Pts requesting Anesthesiologist

[WholeLottaGame7]

I guess that's the question. Is it different? I thought anesthesia was higher stakes and more complex than nursemaid elbow reductions in fast-track.

I appreciate that you appreciate physician-only anesthesia, particularly when it comes to your loved one, but you're walking a fine line of hypocrisy here. I don't know anything about you or your practice habits, but suffice it to say that many of your colleagues in GI are 100% fine with RNs (with markedly less training than a CRNA) running room-air general anesthetics with fent and midaz under supervision from a physician with minimal training in sedation. Ours is not the only field that will sacrifice a "little bit" of patient safety to help their bottom line...

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[nimbus]

I appreciate that you appreciate physician-only anesthesia, particularly when it comes to your loved one, but you're walking a fine line of hypocrisy here. I don't know anything about you or your practice habits, but suffice it to say that many of your colleagues in GI are 100% fine with RNs (with markedly less training than a CRNA) running room-air general anesthetics with fent and midaz under supervision from a physician with minimal training in sedation. Ours is not the only field that will sacrifice a "little bit" of patient safety to help their bottom line...

In my community we can't get paid without a medical necessity note. Our GI's would love to have us for every case but it's not up to them.

 

[Noyac]

There's a difference between intellectual and well trained. I would not consider most of medicine to be an intellectual endeavor. Physicians are intelligent and very well-trained, that does not make them intellectuals. Anesthesiologists are generally better trained and have a deeper understanding than the average CRNA. I stand by my comment that anesthesia is not a particularly intellectual discipline. Even the most complex cases usually come in 3-4 different flavors. There's not much intellectual challenge. I think FFP would agree. For me the joy and the challenge comes in graceful seamless "slick" execution of these not very intellectual cases. I consider myself a practical problem solver, a doer. We are not tech IP patent lawyers or university math professors. If you think we are using that level of creativity and brain power in our daily tasks, you are kidding yourself.

I believe you are expressing Il D's counter to the Dunning-Kruger Effect.
While things come easy to you and others it does not mean that it isn't an intellectual endeavor. It's just one that we do everyday and therefore, the intellectual nature comes easily.

 

[anbuitachi]

anesthesia is pretty intellectual. lap choles are probably similar patient to patient, so its more practical. but when it comes to anesthesia, the lap chole in a healthy 20 yr old is going to be different from the 100 yr old with AS and ef of 5%. basically we have to form a plan for each individual patient, along with what surgery they are getting. of course if you do it for 30 years it will come a lot faster to you. doesn't mean its not intellectual. i think anesthesia is one of the most intellectual specialties actually. feels like most of other specialties treat the specific disease, while we look at entire picture and provide anesthesia after looking at the entire picture.

 

[nimbus]

anesthesia is pretty intellectual. lap choles are probably similar patient to patient, so its more practical. but when it comes to anesthesia, the lap chole in a healthy 20 yr old is going to be different from the 100 yr old with AS and ef of 5%. basically we have to form a plan for each individual patient, along with what surgery they are getting. of course if you do it for 30 years it will come a lot faster to you. doesn't mean its not intellectual. i think anesthesia is one of the most intellectual specialties actually. feels like most of other specialties treat the specific disease, while we look at entire picture and provide anesthesia after looking at the entire picture.

It takes an intern with an IQ of 60 to call palliative care for the 100yo with AS and a 5%EF. Even the dumb Ortho intern with paradoxically high board scores could figure that out

And yes after 20-30 years of seeing similar cases over and over again and making both good and bad decisions, you kinda figure out what to do and can decide quickly.

 

[anbuitachi]

It takes an intern with an IQ of 60 to call palliative care for the 100yo with AS and a 5%EF. Even the dumb Ortho intern with paradoxically high board scores could figure that out

And yes after 20-30 years of seeing similar cases over and over again and making both good and bad decisions, you kinda figure out what to do and can decide quickly.

I've never heard of a surgery resident calling pal care before...

 

[dhb]

I've never heard of a surgery resident calling pal care before...

Never before surgery.

ps: this thread is depressing

 

[Arch Guillotti]

I have 'medically directed' 1:3 - 1:4 for many years and I have seen so many 'fires' put out by me or the covering MD. These medical misadventures would have turned into major harm. I don't know if it's serendipity/luck/spider-sense/God, but I have been blessed to check on rooms right as a significant event is occurring.

Anyone who has worked in a busy ACT practice is familiar with the scenario when you just happen to walk into a room and some debacle is unfolding. The reality is that these situations happen other times too and we have absolutely no idea about them.

 

[Gastrapathy]

I appreciate that you appreciate physician-only anesthesia, particularly when it comes to your loved one, but you're walking a fine line of hypocrisy here. I don't know anything about you or your practice habits, but suffice it to say that many of your colleagues in GI are 100% fine with RNs (with markedly less training than a CRNA) running room-air general anesthetics with fent and midaz under supervision from a physician with minimal training in sedation. Ours is not the only field that will sacrifice a "little bit" of patient safety to help their bottom line...

Moderate sedation is safe provided the goal level is actually moderate sedation and the patients are correctly selected. Thats on me not the nurse. using an anesthesia provider for routine endoscopy is a waste of money and resources. It's the reason colonoscopies cost 3x more in the Northeast than the Southwest.

Anesthesia services are important for GI for complex/advanced procedures and high risk patients. The rest is unnecessary and wasteful (and bad for training fellows because they aren't punished for bad technique). It doesnt change our speed either. If anything, it appears to slow us down.

 

[ranvier]

If a patient comes crashing into the OR and you cannot figure out the machine or get your hands on the meds and equipment you need and take care of the patient then you have jumped the shark as a critical care doc.

If a patient requests your personal services and your system does not allow that to happen despite adequate notice, that is a travesty and you are effectively a manager of your own specialty.

ps I love telling GI to do the case themselves or with their employed Crna....they still need us and they know it.

 

[chocomorsel]

Moderate sedation is safe provided the goal level is actually moderate sedation and the patients are correctly selected. Thats on me not the nurse. using an anesthesia provider for routine endoscopy is a waste of money and resources. It's the reason colonoscopies cost 3x more in the Northeast than the Southwest.

Anesthesia services are important for GI for complex/advanced procedures and high risk patients. The rest is unnecessary and wasteful (and bad for training fellows because they aren't punished for bad technique). It doesnt change our speed either. If anything, it appears to slow us down.

It may not change your speed during the case itself (hardly doubt this as well), your turnover is a lot faster with propofol. Meaning, faster wake ups, less nausea, quicker discharges and more cases. And of course more cases means more money.
Anyway, I am not saying that GA anesthesia is necessary for scoping, but come on. Let's all be real and acknowledge that it does at the minimum translate to faster turnover, and discharges.

 

[Gastrapathy]

It may not change your speed during the case itself (hardly doubt this as well), your turnover is a lot faster with propofol. Meaning, faster wake ups, less nausea, quicker discharges and more cases. And of course more cases means more money.
Anyway, I am not saying that GA anesthesia is necessary for scoping, but come on. Let's all be real and acknowledge that it does at the minimum translate to faster turnover, and discharges.

The studies argue that its saves 3-5 minutes in discharge time. Because the nursing ratios allowed in recovery are 2-3 patients/nurse, this doesn't change the ratios or cost in recovery. That 5 minutes doesn't translate into more procedures unless you have a small recovery space rather than the 4 or 5 to 1. So, yes faster discharge but throughput doesn't change unless you have other limitations. The "extra" money comes from billing for anesthesia services. As for nausea, that may well be true. Since we switched to CO2 for all procedures and use water insulflation , its become so much less common overall.

I'm also not convinced of a safety benefit, particularly when a CRNA is involved. I think we expect patients to be deeper and that leads to more room air generals.

 

[WholeLottaGame7]

The studies argue that its saves 3-5 minutes in discharge time. Because the nursing ratios allowed in recovery are 2-3 patients/nurse, this doesn't change the ratios or cost in recovery. That 5 minutes doesn't translate into more procedures unless you have a small recovery space rather than the 4 or 5 to 1. So, yes faster discharge but throughput doesn't change unless you have other limitations. The "extra" money comes from billing for anesthesia services. As for nausea, that may well be true. Since we switched to CO2 for all procedures and use water insulflation , its become so much less common overall.

I'm also not convinced of a safety benefit, particularly when a CRNA is involved. I think we expect patients to be deeper and that leads to more room air generals.

I think you missed my point. You wanted an anesthesiologist to take care of your child instead of a CRNA, because you know that, in general, more education equals better outcomes. Yet you turn around and argue that you're "not convinced of a safety benefit" of an anesthesia-trained provider over an RN at providing sedation, and even suggest that it might be worse???

Again, I don't know you, and maybe you are the rock-star of GI (goodness knows all the posters here are for anesthesia) and everybody stays comfortably in the moderate sedation range, but statistics say that is probably unlikely. Maybe every time a patient gets fidgety or starts gagging, you're like, "no, don't give her anything else, let's lighten the sedation a little until she cooperates." Maybe.

But since you don't seem to have any awareness of what your colleagues are up to, just know that my 60kg wife received 6mg of midaz and 150mcg of fentanyl at Top-Notch Major Medical Center and had no memories for 7 hours of the day (for a 15min procedure). One of the CRNAs that was working there for propofol sedations told me that anesthesia only got involved because they were regularly responding to rescue sedations; his personal record that he saw was 32mg of midaz.

If you want to argue that having anesthesia involved is not cost-effective to extend to the entire population, you will win that argument 7 days a week. But that's not what we're discussing here. We're discussing what we think is safest (via what we would want for our loved ones).

And I promise, this is not personally directed at you. You're just the GI who happens to swing by our forums and make him/herself available, and for that I commend you.

 

[Gastrapathy]

Of course I'm a rock star GI doc. Seriously, don't worry about offending me. @pgg accused me of pearl clutching earlier ITT (had to look that up) and I still like him.

When the intent is GA, that's very different than moderate sedation. If I walk away from my patient and turn off the oxygen, he'll be fine. If you walk, my kid is dead.

Maybe I'm more comfortable than I should be. I'm only 10,000 procedures past my fellowship and sedation deaths from colonoscopy in the community are somewhere between 1:25k and 1:100k. My group does 30k+ scopes/year and have had 2 events related to ERCP sedation in the distant past. We've used reversals once this year and probably didn't need to (there was an error here, new attending who trained in a program with all CRNAs). We use capnography (although I'm not a believer since we shouldn't need it and it's one more thing to distract the nurses: you are right, there is no waveform. However that is because the patient is trying to speak, etc).

WRT your anecdotes: 32mg of versed is malpractice. 6 and 150 is also a truckload but might be ok in a looooong procedure with a benzo/opioid tolerant patient. I'm not sure what you meant about talking a patient through the procedure but we do that all the time. We know more versed won't help.

I totally agree propofol is better from a patient satisfaction perspective but there's no evidence it's safer. I saw more respiratory events and near misses in advanced fellowship with CRNAs. I think GI expectations drive that. When we are sedating, we will go light. When you are...well why are you here if the patients going to move around like they do for me.

I do lots of awake scopes on physicians, fewer on spouses. I suspect your GI knew he was taking care of an anesthesiologist' spouse and really didn't want her to remember.

 

[WholeLottaGame7]

Of course I'm a rock star GI doc. Seriously, don't worry about offending me. @pgg accused me of pearl clutching earlier ITT (had to look that up) and I still like him.

When the intent is GA, that's very different than moderate sedation. If I walk away from my patient and turn off the oxygen, he'll be fine. If you walk, my kid is dead.

Maybe I'm more comfortable than I should be. I'm only 10,000 procedures past my fellowship and sedation deaths from colonoscopy in the community are somewhere between 1:25k and 1:100k. My group does 30k+ scopes/year and have had 2 events related to ERCP sedation in the distant past. We've used reversals once this year and probably didn't need to (there was an error here, new attending who trained in a program with all CRNAs). We use capnography (although I'm not a believer since we shouldn't need it and it's one more thing to distract the nurses: you are right, there is no waveform. However that is because the patient is trying to speak, etc).

WRT your anecdotes: 32mg of versed is malpractice. 6 and 150 is also a truckload but might be ok in a looooong procedure with a benzo/opioid tolerant patient. I'm not sure what you meant about talking a patient through the procedure but we do that all the time. We know more versed won't help.

I totally agree propofol is better from a patient satisfaction perspective but there's no evidence it's safer. I saw more respiratory events and near misses in advanced fellowship with CRNAs. I think GI expectations drive that. When we are sedating, we will go light. When you are...well why are you here if the patients going to move around like they do for me.

I do lots of awake scopes on physicians, fewer on spouses. I suspect your GI knew he was taking care of an anesthesiologist' spouse and really didn't want her to remember.

Let me try a different tack. Dentists/OMFSs also say that there is no evidence that anesthesia from an anesthesiologist is safer than from a dentist/OMFS. (As they say, however absence of proof is not proof of absence.) Would you let your child receive anesthesia from a dentist in the dentist's office?

Also, giving extra midaz to wipe someone's memory because their spouse is an anesthesiologist is super sketch, by the way. I hope that's not something you would do. Spouse is a physician, also incidentally.

 

[pgg]

@pgg accused me of pearl clutching earlier ITT (had to look that up) and I still like him.

I was a little grouchy and was a bit over the top in that response. My apologies.

 

[Gastrapathy]

I was a little grouchy and was a bit over the top in that response. My apologies.

It's all good.

 

[Gastrapathy]

@WholeLottaGame7

I still think there's a difference between moderate sedation and anesthesia. The dental anesthesia thing isn't something I understand. I think the folks using drugs with the narrow therapeutic windows of most anesthetics need to know what they are doing.

As for treating your physician wife differently than other patients, well...I have the pleasure of doing a fair bit of this sort of thing and it isn't easy. You really want them to have a good experience, so if it appears they aren't, I understand the temptation to be heavy handed.

The interesting thing about 6 and 150 for a short procedure is that the nurse had to go back for more given the normal vial sizes. That means something was up.

I'd like to think I do everything the same but it's kinda like Chris Rock's OJ bit, I understand. I did just scope an anesthesiologist's spouse unsedated but he was the perfect candidate for that.

 

[Robotic Wis-Hipple]

@WholeLottaGame7

I still think there's a difference between moderate sedation and anesthesia. The dental anesthesia thing isn't something I understand. I think the folks using drugs with the narrow therapeutic windows of most anesthetics need to know what they are doing.

As for treating your physician wife differently than other patients, well...I have the pleasure of doing a fair bit of this sort of thing and it isn't easy. You really want them to have a good experience, so if it appears they aren't, I understand the temptation to be heavy handed.

The interesting thing about 6 and 150 for a short procedure is that the nurse had to go back for more given the normal vial sizes. That means something was up.

I'd like to think I do everything the same but it's kinda like Chris Rock's OJ bit, I understand. I did just scope an anesthesiologist's spouse unsedated but he was the perfect candidate for that.

I think what he's getting at is that those that perform moderate sedation should be trained to manage a level of anesthesia above. In addition, using fentanyl and versed, though commonplace, is not what we would use (clearly) as they aren't the easiest drug(s) to titrate safely, by the time you give that last dose you find yourself beyond moderate sedation that lasts a decent time. There's also the thought that the proceduralist should not also be the one providing sedation.

I will say that it appears that you get it, and run an effective practice while trying to maintain a level of safety. It's quite simply that likely every Anesthesiologist on this board has an element of recall bias regarding calls to an offsite location to salvage a "sedation" gone awry. As far as what is the acceptable NNT with GI lead Anesthesia and resultant airway compromise etc, I'm not sure, it's just we are confident ours would be higher. Many of your colleagues are not as cognizant of the issue or blatantly disregard the concern while administering doses that quite obviously breach the moderate sedation threshold.

 

[PonyUp]

I think what he's getting at is that those that perform moderate sedation should be trained to manage a level of anesthesia above. In addition, using fentanyl and versed, though commonplace, is not what we would use (clearly) as they aren't the easiest drug(s) to titrate safely, by the time you give that last dose you find yourself beyond moderate sedation that lasts a decent time. There's also the thought that the proceduralist should not also be the one providing sedation.

I will say that it appears that you get it, and run an effective practice while trying to maintain a level of safety. It's quite simply that likely every Anesthesiologist on this board has an element of recall bias regarding calls to an offsite location to salvage a "sedation" gone awry. As far as what is the acceptable NNT with GI lead Anesthesia and resultant airway compromise etc, I'm not sure, it's just we are confident ours would be higher. Many of your colleagues are not as cognizant of the issue or blatantly disregard the concern while administering doses that quite obviously breach the moderate sedation threshold.

I certainly fall into that category and will openly admit it. Our residency endo experience was pretty much limited to ASA 3s and 4s, and even accounting for our outpatient GI experience [limited to the BMI 40+, OSA patients, or other patients that met exclusion criteria to be done in their community], the n of patients in extremis is probably triple that of the n of ASA 1's I have done.

There were days when all of my patients were bleeding VADs, newly admitted inotrope dependent OHT candidates, ESLD patients trying to get listed, etc, so I can't pretend that I'd be more efficient at handling healthy scopes than someone else that has worked in that setting for eons. But I've dutifully responded to the code blues in the "non-anesthesia" GI suites in the same area, so I certainly think that having a mixed practice with me available has benefited those patients...

 

[anbuitachi]

Of course I'm a rock star GI doc. Seriously, don't worry about offending me. @pgg accused me of pearl clutching earlier ITT (had to look that up) and I still like him.

When the intent is GA, that's very different than moderate sedation. If I walk away from my patient and turn off the oxygen, he'll be fine. If you walk, my kid is dead.

Maybe I'm more comfortable than I should be. I'm only 10,000 procedures past my fellowship and sedation deaths from colonoscopy in the community are somewhere between 1:25k and 1:100k. My group does 30k+ scopes/year and have had 2 events related to ERCP sedation in the distant past. We've used reversals once this year and probably didn't need to (there was an error here, new attending who trained in a program with all CRNAs). We use capnography (although I'm not a believer since we shouldn't need it and it's one more thing to distract the nurses: you are right, there is no waveform. However that is because the patient is trying to speak, etc).

WRT your anecdotes: 32mg of versed is malpractice. 6 and 150 is also a truckload but might be ok in a looooong procedure with a benzo/opioid tolerant patient. I'm not sure what you meant about talking a patient through the procedure but we do that all the time. We know more versed won't help.

I totally agree propofol is better from a patient satisfaction perspective but there's no evidence it's safer. I saw more respiratory events and near misses in advanced fellowship with CRNAs. I think GI expectations drive that. When we are sedating, we will go light. When you are...well why are you here if the patients going to move around like they do for me.

I do lots of awake scopes on physicians, fewer on spouses. I suspect your GI knew he was taking care of an anesthesiologist' spouse and really didn't want her to remember.

WHy is 32mg versed malpractice? 0.4mg /kg for induction with versed. thats only 80kg patient to get 32mg


Anyway, a ton of our issues happen in the endoscopy suites. Lots of ICU admissions, occasional codes, etc. But we are an academic center and our patients are sick as hell. In outpatient endoscopy, they are probably ASA2s w/ no major cardio pulm disease. Why do most anesthetics turn out ok in outpatient scope centers? Cause you dont really need deep sedation.. especially for colonoscpies. you are just shoving a camera. its not like you are cutting them open. EGDs are more stimulating but are also faster. I think we recently closed our weekend in hospital endoscpy suites and just routed them to our outside centers since the weekend patients tend to be healthy.

 

[deleted171991]

WHy is 32mg versed malpractice? 0.4mg /kg for induction with versed. thats only 80kg patient to get 32mg

Because it's "conscious sedation". Hence an intubation dose (even a deep sedation dose) from a physician who doesn't know how to rescue the airway is malpractice.

 

[Gastrapathy]

WHy is 32mg versed malpractice? 0.4mg /kg for induction with versed. thats only 80kg patient to get 32mg


Anyway, a ton of our issues happen in the endoscopy suites. Lots of ICU admissions, occasional codes, etc. But we are an academic center and our patients are sick as hell. In outpatient endoscopy, they are probably ASA2s w/ no major cardio pulm disease. Why do most anesthetics turn out ok in outpatient scope centers? Cause you dont really need deep sedation.. especially for colonoscpies. you are just shoving a camera. its not like you are cutting them open. EGDs are more stimulating but are also faster. I think we recently closed our weekend in hospital endoscpy suites and just routed them to our outside centers since the weekend patients tend to be healthy.

Because we aren't trying to induce GA? Is that a trick question? I did 10 colonoscopies this morning (yes, its **** saturday) and used 25mg of versed total.

Are you saying you have lots of post-procedure ICU admissions and codes related to procedural or sedation complications? If you are saying that many complex inpatients are so sick that they need an anesthesiologist to provide sedation safely, well sure, that's right.

 

[Arch Guillotti]

Because it's "conscious sedation". Hence an intubation dose (even a deep sedation dose) from a physician who doesn't know how to rescue the airway is malpractice.

If everything is OK in the end, how can it possibly be malpractice?

 

[deleted171991]

If everything is OK in the end, how can it possibly be malpractice?

If it's OK, it's not malpractice. But I somehow doubt that many GIs could get away with 0.4 mg/kg of versed, especially when coupled with some fentanyl.

 

[Gastrapathy]

If everything is OK in the end, how can it possibly be malpractice?

Man you guys are tough. Ok. I'll restate.

A finding of malpractice for an individual case requires harm to the patient as the first hurdle. So, if the patient wasn't harmed, then it wasn't malpractice in that individual episode.

However, the decision by a physician with only moderate sedation credentials to use that high a dose of midazolam was likely beyond his scope of practice and, thus, in the event of a bad outcome, would be at risk for a finding of malpractice.

 

[bashwell]

If I understand correctly:

1) The argument is not:
If harm, then malpractice.
If no harm, then no malpractice.

2) Rather, the argument is:
If malpractice, then harm.
If no harm, then that doesn't necessarily mean there's been no malpractice.

Edit: Removed bit about the logical fallacy because I'm not sure that's correct.

 

[deleted171991]

If I understand correctly:

1) The argument is not:
If harm, then malpractice.
If no harm, then no malpractice.

2) Rather, the argument is:
If malpractice, then harm.
If no harm, then that doesn't necessarily mean there's been no malpractice.
(Otherwise it runs the risk of committing the logical fallacy of denying the antecedent).

Legally, if no harm then no malpractice.

Professionally, it's a different story.

 

[WholeLottaGame7]

WHy is 32mg versed malpractice? 0.4mg /kg for induction with versed. thats only 80kg patient to get 32mg

How many times have you given 32mg of midaz?

I've maybe given 12 or 14 in a long cardiac case, but that's about it. I've never given over 5 even for the football player dudes getting blocks. >5mg for a 20min scope is not conscious or probably even moderate sedation unless you're a big dude or chronic benzo/EtOH user.

 

[anbuitachi]

How many times have you given 32mg of midaz?

I've maybe given 12 or 14 in a long cardiac case, but that's about it. I've never given over 5 even for the football player dudes getting blocks. >5mg for a 20min scope is not conscious or probably even moderate sedation unless you're a big dude or chronic benzo/EtOH user.

Oh never. I dont use midaz

 

[WholeLottaGame7]

Oh never. I dont use midaz

Exactly. Because it's a ****ty drug, except in certain circumstances.

 

[IlDestriero]

Maybe the harm is that they slept for 18 hours after the 18 minute procedure.


--
Il Destriero

 

[Noyac]

Of course I'm a rock star GI doc. Seriously, don't worry about offending me. @pgg accused me of pearl clutching earlier ITT (had to look that up) and I still like him.

When the intent is GA, that's very different than moderate sedation. If I walk away from my patient and turn off the oxygen, he'll be fine. If you walk, my kid is dead.

Maybe I'm more comfortable than I should be. I'm only 10,000 procedures past my fellowship and sedation deaths from colonoscopy in the community are somewhere between 1:25k and 1:100k. My group does 30k+ scopes/year and have had 2 events related to ERCP sedation in the distant past. We've used reversals once this year and probably didn't need to (there was an error here, new attending who trained in a program with all CRNAs). We use capnography (although I'm not a believer since we shouldn't need it and it's one more thing to distract the nurses: you are right, there is no waveform. However that is because the patient is trying to speak, etc).

WRT your anecdotes: 32mg of versed is malpractice. 6 and 150 is also a truckload but might be ok in a looooong procedure with a benzo/opioid tolerant patient. I'm not sure what you meant about talking a patient through the procedure but we do that all the time. We know more versed won't help.

I totally agree propofol is better from a patient satisfaction perspective but there's no evidence it's safer. I saw more respiratory events and near misses in advanced fellowship with CRNAs. I think GI expectations drive that. When we are sedating, we will go light. When you are...well why are you here if the patients going to move around like they do for me.

I do lots of awake scopes on physicians, fewer on spouses. I suspect your GI knew he was taking care of an anesthesiologist' spouse and really didn't want her to remember.

We have an ongoing feud with one of our endoscopist. He owns his own shop and uses a crna for which he bills for and never meets a pt until he is about to send a camera up their ass. A PA does all the clinic work. He sends us his cases that the nurse won't do. So he uses an anesthesia professional all while claiming they bring more risk. I guess money is more important to him. He sent me these studies. I know there is a lot here. Critique as you will.

Articles (and accompanying editorials) discussing the risks of endoscopic or anesthesia-related complications associated with propofol-based sedation


Gastrointest Endosc. 2017 Jan;85(1):101-108. doi: 10.1016/j.gie.2016.02.007. Epub
2016 Feb 18.
Patient safety during sedation by anesthesia professionals during routine upper
endoscopy and colonoscopy: an analysis of 1.38 million procedures.
Vargo JJ(1), Niklewski PJ(2), Williams JL(3), Martin JF(4), Faigel DO(5).
Author information:
(1)Department of Gastroenterology and Hepatology, Digestive Disease Institute,
Cleveland Clinic, Cleveland, Ohio, USA. (2)Ethicon Endo-Surgery Inc., Cincinnati,
Ohio, USA; Department of Pharmacology and Cell Biophysics, College of Medicine,
University of Cincinnati, Cincinnati, Ohio, USA. (3)Division of Gastroenterology,
Oregon Health and Science University, Portland, Oregon, USA. (4)Ethicon
Endo-Surgery Inc., Cincinnati, Ohio, USA. (5)Division of Gastroenterology and
Hepatology, Mayo Clinic, Scottsdale, Arizona, USA.

BACKGROUND AND AIMS: Sedation for GI endoscopy directed by anesthesia
professionals (ADS) is used with the intention of improving throughput and
patient satisfaction. However, data on its safety are sparse because of the lack
of adequately powered, randomized controlled trials comparing it with
endoscopist-directed sedation (EDS). This study was intended to determine whether
ADS provides a safety advantage when compared with EDS for EGD and colonoscopy.
METHODS: This retrospective, nonrandomized, observational cohort study used the
Clinical Outcomes Research Initiative National Endoscopic Database, a network of
84 sites in the United States composed of academic, community, health maintenance
organization, military, and Veterans Affairs practices. Serious adverse events
(SAEs) were defined as any event requiring administration of cardiopulmonary
resuscitation, hospital or emergency department admission, administration of
rescue/reversal medication, emergency surgery, procedure termination because of
an adverse event, intraprocedural adverse events requiring intervention, or blood
transfusion.
RESULTS: There were 1,388,235 patients in this study that included 880,182
colonoscopy procedures (21% ADS) and 508,053 EGD procedures (23% ADS) between
2002 and 2013. When compared with EDS, the propensity-adjusted SAE risk for
patients receiving ADS was similar for colonoscopy (OR, .93; 95% CI, .82-1.06)
but higher for EGD (OR, 1.33; 95% CI, 1.18-1.50). Additionally, with further
stratification by American Society of Anesthesiologists (ASA) class, the use of
ADS was associated with a higher SAE risk for ASA I/II and ASA III subjects
undergoing EGD and showed no difference for either group undergoing colonoscopy.
The sample size was not sufficient to make a conclusion regarding ASA IV/V
patients.
CONCLUSIONS: Within the confines of the SAE definitions used, use of anesthesia
professionals does not appear to bring a safety benefit to patients receiving
colonoscopy and is associated with an increased SAE risk for ASA I, II, and III
patients undergoing EGD.


Gastrointest Endosc. 2017 Jan;85(1):109-111. doi: 10.1016/j.gie.2016.06.025.
The endoscopist, the anesthesiologists, and safety in GI endoscopy.
Repici A(1), Hassan C(2).
Author information:
(1)Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milano, Italy; Humanitas
University, Milano, Italy. (2)Endoscopy Unit, Nuovo Regina Margherita Hospital,
Rome, Italy.



Gastroenterology. 2016 Apr;150(4):888-94; quiz e18. doi:
10.1053/j.gastro.2015.12.018. Epub 2015 Dec 18.
Risks Associated With Anesthesia Services During Colonoscopy.
Wernli KJ(1), Brenner AT(2), Rutter CM(3), Inadomi JM(2).
Author information:
(1)Group Health Research Institute, Seattle, Washington; Department of Health
Services, University of Washington, Seattle, Washington. Electronic address:
[email protected]. (2)Department of Health Services, University of Washington,
Seattle, Washington; Division of Gastroenterology, Department of Medicine,
University of Washington, Seattle, Washington. (3)Group Health Research
Institute, Seattle, Washington; RAND Corporation, Santa Monica, California.
Comment in
Gastroenterology. 2016 Apr;150(4):801-3.

BACKGROUND & AIMS: We aimed to quantify the difference in complications from
colonoscopy with vs without anesthesia services.
METHODS: We conducted a prospective cohort study and analyzed administrative
claims data from Truven Health Analytics MarketScan Research Databases from 2008
through 2011. We identified 3,168,228 colonoscopy procedures in men and women,
aged 40-64 years old. Colonoscopy complications were measured within 30 days,
including colonic (ie, perforation, hemorrhage, abdominal pain),
anesthesia-associated (ie, pneumonia, infection, complications secondary to
anesthesia), and cardiopulmonary outcomes (ie, hypotension, myocardial
infarction, stroke), adjusted for age, sex, polypectomy status, Charlson
comorbidity score, region, and calendar year.
RESULTS: Nationwide, 34.4% of colonoscopies were conducted with anesthesia
services. Rates of use varied significantly by region (53% in the Northeast vs 8%
in the West; P < .0001). Use of anesthesia service was associated with a 13%
increase in the risk of any complication within 30 days (95% confidence interval
[CI], 1.12-1.14), and was associated specifically with an increased risk of
perforation (odds ratio [OR], 1.07; 95% CI, 1.00-1.15), hemorrhage (OR, 1.28; 95%
CI, 1.27-1.30), abdominal pain (OR, 1.07; 95% CI, 1.05-1.08), complications
secondary to anesthesia (OR, 1.15; 95% CI, 1.05-1.28), and stroke (OR, 1.04; 95%
CI, 1.00-1.08). For most outcomes, there were no differences in risk with
anesthesia services by polypectomy status. However, the risk of perforation
associated with anesthesia services was increased only in patients with a
polypectomy (OR, 1.26; 95% CI, 1.09-1.52). In the Northeast, use of anesthesia
services was associated with a 12% increase in risk of any complication; among
colonoscopies performed in the West, use of anesthesia services was associated
with a 60% increase in risk.
CONCLUSIONS: The overall risk of complications after colonoscopy increases when
individuals receive anesthesia services. The widespread adoption of anesthesia
services with colonoscopy should be considered within the context of all
potential risks.




Gastrointest Endosc. 2014 Apr;79(4):657-62. doi: 10.1016/j.gie.2013.12.002. Epub
2014 Jan 25.
Effect of propofol anesthesia on force application during colonoscopy.
Korman LY(1), Haddad NG(2), Metz DC(3), Brandt LJ(4), Benjamin SB(2), Lazerow
SK(5), Miller HL(5), Mete M(6), Patel M(7), Egorov V(7).
Author information:
(1)Chevy Chase Clinical Research, Chevy Chase, Maryland, USA. (2)Division of
Gastroenterology, Georgetown University Hospital, Georgetown University School of
Medicine, Washington, DC, USA. (3)Division of Gastroenterology, Hospital
University of Pennsylvania, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania, USA. (4)Division of Gastroenterology, Montefiorep
Medical Center, Albert Einstein School of Medicine, Bronx, New York, USA.
(5)Gastroenterology Division, Department of Veterans Affairs Medical Center,
Washington, DC, USA. (6)Department of Biostatistics and Bioinformatics, MedStar
Health Research Institute, Washington, DC, USA. (7)Artann Laboratories, Trenton,
New Jersey, USA.

BACKGROUND: Sedation is frequently used during colonoscopy to control patient
discomfort and pain. Propofol is associated with a deeper level of sedation than
is a combination of a narcotic and sedative hypnotic and, therefore, may be
associated with an increase in force applied to the colonoscope to advance and
withdraw the instrument.
OBJECTIVE: To compare force application to the colonoscope insertion tube during
propofol anesthesia and moderate sedation.
DESIGN: An observational cohort study of 13 expert and 12 trainee endoscopists
performing colonoscopy in 114 patients. Forces were measured by using the
colonoscopy force monitor, which is a wireless, handheld device that attaches to
the insertion tube of the colonoscope.
SETTING: Community ambulatory surgery center and academic gastroenterology
training programs.
PATIENTS: Patients undergoing routine screening or diagnostic colonoscopy with
complete segment force recordings.
MAIN OUTCOME MEASUREMENTS: Axial and radial forces and examination time.
RESULTS: Axial and radial forces increase and examination time decreases
significantly when propofol is used as the method of anesthesia.
LIMITATIONS: Small study, observational design, nonrandomized distribution of
sedation type and experience level, different instrument type and effect of
prototype device on insertion tube manipulation.
CONCLUSIONS: Propofol sedation is associated with a decrease in examination time
and an increase in axial and radial forces used to advance the colonoscope.



JAMA Intern Med. 2013 Apr 8;173(7):551-6. doi: 10.1001/jamainternmed.2013.2908.
Complications following colonoscopy with anesthesia assistance: a
population-based analysis.
Cooper GS(1), Kou TD, Rex DK.
Author information:
(1)Division of Gastroenterology, University Hospitals Case Medical Center,
Cleveland, OH 44106, USA. [email protected]
Comment in
JAMA Intern Med. 2013 Apr 8;173(7):556-8.
JAMA Intern Med. 2013 Sep 23;173(17):1660.
JAMA Intern Med. 2013 Sep 23;173(17):1659-60.

IMPORTANCE: Deep sedation for endoscopic procedures has become an increasingly
used option but, because of impairment in patient response, this technique also
has the potential for a greater likelihood of adverse events. The incidence of
these complications has not been well studied at a population level.
DESIGN: Population-based study.
SETTING AND PARTICIPANTS: Using a 5% random sample of cancer-free Medicare
beneficiaries who resided in one of the regions served by a SEER (Surveillance,
Epidemiology, and End Results) registry, we identified all procedural claims for
outpatient colonoscopy without polypectomy from January 1, 2000, through November
30, 2009.
INTERVENTION: Colonoscopy without polypectomy, with or without the use of deep
sedation (identified by a concurrent claim for anesthesia services).
MAIN OUTCOME MEASURES: The occurrence of hospitalizations for splenic rupture or
trauma, colonic perforation, and aspiration pneumonia within 30 days of the
colonoscopy.
RESULTS: We identified a total of 165 527 procedures in 100 359 patients,
including 35 128 procedures with anesthesia services (21.2%). Selected
postprocedure complications were documented after 284 procedures (0.17%) and
included aspiration (n = 173), perforation (n = 101), and splenic injury (n =
12). (Some patients had >1 complication.) Overall complications were more common
in cases with anesthesia assistance (0.22% [95% CI, 0.18%-0.27%]) than in others
(0.16% [0.14%-0.18%]) (P < .001), as was aspiration (0.14% [0.11%-0.18%] vs 0.10%
[0.08%-0.12%], respectively; P = .02). Frequencies of perforation and splenic
injury were statistically similar. Other predictors of complications included age
greater than 70 years, increasing comorbidity, and performance of the procedure
in a hospital setting. In multivariate analysis, use of anesthesia services was
associated with an increased complication risk (odds ratio, 1.46 [95% CI,
1.09-1.94]).
CONCLUSIONS AND RELEVANCE: Although the absolute risk of complications is low,
the use of anesthesia services for colonoscopy is associated with a somewhat
higher frequency of complications, specifically, aspiration pneumonia. The
differences may result in part from uncontrolled confounding, but they may also
reflect the impairment of normal patient responses with the use of deep sedation.


JAMA Intern Med. 2013 Apr 8;173(7):556-8. doi: 10.1001/jamainternmed.2013.4071.
Anesthesia for colonoscopy: too much of a good thing?
Wernli KJ(1), Inadomi JM.
Author information:
(1)Group Health Research Institute, Seattle, WA 98195, USA.

Comment on
JAMA Intern Med. 2013 Apr 8;173(7):551-6.

 

[MirrorTodd]

Does that mean he wants to do his procedures without any sedation whatsoever? Or is he just against propofol?

 

[Noyac]

Does that mean he wants to do his procedures without any sedation whatsoever? Or is he just against propofol?

Who knows. He is confused.

 

[Gastrapathy]

Im familiar with these studies. The 2016 Inadomi paper generated a lot of discussion. My overall opinion is that they may show that deep sedation is marginally more risky than moderate sedation despite the addition of an anesthesia provider.

Also, although they tried to match patients, Charleston scores are far from perfect and, in the low use regions, I think the populations may not really be equivalent. I do believe it's possible that complication rates increase when you remove patient feedback. The study about force is totally believable.

 

[MirrorTodd]

Im familiar with these studies. The 2016 Inadomi paper generated a lot of discussion. My overall opinion is that they may show that deep sedation is marginally more risky than moderate sedation despite the addition of an anesthesia provider.

Also, although they tried to match patients, Charleston scores are far from perfect and, in the low use regions, I think the populations may not really be equivalent. I do believe it's possible that complication rates increase when you remove patient feedback. The study about force is totally believable.

That doesn't read as if it's "anesthesia's" fault though. It sounds like the operators went hard and fast instead of slow and steady. I would argue that it's up to the scope slinger to be careful no matter what level of sedation the patient has.

 

[Groove]

I appreciate all the responses. Honestly, I've been more than shocked at the level of perturbation from some of the anesthesiologists in here at the thought of having to do a solo case for a "VIP request". Everything from fear of angering CRNAs to the inability to facilitate such a request 2/2 ACT model, to loss of skills from lack of enough solo cases and encouragement that "I might be better off with a CRNA because the MD will be rusty, etc..". It's been really disheartening. Many of you sound helpless in your current model of practice and completely willing to imply that for solo cases a CRNA is not only a good option but perhaps a better option for the pt. For those of you that said you would be happy to accommodate such a request and would make it happen, I applaud you. As an ER physician, but more so as a recent patient, it's been really eye opening and I've found myself wondering if you've lost your speciality already and are just riding it out in this "supervisory air traffic controller" mode until CRNAs gain complete and ultimate autonomy with no need for your supervision in any capacity. We aren't nearly as close to losing our specialty to MLP encroachment but could perhaps learn some lessons from you guys.

Meanwhile, I had both operations. I got so nervous hearing what the nay sayers had to say on here that I chose to keep my mouth shut and take the CRNA. I met the anesthesiologist briefly before both operations and the CRNA did all the heavy lifting. They were great, personable, competent and I have no complaints. Everything went smoothly. Up until now I've always encouraged family and friends to request an anesthesiologist for their operations but I think I've now changed my mind. You're right, maybe the CRNA is just as good or better in these cases for all the reasons you guys have mentioned in here.

 

[deleted171991]

I've found myself wondering if you've lost your speciality already and are just riding it out in this "supervisory air traffic controller" mode until CRNAs gain complete and ultimate autonomy with no need for your supervision in any capacity.

I wonder about this on a weekly basis. It is obvious to me that we are training our replacements. Many department chiefs let "our CRNA colleagues" get away with a lot, because they depend on them for staying profitable, and it's not that easy to replace a W-2 CRNA. Because of this, many anesthesiologists also try not to upset the apple cart, especially if pre-retirement or afraid of losing their jobs. Every year, the CRNAs try to push more, do more, and erode more of our physician-only hospital privileges, until they will be allowed to do everything we are. Again, it's obvious, but nobody talks about it, nobody fights against it at leadership level. When the generals share the same interests as the enemy, the battle is already lost.

 

[nimbus]

I wonder about this on a weekly basis. It is obvious to me that we are training our replacements. Many department chiefs let "our CRNA colleagues" get away with a lot, because they depend on them for staying profitable, and it's not that easy to replace a W-2 CRNA. Because of this, many anesthesiologists also try not to upset the apple cart, especially if pre-retirement or afraid of losing their jobs. Every year, the CRNAs try to push more, do more, and erode more of our physician-only hospital privileges, until they will be allowed to do everything we are. Again, it's obvious, but nobody talks about it, nobody fights against it at leadership level. When the generals share the same interests as the enemy, the battle is already lost.

But what's the alternative? What's the solution for these departments that have come to rely on CRNAs. How do they recruit and retain them?

 

[teeva]

I appreciate all the responses. Honestly, I've been more than shocked at the level of perturbation from some of the anesthesiologists in here at the thought of having to do a solo case for a "VIP request".

It's just how your institution and other places are. At my community private practice hospitals, we have no CRNAs. It's not a big deal to request a surgeon or anesthesiologist. The OR coordinator or secretary has our work schedules will can take care of requests. And my colleagues and I will switch our daytime schedules around on short notice if needed to accommodate requests.

As an ER physician, but more so as a recent patient, it's been really eye opening and I've found myself wondering if you've lost your speciality already and are just riding it out in this "supervisory air traffic controller" mode until CRNAs gain complete and ultimate autonomy with no need for your supervision in any capacity. We aren't nearly as close to losing our specialty to MLP encroachment but could perhaps learn some lessons from you guys.

CRNA are a tidal wave probably like PA/NP. Can't really stop it. Too much money is at stake. But instead for young attendings like me, hope the tidal wave finally hits shore and wipes everything out and people realize what hit them. Only way to do that I think is to let CRNA have full independence and no supervision. Let them take on all the liability, responsibility, call, malpractice insurance coverage, and deny them firefighter services. Maybe within 5-10 years morbidity/mortality will be shown to be worse. However, at that point gotta be careful what you wish for, because perhaps a 5% worse outcome won't be enough to make changes. Easy for me to say because I'm solo and haven't had any interaction with CRNA since middle of residency, but that could change any day.

 

[pgg]

One problem is that institutions that have problems with poor care and complications have an incentive to not draw attention to them. See no evil, etc.

I used to moonlight at a rural community hospital where substandard care was IMO unpleasantly common. And it was institution-wide. ER docs (some not EM trained) who did weird things. Radiologists who commonly missed stuff. Intensivists (who largely weren't intensivists) who'd accept a critically ill patient at midnight but not actually see them until AM rounds. Surgeons who had puzzling difficulty with common cases (this breed's pathognomic calling card is along the lines of "wow I've never seen a patient with anatomy this abnormal before" and "wow this patient bleeds more than any other patient I've ever seen" and "these instruments are dull/broken/wrong/left-handed/not what I'm used to"). Ward nurses who can't or won't get drugs to patients on time or don't notice or report abnormal vitals for hours. Retread locum anesthesiologists who read romance novels during cases. OSA patients who die after ankle surgery under MAC because someone gave them a PCA with a basal rate in an unmonitored bed. An orthopedic surgeon who fled a neighboring state because of lost credentials and dozens yes dozens of prior and pending malpractice actions (I don't think that state med board had yet taken action), who lasted about a year before even our hospital couldn't take it any more and revoked his credentials.

This place never had a multidisciplinary M&M conference.

When there's that much morbidity and mortality floating around, the difference between the things an average CRNA does compared to the things an average anesthesiologist does is just lost in the noise.

I think this is where midlevels are making the largest inroads to independent practice. Not only is no one looking for their complications, there is active disinterest in hearing about them because anything short of a sentinel event just isn't worth the time.

Maybe this will change with bundled payments and financial penalties for complications.

 

[Groove]

Only way to do that I think is to let CRNA have full independence and no supervision. Let them take on all the liability, responsibility, call, malpractice insurance coverage, and deny them firefighter services. Maybe within 5-10 years morbidity/mortality will be shown to be worse.

The fundamental problem is that you guys are training your own replacements and you're training them with a skillset that is comparable with your own. If CRNA schools are being taught by anesthesiologists and they are training under anesthesiologists, why would you expect their performance to be any different than your own? If you think there's going to be this glaring difference in quality care or outcomes that is going to fundamentally shift health care/hospital policy and/or public perception, you're kidding yourself. These are not your friends, brothers and sisters. These are nurses who have come to take your job and claim equality to you...with a smile to your face and a dagger to your back.

 

[IlDestriero]

You're kidding yourself if you think they're bringing the same skills to the table. Not tube monkey skills, but the other stuff they don't get by completing medical school and doing the complex cases during training. They apparently don't think that matters. I guess they have Dr. Google to the rescue.


--
Il Destriero

 

[deleted171991]

The fundamental problems is that you guys are training your own replacements and you're training them with a skillset that is comparable with your own. If CRNA schools are being taught by anesthesiologists and they are training under anesthesiologists, why would you expect their performance to be any different than your own? If you think there's going to be this glaring difference in quality care or outcomes that is going to fundamentally shift health care/hospital policy and/or public perception, you're kidding yourself. These are not your friends, brothers and sisters. These are nurses who have come to take your job and claim equality to you...with a smile to your face and a dagger to your back.

1. They don't have the same skills as us, especially between the ears.
2. Fewer and fewer people (especially the ones that matter) know and/or appreciate that.
3. Those of us who are employed in an ACT practice can't do **** (to reverse this).
4. Those of us who are partners in an ACT practice won't do ****.

 

[deleted171991]

Who knows. He is confused.

I doubt he is confused.

This is how the typical private GI a$$hole who owns an endo center rolls:
Easy/private patients -> own GI center +/- own CRNA or his fixed fee anesthesiologist, big profits. Tough/Medicare patients -> hospital, their anesthesiologist, their high malpractice risk for peanuts.

 

[nimbus]

I doubt he is confused.

This is how the typical private GI a$$hole who owns an endo center rolls:
Easy/private patients -> own GI center +/- own CRNA or his fixed fee anesthesiologist, big profits. Tough/Medicare patients -> hospital, their anesthesiologist, their high malpractice risk for peanuts.

Makes sense. Why would anybody do it any other way? Just smart. Not necessarily an a**hole. Isn't that the entire point of owning your own endoscopy center?

 

[anbuitachi]

How do these community hospitals even survive and not be loaded in debt esp if it's loaded w poor healthcare. We have a large institution academic and I feel like this place would go bankrupt w.o residents.

 

[nimbus]

How do these community hospitals even survive and not be loaded in debt esp if it's loaded w poor healthcare. We have a large institution academic and I feel like this place would go bankrupt w.o residents.

Easily by doing a bunch of 12min gallbladders and 1hour total knees. And providing protocol driven care with clinical pathways.

 

[deleted171991]

Makes sense. Why would anybody do it any other way? Just smart. Not necessarily an a**hole. Isn't that the entire point of owning your own endoscopy center?

You may call it "smart", in a jungle capitalism sort of way, but to me it's stupid and short-sighted. The best business deals are win-win. When you're trying to shunt most of the profits from the local anesthesia group, sooner or later they'll find a way to screw you back.