Wednesday, October 29, 2014

GI Doctors Want To Make Their Patients Less Safe During Procedures

This is pretty freaking unbelievable. Despite the fiasco of the death of Joan Rivers during a routine endoscopic procedure under sedation, some gastroenterologists want to provide even less monitoring of their patients. Some GI doctors are resentful of ASA guidelines to improve patient safety during a procedure. The ASA has declared that all patients under sedation, even "only" moderate sedation, must have their end tidal CO2 monitored.

Apparently even this minor inconvenience is too burdensome for some GI to take. A paper was presented recently at the American College of Gastroenterology Scientific Meeting that tries to refute the necessity of capnography for ASA 1 or 2 patients under moderate sedation for colonoscopy. The study claims that there is no benefit to capnography for this patient population.

According to Dr. Paresh Mehta, the author of the study, the ASA has "mandated something without any evidence of benefit with moderate sedation. Yet capnography increases the cost of colonoscopy because all endoscopy centers have to purchase these devices and specialized nasal cannulas. You have to train your staff how to use the device because not everybody is familiar with looking at wave forms and making decisions off that."

You can practically hear the derision of the ASA from the statement. But Dr. Mehta's so called evidence based practice is so short sighted it's almost malpractice. Anybody with any experience with oximetry and capnography knows that the two instruments work best when done in tandem. Pulse oxes are great for detecting hypoxia before the patient becomes cyanotic. But they also have a lag in their reading. Depending on a patient's pulmonary status, a patient can be apneic anywhere from 30 seconds to two minutes before the pulse ox starts trending downward. Once the numbers start dropping and resuscitation is begun, there is a very scary period where the numbers continue to drop as the pulse ox lag starts to catch up with the real oxygen saturation. It is during this frantic hypoxic episode that a patient can suffer a cardiac arrest or stroke. If capnography is present, a patient's apnea can be detected and corrected immediately. Isn't preventing these potential complications alone worth the price of having a another monitor in an endoscopy center?

GI docs may also be lulled into thinking ASA 1 and 2 patients are chip shots to sedate. Anesthesiologists know that any patient can have respiratory distress regardless of ASA status. Maybe the patient has an undiagnosed sleep apnea. Perhaps they are taking medications at home that make them more susceptible to sedatives but they didn't disclose that information to the doctor. Just because somebody is an ASA 1 doesn't make them immune from an anesthetic catastrophe.

Finally it doesn't seem right that not all patients are getting the same level of care when it comes to safety precautions. The endoscopy center already owns capnography monitors for their other procedures. Why not use them on all patients getting sedation? Why discriminate one group of patients from another? Imagine how a GI will respond to a malpractice lawyer asking him why a patient died from respiratory distress because the patient went apneic for too long before being detected and capnography was available but not used, "But I read a study that said capnography is not necessary during a colonoscopy." Better whip out that checkbook right then and there.

Obviously the main reason GI doesn't want to use capnography is mentioned in Dr. Mehta's statement; they don't want to spend the money. They don't want to have to buy the equipment. They don't want to have to train people on how to use it (though today's equipment is as simple hooking it up to the patient and turning it on. Not rocket science). Surgery centers are all about cash flow and profits. That's why they don't want any anesthesiologists or their pesky safety equipment to keep them from their assembly line of endoscopic examinations.

The AGA should be ashamed of presenting a study like this that advocates expediency and profits over patient safety.


  1. Devil's advocate: what if lower cost means more access to colonoscopies and thus more cancer death prevention? Either way, Cologuard home testing will be the future.

    1. How much is a safe procedure worth to a patient? If you are truly pinching pennies, there's no evidence that ECG monitoring saves lives either. It wasn't that long ago that anesthesiologists checked a patient's heart rate by feeling for a pulse. Somehow many patients survived their procedures just fine.