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As the cancer patient lay on the operating room table, she felt the surgeon remove her intestines and splay them over her abdomen. Terrified, she was awake but unable to provide a signal -- a wiggle of a toe, the bat of an eyelash -- to communicate the excruciating pain she was suffering.

Paralyzed by drugs commonly used during surgery, the woman was trapped in a body that could feel and hear but could not move as a surgeon sliced a tumour from her cecum, a small pouch connected to the colon, deep inside her abdomen.

"I couldn't breath[e] and was very scared. I can't find adequate words to describe the horror," she wrote in a letter to the Health Services Appeal and Review Board, made public for the first time today. ". . . I felt my intestines pop out of my body very quickly and they were laid on the right side of my body." Her intestines, she wrote, felt very warm.

While such a story is sometimes considered an urban myth, this woman's story is truly horrifying. She felt a catheter being inserted into her body. And a hand touch her stomach. Then there was the searing pain of a knife taken to her abdomen, what she likened to "putting naked flesh on a stove."

There was strong pressure, then the cut of scissors. She tried to move her hands and feet -- anything to alert the surgeon and anesthesiologist -- but the muscle relaxants had rendered her motionless during that April 7, 2004, operation at a Sarnia hospital.

In the background, she heard operating room chatter: people talked about how unfortunate it was that Martha Stewart was greedy because of how little she had financially gained for having to go to jail.

Although a Health Services Appeal and Review Board order prohibits the patient's name from being published, her story provides details of the rare yet terrifying phenomenon of anesthetic awareness.

It is thought to be mercifully rare, occurring only once or twice out of every 1,000 operations. But small percentages can spell big numbers.

A conservative estimate suggests 1,824 Canadians are awake during an operation every year, according to Gilles Plourde, an anesthesiologist at Montreal Neurological Hospital, who studies the mechanisms of anesthetic and awareness during surgery. Of those, 180 or so would have the terrifying combination of being awake and in pain.

"It can lead to posttraumatic stress disorder, it can elevate stress hormones," Dr. Plourde said. "It can be terrifying because the patients don't understand what is going on."

According to Shane Sheppard, president of the Canadian Anesthesiologists Society, to be awake and in pain during an operation is "extremely rare. You get to go on Oprah when that happens."

Dr. Sheppard cites a U.S. study that suggests anesthetic awareness may be even more rare than commonly thought, occurring in only one in 50,000 operations.

A patient who is aware would show a change in heart rate, blood pressure and sometimes even perspire, tipping off the anesthesiologist that the patient is "light." However, those vital signs are often up and down during an operation, anyway, making it an imperfect signal, he said.

In the Saskatoon City Hospital where Dr. Sheppard works, a high-tech tool called a brain activity monitor is used on some patients who are under a general anesthetic during surgery.

Scott Beattie, deputy anesthesiologist-in-chief at Toronto General Hospital, said the doses of drugs required to give an anesthetic vary greatly among the type of patient. Typically, patients are given a narcotic, a muscle relaxant and an inhalation vapour, the latter of which relieves pain and erases memory.

He knows of one case where a Toronto patient recalled conversations from surgery and yet none of her vital signs were up during surgery.

"In this case, by all measured signs, it was apparently a good anesthetic, we don't know why this happened," Dr. Beattie said. ". . . What we're looking at is a variability from patient to patient. This variability is a huge issue."

The vigilance of anesthesiologists, who are highly trained medical specialists, he said, makes anesthetic awareness very rare.

Those who have been unfortunate enough to be awake during surgery describe it as akin to being buried alive. Patients are haunted by nightmares, suffer panic attacks and experience intense flashbacks.

Carol Weihrer, president and founder of the U.S.-based group Anesthesia Awareness Campaign, Inc., knows the pain of being awake during surgery all too well. She was conscious while doctors surgically removed her right eye and fiddled with a tube down her throat during a Jan. 24, 1998, operation.

"I saw them cut the optic nerve," Ms. Weihrer said in a telephone interview in Reston, Va. "And I heard the surgeon say 'You have to really pull hard to get the eye out.' "

Though medicine is often referred to as more art than science, nowhere is that more true than with anesthesia.

The amount of anesthetic required isn't easy to calculate as it depends not only on body weight but how much muscle and fat a person has and what type of operation they are about to undergo. Physical fitness and other conditions, such as diabetes or alcohol abuse, also make it more difficult to calculate the right amount to keep a patient under.

Michael Wang, professor of clinical psychology in the medical school at the University of Leicester in England, said patients who have experienced anesthetic awareness are commonly afflicted with panic attacks at night.

Dr. Plourde of Montreal said that over the years about 20 patients have been referred to him by colleagues. The medical literature, he said, shows that posttraumatic stress disorder tends to arise in those who have "had pain or been terrified" and "in patients whose claims are denied or ridiculed."

In the Sarnia woman's case, she had no history of a psychiatric disorder before the surgery. Until the operation, she was described as outgoing, according to a psychiatrist's report filed as an exhibit with the Health Services Appeal and Review Board.

After the operation, she told her surgeon, Joan Ross, about being awake. She said the surgeon responded by saying: "It is unimaginable, unthinkable, impossible," according to the letter by psychiatrist R. Olukayode Jegede, who assessed the Sarnia woman.

"The patient felt that the doctor was basically telling her that she was lying," wrote Dr. Jegede, who described the patient in the Jan. 11, 2005, letter as having an obvious case of posttraumatic stress disorder.

"Later on, Dr. [Muriel] Yarde, the anesthesiologist, spoke to her and mentioned that her experience of being conscious during surgery might have occurred because of the level of the patient's blood count," the same letter said.

When the Sarnia woman saw the surgeon at church, some six months after the operation, in October, 2005, she said Dr. Ross pulled her aside and said: "Now that Dr. Yarde and I have admitted it, what else do you want from us?" according to that same psychiatrist letter.

When she told the surgeon she was having nightmares, she said "Dr. Ross made light of it by telling her that she did not need to have any nightmares since there are so many medications available," according to the letter.

In that letter, the psychiatrist concluded the patient's condition was precipitated by three events: her "unusual experience during surgery in which she was partly conscious while much of the surgery was going on and felt severe pain," the "alleged rudeness and lack of compassion of the surgeon immediately after surgery," and the "prescription of Demerol for her by the surgeon after surgery even though it was clearly stated that she was allergic to Demerol."

Dr. Jegede's letter was based on conversations he had with the Sarnia woman and not with the surgeon and anesthesiologist. Repeated attempts to contact Dr. Ross and Dr. Yarde have been unsuccessful.

The patient told The Globe and Mail yesterday that she has complete confidence in Dr. Ross. "The doctor is an excellent doctor. She did her job. I don't know why you [have to] name this doctor. It is unfair."

Toni Adey, director of community relations with Bluewater Health, the legal corporation of the three hospital sites, said she cannot comment on the specific case without the patient's written consent due to the Personal Health Information Protection Act. However, she stressed that the hospital has a formal review process for patient complaints, which includes a chart review and discussions with caregivers involved, such as doctors and nurses.

"A clinical conference is completed to identify process recommendations or changes if required," Ms. Adey wrote in an e-mail. "The results of the review are then communicated and shared with the patient or family member."

Exhibits filed with the Health Services Appeal and Review Board, where patients go to get out-of-country treatment funded, show a patient desperate for relief. The Sarnia woman tried yoga, massage and antidepressants, not only to relieve her nightmares but to help decrease her arthritic pain.

She saw eight health professionals in all. Receipts entered as exhibits show she paid $625 out of pocket for a psychologist; another $359 for a naturopathic doctor. There was $425 on massage and $400 on acupuncture.

When all treatments failed to rid her of the nightmares, she asked the Ontario government in July of 2006 to fund out-of-country treatment for posttraumatic stress disorder at a mental health clinic in Michigan. The government refused and she therefore appealed her case to the board.

In denying her case, the Health Services Appeal and Review Board tribunal wrote in a Feb. 20, 2007, decision that it was not necessary for the Sarnia woman to travel outside of Canada for posttraumatic stress disorder treatment as there are psychiatrists in the city she resides.

Although the Sarnia woman refused further comment, in documents before the board, she describes being awake during her cancer surgery as being the "most traumatic experience in my life."

Measuring brain activity

With a brain activity monitor, a sticky sensor strip is placed on the patient's forehead. There, brain activity is measured, then compared with records held in the brain activity monitor's memory. It shows a number that indicates how far under the patient is believed to be.

The theory is that when a patient is awake but paralyzed, the machine will show the patient is experiencing a high level of awareness to alert the anesthesiologist to adjust the medication.

Though not perfect, the machines are one more piece of information for anesthesiologists to process as they manage the delicate balancing act of trying to keep surgical patients under.

Shane Sheppard, president of the Canadian Anesthesiologists Society, said: "People were trying to develop this concept for many years. This company finally hit the market with technology that was good enough to be approved by regulatory authorities but it's not perfect. The next generation will be better. [But] if you ask me do I want one when I have an anesthetic, the answer is yes."