There is mounting evidence that propofol is the ideal anesthetic for endoscopic procedures. At the recent Digestive Disease Week conference in New Orleans, which bills itself as the "world's largest gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy, and gastrointestinal surgery," there were many presentations and posters extolling the use of propofol for GI sedation. If you go to the DDW web site and search under "propofol sedation" you will see many talks of the advantages of propofol over traditional sedatives like Versed and Fentanyl. See here and here and here for examples.
However when Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, made his case at the conference for having anesthesiologists administer the propofol, he was widely criticized in the GI dominated room. One prominent gastroenterologist, Dr. Douglas Rex, had reviewed 600,000 cases of endoscopist administered anesthesia and found no adverse safety issues. (How did he have the time?) He accused the ASA of enriching its own members by keeping the FDA from approving a computer administered propofol infusion device that would not require an anesthesiologist to be present.
This got me thinking, why do GI docs care so much about using propofol without anesthesiologists present in the room? The following are three excuses I've heard from gastroenterologists about why they want to administer their own propofol sedation.
Anesthesiologists are not readily available when you are ready to start a case. In other words, our lack of presence is slowing them down. Well there is a ready answer for that--hire more anesthesiologists. If there were not enough nurses or not enough scopes available, you would expect them to spend money to get more, therefore decreasing downtime and increase revenue. The same logic should apply to hiring more anesthesiologists.
Anesthesiologists slow down the procedure schedule. I've heard this one many times. We spend an eternity in GI Time carefully looking over the patients' H+P and talking to patients. We delay cases when there are missing lab work or ECG's. We have to take the patient to recovery after a procedure and won't allow the next patient to be whisked in without first interviewing them. I have two words for that: PATIENT SAFETY. In the name of patient safety anesthesiologists make sure the patient can undergo a sedation safely with as few complications as possible. The hurried life of gastroenterologists often keep them from noticing the finer details in life, like a patient having had an esophagectomy with gastric pull up but is scheduled for a PEG.
Anesthesiologists cost the patient more money. I've always felt this was a deceitful way of keeping anesthesiologists out of the GI suite. The patient makes the same copay whether an anesthesiologist is present or not. In fact if the insurance company denies reimbursement for the anesthetic, it is the anesthesiologist that bares the loss. Let's face it, the only money the GI doc is trying to save is the insurance companies' and his own.
What is the underlying commonality of all this? Willie Sutton would know; it's all about the money. When the anesthesiologist notices a missing ECG and "delays" a case by ordering one in a 65 year old patient with history of atrial fibrillation, that is costing the gastroenterologist time, which of course equals money. While it's true that 95% of the time the endoscopist can administer the sedation safely without complications, is it really worth the heartache and headache if something bad happens? And over hundreds of cases of sedation invariably something will. Does the endoscopist really want to have the responsibility of ensuring a patient's safety when an anesthesiologist is able and willing to help out? Having an anesthesiologist present for sedation is a small price to pay for this peace of mind. I'm sure a vast majority of patients would agree.
Plus, at least in my hospital, when the S hits the fan, they call for us anyways. Often times I find that they weren't aware of a glaring problem either with the pt or in the delivery of anesthetic. I wouldn't ever want a GI doc to be responsible for my safety - I haven't seen any of them do it well yet.ReplyDelete