Welcome back to Analyze Scripts, where a psychiatrist and a therapist analyze what Hollywood gets right and wrong about mental health. Today, we are analyzing the 2007 film "Awake." This movie stars Hayden Christensen, Jessica Alba and Terrence Howard. There is a nefarious plot to kill Clay who finds out during surgery. According to our guest, Dr. Gonzalez from the Yale Anesthesia Department, Clay experiences intraoperative awareness AKA "awareness" during surgery.  The movie is filled with plot holes and some pretty inaccurate medical information. We learn so much from Dr. Gonzalez about anesthesia and patient pain. PTSD, medical factiods and financial stressors are topics in this episode. We hope you enjoy!

Dr. Gonzalez Podcast Episode on Interoperative Awareness

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Dr. Katrina Furey, MD: Hi, I'm Dr. Katrina Fieri, a psychiatrist. And I'm Portia Pendleton, a licensed clinical social worker. And this is Analyze Scripts, a podcast where two shrinks analyze the depiction of mental health in movies and TV shows. Our hope is that you learn some legit info about mental health while feeling.

Portia Pendleton, LCSW: Like you're chatting with your girlfriends.

Dr. Katrina Furey, MD: There is so much misinformation out there, and it drives us nuts. And if someday we pay off our.

Portia Pendleton, LCSW: Student loans or land a sponsorship, like.

Dr. Katrina Furey, MD: With a lay flat airline or a major beauty brand, even better. So sit back, relax, grab some popcorn and your DSM Five, and enjoy. Welcome back for another very exciting episode of Analyze Scripts. As part of our Halloween month today, we are covering the 2007 thriller mystery movie called Awake with our wonderful guest, Dr. Antonio Gonzalez. And I cannot think of anything scarier than being awake during a surgery, so this is perfect for our Halloween month. But just as a quick bio, dr. Gonzalez is an associate professor of anesthesiology and the director of the Obstetrics anesthesia Fellowship at Yale New Haven Hospital. He completed his residency program at Rutgers in New Jersey and decided to pursue a fellowship in obstetric anesthesia at Columbia University in New York. And I will actually be joining one of his podcasts in the near future to talk about eternal mental health and anesthesia, which I'm really excited about. But thank you so much, Dr. Gonzalez, for joining us.

Dr. Antonio Gonzalez, MD: Thank you so much for the invitation. I'm really happy to be here with you today.

Dr. Katrina Furey, MD: So, Portia, where do we even get started with this movie? Have you seen it before?

Portia Pendleton, LCSW: I have not seen the movie ever. I think that something like this would probably have been a little scary to watch. Yeah, I think a lot of people who are not in medicine and maybe people who are in medicine, I think it's a common fear to wake up during surgery. I think a lot of people going in get really calmed down once talking to the anesthesiologist or telling them that this is their process or this is.

Dr. Katrina Furey, MD: How it's going to be.

Portia Pendleton, LCSW: And all of the machines and monitors that they now have, you were saying a little bit before we got started today. So I think this is just like a pretty common fear that people have going into surgery.

Dr. Katrina Furey, MD: What do you think, Dr. Gonzalez?

Dr. Antonio Gonzalez, MD: Yes, I think that definitely introvertive awareness. It's definitely a fear of our patients. And unfortunately, this movie actually may have hyped that fear. But fortunately, the reality is that introvertive awareness is relatively rare, particularly these days. We have way better medications, way better monitors that help us to prevent intraperative awareness. The incidence has been documented to be somewhere around 0.1% to 0.2% in the United States.

Dr. Katrina Furey, MD: So what is that, like, one to two out of 1000 cases? Something like that?

Dr. Antonio Gonzalez, MD: That is correct, yeah. Because there are so many surgeries in the united States, that's about 20,000 to 40,000 cases a year, which still a lot. Right. The consequences of interoperative awareness can go from just having fear of future surgeries, even withholding surgeries for some of their relatives, particularly their kids, because they are so scared of what happened to them, they may actually be very fearful of letting their relatives go through surgery. Yeah. So that is one of the consequences. But, again, it's relatively rare these days.

Dr. Katrina Furey, MD: Okay. Dr. Gonzalez.

Portia Pendleton, LCSW: Is there anything in common.

Dr. Katrina Furey, MD: That the people who this happens to.

Portia Pendleton, LCSW: With each other, or is it just kind of like yeah.

Dr. Katrina Furey, MD: Is there, like, a way to predict it that it could?

Dr. Antonio Gonzalez, MD: So we don't have particularly great ways of predicting who will have operative awareness. We do know that there is a certain patient population or certain surgeries. So there are surgeries like trauma, cardiac surgery, and Obstetric. Anesthesia. Obstetric cases seem to be and when I mean Obstetric cases, Caesarean deliveries, particularly. These are cases that are very well known to have an increased risk of intraperative awareness. The reason behind it is because trauma patient and cardiac patients have a very delicate hemodynamics, meaning their blood pressure, it's low, tends to be on the lower side. They have a high risk of coronary vascular disease. So having their blood pressure too high or too low, it's at extreme risk. So in order to maintain that balance between the anesthesia that it's provided and the hemodynamics, those patients tend to be at a higher risk. And that implies for both trauma patients and cardiac patients. Now, the Obstetric patient population is at increased risk because of the risk that the anesthesiologist may perceive from the drugs transferring to the baby. So all the medications we give to mom will go to baby, and that increase in medications has been thought to be pretty dangerous to the baby. So anesthesiologists at some point, we're very scared of giving extra medications to mom nowadays. Again, I think that because our monitoring and the drugs that we have available and the awareness that introvertive awareness in this particular patient population, it's higher, we have improved the techniques that we have for providing general anesthesia. Now, that being said, we do a lot of our anesthesia under regional, and having pain during a surgery, even with epidural or a spinal, can be equally as scary, if not even more scary than having introvertive awareness while asleep.

Dr. Katrina Furey, MD: I was wondering that. So, before we get into this a little further, I just want to give a quick recap of the plot of this movie. So, in the movie Awake, we see Hayden Christensen playing the main character, Clay Bearsford Jr. Who is, like a fancy pants financial person, super uber rich. He does something with stocks, probably, that I don't understand. And you see this interesting relationship with his mom early on, who's played her name's Lilith, and she's played by Lena Olin. And then we see Jessica Alba. This is one of her big roles, playing Sam Lockwood, who's his fiance. They get married very quickly because he is waiting for a cardiac transplant due to history of cardiomyopathy, which is something that happens. That seemed pretty accurate. And then we see Terrence Howard playing his friend and surgeon, Dr. Jack Harper. And spoiler alert, turns out all of the medical professionals on the team, including his fiance, were in on this plot to murder him during the transplant in order to inherit all his money and pay off some malpractice debt. Luckily, I think it was the anesthesiologist. The original one backed out. So this other guy was there, and somehow he figured out the plot, and he alerted authorities. And eventually, I think Dr. Harper injected the heart with adriamycin. I believe the Clay did, I guess, technically die on the table. When they delivered that news to his family, the mother committed suicide. I can't remember what she overdosed on. I'm assuming maybe Digoxin, which was in his bag. And then they wheeled the mom in and gave him her heart. And so he survived, and all the people got arrested. The end. That's basically the plot. Really quick. So getting back to what you were saying, Dr. Gonzalez, about the intraoperative awareness. So when you were saying that with these certain cases, trauma, cardiac, and OB with regional anesthesia, I'm thinking like an epidural, like for a C section or something like that. Like, if they give the epidural and it fails either in a C section or a regular delivery, vaginal delivery, would that be considered interoperative awareness?

Dr. Antonio Gonzalez, MD: Well, if the patient is experiencing pain, yes, that can be as traumatic as experiencing intraperative awareness, because the patient mentally is completely there, but the patient is completely feeling the experience of the pain. And the definition of pain, actually, it's not only physical, but there is an emotional component to pain. Right. So what you describe as pain, you can only be the person that knows what pain is for you. So what we've learned through the years is that we are not the best judge of what pain is. The patient is the best judge of what pain is because pain is what the patient tells you pain is.

Portia Pendleton, LCSW: I'm so glad you said that.

Dr. Katrina Furey, MD: I think that's really important and to keep in mind the emotional side of it.

Portia Pendleton, LCSW: I like that also, just as I don't know a similarity right. In mental health, like pain mental pain, emotional pain is, like, what the patient is describing versus my definition in the DSM. But I really like that. Or just validating their experience. Well, this is what they experienced. Maybe someone else's was different.

Dr. Katrina Furey, MD: Right.

Portia Pendleton, LCSW: I really like that.

Dr. Antonio Gonzalez, MD: Yeah. I think that it's a great opportunity, because, as you mentioned, sometimes if, as physicians, we try to give an explanation to pain, right. We may actually minimize the patients. And at the end of the day, what ends up happening is that the patients feels that their feelings, they're being gaslighted. So the patient is telling you, this is what I feel, and you say, well, it's not that big of a deal. Right. But it is to the patient, it is. So pain is, again, what the patient tells you pain is.

Dr. Katrina Furey, MD: No, I think that's great. And in my line of work, in private practice, I do end up seeing well, I see primarily women around pregnancy and postpartum. So I've heard many cases where the epidural failed, or it only took on half the side, or someone had a history of back surgery, so they met with the anesthesiologist ahead of time to talk about pain management options. And it is a super important aspect of prenatal care, especially delivery, and I'm sure that extends to other surgeries as well. So, Dr. Gonzalez, what are your thoughts about the way anesthesia was depicted in this movie? What they get right, what they get wrong?

Dr. Antonio Gonzalez, MD: Well, there are so many things that they well, the one thing that they got right was to select the patient that was having a cardiac surgery. As we mentioned, patients with cardiac surgery have an increased risk of having introvertive awareness. So they got that one part right. Then the other thing is that it seems like they have a substitute anesthesiologist that's coming from another institution. It doesn't quite happen that way. You need to have privileges at that place. It's a little credentialed. Yeah. Unless he's a traveler. Sometimes we have anesthesiologists that are considered what is the term? Locums. That's correct, yes. So locums might have been a locums that they call in to substitute, but it's actually quite hard to find locums for very specific cardiac surgery. So I think that the other thing that I think was very wrongfully depicted was how easy he may look. The induction. The induction was basically he took this three CC syringe or four CC syringe. He gave it to the patient. He said, count back to ten. Cardiac inductions are very complicated. It requires a balance of many medications. Again, because there is this hemodynamic balance that you want to maintain. You don't want the patient's blood pressure to go too high. Do you want the patient's blood pressure to go too low? So that also it seems like it was completely off. And there is a point where the surgeons are discussing, like, well, we won't need you for a little bit, so go get a drink. We never leave the operating room.

Dr. Katrina Furey, MD: Right.

Dr. Antonio Gonzalez, MD: I know there is always somebody from anesthesia in the room that be like the anesthesiologist or anesthetist, but we just don't leave the patient in the or. Just because the surgeon tells us that they're not going to need us for a bit. So that was totally wrong.

Dr. Katrina Furey, MD: Right. In my experience in medical school, rotating through that's exactly right. Even these long cases like cardiothoracic surgery, the anesthesiologist, maybe a resident, maybe the nurse, anesthetist. These words are hard to say. Someone's always there watching the monitor. They might be doing something else at the same time. I remember one time there was a resident practicing his golf swing, and I was like, this seems pretty unprofessional. But they're always watching the monitors. And I would imagine like this, especially watching the blood pressure, the heart rate, things like that. And they're always checking. They kept checking, at least in the cases I would be in, they would do things to check. The patient was still under enough. Not too far under. Not coming out of it either.

Dr. Antonio Gonzalez, MD: Yes. And as you mentioned, sometimes the anesthesiologist, a lot of what we do, we may not be actually looking at the monitors, but because we're actually trained for so it's a three year program. By the sound of the machines, you actually know what is wrong. Like the pulse oximeter has a very typical sound. When the saturation drops, the alarms on the monitors are set off to go at X levels. Right. So you can set up your alarms. So even if we're like, let's say, fixing our medication drips or we're working on something that it's not necessarily looking at the monitor, just hearing the monitor, we are aware of what actually the vital signs are, and of course, the alarms are ever present. So we're always very aware of these alarms and everything that surrounds. We use pretty much all our senses when caring for patients.

Dr. Katrina Furey, MD: That makes a lot of sense.

Portia Pendleton, LCSW: It's interesting. I think there was an episode on Grey's Anatomy years ago about the anesthesiologist at the hospital was like, has a substance use disorder. And he was, like, falling asleep next to the patient. And of course, it's a drama, so the young resident had to do something and didn't want to get in trouble by the attending or something. But I feel like I've seen not a lot of medical dramas. I mean, that's not like my jam. But the couple that I have there seems to always be the anesthesiologist is like sometimes a villain. I don't know.

Dr. Katrina Furey, MD: Is that a stereotype? Yeah. Is that a stereotype?

Portia Pendleton, LCSW: Or like, maybe just in TV, the.

Dr. Katrina Furey, MD: Psychopath is often the villain too, so we can empathize.

Portia Pendleton, LCSW: Yeah, it seems like it's a lot of risk with that job.

Dr. Antonio Gonzalez, MD: I think that psychiatrists, dentists, and anesthesiologist seems to be the highest the physicians with the highest incidence of substance use.

Dr. Katrina Furey, MD: Disorder, I believe that's right, yeah.

Dr. Antonio Gonzalez, MD: And suicide as well, I think. Yeah. Maybe media has picked up on that. Maybe.

Dr. Katrina Furey, MD: Interesting. I think in my training, I was taught that in those specialties, you have the easiest access to controlled substances in terms of the risk of substance use disorders. So that's one reason the rates are higher. And then suicide. I didn't know anesthesiologists also had a high rate of suicide.

Dr. Antonio Gonzalez, MD: Yeah. I haven't reviewed the statistics on this, but I think that it used to be that way. I think actually, dentists might be number one. For some strange reason, anesthesiologists are high up in there.

Dr. Katrina Furey, MD: One big issue I had with this movie was the plot, because I feel like they went to great lengths to pay off a prior malpractice lawsuit. And I feel like they'd all have malpractice insurance, right? Even if I know there's certain specialties. Like, I think OB, for example, has a really high rate of malpractice insurance. Wouldn't they have malpractice to cover any claims?

Dr. Antonio Gonzalez, MD: Yes, they would.

Dr. Katrina Furey, MD: Think. And Portia, I think you were reading some criticisms of the movie. I think the general public also caught on to that, like, wow, this is like a really intricate plot to go through to pay off prior lawsuits.

Portia Pendleton, LCSW: I don't know. Murdering someone, you have to be so backed into the corner hopeless, like no other options. And it's like, I mean, A, yeah, like, you're right about the malpractice. You should have an insurance through the hospital. You're not even in private practice paying for your own, and that maybe you cut corners with that. It just seems OD that they taking going to these lengths of murdering a patient that Dr. Jack Harper was, like, friend. And it's like, at what point did the friendship turn into this? Was it fake? The whole, like, I think that's know, I watched the movie, you know, taking.

Dr. Katrina Furey, MD: Notes because we're professionals.

Portia Pendleton, LCSW: We're professionals at watching TV here, and I was just lost with a lot of the line, so I'm glad to hear it know, I guess just me, but pretty gaping holes in some of it.

Dr. Katrina Furey, MD: Yeah. And what did you think about that relationship of the friendship between Dr. Harper and Know? Because at least in psychiatry, we are big and not just psychiatry, but mental health in general, we are big boundary people. We really talk about boundaries and how to maintain them, especially in professional settings. I think in some other fields of medicine, I'm thinking more like primary care pediatrics in the old school days when you'd have the family doctor who took care of everyone in the town, I think the boundaries would have been a little different. But I always thought, especially when it came to things like surgery, it was really important not to operate or doing a seizure on people you're close to. Is that still the case?

Dr. Antonio Gonzalez, MD: Well, I think it's probably the right thing to do because your feelings for your significant other or friend may actually interfere with your judgment. But again, I think it's more of a judgment call than a set rule. I do think that there are certain surgeries and certain procedures that we probably shouldn't be doing for our family members or for close friends, because, again, our judgment may be cloud by our feelings for that person. You may not necessarily take the best decision when you're put in that place.

Dr. Katrina Furey, MD: Yeah, I think suturing up a superficial wound like your child cuts their knee. Oh, I can suture that up real quick. Feels very different to me than doing cardiac anesthesia or surgery on your buddy that you go fishing with. Yeah, right. Yeah, I would agree.

Portia Pendleton, LCSW: I could see I was thinking just, like, what would I be comfortable with a friend doing? But maybe I don't know. I mean, I'm thinking of specialties, like, ortho I could see a friend doing but not OB. It's, like, all private, and then definitely not psychiatry, but I don't know. Cardiac surgery? I don't think cardiac no, it's like your heart opening my chest. I don't want you I think it's.

Dr. Katrina Furey, MD: Important you feel like you trust the surgeon and the anesthesiology team, but to have it be like your buddy, that's risky. And what an ultimate betrayal.

Portia Pendleton, LCSW: I mean, he trusted this person. He chose to have this procedure done by, I guess, at least rating wise, like a doctor with a lower success rate than right. The mom brought in this specialist who was operating on presidents and had all.

Dr. Katrina Furey, MD: This prestige play picked Dr. Harper.

Portia Pendleton, LCSW: And then right. To have this nefarious plot going on was just I was really shocked. I was also really shocked that Sam was in on it, his fiance, because at first, I think the movie kind of sets you up to not, like the mom. Right. Like, Lilith seems, you know, like, she doesn't have his best interests at heart.

Dr. Katrina Furey, MD: It's controlling. Maybe they're enshring and not letting him.

Portia Pendleton, LCSW: Live or be independent. Right. But then know, I was like, wow, really weaseled her way in. So I don't but she was a nurse, I think, so she had some info about his medications, which the mom, Lilith, was first, really surprised and pleased. Like, wow, like, you really have been taking care of him. I see all the medications in your bag. But then that's also ultimately how she found out that Sam was in on it. Right.

Dr. Katrina Furey, MD: She saw, like, I think Sam left her purse behind, and the medications fell out. And when she went to go put everything back in the purse, she saw some mail where the name didn't match up, and then somehow she put it.

Portia Pendleton, LCSW: Together, but that wasn't clear.

Dr. Katrina Furey, MD: But again, also like, okay, so the names don't match up. That wouldn't automatically make me think, like.

Portia Pendleton, LCSW: Oh, no, you're in on it to.

Dr. Katrina Furey, MD: Murder my son while he's in this heart transplant. The plot was a little far fetched, but I did think it was entertaining, and I did know with Clay on the table, often the anesthesiologist is, like, the first person you meet when you're coming in for surgery that day and.

Portia Pendleton, LCSW: The first person you see when you wake up.

Dr. Katrina Furey, MD: So I think that's very important, as well, to your whole experience of surgery. And can you tell us a little bit, Dr. Gonzalez, about in your role, what that entails and how you sort of take care of the patient in broad strokes. And if this movie we've already talked about how the induction was totally off, but what the movie sort of got right and wrong.

Dr. Antonio Gonzalez, MD: Yeah. So I think that the role of the anesthesiologist is very important. And I think that as anesthesiologist, we realize that, as you mentioned, unfortunately, the way our system is, we usually meet our patients just the day of surgery, right? So what that entails is that we actually need to create rapport with our patients very quickly. We know that the patients are coming in for a very stressful moment in their life. Sometimes it's very big surgery, sometimes it's very minor surgeries, right? But independently of what type of surgery the patients are coming for, we need to create that rapport and we need to bring the confidence to the patient. And as anesthesiologist, I think that we try to do that the moment we're talking to the patient. The first time we talk to the patients, it's all about creating rapport and creating a team experience in which you let me know what are your goals and we can try to meet those goals and expectations. What are your fears? Some patients tell you that their major fear is pain. Some patients tell you their major fear is throwing up because all the nausea, they've experienced so much nausea after. So then you can reassure the patient, okay, so this is our plan. This is going to be our plan to address the pain. This is going to be our plan to address the nausea. And again, we do this for all types of surgery. And I think that's very important as anesthesiologist to try to create that rapport and always be, when talking to the patient, basically addressing what are your major fears and how this is our plan to address those.

Portia Pendleton, LCSW: That's such an important question. I think such an important part of the team. I think other people are just kind of part of the team, which makes sense. Like, okay, this is a surgery. They ask you a million questions like why are you here? What's your name? What's your birthday? Over and over again. So they're doing the right thing. But then for someone to ask, right, what are you scared of?

Dr. Katrina Furey, MD: Right?

Portia Pendleton, LCSW: What are you scared of today? How can we help you? Do you have any questions? Is really helpful. And I think just lets see the patient feel like they're a part of the team, like they're being validated, listened to, important, which of course they are. But I think in the system when you have maybe two to five, maybe surgeries that day, it's just like it becomes for everybody that's working, there just procedure. So I think those questions just stand out as really helpful and nice, good patient care.

Dr. Katrina Furey, MD: And the anesthesiologist is the person who you really meet at the beginning, who asks you all these questions, checks on your allergies, looks in your mouth to see like, okay, how big are those tonsils? How are we going to sort of intubate? You most comfortably asks you what you're worried about, and then they walk with you in most of the time, and they're with you, getting you on the table, getting you positioned, making sure you're comfortable, saying, okay, it's going to be cold in here, let's put a blanket on. They do a lot of that caretaking right away. I think when people are really scared, even if it's a minor surgery, I don't know who's not scared when they're going into a surgery. And of course, the surgeon comes in and they're really focused on the surgery, and of course, they want to make the experience good, too. But you're usually, like with the anesthesiologist, I think, the longest as you're consciously awake and then coming out of the surgery, that's who's also waking you up and making sure you're okay. That's who's checking on you in post op and things like that. So it is interesting that such an important member of the team and you're right, you really meet them that day and then you don't see them again, right? Like at the follow up for the surgery and stuff, you never get to see them. Is that a part of the job? Do you mind that, or do you wish that you could check on these people again?

Dr. Antonio Gonzalez, MD: Well, it's actually very interesting that you ask because one of the things that actually inspired me to become an obstetric anesthesiologist, particularly, was I sometimes felt that I was in these very long surgeries, and when I went to see the patients post op, they would not remember me. And there wasn't really a problem with the patient not remembering me. It wasn't really an ego thing. It was more like, I don't feel like he thinks I'm part of this team taking care of him. I didn't feel like I was part of the team again. But on the other hand, I just happened to see a patient in a hallway and he's like, oh, you did my epidural for labor. And I'm like, oh, I did. And that was like, oh, these patients do remember me. Do appreciate what we're doing. And although, again, it's not an ego thing, but it's just that feeling of being part of something more, like, you know, that you help somebody and they actually remember that you were part of that, alleviating the pain, and it just feels good. It makes you feel like you're really part of a team that addresses the patient's pain and all this. And that's what really brought me into obstetric anesthesia. Going back to what we were talking about, the patients, the pre op part. Again, because of my obstetric anesthesia background, most of the literature that I've reviewed is on that field. And there is a very interesting article that has changed the way I practice that basically addressed what we were just discussing, which was basically, you ask the patients would you rather have better analgesia or more side effects, depending on the dose? And the interesting thing it's a very interesting study, but the outcome of the study was that patients actually knew exactly what they wanted. The patients that were overly concerned about pain ended up consuming more pain medication. And the patients that were overly concerned with the side effects did not consume as many medications. So the patients always know. And that's why always asking your patients, what are your weigh the risk and benefits, or what are your main outcomes? What do you want to experience here? More pain, slightly less pain, slightly more side effects of the medications, or you're okay with pain knowing that your side effects are going to be less?

Dr. Katrina Furey, MD: The patients know that's actually really interesting and really important to keep sort of their autonomy and their preferences. So, Dr. Gonzalez, I know you're not like a transplant surgeon, but I thought it was pretty unlikely that the mother would just be, like, wheeled in, especially after having overdosed on something and her heart would be given right to her son.

Dr. Antonio Gonzalez, MD: Yeah, absolutely.

Dr. Katrina Furey, MD: What do you think about that?

Dr. Antonio Gonzalez, MD: Yeah, absolutely. I think you're absolutely right. And at some point, I was hoping to bring that up. First of all, as you mentioned, there is a battery of tests that the donor needs to go through before they can be a donor.

Portia Pendleton, LCSW: That's number one blood type, right?

Dr. Katrina Furey, MD: It's not just like, oh, it's a blood type match. There's like, so many more things they have to check.

Dr. Antonio Gonzalez, MD: There's so many more tests. And it seems from the movie that the mom have actually taken the purse from Sam, right? So presumably she took medications that could have actually make her heart stop. Right, which means that the period of ischemia of the heart may not have make her a good donor for her heart. She might have been able to donate her cornea and other things that actually don't have a very specific ischemia time. But there are organs that have a very limited ischemia time, meaning that the time that the organ is without perfusion or without oxygenation, without blood flow. And that is very important. The heart is one of the organs that needs perfusion for very crucial timing. It's a very small window of ischemia for the heart yes.

Dr. Katrina Furey, MD: That she'd take, again, cardiac medication that likely stopped her heart. It does seem like she called her surgeon of choice ahead of time and was like, get here now. We only have so much time. But still, it's just completely unlikely that that would have happened. It was kind of a beautiful, I guess, part of the story that they could both, in this other realm, connect with each other and she could talk to him and they got to say this goodbye. That was pretty beautiful. But in terms of accuracy, there's no way that would have happened. And so getting. Back to the title of the movie Awake, and the whole premise that he's awake in surgery and aware of everything that's going on. I think a fascinating question that comes to my mind is like, how do we define awake? Is it consciousness? Is it memory? Is it feeling? And then how do you assess it during and after something like a major surgery?

Dr. Antonio Gonzalez, MD: Yeah, that's a very interesting question. And I was thinking myself the same thing throughout the movie. And at the end, I'm still not even clear that either he was awake. We probably will never know the answer, according to the movie. But interoperative awareness, it's basically the incidence of a failure to suppress arousal, experience and episodic memory. So for you to have recall, in order for you to have introoperative awareness, there has to be recall. There are some incidents of patients actually hearing things, but they may not have necessarily distress about it because hearing and depth of sedation, the depth of sedation goes anywhere from hearing to actually not even being able to have recall. So you're going to see the worst cases of interoperative awareness when there is recall, and the patient can actually tell you how stressed they were about the experience. So they've come up with some classification. It's called the Michigan Awareness Classification, and it goes from zero, class zero, which is basically no awareness, to class one, which is auditory perceptions, class two, which is tactile perception. So they feel the surgical manipulation, they feel the endotracheal tube. And then there is class three, which is they actually feel pain. Class four, they actually have paralysis. And this is what seems to actually be happening here. He's experiencing paralysis because he said, just move something, right? He's trying to move something. He can't move anything. So he probably is there at a class four. Later on, we know that he's definitely at class five, where he's probably experiencing pain and paralysis. And then you can actually assign a D if the patient tells you that it was very stressful. They have the fear, they had fear, they had anxiety, a sense of suffocation or doom. So basically all these classifications, you can actually add a D to them. And the higher they are, and especially if they have a D next to them, the more likely these patients will have sequela. As in your profession, you can probably talk about what happens to these patients that have interpreted awareness. Right? And you were talking about moms that have pain during surgery. So that could lead to post traumatic stress disorder. But I'm not the expert there.

Dr. Katrina Furey, MD: I would imagine it would. Right. I would imagine when we think about post traumatic stress disorder, I like to think of that as a disorder of Stuckness. And I always tell my patients, like, it's normal after you've lived through something traumatic, to have the symptoms of PTSD, the hyperarousal, the hyper, vigilance, intrusive thoughts, altered avoidance, altered mood, altered line of thinking and things like that initially, because who wouldn't? We sort of call that an acute stress response. But then once it persists, usually after, like, a month or continues beyond that, then we start to think of it as something called PTSD or post traumatic stress disorder. And there's some really great treatments out there for that, including things like cognitive processing therapy or CPT, EMDR, different types of psychotherapies and medications, and patients can really get a lot better. I love treating PTSD for that reason. But I would imagine the first criterion to meet diagnostic criteria for PTSD is to have a life threatening situation happen to you or to be vicariously exposed to it, which I think is really important as a new addition to the DSM criteria. I think this will qualify.

Portia Pendleton, LCSW: Yeah, I'm just even imagining a patient coming in and describing this. I would expect a person to develop PTSD from it, and then it's like.

Dr. Katrina Furey, MD: Is that a disorder, or is that, like, a normal human response to being consciously awake but paralyzed during cardiac surgery? Right.

Portia Pendleton, LCSW: That's where you're like, well, like, trouble sleeping following. I would imagine maybe some nightmares. Might be afraid to fall asleep 100%. Or obviously, like you were saying before, Dr. Gonzalez, afraid of returning for future medical care or surgeries or telling loved ones to not do it, or their experience. So it feels really serious. And obviously, many traumas can be, but also unique. I haven't worked with someone that this has occurred to, obviously, because it is rare, but I'm just imagining, like, poor Clay when he wakes up, and if he does recall at one of those levels that you described, then what? And also write the murder plot. I mean, that was like taking the cake, let alone feeling pain.

Dr. Katrina Furey, MD: I know. Like, such intense pain, right. And being so paralyzed and helpless. I almost can't imagine anything worse.

Portia Pendleton, LCSW: He's standing up. We talked a little bit about the dissociation. That being an interesting way to show it. So sometimes when somebody's experiencing a trauma, they might dissociate and kind of see.

Dr. Katrina Furey, MD: Themselves from up above. And they did show that when he sort of zoomed out, then it took a turn where he's then solving the.

Portia Pendleton, LCSW: Plot, like, walking around, figuring it out.

Dr. Katrina Furey, MD: Like, I don't think yeah, that's not quite dissociation, but up until that point.

Portia Pendleton, LCSW: It was a great depiction of.

Dr. Antonio Gonzalez, MD: It.

Portia Pendleton, LCSW: Just it was wild.

Dr. Katrina Furey, MD: It was wild. What a wild movie. Dr. Gonzalez, as we wrap up, is there anything else you'd like to add or anything we haven't touched on that you think is important?

Dr. Antonio Gonzalez, MD: What it's really important here is for the patients to really voice out their experience. Right. One of the things that we see as physicians, we're not necessarily, particularly not psychiatrists or psychologists, we are not necessarily very well versed in how to deal with the consequences of what happens interoperatively. And it's important for the patients to say, hey, this is what I felt. But equally as important is for physicians to actually avoid minimizing what the patient felt and actually acknowledge that something happened and say, hey, I'm really sorry that you went through this. Let's try to figure out what resources we have to help you to get better, to get through these. It's actually something that I've always wondered is when is the best time to reach out for the patients? When, for example, in our case, we do C sections, right? And the patients are telling us that they're feeling pain, so they actually quickly voice out their experience so we can quickly do something about it. And even then, it's hard to figure out if you should approach the patient, shouldn't approach the patient, because not every patient won't consider a short time of discomfort or pain as traumatic. So it's a thin line in which basically we rely on the patient telling us, this is what I felt, this is how I feel now, so that we can actually look for help again, because as anesthesiologist or, surgeons may not be the best person to deal with it, but we can look for the resources.

Dr. Katrina Furey, MD: And I do think, actually, at least in my clinical experience, given what I do, it has been I can tell you without a shadow of a doubt, it has been so validating and healing for my patients who have experienced trauma within previous childbirth deliveries or IVF procedures or other things like that, who felt minimized by the team at the time when they go in for the next thing and their anesthesiologist is the one who asks them just the questions you're mentioning. Now, I'm wondering if it was you.

Portia Pendleton, LCSW: Or if you've just trained, like, some.

Dr. Katrina Furey, MD: Really good team members. But when they ask them about these things and they share their prior traumatic experience, which is very hard for them, right, like, to even share, period, but then, especially if they've felt minimized or invalidated in the past, when they share it this time, and it's met with compassion and validation, it goes so far in their healing. And so I think you're spot on, and I hope this can serve and your continuing education can serve to just keep reinforcing that to the anesthesiology team that that is really important and such a crucial time to give that validation to patients who might really need it. And I think that would go for any patient, but especially any patient with a history of PTSD prior to that. And that's a hard thing to ask about.

Portia Pendleton, LCSW: Yeah, I could definitely see it in pregnancy traumas. I think it's a pretty common experience with just, like, whether or not it's their perspective of something happening. Everything moves fast sometimes, as both of you know, I'm sure if it's supposed to be a regular delivery and all of a sudden it's not like that can be scary. And sometimes you have to prioritize saving a patient so things aren't explained slowly. It's the after of, like, okay, I know. That was really scary.

Dr. Katrina Furey, MD: Kind of debriefing.

Portia Pendleton, LCSW: Yeah, the debrief I would imagine being really helpful.

Dr. Katrina Furey, MD: And we always I think in mental health, we always assume our patients have a trauma history rather than assume they don't. And I don't think that's because there's like I mean, maybe there is a higher incidence given the patients we're seeing. But I think then if you can just sort of approach it in more of like a trauma informed framework and just assume, like, okay, let's just assume this person has had some experience in their life where they felt helpless or stuck or not heard. How do we approach them here so that they don't feel that you don't even have to ask, do you have a trauma history? You could just assume. And then I think that just goes a really far away. So I'm so glad, Dr. Gonzalez, to hear that you're just doing know that makes this psychiatrist very happy.

Dr. Antonio Gonzalez, MD: Yeah, well, I think that a lot of it has to do with the fact that some time ago, we actually read this very nice article that came out that was titled Failure of Communication, and it was actually written by a patient who experienced interoperative pain. I actually had the pleasure to have a podcast with Susanna Stanford, who is a patient who experienced introvertive pain, and she shared with us through that paper that was a couple of years ago, her experience. And from the time I read that paper, I started realizing how important that communication part is and not minimizing their pain and actually trying to address the situation in the moment and offering alternatives. Right. The most important thing, as you mentioned, is the patient needs to feel that first of all, they're being heard and that their concerns will be addressed. The worst we can do is tell them that it's not that big of a deal. Baby is okay. That's usually what we hear. Oh, the baby's okay. So it's going to be fine. The means doesn't justify the end.

Dr. Katrina Furey, MD: Well, that's wonderful. Thank you so much, Dr. Gonzalez, for joining us today. I think we will try to link to that paper in our show Notes. If anyone is interested in reading that.

Portia Pendleton, LCSW: Further and maybe also your podcast, if you want to tell us, give us.

Dr. Katrina Furey, MD: A little shout out yeah.

Portia Pendleton, LCSW: Where they can find your podcast.

Dr. Antonio Gonzalez, MD: Yes, the podcast is Yale Anesthesiology, and I will share the link as well.

Dr. Katrina Furey, MD: Thank you. And we want to thank all of our listeners for joining us today. You can find us at Analyze Scripts podcast on Instagram and TikTok. We recently updated our Instagram handle, so now it's Analyze Scripts podcast across the board, and we hope that you will join us next week as we cover the Nightmare Before Christmas on our Halloween month.

Portia Pendleton, LCSW: Yes.

Dr. Katrina Furey, MD: So we'll see you next Monday.

Portia Pendleton, LCSW: Thank you so much for joining us.

Dr. Katrina Furey, MD: Bye.

Dr. Antonio Gonzalez, MD: All right. Thank you so much for having me. This was great. Thank you.

Dr. Katrina Furey, MD: This podcast and its contents are a copyright of analyzed scripts, all rights reserved. Any redistribution or reproduction of part or all of the contents in any form is prohibited. Unless you want to share it with your friends and rate review and subscribe, that's fine. All stories and characters discussed are fictional in nature. No identification with actual persons, living or deceased places, buildings, or products is intended or should be inferred. This podcast is for entertainment purposes only. The podcast and its contents do not constitute professional mental health or medical advice. Listeners might consider consulting a mental health provider if they need assistance with any mental health problems or concerns. As always, please call 911 or go directly to your nearest emergency room for any psychiatric emergencies. Thanks for listening and see you next time.

Dr. Katrina Furey, MD: Our don't.

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