a chronic lack of medical consensus on whether or not this was accepted good practice. Apparently, most devices sold as consciousness monitors hadn't been studied for effectiveness in reducing the incidence of anaesthesia awareness anyway. The furthest informed opinion seemed able to stretch was a conclusion by the American Society of Anesthesiologists that “the decision to use brain function monitors should be made on a case-by-case basis by the individual practitioner for selected patients”. I'm well aware that I presented no elevated risk when I showed up (not of that type, anyway). There was nothing special or non-standard about me whatsoever. Grist to the health-service mill: quiet, unassuming, unquestioning, with a nice line in deferential and self-deprecating humour, which I found years ago appeals strongly to the medical profession. So in the end, Roberts was useless to me. No reasonable case against hospital or anaesthetist, no chance of a successful lawsuit, no point. It was honourable of him, in a way, to admit it; he was excited by the prospect of pursuing this one, and after 10 or 20 years suing local councils for uneven paving stones, I'm not altogether surprised. He was positively itching to get stuck into something that would let him stretch his mind (which from the outside appeared fast-contracting, profoundly frustrated, and unhappy). No concern of mine, though, sadly. I had something else in mind. I'd been looking for something rock-solid from Roberts, and there was nothing there. No win, no fee; and yet no case, you pay for the consultation. He was a threadbare man treading water in a grubby firm, but I didn't mind. You takes your choice, you pays your money. You have to speculate to accumulate. Et cetera. Mr Weatherley doesn't sign the cheques. That would be absurd. They come through someone else. It's rather old-fashioned in these days of broadband and internet banking and titanium implants and robot surgery, but just as they went in with a knife, so did I, and there's something so pleasing about a signed piece of paper. Just as in teaching, the key notion is to pitch your expectation properly; excess ambition is invariably punished either by abject failure on your part or by a negative (in my school, occasionally violent) reaction from your subject. Every couple of months they come, the cheques. It's enough for me not to work, enough for me to keep paying off my mortgage, and enough for me to engage one or two absolutely first-class people on the legal and financial side. I wouldn't say my needs are modest, but they're not extravagant. I have no family—20 years of teaching in London put me off that notion absolutely. I have no partner. Probably the teaching as well, but I don't seem to be able to muster the necessary enthusiasm for other people. Weatherley could talk all four legs off a donkey, no doubt while removing half its intestine at the same time. His callow young house-officer was no match for him at all. Through the pain I even managed to take a few mental notes for myself, and I like to think these days I'm that touch more persuasive for it. I couldn't see her, of course, locked rigid and staring at the ceiling, but she sounded like she was exhausted, no doubt coming to the end of a horrific shift tacked on to the end of an equally horrific week. Something in her voice reminded me a little of one or two of my old students. In a class of thirty-plus, you'd usually have a couple unfairly written off, either as problem children or as slackers; but if you took that extra time to look, engaged with them that touch more sensitively, you'd notice the bags under the eyes, the shadows on the faces, and from time to time the faintest suggestion of a bruise expertly covered with foundation, like the edge of a raincloud far away. So far away you know it'll be spent before it ever rains on you. This young house-officer's name—they only used her first name—was Venetia, and she was from one of the tiny handful of remaining families in the country that could still actively have cared about its reputation. It was the most ridiculous of situations. No doubt they'd questioned her choice of profession, and no doubt she, like Weatherley, had been driven by a perverse and unnecessary need to do something for the common weal. Now, briefly, they shared a problem. No doubt he had on some previous occasion been very persuasive. Or perhaps—let's not jump to conclusions—perhaps she'd been the persuasive one. It matters not; what was without question was that he was in the driving seat now. Thoroughly in command. His hands danced inside me with a precision that was reassuring even through dizzying pain, and his mind was working efficiently away at something else entirely. He was truly an impressive man. A few choice comments here and there, the name of a very discrete colleague at a nondescript but reassuringly expensive Chelsea address, a choice of three or four dates. No doubt the chumminess of his team meant he felt safe enough, and of course there was meant to be no one else there. Nothing was explicit. But you can't survive as a teacher in a school like mine without a very sharp ear for throwaway comments and an ability to put two and two together with your mind distracted. In fact, I rather think the pain and the tugging and that mesmeric ceiling tile—and who knows, perhaps the drugs—helped me think even more quickly than usual. Or, let's say, to be that bit more sensitive. Weatherley, too, was a sensitive man. Nothing he said was harsh, nothing brutal, nothing forceful. Within his field he must be an excellent teacher. He was measured, precise, persuasive, effective. The better he had kept his counsel.
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