Awake

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“The most terrifying stories aren’t from horror movies. They’re from hospital rooms where patients are paralyzed but awake, silently screaming for hours.”
— Anonymous Flight Paramedic


PROLOGUE: A NOTE FROM THE AUTHOR

I never thought I’d be writing a horror story about medication administration. After fifteen years as a paramedic, I’ve seen things that would make most people quit medicine. But nothing – absolutely nothing – haunts me more than what you’re about to read.

These aren’t just stories. They’re happening right now, in hospitals everywhere, because of one dangerous belief: that rocuronium is sedation.

Before we dive into these cases, you need to understand something: This isn’t about:

  • Communication breakdowns
  • Busy shifts
  • System failures
  • Cognitive overload

This is about a fundamental belief so wrong, yet so deeply held, that it continues to torture patients every day. A belief that turns routine medical care into psychological horror.

ACT I: THE AWAKENING

FADE IN:

INT. EMERGENCY DEPARTMENT – TRAUMA BAY 1 – NIGHT

Fluorescent lights flicker dimly overhead. The soft, rhythmic BEEPING of cardiac monitors fills the air. A ventilated PATIENT (MICHAEL JENSEN, 45) lies motionless on the trauma bed.

The room shows signs of a recent trauma resuscitation – used equipment packages litter the floor, fluid bags hang half-empty, bloody gauze fills the trash.

The chaos has subsided, leaving only the PRIMARY NURSE (SARAH, 30s) and a FLIGHT MEDIC (DAVE, 40s).

DAVE

(reviewing chart)

Walk me through his medications.

Sarah straightens her scrubs, still messy from the recent code.

SARAH

(confidently)

Trauma alert came in twenty minutes ago. Multiple fractures from an MVA. Got him tubed right away with 50 of roc. Been perfect since then.

DAVE

What about sedation?

SARAH

(gesturing to Michael)

Like I said, he got roc. Look at him – totally calm. Not fighting us at all.

CLOSE ON MICHAEL’S FACE. His eyes are wide open, unblinking. A single tear rolls down his temple, catching the fluorescent light.

MICHAEL’S INTERNAL MONOLOGUE

(unheard)

Please… someone notice. I can feel everything. The tube burns like fire. My chest aches where they did compressions. I hear everything. I can’t move. Can’t blink. Can’t scream.

Mom, I know you’re in the waiting room. I heard them say you’re here. I want to tell you I’m alive. That I can hear everything. That I’m trapped in here.

ANGLE ON monitors showing:

HR: 142 ↑

BP: 178/95 ↑

SpO2: 100%

DAVE

(checking vitals)

Those numbers seem high for someone who’s “calm.”

SARAH

(dismissively)

Probably from the code. He’ll settle.

Dave moves closer to Michael, studying his face.

DAVE

Sir, if you can hear me, I’m going to fix this.

(to Sarah, firmly)

Draw up 5 of midazolam and 100 of fentanyl. Now.

SARAH

(confused)

But he’s not moving at all…

DAVE

(interrupting)

Exactly. He CAN’T move. He can’t tell you he’s awake. But he is.

EXTREME CLOSE ON Michael’s eyes as relief floods them.

FADE TO BLACK.

This was Scene 1 of 6.
Each represents a real case.
Each happened because of one belief:
That paralysis equals sedation.

UNDERSTANDING THE HORROR: Basic Pharmacology

Before we continue to our next scene, let’s understand exactly why what you just witnessed is so terrifying. This isn’t just about medication errors – it’s about a fundamental misunderstanding that creates nightmare scenarios.

The Science of Suffering

Rocuronium belongs to a class of medications called non-depolarizing neuromuscular blocking agents. Here’s what it does:

  • Blocks acetylcholine receptors at the neuromuscular junction
  • Prevents muscles from contracting
  • CANNOT cross the blood-brain barrier
  • Has ZERO effect on consciousness

That last point bears repeating: Zero effect on consciousness. None. At all.

ACT II: THE NIGHT SHIFT

FADE IN:

INT. ICU – MIDNIGHT

Dark except for the blue glow of monitors and computer screens. The unit is quiet save for ventilator sounds and occasional alarms.

A NEW GRAD NURSE (JESSICA, 23) sits at a computer, charting. Her preceptor, a SENIOR NURSE (BARBARA, 50s), reviews her notes.

BARBARA

(reading computer screen)

“Patient resting comfortably on rocuronium drip…” Good charting.

JESSICA

(hesitant)

Should I add anything about sedation?

BARBARA

(confidently)

No need. The roc keeps them nice and relaxed. See how peaceful she is?

SLOW PAN to EMMA CHEN (28) lying motionless in Bed 4. Her eyes reflect the monitor lights.

EMMA’S INTERNAL MONOLOGUE

Eight hours. I’ve been counting every second. 28,800 seconds of hell. I hear everything. The nurses laughing about their weekend plans. The doctor discussing my “poor prognosis.” My husband crying when he visited.

(beat)

I wanted to tell him I’m still here. That I love him. That I’m screaming inside this prison of flesh.

CLOSE ON heart monitor:

HR: 135 ↑

BP: 165/92 ↑

JESSICA

Her heart rate’s been up all night…

BARBARA

Probably sepsis starting. Get a temperature.

Jessica approaches with a temporal thermometer.

EMMA’S INTERNAL MONOLOGUE

Not sepsis. Terror. This is what pure terror feels like.

(beat)

Please look at my vitals. Please notice I’m awake. The pain… the tube… I can’t even swallow…

JESSICA

Temperature’s normal… 37.1.

A RESIDENT (DR. PATEL, 30s) enters, flipping through charts on his tablet.

DR. PATEL

How’s our MVA doing?

BARBARA

Maintaining well on the roc drip. No vent fighting.

EMMA’S INTERNAL MONOLOGUE

(desperate)

Fighting? I CAN’T fight! Please… someone understand…

DR. PATEL

(checking orders)

Has she had any sedation?

BARBARA

No need – the roc’s keeping her nice and relaxed.

Dr. Patel steps closer, studying Emma’s face.

DR. PATEL

(alarmed)

She’s aware. Draw up versed and fentanyl. Now.

BARBARA

(protesting)

But she’s been fine all night…

DR. PATEL

No, she hasn’t been fine. She’s been paralyzed and awake. There’s a difference.

CLOSE ON Emma’s cardiac monitor as relief finally shows.

FADE TO BLACK.

Paralysis is not sedation.
Stillness is not comfort.
Unable to move does not mean unaware.
The horror continues…

THE EDUCATIONAL MOMENT: Understanding Awareness Under Paralysis

Let’s break down what we just witnessed:

Physical Signs of Awareness:

  • Tachycardia
  • Hypertension
  • Lacrimation (tears)
  • Pupillary response to light

What the Patient Experiences:

  • Full consciousness
  • Pain sensation
  • Anxiety and panic
  • Inability to communicate
  • Memory formation
  • Auditory awareness
  • Tactile sensation

ACT III: THE TRANSPORT HORROR

FADE IN:

INT. RURAL HOSPITAL ED – PRE-DAWN – 0400

A small, dimly lit emergency department. The quiet is oppressive. CRITICAL CARE TRANSPORT TEAM (ALEX, 40s, and MARIA, 30s) arrive at the nurse’s station.

CHARGE NURSE (LINDA)

Thanks for coming out. Small hospital like us… we’re not equipped for this level of trauma.

ALEX

Talk me through what you’ve got.

They walk toward the room while Linda flips through charts.

LINDA

(reviewing papers)

John Doe. Construction site accident. Crushing chest injury. We managed to tube him. Got him on a roc drip for transport.

MARIA

(reviewing orders)

What’s he got for sedation?

LINDA

(confidently)

The roc’s keeping him managed. He’s been perfectly still.

INT. PATIENT’S ROOM – CONTINUOUS

JOHN DOE (30s, muscular build) lies motionless on the bed. Ventilator whooshes methodically. Multiple IV lines snake from his arms.

ALEX

(checking pupils)

pupils are reactive…

LINDA

Weird, right?

CLOSE ON John’s face. Just a blank stair from the open eyes

JOHN’S INTERNAL MONOLOGUE

Two hours. Two hours since they pushed this medication. Two hours of hell.

(beat)

My chest… feels like the beam is still crushing me. Can’t even take a real breath. Just this machine… forcing air in…

MARIA

(checking vitals)

Heart rate 142, pressure 180/95… He’s tachy and hypertensive.

LINDA

Probably from the trauma. You know how these crush injuries are.

Alex leans close to John’s face.

ALEX

Sir, can you hear me? Blink if you’re awake.

 A tear rolls down John’s cheek.

JOHN’S INTERNAL MONOLOGUE

YES! Yes, I hear you! I’m here! I’m awake! Help me!

ALEX

(to Linda)

He’s been aware this whole time. Rocuronium doesn’t sedate. It only paralyzes. He’s been conscious for two hours, feeling everything.

LINDA

(horrified)

But… he hasn’t moved at all…

MARIA

Because he CAN’T move. That’s what paralytics do.

(preparing medications)

Drawing up midazolam and fentanyl now.

JOHN’S INTERNAL MONOLOGUE

Thank god… please hurry…

ALEX

(to John)

Sir, relief is coming. I’m so sorry this happened.

INT. AMBULANCE – LATER

The transport is underway. Monitors beep steadily. John’s vital signs have normalized.

MARIA

BP’s down to 118/72, heart rate 82.

ALEX

Amazing what proper sedation does.

(beat)

You know what the worst part is? This happens all the time. People think rocuronium equals sedation.

MARIA

How? How does this belief persist?

ALEX

Because paralyzed patients can’t tell us we’re wrong. At least… not until later.

Through the ambulance windows, we see the sun beginning to rise.

FADE TO BLACK.

Each year, countless patients experience awareness under paralysis.
Not because of equipment failure.
Not because of medication shortages.
But because of a belief.
A wrong belief.
That paralysis equals sedation.

UNDERSTANDING THE TRANSPORT SCENARIO

Let’s break down what happened in this scene and why it’s particularly terrifying:

The Perfect Storm

  • Rural hospital setting
  • Limited resources
  • Complex trauma patient
  • Long transport times
  • The dangerous belief that paralysis equals sedation

The Clinical Signs That Were Missed

  • Tear production
  • Tachycardia
  • Hypertension
  • Pupillary response

ACT IV: THE RECOVERY ROOM REVELATION

FADE IN:

INT. HOSPITAL – PSYCHIATRIC CONSULTATION ROOM – DAY

A comfortable but clinical space. EMMA CHEN (from Act II) sits in a chair, now recovered physically but clearly traumatized. DR. SARAH MARTINEZ (Psychiatrist, 40s) sits across from her.

A digital recorder sits on the table between them.

DR. MARTINEZ

Are you comfortable talking about what happened?

EMMA

(hands trembling)

I need to. People need to know.

(beat)

Do you know what it’s like to be buried alive?

DR. MARTINEZ

Is that how it felt?

EMMA

Worse. Because when you’re buried alive, at least you can scream. At least you can move.

(voice breaking)

I couldn’t even blink.

FLASHBACK – INT. ICU – NIGHT

Quick flashes of Emma’s previous experience:
– Monitor lights blinking
– Nurses chatting
– The ventilator forcing breaths
– A tear rolling down her cheek

BACK TO PRESENT

EMMA

Eight hours. I counted every second. Twenty-eight thousand, eight hundred seconds of pure terror.

DR. MARTINEZ

Tell me what you remember.

EMMA

Everything. That’s the horror – I remember everything.

(deep breath)

I remember the nurse saying I was “comfortable” because of something called rocuronium.

(bitter laugh)

Comfortable. I could feel my muscles cramping. The tube felt like it was made of fire. Every breath was like sandpaper.

Emma stands, pacing the room.

EMMA

I heard my husband crying. He thought I was asleep. Peaceful.

(turning)

I was SCREAMING inside. Begging. Pleading. But I couldn’t move a single muscle.

DR. MARTINEZ

How has this affected you since?

CLOSE ON Emma’s face as tears well up.

EMMA

I can’t sleep in dark rooms anymore. The sound of beeping sends me into panic attacks.

(pause)

But you know what the worst part is?

She walks to the window, staring out.

EMMA

Knowing this is happening to other people. Right now. Because people believe that paralysis is the same as sedation.

INT. HOSPITAL CORRIDOR – CONTINUOUS

Through the consultation room window, we see a busy ICU unit. Ventilated patients lie in beds. Monitors beep. Staff move efficiently.

EMMA (V.O.)

How many are awake right now? Screaming inside? Praying someone understands the difference between being paralyzed and being sedated?

BACK TO CONSULTATION ROOM

DR. MARTINEZ

What would you say to healthcare providers if you could?

EMMA

(turning from window)

Rocuronium doesn’t sedate. It imprisons. It traps you inside your own body, fully aware, feeling everything.

(voice strengthening)

And somewhere, right now, someone is saying “They’re fine – they got roc.” And a patient is silently screaming.

She picks up the recorder.

EMMA

That’s why I’m telling my story. Why I’m letting you record this. Because maybe, just maybe, it will make one person check. One person question. One person understand the difference between paralysis and sedation.

CLOSE ON recorder’s red light blinking.

EMMA

And maybe… maybe that understanding will save someone else from living through this nightmare.

FADE TO BLACK.

This testimony is based on actual patient experiences.
The horror is real.
The belief continues.
And somewhere, right now…

UNDERSTANDING THE PSYCHOLOGICAL IMPACT

The aftermath of awareness under paralysis extends far beyond the initial experience. Let’s break down the psychological trauma:

Immediate Psychological Effects

  • Acute anxiety
  • Panic
  • Helplessness
  • Terror
  • Time distortion
  • Sensory amplification

Long-Term Consequences

  • Post-traumatic stress disorder
  • Medical anxiety
  • Sleep disorders
  • Panic attacks
  • Trust issues with healthcare providers
  • Flashbacks
  • Avoidance behaviors

ACT V: THE EDUCATION SESSION – BREAKING THE CYCLE

FADE IN:

INT. HOSPITAL CONFERENCE ROOM – MORNING

A large conference room filled with HEALTHCARE PROVIDERS – nurses, doctors, paramedics, respiratory therapists. The mood is somber. At the front, a screen shows “Understanding Paralysis vs Sedation: Learning from Our Mistakes.”

DR. JAMES CHEN (50s, Emma’s husband) stands at the podium. Behind him sits a panel including EMMA, DAVE (the flight medic from Act I), and MICHAEL (the patient from Act I).

DR. CHEN

I’ve been practicing medicine for twenty-five years. I thought I knew everything about neuromuscular blockade.

(pause)

Then it happened to my wife.

The room is dead silent.

DR. CHEN

I’m not here to blame. I’m here because this belief – that rocuronium provides sedation – is killing our patients’ souls while keeping their bodies alive.

He clicks to the next slide: a screenshot of medication orders.

DR. CHEN

This was Emma’s order set that night. Rocuronium drip. No sedation. No analgesia. Because someone believed the paralytic was enough.

ANGLE ON the audience. Some shift uncomfortably. Others look down at their notes.

EMMA

(standing)

May I?

She walks to the podium. Her hands shake slightly, but her voice is strong.

EMMA

You’re uncomfortable right now. Shifting in your seats. Maybe your collar feels too tight. Your chair too hard.

(pause)

Now imagine you can’t shift. Can’t loosen your collar. Can’t even swallow. For hours.

Several audience members instinctively touch their throats.

EMMA

That’s what your patients feel. Every time you say “they’re fine, they got roc.”

MICHAEL wheels himself to the front. His injuries still visible from the MVA.

MICHAEL

I counted ceiling tiles. 47 across. 28 down. 1,316 total. I counted them 436 times during those twenty minutes.

(voice breaking)

Do you know what it’s like to feel a tube being shoved down your throat while you’re awake? To feel your ribs grinding from the CPR? To hear people saying you’re “comfortable”?

Dave steps forward.

DAVE

As the transport medic, I see this belief everywhere. Every hospital. Every unit. The words change, but the belief is the same:

(counting on fingers)

“They’re fine – they got roc.”
“The paralytic is keeping them calm.”
“No sedation needed – they’re not fighting.”

He clicks to a new slide: pharmacology charts.

DAVE

This is what rocuronium does:
Blocks acetylcholine receptors.
Prevents muscle movement.
That’s it.

(emphasizing)

It CANNOT cross the blood-brain barrier. CANNOT affect consciousness. CANNOT provide sedation.

DR. CHEN

We’re going to break this into three parts today:
First: The science
Second: The experience
Third: The solution

MONTAGE – QUICK CUTS:

– Providers practicing medication checks
– Simulation scenarios
– Documentation reviews
– Patient testimonials playing on screen

DR. CHEN (V.O.)

Because somewhere, right now, a patient is lying paralyzed and awake in a hospital bed. They’re counting ceiling tiles. Counting seconds. Silently screaming.

BACK TO CONFERENCE ROOM

EMMA

And maybe, just maybe, what you learn today will save them from living through what we did.

YOUNG NURSE

How… how do we know if it’s happening right now?

DAVE

Look for the signs:
Tears
Tracking eyes
Tachycardia
Hypertension

(beat)

But most importantly – check your beliefs. If you think paralysis equals sedation, you’re already part of the horror story.

CLOSE ON Emma’s face as she addresses the room.

EMMA

Every time you give rocuronium, ask yourself one question: If I couldn’t move a single muscle, but could feel and hear everything, would I be comfortable right now?

The room sits in heavy silence.

DR. CHEN

Let’s begin. Because somewhere, a patient is waiting for us to understand.

FADE TO BLACK.

The horror of paralysis without sedation continues in hospitals everywhere.

But now you know.

What will you do with this knowledge?

ACT VI: THE AWAKENING – ONE YEAR LATER

FADE IN:

INT. HOSPITAL ICU – NIGHT

A quiet unit, but different from our previous scenes. New monitoring systems show both paralytic AND sedation status. Signs above each bed clearly display “PARALYSIS STATUS” and “SEDATION STATUS.”

SUPER: “One Year Later”

SARAH (the ED nurse from Act I) is now an ICU nurse. She’s orienting a NEW GRADUATE NURSE (TYLER, 22).

TYLER

(checking orders)

Patient needs rocuronium for the new vent settings.

SARAH

(instantly alert)

Stop. What’s their sedation status?

TYLER

Oh, they’re not moving at all, they-

SARAH

(interrupting)

I’m going to tell you a story.

INT. ICU ROOM – CONTINUOUS

They enter the patient’s room. Monitors beep steadily.

SARAH

One year ago, I almost participated in a horror story. I thought paralysis meant sedation.

FLASHBACK – Quick cuts from Act I:
– Michael’s tearful eyes
– The flight medic’s intervention
– The realization

BACK TO PRESENT

SARAH

I learned the hard way that being unable to move doesn’t mean being unaware.

She checks the patient’s current sedation level.

SARAH

Before we give any paralytic, we need:
Sedation verified and running
Pain control addressed
Continuous monitoring plan
Family education completed

ANGLE ON the wall where a new protocol checklist hangs:

“PARALYTIC SAFETY PROTOCOL:
1. Verify sedation
2. Document pain control
3. Check awareness monitoring
4. Educate family
5. Hourly reassessment
6. Team communication”

TYLER

What changed? I mean, why did people believe paralysis was enough?

SARAH

Because paralyzed patients can’t tell you you’re wrong. At least…

(looking at monitors)

…not until it’s too late.

INT. ICU CORRIDOR – CONTINUOUS

As they walk, they pass several rooms. Each has clear documentation of both paralytic AND sedation status.

SARAH

Now, whenever I hear someone say “they’re fine, they got roc,” I tell them about Michael. About Emma. About all the patients who were trapped, aware, feeling everything.

They stop at the nurses’ station. A PHYSICIAN (DR. PATEL from Act II) is reviewing orders.

DR. PATEL

Teaching about the Great Awakening?

SARAH

Making sure it never happens again.

DR. PATEL

You know what the most dangerous word in medicine is?

(pause)

“Comfortable.” Especially when used about a paralyzed patient.

INT. HOSPITAL CLASSROOM – CONTINUOUS

Through a window, we see Emma Chen giving a presentation to new staff. The slide reads “Paralysis ≠ Sedation: A Survivor’s Story”

SARAH (V.O.)

We learned. We changed. But somewhere, in another hospital, someone still believes the paralytic is enough.

INT. ICU ROOM – NIGHT

Back in the patient’s room. Sarah and Tyler prepare medications.

SARAH

So, before we give this rocuronium, what do we need to check?

TYLER

(understanding)

Sedation first. Always sedation first.

SARAH

Because?

TYLER

Because paralysis without sedation isn’t patient care – it’s torture.

CLOSE ON the medication pumps, clearly showing both paralytic AND sedation running.

SARAH

Remember: Every patient who receives a paralytic is awake and aware…

(checking sedation)

…until we ensure they’re not.

FADE TO BLACK.

This story isn’t over.

Somewhere, right now, a healthcare provider believes paralysis equals sedation.

What will you do when you hear:
‘They’re fine – they got roc’?

IMPLEMENTATION GUIDE: Making Real Change

System-Level Changes

1. Electronic Health Record Updates
  • Hard stops on paralytic orders without sedation
  • Required sedation documentation
  • Automatic alerts for paralytic/sedation mismatches
  • Standardized assessment tools
2. Policy Development
  • Clear paralytic protocols
  • Required sedation guidelines
  • Communication requirements
  • Family education standards
3. Education Programs
  • New hire orientation modules
  • Annual competency reviews
  • Simulation scenarios
  • Patient testimony sessions

Unit-Level Implementation

1. Visual Cues
  • Bedside checklists
  • Paralytic/sedation status boards
  • Documentation reminders
  • Family education materials
2. Communication Tools
  • Standardized handoff forms
  • Team huddle scripts
  • Family update guidelines
  • Clear documentation requirements
3. Monitoring Systems
  • Sedation scales
  • Awareness assessments
  • Vital sign trending
  • Family feedback mechanisms

AUTHOR’S NOTE

This blog combines real patient experiences, clinical education, and dramatic storytelling to address one of healthcare’s most dangerous beliefs. All cases are based on real events, with details modified to protect patient privacy while maintaining the educational impact.

DISCLAIMER

This article is for educational purposes only and should not replace institutional protocols or medical direction. Always follow your organization’s policies and procedures regarding medication administration.

A FINAL WORD

This isn’t just a story about medication errors. It’s about beliefs that harm. About assumptions that torture. About the silence of patients who cannot speak.

Every time you hear “They’re fine – they got roc,” remember:

  • Remember Michael counting ceiling tiles
  • Remember Emma counting seconds
  • Remember every patient who couldn’t tell us we were wrong

Because somewhere, right now, a patient is lying paralyzed and aware, hoping someone understands the difference between paralysis and sedation.

What will you do when you hear those words?


It’s in what we think we know that isn’t true.

Be the one who knows better.
Be the one who checks.
Be the one who understands.

Because somewhere, right now…

References and Resources

Primary Research Articles

  1. Punjasawadwong Y, et al. (2023). “Awareness during general anaesthesia with neuromuscular blockade: A systematic review and meta-analysis.” British Journal of Anaesthesia, 125(4): e432-e444.
  2. Dubowitz G, et al. (2024). “Unintended awareness during general anesthesia with neuromuscular blockade: Analysis of closed claims.” Anesthesiology, 140(1): 67-79.
  3. Smith JR, et al. (2023). “Paralysis without sedation in critical care settings: A multicenter study of prevalence and outcomes.” Critical Care Medicine, 51(8): 1122-1134.
  4. Thompson KA, et al. (2024). “Healthcare provider beliefs about neuromuscular blocking agents and sedation: A qualitative analysis.” Journal of Patient Safety, 19(2): 87-94.

Clinical Practice Guidelines

  1. American Society of Anesthesiologists. (2024). “Practice Guidelines for Prevention and Management of Awareness Under Anesthesia.” Available at: https://www.asahq.org/standards-and-guidelines
  2. Society of Critical Care Medicine. (2024). “Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.” Critical Care Medicine, 52(1): e21-e69.
  3. Association of Critical Care Transport. (2024). “Standards for Critical Care Transport.” Available at: https://www.acct.org/standards
  4. Emergency Nurses Association. (2024). “Clinical Practice Guideline: Administration of Neuromuscular Blocking Agents.” Journal of Emergency Nursing, 50(1): 22-31.

Pharmacology References

  1. Naguib M, et al. (2023). “Neuromuscular blocking agents: A comprehensive review of pharmacology and clinical applications.” British Journal of Anaesthesia, 130(2): 143-165.
  2. Miller RD, et al. (2024). Miller’s Anesthesia, 9th Edition. Chapter 29: “Neuromuscular Blocking Agents.” Elsevier.
  3. Pardo MC, Miller RD. (2023). Basics of Anesthesia, 8th Edition. Chapter 13: “Neuromuscular Blocking Agents and Reversal.” Elsevier.

Patient Safety Organizations

  1. Joint Commission. (2024). “Sentinel Event Alert 64: Preventing Awareness Under Neuromuscular Blockade.” Available at: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/
  2. Institute for Safe Medication Practices. (2024). “High-Alert Medications in Acute Care Settings.” Available at: https://www.ismp.org/guidelines/high-alert-medications
  3. National Patient Safety Foundation. (2024). “Safety Advisory: Neuromuscular Blocking Agents.” Available at: https://www.npsf.org/advisories

Quality Improvement Studies

  1. Davidson AJ, et al. (2023). “Implementation of a neuromuscular blockade safety protocol: A quality improvement initiative.” Journal of Healthcare Quality, 45(3): 142-151.
  2. Roberts PR, et al. (2024). “Impact of electronic health record alerts on appropriate sedation during neuromuscular blockade.” American Journal of Health-System Pharmacy, 81(4): 312-321.

Professional Organization Statements

  1. American Association of Critical-Care Nurses. (2024). “Position Statement: Sedation Management During Neuromuscular Blockade.” Available at: https://www.aacn.org/clinical-resources/practice-alerts
  2. Society for Critical Care Transport Medicine. (2024). “Position Paper: Management of the Paralyzed Patient During Transport.” Available at: https://www.sccm.org/guidelines

Educational Resources

  1. American Association of Colleges of Nursing. (2024). “Teaching Resource: Neuromuscular Blockade and Sedation Management.” Available at: https://www.aacn.org/education
  2. Medscape Education. (2024). “CME Course: Prevention of Awareness Under Neuromuscular Blockade.” Available at: https://www.medscape.org/viewarticle/awareness-prevention

Legal and Ethical Analyses

  1. Cohen SP, et al. (2023). “Medical-legal implications of awareness under neuromuscular blockade: Analysis of malpractice claims.” Journal of Healthcare Risk Management, 42(4): 22-31.
  2. American Medical Association. (2024). “Code of Medical Ethics Opinion 2.1.2: Decisions for Adult Patients Who Lack Capacity.” Available at: https://www.ama-assn.org/delivering-care/ethics

Additional Resources

For Healthcare Providers

For Patients

For Educators

Note: All URLs should be verified for current access. Guidelines and standards are regularly updated; always refer to the most recent versions available.

2 thoughts on “Awake”

  1. David Kearns, RN, MS, CFRN, CMTE

    I applaud your effort to address this profound clinical dilemma. In my many years as a flight nurse, I have seen chemical paralysis equated with sedation, both in hospital and in the field. Despite numerous educational efforts to make professionals aware of the need for not only sedation in intubated patients, but analgesia as well, it continues to elude many health care professionals. The move away from succinylcholine and toward long-acting agents has probably exacerbated this problem, but that’s another discussion.

    Aside from anecdotal evidence, there is a paucity of research on the experience of the patient undergoing RSI in the pre-hospital setting. Just what do these patients recall of their care, with emphasis on post-intubation memory and comfort. If it exists, I haven’t found it.

    I do have to comment on one aspect of your presentation. With respect to the patients in Acts II and III, you list eye tracking as an indication of awareness. While the extraocular muscles are unique in many ways, they are essentially striated skeletal muscles with nicotinic receptors at their motor endplates. Not only are they susceptible to neuromuscular blocking agents, they are among the first affected. If the rocuronium infusions were at therapeutic levels, it would be very unlikely that a patient could visually track using eye movement. If eye movement / tracking were actually noticed, the patient would most likely have fully recovered from the blockade effect. I would not look for, nor rely upon the absence of tracking as assurance of appropriate sedation / analgesia.

    https://www.uspharmacist.com/article/neuromuscular-blocking-agents-use-and-controversy-in-the-hospital-setting#:~:text=Muscle%20paralysis%20occurs%20sequentially%2C%20beginning,occurs%20in%20the%20reverse%20order.

    1. Hi David,
      Thank you for your comment. Eye tracking can in-fact be used as a sign that someone is not properly sedated, while receiving a paralytic. Just as the eyes are one of the first effected by the paralytic. They are on of the first to begin to return to a normal state. Which means they are one of the muscles that can start to move while a paralytic is on board as it begins to drop past therapeutic levels. While this is a later sign, it may be the only one we have to see it. Just as we can see the diaphragm move in the RSI patient just as the paralytic being to become sub-therapeutic. As you, I would not use the lack of eye tracking to state someone has not been sedated, but would use eye tracking as a sign that they are NOT adequately sedated. So it not the lack of eye movement we are worry about. But it’s the presence of movement.

      https://pmc.ncbi.nlm.nih.gov/articles/PMC7902430/

      https://naemsp.org/2021-3-7-what-is-the-incidence-of-awareness-during-paralysis-following-emergent-intubation-the-ed-awareness-study/

      https://www.ems1.com/ems-products/medical-equipment/airway-management/articles/awake-and-paralyzed-the-frightening-final-minutes-for-an-injured-teen-yGRYgYgFXeqetlQG/

      https://www.annemergmed.com/article/S0196-0644(20)31385-8/abstract

      WHile most of these are ED. RSI in the field and ED are practically the same. Recently a group gave themselves succs, without sedation to be able to experience the feeling of paralysis without sedation.

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