To the Editor
Should anesthesia personnel be involved in conscious sedation methods for endoscopy? This is, I believe, a misframing of an important issue.
Prior to going into anesthesiology, I had planned to do internal medicine. As a result, I spent a great deal of time working with cardiologists, pulmonologists and gastroenterologists. I saw cardioversion performed once with the patient having received 20 mg Valium and being left obtunded for 30 hours. I once saw a patient with severe AS/MS (rheumatic heart disease) code and die because of what I believe to be panic, with no reserve to mount a sufficient cardiac output in the face of massive catecholamine release. The cardiologist had given the patient a ‘safe’ dose of 2.5 mg Valium IV.
Let’s see… There were bone marrow biopsies and aspirations, grindingly done with nothing but local anesthesia (I didn’t realize that local anesthetics worked well on the periosteum).
For colonoscopy I saw internists give Demerol/Valium and later Demerol /Versed cocktails. The results: the vast majority of colonoscopic procedures evoked responses consistent with significant pain. I saw patients groan, squirm, cry out and shed tears.
Do internists know how to use opioids? Prior to PCA, most internists used to order Demerol 25-50 mg q3-4 hr (early 1980s) for “alleviating’ painful conditions.
The fact is, few internists know anything about sedative/amnesic/analgesic drug management. They have developed ever-increasingly invasive procedures with no sensibility about the pain and discomfort they cause. (‘Hold still, Mrs. Jones, this won’t take much longer …. Don’t move Mr. Smith, we’re almost there.’).
What has happened is the same process as putting a frog in a pan of water and heating it up slowly. Internists have gradually come to do more invasive procedures over time, and if just a little more pain occurs than for less invasive procedures, that should be quite all right.
I challenge any endoscopists to face reality: What are the endpoints at which you would say that better anesthetic/analgesic regimen is needed than you are capable of giving? You don’t have an answer to that. You’ve never even thought about doing a visual pain analogue study.
Is amnesia equivalent to adequate anesthesia? Of course not, except to internists. Yet if it were not for Versed, I dare say very few patients would return to their endoscopists for repeat checkups. Even with Versed, I would argue that if patients’ families saw what occurred in endoscopy suites, they wouldn’t let Grandma go back.
As anesthesiologists, we sometimes use amnesic agents to cover up a weak block, but we don’t make it a daily practice. The anesthesiologist whose patients writhed under the surgeon’s knife on a routine basis would be someone who would quickly develop a ‘doesn’t know what he’s doing’ reputation among surgeons.
In the wake of numerous mishaps at the hands of endoscopists in the mid-8N, procedural and post-procedural monitoring standards were enacted in most hospitals, and Versed-dosing guidelines were downscaled. (Did it take a warning from Roche to tip anesthesiologists that 0.3-0.7 mg/kg of Versed was an overdose? Then why didn’t endoscopists figure this out on their own, as we did in 1985, if they really knew what they were doing?)
Few anesthesiologists today perform anesthesia services for endoscopy, because of insurers’ unwillingness to pay for it. Yet who has done cost benefit studies, whereby propofol/mivacurium was used and compared to Demerol/Versed, in order to bring evidence before insurers supporting anesthesiology in the GI suite ? My guess is that the procedural and recovery times saved would make general anesthesia very competitive on a pure cost basis, and it would be greatly superior if quality of effect was counted, much as quick GA for cardioversion has proven itself. (Surgeons have known for years that a non-moving target is easier to operate on.) Moreover, as most endoscopy patients are elderly, it makes sense to have someone properly monitor them and be ready to treat any pulmonary or cardiovascular events, while the internist tunnels his way deep into the patients bowel.
We need to educate our internist colleagues, truly educate them, by getting in -and helping them do the job properly. The primary reason why anesthesiologists don’t give anesthesia for GI endoscopies is because neither internists nor anesthesiologists are used to working with each other. Yet, if we throw out the barriers of inertia and tradition, and focus on the needs of patients, it is dear that we need to build some new service bridges.
Mark P. Schooley, M.D. San Juan Capistrano, CA