I'm sorry I'm not following your points here. If a routine ASA 1 patient aspirates they usually do fine; in fact a decent minority of these patients have some type of silent aspiration during these procedures, they just don't manifest symptoms for reasons stated. I can count on two hands the number of people I've pre-opped for other cases who have had lung base findings on a chest x-ray/CT who had a endo done in recent days. Now if this occurs in a patient with intrinsic lung disease, pulmonary hypertension, cardiac comobidities... there isn't really a comparison. We shouldn't have to do cases in places that suck ass for patients that we deem high risk. I didn't train for 8 years to dig myself out of holes, I learned all this @#$% to prevent them also. If the patient was truly informed during their consent about what your concerns are, they would agree with you, trust me.
Again, I agree that not all patients are appropriate for an ASC setting. Obviously you SHOULD try to avoid problems before they happen. There was an extreme example given of a BMI 60 case with a high chance of bleeding. Obviously most all of us are going to punt that to the hospital.
The risks with that BMI 60 patient with the bloody case are not the same as the person presented here with QHS o2 for a simple endoscopy.
I have had ASA1 and ASA2 colonoscopies aspirate and go to the hospital for CXR and IV ABX.
I have had ASA 1 and ASA2 flip into AF and get transferred to the hospital.
What about somebody with a pacemaker for a quick knee scope? I mean they MAY need the hospital for a device malfunction . They MAY need EP standing by to intervene on the device...
What about someone with coronary stents within the past couple of years? They MAY need a cath lab in an emergency.
These decisions are not always easy, but an important part of your job and how you are perceived. Consider them carefully - is my point.
So I guess what you are telling me is: You feel that the chance of aspiration and pulmonary insult during this endoscopy for this patient is so high that it warrants the case be canceled and done at the hospital, the patient be inconvenienced, the surgeons schedule to change, the financial impact of the center and the doctor losing this case..
And I just plain disagree with that risk assessment. Aspiration and pulmonary insult during this quick procedure is a very low risk event in my mind (unless there is some other factor i am missing with the history).
AND in the HIGHLY unlikely event that there are drastically increased O2 requirements, I transfer to the hospital and take excellent care of the patient at the center in the meantime.
ALL patients have some risk. SOME more than others, but its not like you can just say, yeah there is some increased risk here lets punt to the hospital. Its a big inconvenience, make sure you are not OVERSTATING the risk in our own mind. This judgement call is an art that comes with experience.
