Intraoperative awareness

Intraoperative awareness (IOA) represents a range of heterogeneous experiences and is a topic of considerable relevance, not only to anaesthetists, but to all theatre staff. This chapter focuses on communications that the anaesthetist may find helpful in ameliorating or preventing adverse sequelae associated with IOA. This is a well-described, infrequent complication of general anaesthesia which can have serious long-term psychological consequences. First recognized as a medical complication in 1846, there have been numerous reports since the 1950s. Considerable research has been devoted to its understanding and prevention over the past two decades. IOA has increasingly come to the attention of clinicians, patients and the media. It is also a medico-legal issue and high compensation awards have been made. The ASA practice advisory for anaesthesiologists states that, ‘Intraoperative awareness occurs when a patient becomes conscious during a procedure performed under general anaesthesia and subsequently has recall of these events.’ This may include: sensations of weakness; inability to communicate, move or scream; auditory and tactile perceptions; feelings of helplessness; acute fear, panic and pain; believing to have been abandoned and betrayed; and being dead, or about to die. Explicit awareness (declarative memory) permits conscious recall of intraoperative events such as auditory, visual and tactile experiences, paralysis and pain. There is a striking similarity of experiences among patients, but only a minority (35 % ) may inform their anaesthetists. Explicit awareness has been the subject of the majority of investigations related to IOA and is the main topic of this chapter. Implicit awareness (non-declarative memory): information can be recollected but cannot be recalled or consciously retrieved. There is strong evidence for auditory information-processing of material relevant to the patient’s well-being, whether beneficial or threatening. The overall incidence of IOA varies, but has been reported to be between 0.1 and 0.9 % with 30 000–40 000 cases annually in the USA. However, the true incidence of recall is probably underestimated. According to a 2010 report by the ASA closed claims project, IOA occurs in less than 1 in 700 cases. Causes were largely attributed to light anaesthesia and anaesthetic delivery problems.

Needle phobia

Needle phobia describes an anticipatory fear of needle insertion, and is a well-recognized clinical entity of particular relevance to the anaesthetist. It may affect up to 10 % of the general population, is more common in the young, and can prevent patients from seeking medical care by avoiding immunizations, necessary blood tests or hospital procedures. The development of trust, a perception of control and an understanding of the conscious–subconscious aspects of the problem can help patients. In addition, patience, time and recognized communication skills are frequently needed if this distressing problem is to be managed effectively . Needle phobia is usually a learned response. Trust, control and perceptions rather than the pain itself are the key issues in needle phobia. Nevertheless pain reduction strategies such as EMLA, ice , premedication such as dexometomidine, stress-reducing medical devices and hypnosis, may have a role in management. Anaesthetists have traditionally used reassurance, EMLA and avoidance of needle insertion in the awake patient by giving inhalational inductions. However, this approach tends to reinforce the avoidance behaviour of both anaesthetist and patient! In addition, it wastes a valuable opportunity to educate patients in ways that can provide them with the necessary skills to manage future blood tests, drips and the like more easily. In some cases avoiding IV access prior to inducing anaesthesia—for example, at a Caesarean section — can put patients at increased risk of complications. Patients with needle phobia are like all patients only more so! At one level they function consciously and logically and are amenable to reason. However, in the context of hospital procedures such as blood tests and IV cannulation, subconscious responses take over. These patients often recognize that their behaviour is silly or even stupid, but find that they just can’t help themselves. They may describe their predicament as being in ‘two minds about it’ or ‘beside themselves’. This mind set illustrates, probably more clearly than any other, the conscious–subconscious basis of the problem.

Language and the subconscious

Many of the communications commonly encountered in anaesthetic practice elicit subconscious responses, and, because this is so, they frequently go unrecognized. This form of communication involves verbal and non-verbal cues also known as suggestions that can elicit automatic changes in perception or behaviour. Much of this chapter is based on language structures that are thought to make subconscious changes in perception, mood or behaviour more likely, both with patients and anaesthetists themselves. Recognizing subconscious responses will facilitate communication. As is discussed later, anaesthetists can communicate with patients and colleagues in ways that utilize subconscious functioning. To all intents and purposes this looks like intuitive communication, when in reality it has structure and therefore can be learned and taught. The conscious and unconscious states are familiar to all anaesthetists. However, it is frequently unappreciated that all patients, whether in an unconscious or conscious state, will also be functioning subconsciously. In the unconscious patient it is well recognized that subconscious activities still occur—for example, in implicit awareness. Most people would appreciate that there are times during consciousness when they switch off the ‘logical brain’ and enter ‘daydream’-type thinking or they ‘tune out’. People including anaesthetists tend to function subconsciously most of the time—for example, during routine activities such as driving home on ‘autopilot’ and arriving home without realizing it consciously. The ability we all have to function automatically—that is, subconsciously—frees up the conscious part of the mind to focus on other things such as planning tomorrow’s ‘neuro’ case. The teleological basis for this ability lies in being able to filter the massive amount of information continuously presented to the individual. This allows the conscious mind to focus on what it perceives to be important—facilitating learning, logical thinking and problem solving. During activities where logical thinking is not a requirement, the subconscious comes to the fore. This is characterized by dissociation from the external environment—being ‘in your own world’. Paradoxically, at times of extreme stress, the subconscious tends to take over when the conscious part of the mind becomes so overwhelmed by external inputs it ceases to function logically.

To begin …

Communication is an innately fascinating and, on occasions, a somewhat mysterious topic. At its heart, it is the means of expressing, both to ourselves and to others, how we perceive the world and how we influence the world around us. It is a tool for exchanging information and meaning, but also a way to connect with others. While obviously a means to an end, it is also an end in itself—without the ability to share with others, life would be greatly impoverished. The many human dimensions of communication— the practical, the social, the linguistic, the lyrical, the subliminal, its ability to soothe and to injure, to inform, to entertain, to terrify—are what make this topic so challenging. Anaesthesia has come a very long way since the 1840s. The advent of safer and more selective drugs, coupled with ever more sophisticated technology, has made the practice of anaesthesia safer, yet also more complicated. The patients that we treat are often older, have multiple co-morbidities, and are undergoing procedures that would have been unthinkable 20 years ago. Yet with the increasingly complex workload have come the additional pressures of time and resource allocation. Patients are admitted on the day of surgery, leaving minimal time for anaesthetic assessment. Anaesthetists are frequently busy, isolated and unavailable when working in theatre, or find themselves working at multiple sites with little opportunity for interaction with colleagues. Similarly, theatre staff rarely work in the same operating room with the same team on a regular basis. The hospital administrators are under constant pressure as they strain to contain costs and reduce length of stay, while wards are increasingly understaffed and overworked. In the midst of all this, patients are left wondering who is actually caring for them, and if anyone is listening to their concerns. Anaesthetists play a crucial role in multi-professional teams in a wide variety of clinical settings of which theatre is only one. There is the high dependency unit (HDU), the labour suite, paediatrics, the chronic pain clinic—to name but a few. In almost every aspect of anaesthetic clinical practice the ability to communicate effectively is a vital component of patient care.

Administrators

In our modern healthcare systems, clinicians find themselves dealing face-to-face with administrators at many different levels. Unfortunately, there often appears to be a major disconnect between the two parties, and priorities may appear to be vastly different. For the busy clinical anaesthetist who encounters this in passing, there may be transient frustration and confusion before simply getting on with the job. For the anaesthetist with a designated management role, the problem doesn’t go away that easily. Both, however, will benefit from some deeper insight into the nature of these interactions to help everyone to better achieve their goals. The ‘LAURS’ concept as presented in Chapter 2 emphasizes the generic attributes of the approach to a meaningful interaction. Of particular interest in attempting to apply this framework to our dealings with administrators is the recognition that the management ‘world’ is exactly that — a seemingly different place that abounds with its own distinctive language, practical tools, and approaches to problem solving with which most clinicians have little familiarity. There may indeed be a sense of entering a different domain, much like the person entering the healthcare system as a patient. Hence in this chapter there is a deliberate intent to present some of these practical tools and perspectives to help better understand this other world and the people who abide there and relate it to these general principles. The results may be surprising. Dr Celia Roberts has recently been appointed Director of the Anaesthesia Service of a large public teaching hospital. Being an expert in her field she had conducted research, written several papers and been responsible for the teaching of specialist trainees. There is little in her chosen area of expertise that she doesn’t know how to deal with. In her day-to-day work she needs to think on her feet, work independently and be accountable for her individual actions. Where appropriate, she assumes a leadership role, giving clear and concise instructions to the team around her. Celia approaches her work with a high commitment to one-to-one interaction between herself as a skilled exponent of a specialised craft—clinical anaesthesia—and the patients who are seeking her help.

Patients with special needs

Most anaesthetists recognize that there are specific groups of patients with whom communication is especially difficult due to issues relating to language. These groups are patients in whom a disease process interferes with communication—for example intellectual disability or hearing impairment, those with whom we do not share a common tongue, and those patients whose cultural background differs from ours. Patients with communication difficulties are disproportionately represented in the hospital population for a variety of reasons. The elderly form the bulk of hospital inpatients and are much more likely to have problems such as dementia, confusion, sedation and dysphasia. It is important to be cognisant of the issues that may arise with patients who have communication problems and, in addition to being aware of these problems, it helps to have a structured way of approaching the issue. Reading the patients’ notes prior to consultation gives advance warning of issues such as dementia or hearing impairment and allows communication to be tailored to the patients’ needs. Sometimes the patients’ understanding of language may be difficult to assess on first meeting—anaesthetists have all encountered patients who answer questions with a smiling ‘yes’ or ‘no’, only to subsequently discover their comprehension has been minimal. Enquiring of relatives, friends and staff helps to give a picture of a patient’s ability to communicate in the chosen language. Similarly, enquiring of the patient how communication can be facilitated, is helpful. … ‘It says in your notes that you have trouble finding words since your strok —is there anything I can do to make it easier for you to speak?’… Once the communication problem has been delineated it makes it easier to move on to the next step. Having orientated oneself to the patient’s particular problems with communication, it is also important to orientate the staff with whom one is working. …‘Rob, we are going to see Mr Smith now. He’s had problems with alcohol withdrawal over the last few days and he is still a bit confused. It is probably best if just one of us does the talking — are you happy to do that? ’ Not: ‘I wish you wouldn’t contradict me when I’m talking to patients…’ …

The paediatric patient

Anaesthetists usually develop their communication skills through experience over many years of trial and error. Much angst can be avoided by learning some simple techniques that can facilitate interactions during the delivery of anaesthesia care. Caring for children from newborn to adolescence provides the anaesthetist with unique opportunities to use communication to improve anaesthesia care. To a parent, the matter of handing over control and protection of their child to the anaesthetist is invariably difficult, emotional and can lead to significant distress. This is irrespective of whether the surgical intervention is major or not. For their child to attend the hospital for a procedure, families have frequently made unspoken and intricate arrangements in their schedule. Making these arrangements adds to the other stresses of coming in for surgery. Being mindful of this can help the anaesthetist communicate in a way that recognizes the possible complexity for some families of even attending the hospital on time. In recent years the increasing popularity of day-surgery admission has meant that many parents meet their child’s anaesthetist for the first time only minutes before the procedure. However, much can be done to enhance patient and parent rapport even when only a short time is available. Flexibility in approach is paramount. The age of the child determines how the ‘LAURS’ of communication can be implemented to facilitate patient rapport, trust and engagement during anaesthesia care. Communicating with children is similar to, yet differs from, communicating with adults. Children live in a subconscious world of play and make-believe. They are highly responsive to suggestion, and the use of subconscious language and non-verbal cues is frequently more effective than the usual adult logical communication most doctors are familiar with. Because of this, children often do not appear to be paying attention and instead frequently behave spontaneously, subconsciously or contrary to what is being asked of them. Adults when stressed will often do this too. As with adults, the aim of communicating effectively with children is to promote autonomy and a sense of control.

The obstetric patient

The obstetric anaesthetist’s clinical practice is concerned with the safety of not one, but two intricately interwoven individuals, and much of this takes place in the presence of a third party—partner, friend or relative. Pregnancy and birth are natural and normal processes in the lives of most people. In this context, communication might be expected to be a matter of common sense and somewhat intuitive. How we communicate with women is a pivotal factor in determining their experience and, although recognized as such by many within the midwifery community , this is perhaps less so by doctors. Advances in medicine and changes in society over the last 100 years have resulted in a safer but, socially and technologically, a more complex experience for both women and their babies. Communication in childbirth originally occurred between women caring for each other, but this subsequently became dominated by an authoritarian medical machine, which has left some women feeling vulnerable and ‘processed’. Recognition of the importance and value of patient rights and satisfaction has been responsible for a cultural shift in many maternity units. However, the medicalization of childbirth continues to take over even when labour is proceeding normally. Anaesthetists are perfectly positioned as providers of analgesia and anaesthesia, within a multidisciplinary team, to communicate with women in a way that empowers them and supports their autonomy. Women become highly focused on the pregnancy and labour as the evidence looms ever larger in front of them. Pregnancy and childbirth usually represent a challenging psychological and physiological experience. This focus of attention on the pregnancy makes women highly suggestible to subconscious communications. For this reason, messages received can function as powerful determinants of how women perceive their pregnancy, and respond during childbirth. Central nervous system (CNS) changes occur that reduce anaesthesia requirements during pregnancy and increase hypnotizability, dissociation, daydreaming and an ability to use imagery to experience labour in a fulfilling way. There is a range of emotional responses to pregnancy. For some, there is joy and excitement, while for others there is no excitement—just fear and anxiety. Overlaying this, there may be pre-existing generalized anxiety, social concerns, obstetric problems and other complications.

Hypnotic techniques

Anxiety, fear, tension and apprehension are common emotions in patients undergoing surgery. Clinicians are becoming increasingly aware of the importance of patients’ psychological reactions as well as their physical needs. For instance, surgeons now explain more to their patients than was formerly the case. The anaesthetist is therefore presented with an opportunity to use the pre-operative anaesthesia assessment as a means of fostering greater rapport and providing reassurance. There is, of course, still much reliance upon sedative and analgesic drugs to relieve anxiety and tension prior to major anaesthesia. However, sedatives are not the only answer. Sedation can be accomplished pharmacologically, but drugs cannot re-educate patients in a way that enables them to respond more positively to their medical or surgical treatment. The challenge for anaesthetists seeking to provide optimal anaesthetic care for their patients is not only to become more expert in the latest state-of-the-art technology, but rather to acquire the skills necessary to function effectively in the role of physician healer. Hypnosis is not a ‘therapy’, but a potentially valuable tool in the anaesthetist’s professional armamentarium, and deserves to receive equal consideration with other tools and skills which anaesthetists acquire. Hypnotic techniques can influence communication to such a degree that the patient’s entire medical experience is beneficially affected. Anaesthetists trained in the use of hypnosis can use this approach in ‘formal hypnosis’ or as ‘awake suggestions’. Hypnosis has had a cyclical history of acceptance and rejection. It has been practised in one form or another for thousands of years. However, it was not until 1828 that a scientific publication first reported its effectiveness as an anaesthetic for surgery. However, when volatile agents were introduced, the use of hypnosis as a sole anaesthesia technique died out. Because of its historical association with magic, hypnosis has had to struggle to become disentangled from faith-healing methods and the occult. In a number of hospitals around the world, hypnosis is used as an adjuvant to pharmacological anaesthesia, either before or after general anesthesia. At the same time, the fact that major surgery has been comfortably performed entirely under hypnosis overcomes some of the scepticism associated with its ancillary uses.

Teaching and research

This chapter is designed to give an overview of a number of specific situations in teaching and research relating to anaesthesia where communication skills may be useful. Whilst there are many others, these have been chosen because, in the authors’ experience, they are often unfamiliar or poorly performed, or assumed to be part of the ‘tacit’ skill set that cannot be formally taught. Perhaps the most important interaction that occurs between anaesthetists is that which occurs during teaching. Communicating with trainees in order to bring about a change in knowledge, skills and attitude is probably the most sophisticated form of communication anaesthetists employ other than the context of therapeutic communication with patients. Scant attention is often paid to the unconscious way in which anaesthetics trainees learn. Anaesthesia, like surgery, is learnt, not taught. Much of the beliefs, behaviours and attitudes that trainees acquire comes implicitly as they observe and copy their mentors’ actions. Part of becoming an anaesthetist involves the acquisition of ‘anaesthetic culture’—the sense of professional identity which may be either a positive or a negative one. When working with trainees, not only should they be taught the knowledge and skills to do the job, but, more importantly, senior anaesthetists should be modelling, and explicitly teaching them, better ways to interact with colleagues. It is far beyond the scope of this chapter to address the issues surrounding education in anaesthesia. However, it is useful to explore one aspect of teaching—that is, feedback in order to highlight some basic principles. Everyone loves feedback—so long as it is positive! No-one likes to feel that they are being unfairly, or even fairly, criticized. So how can anaesthetists give the feedback our trainees so desperately crave? As in all communication the key lies in establishing a rapport. Most trainees spend long enough in a department to establish a reasonable relationship with at least one or two trainers. It is difficult to give feedback to a trainee whose baseline capabilities are uncertain. … ‘Does he always make a pig’s ear out of arterial cannulation or is he just having a bad day? ’ …