Is Gastroenterology The Best Medical Field?

Cha Ching!

Is gastroenterology the best field in medicine? Gastroenterologists enjoy some of the highest incomes among physicians. Some 18 million colonoscopies are done each year in the US, making it the most commonly performed procedure in the country. GI is estimated to bring in almost $3 million in revenue per physician in 2019, double what it made only three years ago. By some calculations, gastroenterology is responsible for $1 TRILLION in medical expenditures each year.

With eye opening numbers like these, it's no wonder that the smart money is starting to pour into gastroenterology. Private equity investors are buying up GI practices to get in on this hot action. The investors are cutting expenses by consolidating office and equipment expenses. They are also able to negotiate better insurance reimbursements by forming larger groups.

GI is relatively easy to make money through buyouts. Many gastroenterologists practice in ambulatory surgery centers that are usually already highly profitable. Purchasing multiple ASC's gives them higher purchasing power and a more efficient backoffice. They are making their businesses even more profitable by bringing inhouse other expenses like pathology and anesthesia services. Why pay another physician a fee when you can pay them a set salary?

So is GI the best field in medicine? From a financial standpoint, it sure looks like a winner. The fees generated from endoscopic procedures would make any general surgeon hopping mad with envy. GI doctors can do dozens of procedures per day in each ASC, generating tens of thousands of dollars in revenue. Surgeons by comparison may only do two or three operations on a good day. As endoscopy gets more advanced, GI doctors are also slowly encroaching on the general surgeons' bread and butter of treating bowel diseases, with the advantage of not making any painful incisions. It looks like GI is ready to take over the medical world. The smartest people in the financial world certainly believe that.

Sedasys is DEAD!

In one of the greatest victories for patients and physician anesthesiologists so far this year, Johnson and Johnson has announced that it is no longer selling the Sedasys system for automated propofol sedation. The machine never lived up to the company's sales expectations. Its elimination is part of J&J's corporate restructuring that will cost company 3,000 jobs.

Anesthesia is not just about pushing drugs. Sedating patients is more than filling up a large syringe of medication and waiting for the procedurist to tell us when to put patients to sleep. Physician anesthesiologists have been at the forefront of patient safety for a century and no machine is going to be replace our vigilance in keeping patients safe during a procedure.

The physicians who were hoping to benefit the most from Sedasys, the gastroenterologists, should get down on their knees and thank the powers above that they will no longer have the machine to play around with. It was only just a matter of time before one of them got into serious airway trouble using a drug most of them are unfamiliar with. And physician anesthesiologists may not always be around to save their ass.

I have always been skeptical of the potential monetary savings from Sedasys. The risks a patient faces when being given a powerful anesthetic by an uncaring, unfeeling box of circuit boards does not justify the minuscule cost savings hoped for by its advocates. The GI doctors who were pushing for the approval of Sedasys the hardest from the FDA will now just have to go back and learn to play nice with the physician anesthesiologists who are making sure their patients survive their procedures in relative safety and comfort.

Preaching To The Choir

There are some scientific papers out there that are so original and groundbreaking that they change the paradigm of science and medicine as we know it. Think about Watson and Crick's discovery of DNA or Marshall and Warren's description of H. pylori. These are truly revolutionary research that changed the course of medicine and well deserving of their Nobel prizes. This paper presented at the recent Digestive Disease Week, the preeminent GI conference in the country, isn't one of them however.

Presented at DDW by Dr. Otto Lin from the Virginia Mason Medical Center in Seattle, the study compared the effectiveness of the Sedasys system of propofol infusion with moderate sedation that GI docs normally administer. The Sedasys patients were first given 50-100 mcg of fentanyl followed by propofol infusion from the machine. The control group of patients received only midazolam and fentanyl. A total of 1,466 patients participated in the study. Of those, 1,013 underwent a colonoscopy, 285 had EGD's, and the rest had both.

So how did the robots do? According to Dr. Lin, the patients and physicians very much preferred propofol over the simple cocktail of Versed and fentanyl. Patients went to sleep faster, woke up quicker, and had better retention of facts after the procedure. Patients reported less pain during the procedure and less grogginess afterwards. However their overall satisfaction between the two modalities was not statistically different. Nine patients reportedly suffered laryngospasm that required mask ventilation to break. There were also cases of agitation and discomfort attributed to "monitoring" issues. Dr. Lin's team was so confident about Sedasys that they even started using the machine for off label uses such as complex colon polypectomies and endoscopic ultrasounds. However they didn't have enough numbers of those complicated cases to make any recommendations.

The researchers and GI docs present at the meeting hailed this paper as strong proof that propofol given by a machine is as safe and effective as one administered by an anesthesiologist. Naturally the GI audience in attendance would only see the results that were trumpeted by their GI colleagues instead of noticing the obvious and serious flaws in the study.

First of all, the study authors compared the use of propofol against a standard cocktail of Versed and fentanyl. That is hardly original work. There have been numerous papers detailing the superiority of propofol sedation against a combination of benzos and narcotics in GI procedures. It is well known that patients wake up faster, feel less confused afterwards, have superior amnesia of the procedure, and are able to leave the recovery room faster. So none of this paper's results are surprising. What they should have used as a control was propofol when given by an anesthesiologist to see if those criteria are any different when matched up against Sedasys. With this fundamental flaw in the study, the paper is essentially meaningless.

Then there is the question of the nine cases of laryngospasm among their patients. Nine episodes of laryngospasm seems excessive to me. The numbers sound even worse when one considers that the laryngospasms probably occurred within the 285 patients who underwent EGD's, not the 1,013 cases of colonoscopies. So nine patients with airway obstruction severe enough to recover positive mask ventilation is a very high rate of this complication.

I also wonder who provided the mask ventilation to break the laryngospasm. Was it the gastroenterologist? Would he have just dropped his scope in the middle of the case to run to the head of the bed to slap the mask on the patient? Was it the GI nurse who probably hadn't masked a patient since her last ACLS course a couple of years earlier? Or did they have to emergently scream for help from the nearest anesthesia provider to rescue their patient before they died on the procedure room table? My guess is that it was the latter since the GI knows that no anesthesiologist would willingly turn away from a patient whom they have never met or discussed the risks and complications of receiving propofol but is willing to help their fellow human being from dying of a needless complication of incompetent sedation.

So yeah the GI docs love the results of this "study" on the effectiveness of Sedasys. It tells them exactly what they wanted to hear. But with an estimated seven million EGD's performed in the U.S. each year, that translates to nearly 25,000 cases of laryngospasm and airway emergencies that require active intervention to keep the patient from dying if Sedasys is used for all of them. Those alarming numbers about Sedasys should be what concerns gastroenterologists and federal health regulators, not how much money they think they are saving from cutting out the anesthesiologists.

New York Tells Insurance Company To Pay For Anesthesia Services For Colonoscopies

The New York Attorney General's Office has ordered an insurance company to pay for anesthesia services rendered during colonoscopies. The State AG Eric T. Schneiderman penalized Emblem Health $25,000 for billing a patient for anesthesia after his screening colonoscopy. According to the Affordable Care Act, aka Obamacare, screening colonoscopies are part of the free health maintenance procedures that are mandated by the law.

The insurance company ran afoul of the law when a patient was billed $1,320 by an anesthesiologist who was not part of his insurance network. The company paid $924 but told the patient to pay the balance. That's when the patient lawyered up and called the AG's office. According to the Attorney General, anesthesia is a necessity when a patient undergoes colonoscopy. Therefore, as required by the ACA, the patient does not have to pay any deductibles, copays, or coinsurance.

What can we take away from this? One, that anesthesiologists should get down on their knees and thank their deity of choice for the ACA. Now, when patients who have these government insurance plans come in for colonoscopies, their anesthesia bills can't be denied as so many private insurance companies try to do.

What is more amazing to me though is the obscene amount of money the anesthesiologist is billing. A colonoscopy typically takes no more than ten to fifteen minutes. In the hands of an efficient or unscrupulous gastroenterologist, seven or eight colonoscopies can be knocked out in an hour. If this anesthesiologist is able to collect that much money on each one, it's easy to see why some anesthesiologists truly have the best paying job in America.

Which Institution Is The First In The Country To Embrace Sedasys?

Though the Food and Drug Administration approved the use of Sedasys in 2013, it has taken a year for the first hospital to accept its use in a clinical setting. Sedasys is a computerized system that administers propofol autonomously without the presence of an anesthesiologist in the room. It was mired in regulatory limbo for years before the FDA, in extraordinary fashion, reversed its own earlier ruling and allowed it to go into the market, thus realizing most GI doctors' propofol fantasies.

The first medical center to embrace Sedasys has turned up in...Seattle, Virginia Mason to be exact. Otto Lin, M.D., the Director of Quality Improvements at Virginia Mason and also a gastroenterologist, proudly states that, "It really allows us to use propofol, which we believe is superior to midazolam and fentanyl, in outpatients without having the added cost of having the anesthesiologist administer the drug."

Quite frankly, unless the anesthesiologists at Virginia Mason are employed by the hospital, Dr. Lin and the other GI's who work there may have trouble finding any anesthesiologist to back them up when, not if, an airway emergency occurs. Any anesthesiologist knows that once he steps into that procedure room, or even if he is within earshot of the impending disaster behind that closed door, the liability for the airway catastrophe instantly shifts to the anesthesiologist and away from the GI doc. Do they expect anesthesiologists to rush into an unknown and unstable situation at any time and just perform an airway resuscitation on a complete stranger out of the charitable goodness of our hearts?

Anesthesia reimbursement for endoscopies have been steadily eroding anyway. Sedasys was approved by the FDA only for ASA 1 or 2 patients. Insurance companies have increasingly denied anesthesia payments for MAC administered to these relatively healthy patients. Therefore it probably isn't going to have a major effect on most anesthesiologists' incomes. Any anesthesiologist whose livelihood depends on giving anesthetics exclusively to ASA 1 or 2 endoscopy patients every single day probably isn't living up to the potential of his hard earned board certification and should probably move on to something more professionally fulfilling in his life.

So let's see what happens now that Sedasys has been unleashed out into the wild. Will the cost savings really justify its exclusion of the potentially life saving presence of a second physician in the room? Will gastroenterologists accept full responsibility for a patient's airway calamity or will they still attempt to push the job to any anesthesiologist that just happens to be walking past the endoscopy suite? Only time, and a few unfortunate complications and possibly deaths, will answer that question.

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.

The Scariest Doctors I Work With

I've worked with angry doctors. I've worked with slow doctors. I've worked with funny doctors. But do you know which physicians worry me the most? No it's not the psychopath surgeon whose mother never taught him how to talk with his inside voice. Nor is it the befuddled old coot of a surgeon who meticulously labors through a case that would take half the time in the hands of a more competent physician. No the procedurists that worry me the most in a procedure room are...first year GI fellows.

Why do these young innocent physicians scare the crap out of me? It really is no fault of their own. Every doctor has a steep learning curve that has to be traversed before they can be the experts they will eventually become. Unfortunately for me, new GI fellows are acquiring their craft by obstructing the part of the patient I am most responsible for safeguarding, the patient's airway.

When these young doctors first grab hold of an endoscope, they literally don't understand the ups and downs of the instrument. They'll fiddle with the myriad of knobs and locks to try to understand how to aim the scope in all directions. They'll play with the various valves and buttons to determine how to suction or insufflate. It makes my sphincters tighten just anticipating what is about to happen.

Then the dreaded procedure begins. The fellow will sort of bend the end of the scope to what he thinks is the approximate curvature of the tongue and the oropharynx. He will pass the scope through the lips then...get completely lost. All he'll see on the monitor is a red or orange monochromatic screen. Unless he pushes really hard into the soft tissue in the mouth in which case he may see white as all blood under the mucosa is pushed away from the end of the instrument.

In the meantime my job is to preserve the patient's airway while sedating her well enough so that she doesn't jump off the table as the neophyte continues his lesson. If the patient starts coughing or moving, I'll get the much despised, "Anesthesia, patient's waking up!" and it will be my responsibility to keep the patient still with more drugs while the fellow continues to meander his way down the mouth.

Eventually he will advance far enough past the tongue to actually see the vocal cords. It is at this point, when the greatest danger to the patient is present, that most of them decide to pause to admire the view, as if they think they are ENT surgeons. They may blow air directly on the cords to keep open the space around the tip of the scope, which of course causes the cords to become irritated and the patient to cough. Once again I'll have to respond to "Anesthesia, patient's waking up!" as if it is my fault. Or worse, the tip of the endoscope may become smeared with saliva and the fellow decides he needs to wash it with a squirt of water, which again leads to coughing, or worse, laryngospasm. All of these reactions the patient is suffering somehow have to be mitigated by me or the doctor won't be able to continue.

Once he's had a good look at the cords, he will then proceed to enter the esophagus. He will try to enter through that tiny little space right below the arytenoids and through the upper esophageal sphincter. Here is where most of them baffle me. They will tell the patient to swallow the scope to open up the sphincter. How quickly they forget that I have to sedate the patient so deeply for them to get to this point that the patient is not able to cooperate to verbal commands. This step may take awhile as there is usually a slight bend in the UES before the scope will enter the esophagus properly. Once they have passed this point I can finally let out a quick sigh of relief as the airway is now at less risk of obstruction once the scope has passed.

I know they have to learn their trade somehow. And after a few thousand endoscopies under their belts, they will be one of the highest paid physicians in the country. But in the meantime I don't think patients understand what risks they are taking when they have GI fellows practicing their procedures on them. Maybe this is one of those times where a model simulation of an endoscopy, like simulations of airway intubation, can be both safe and effective. I'm sure getting tired of pushing more propofol just so the fellow can get the endoscope past the patient's uvula.

The Murky Death Of Joan Rivers

I have tried not to comment on the untimely death of comedienne Joan Rivers last week due to the fact that the investigation into her demise at the Yorkville Endoscopy center in Manhattan is still ongoing. However, more details are starting to leak out about that fateful day and the story is starting to get more disturbing.

Ms. Rivers was scheduled to have a procedure performed at the center that day by her personal gastroenterologist, Dr. Lawrence B. Cohen, to evaluate a worsening hoarseness in her famously raspy voice. Ms. Rivers appeared to be in good health and spirits at the time, even performing the night before at a club.

Now it's not uncommon for GI docs to evaluate hoarseness. What does the GI tract have to do with poor phonation? Severe gastric reflux can produce acid that comes up the esophagus and potentially damage the cords. Therefore it's not unheard of for a GI physician to perform an endoscopy to look for evidence of reflux that might lead to vocal cord damage.

Up to this point I have no problems with the story. Then the whole episode starts to go awry. At first the news was that Ms. Rivers went into respiratory and cardiac arrest during the procedure. The first thing I thought of was laryngospasm, which is not uncommon during upper endoscopies performed with only conscious sedation or monitored anesthesia. An anesthesiologist present would have known precisely how to reverse the laryngospasm as that has been drilled into us since day one of residency training. However, it would have been unusual for Dr. Cohen to have used an anesthesiologist to give sedation to Ms. Rivers since he is well known in academic circles for looking with disdain at using anesthesiologists at all for endoscopies. He's one of those GI docs who feels he can simultaneously perform his duties of a gastroenterologist and an anesthesiologist without jeopardizing patient safety. So it's highly likely that Dr. Cohen was the one directing the nurses in the room to give IV sedation for the procedure, despite the claims of Yorkville spokeswoman Marcia Horowitz, who states that an anesthesiologist is always at a patient's bedside throughout the procedure and "immediately assumes control of the airway and assists with a patient's ventilation" if the patient is in jeopardy.

Ms. Horowitz says the center has three or four anesthesiologists working any given time to help with airway management. Yet they also say that succinylcholine is not available at the facility. Whaaa? I don't know of ANY anesthesiologist who will work anywhere without having access to at least one vial of succinylcholine at a moment's notice. It is precisely for emergencies like a laryngospasm that a rapidly acting muscle relaxant is most essential. So to claim that they have multiple anesthesiologists standing by with all the latest resuscitation equipment ready yet have no sux around doesn't make any sense at all.

Now comes the bombshell that Ms. Rivers had her vocal cords biopsied by an ENT surgeon who isn't even authorized to do procedures at Yorkville Endoscopy. In fact the surgeon was assumed by the center's staff to be a makeup artist for Ms. Rivers. Curiously, without knowing the identity of this person, they let her into the procedure room with her little black bag of equipment. If that's not the worst Joint Commission violation in the first degree, I don't know what is. First of all, did Ms. Rivers even know this surgeon or that she would be coming in during her EGD to possibly perform a vocal cord biopsy? Was the surgeon's name on the consent? Was there even a consent for vocal cord biopsy since the staff didn't even know the surgeon? Are the staff at Yorkville Endoscopy so intimidated by the GI doctors that they are afraid to raise questions about irregularities in the procedures?

The identity of this ENT hasn't been revealed, yet she could possibly be the worst ENT surgeon in the world. An ENT surgeon has looked at thousands of vocal cords during a lifetime of practice, including many airways horribly deformed by cancer. Therefore if Ms. Rivers went into laryngospasm, presumably the ENT would have just as much or more experience than the anesthesiologists in intubating her to reverse her hypoxia. One may assume that anesthesiologists have more experience with intubating the trachea, but many anesthesiologists who work at these outpatient ambulatory centers probably haven't intubated a patient in years. Even if the ENT had difficulty intubating Ms. Rivers, which they eventually did, the surgeon would have been the perfect person to perform an emergency tracheotomy to save her life.

So this raises the question of how Ms. Rivers was being monitored during her endoscopy. Did she have all the basic monitoring equipment in place according to ASA guidelines, including pulse oximetry? Even if she went into laryngospasm, there is usually at least a few seconds to get the endotracheal tube in place to prevent hypoxia leading to cardiac arrest and brain damage. The surgeon would have been in precisely the right location to quickly insert the tube. Yet it sounded like they didn't realize the patient was desaturating quickly until it was too late. 

So as you can see, a lot of this story doesn't make sense yet. The investigation into what happened in that procedure room will take months to complete and may never be completely revealed to the public. In the meantime, Dr. Cohen has lost his job as the medical director and procedurist at Yorkville Endoscopy. And I'm once again having to explain to my patients in preop why they won't suffer the same fate as poor Joan Rivers.

A New Way To Give Anesthesia For Colonoscopies

Now here is a new way to give anesthesia for a colonoscopy. I didn't know that the brachial plexus reached all the way down to the large intestine. I must have missed that class in residency.

Colonoscopies With Propofol. A Surprising Endorsement From The LA Times

By now we've all heard about the controversy of paying for anesthesiologists to give propofol during colonoscopies. The usual bias is that the procedure doesn't require the heavy sedation that is achieved with propofol. Colonoscopies in most parts of the world are performed with little if any sedation. If every colonoscopy in America suddenly needed an anesthesiologist to provide sedation, the country will be driven even more quickly into bankruptcy.

Yesterday, the LA Times consumer reporter, David Lazarus, penned a surprisingly accommodating article about using propofol for lower endoscopies. In the story, he criticizes the practice of health insurer Anthem Blue Cross in denying reimbursements to anesthesiologists who administer propofol to patients which the company deems are not medically necessary. Mr. Lazarus quotes one patient named Michael who says, "I can't imagine going through that procedure without anesthesia."

Mr. Lazarus goes on to accuse Anthem and other health insurance companies of being penny wise and pound foolish. He interviews Dr. Eric Esrailian, co-chief of the Division of Digestive Diseases at UCLA who defends the practice. Says Dr. Esrailian, "Colon cancer is a preventable cancer. Screenings are the key. We should do whatever is necessary for society to be screened." He states he would use propofol for all his colonoscopies if it weren't for having to deal with insurance company reimbursement problems.

The reporter goes on to list the potential down sides of using moderate sedation instead of propofol. He quotes a letter from Alister George, medical director of the Digestive Health Center in Thousand Oaks, CA. In the letter that is sent out to patients, Mr. George describes the side effects of moderate sedation, including, "The pain experienced while undergoing conscious sedation may be very unpleasant for some patients. The drugs used for conscious sedation may cause side effects such as prolonged drowsiness, low blood pressure, nausea and vomiting. Compared to propofol, the recovery time for conscious sedation is considerably longer."

Mr. Lazarus chastises the insurance companies for not reimbursing anesthesiologists who provide propofol for colonoscopies as being extremely short sighted. If people understood how propofol can make colonoscopies virtually painless, then more would probably get screened, preventing thousands of colon cancers from forming and saving the insurers billions of dollars. Studies have even shown that colonoscopies performed with propfol sedation yields a higher success rate of detecting colonic polyps vs. ones done under conscious sedation.

This is the kind of reporting that the ASA should be actively seeking from news media all around the country. While doctors may grumble and write letters to insurers defending their practices, nothing gets the companies more defensive than having the the general public, and hopefully politicians, breathing down their necks at their callousness in denying comfort to patients who need and want it.

Sedasys Is Here. Who Will Be Affected The Most?

Sedasys

 

The Food and Drug Administration has finally approved the use of Sedasys in the GI endoscopy suite. Sedasys is a computer operated propofol infusion device that automates patient sedation while he is getting an endoscopy. The device monitors six parameters including heart rate, blood pressure, pulse ox, respiratory rate, end tidal CO2, and patient responsiveness to deliver a sedating dose of anesthetic. It is approved only for ASA 1 or 2 patients undergoing EGD's or colonoscopies.

The battle for the approval of the Sedasys system has been going on for years, with Johnson & Johnson and gastroenterologists pitted against anesthesiologists. The ASA won a small victory last year when the FDA initially rejected Sedasys. However, in an unprecedented move, the FDA reconsidered the rejection and now has given the go ahead for the device.

Do you think that there is no way a computer program could function as well as a human anesthesiologist? You better think again. Before you get too cocky, there are several studies that have shown that computers can administer sedation as well as or even better than an anesthesiologist. They are also less likely to oversedate the patients too.

As with any new disruptive technology, there are bound to be winners and losers once all the dust is settled. Who are the likely losers if this equipment becomes widely available? Could it possibly hurt CRNA's? Since it is approved only for sedating healthy patients, most GI docs probably wouldn't use an anesthesiologist anyway in such situations. However, they might use CRNA's instead. The low cost CRNA's suddenly find themselves squeezed between the even cheaper Sedasys for healthy patients and the more expensive but higher expertise of anesthesiologists for sick patients. Uh oh.

What about gastroenterologists? They may think that they can finally rid themselves of the dead weight of anesthesia providers and keep all the money to themselves. However, FDA approval is contingent on having a trained anesthesia provider available immediately for possible airway emergencies. Even that may not be fast enough if nobody is watching the patient except some computer program which is almost always reactive instead of proactive. GI docs may see their malpractice insurance rise as a result of this increased responsibility.

How does the patient fare through all this? I shudder at the possible short cuts endoscopy units might consider once there is no anesthesiologist around to remind them about proper patient safety. We already know that GI docs have a much lower criteria for monitoring patients than anesthesiologists. I also wonder how reactive Sedasys is. Anybody who has ever administered GI anesthesia knows that patients can be maximally stimulated by the endoscope one second then completely relaxed the next once the scope goes past a particularly difficult passage. As an anesthesiologist I've seen far too many instances where the GI doc is yelling at the anesthesiologist to give more sedation because the patient is moving. By the time the extra bolus of propofol has reached the patient's bloodstream the scope has worked through its loop. Now the patient is relaxed but oversedated and his airway is obstructed. Will Sedasys recognize these temporary events and hold back or will it keep pumping propofol into the patient only to overdose when the crisis passes? If the machine does dribble less anesthetic to the patient to prevent oversedation, will that just create more anxiety for the patient?

Anesthesiologists may not be the winners here but I don't think we'll be too badly hurt either. Our expertise will stand out since we will still be called upon to do the difficult cases. Our mastery of the airway will also be evident when we are inevitably called to the endoscopy unit to provide emergency airway support. While there will be some anesthesiologists who may lose their cushy ambulatory surgery center endoscopy jobs, most anesthesiologists don't give anesthesia only for endoscopies. Most ASC's provide orthopedic, urologic, and other procedures that will still need an anesthesiologist present. So I don't see a huge disruption to anesthesiologists either. With a projected shortage of anesthesiologists in the future, our craft should be better utilized on patients who truly require the full gamut of our training. Technology is inevitable. We better get ourselves used to providing a higher level of medical treatment and let the bottom fall out where they may.

Wouldn't You Rather Have Propofol?

 I walked into the GI procedure room one morning while a colonoscopy was underway using conscious sedation. The GI doctor was ordering vial after vial of sedatives while the nurse was frantically trying to get the drugs from the lockbox, chart the patient's vital signs, and attempt to hold down the patient all at the same time. I would have stepped in to help except, well, I was not requested for the patient's sedation and thus did not give the patient an informed consent for anesthesia.

I quickly peeked at the amount of drugs that the team was having to give in order to somewhat relax the patient. So far, as you can see in the picture, the gastroenterologist had given the patient eight milligrams of midazolam and two hundred micrograms of fentanyl. This seems like a lot of drugs for what should be a simple procedure where the patient is supposed to be given just enough for relaxation.

Needless to say, when patients are informed that are going to be under conscious sedation, they are given the sugar coated story about how they'll only feel a slight pressure as the colonoscope is passed through the colon and they should be able to tolerate it with deep breathing and minimal amounts of sedatives. While that may be true for a few diehard people, the majority of patients find it very uncomfortable and will request more medications until they are knocked out, thereby converting a conscious sedation into a MAC sedation.

In order to give that much sedation, it's not unheard of to give double digit milligrams of midazolam and hundreds of micrograms of narcotics, especially for younger or larger adults. Unfortunately for the patients and the doctor's office, a colonoscopy concludes very rapidly, within minutes after the scope reaches the cecum. Now you are left with an unconscious patient with drugs that will persist in the bloodstream for hours. All those narcotics, along with the distended bowel caused by the endoscope, potentiates postoperative nausea and vomiting. You are left with a semiconscious patient in the recovery room that you can't discharge because of their sedation and postop nausea sitting around waiting for the drugs to wear off. This slows down the workflow of the operating schedule and potentially leads to expensive staff overtime. In my opinion, that doesn't sound very cost effective.

Wouldn't you rather just have an anesthesiologist give a single vial of propofol, which is more than enough for most colonoscopies, and bypass all these potential complications? Plus it has been shown that more polyps are picked up by the gastroenterologist when an anesthesiologist is present to give the sedation. Yeah, it sounds like a no brainer to me too.

Anesthesiologists Give Better Colonoscopies

A recent JAMA article has ignited another storm of controversy over the use of anesthesiologists in routine colonoscopies. They found that the use of anesthesiologists in the GI suite has increased over the past few years, from 14% in 2003 to 30% in 2009, most of which go to "low risk" patients. The authors speculated that the reasons for this include quicker turnaround of cases with the use of propofol, patient preference, and most cynically, financial gain by the physicians.  Skeptical Scalpel wrote in KevinMD that a likely reason for an expanding role of anesthesiologists in GI is because of medicolegal reasons, or cover your ass. If there is a complication with the sedation, such as an aspiration or cardiac arrest, it is more convenient for the gastroenterologist to blame somebody else if there is another MD in the room. It's harder to pin the blame on the nurse giving the Versed that he himself ordered given to the patient.

I'd say we have all forgotten another benefit of having anesthesiologists give the sedation for an endoscopy. Last year I mentioned a paper was presented at Digestive Disease Week, the largest GI conference in the country, that concluded colonoscopies were more effective if an anesthesiologist was giving propofol. More polyps were found when we were in charge of monitoring the patient. This only makes sense as the GI docs can concentrate their efforts on the actual scoping of the patient instead of worrying about the patient's vital signs, assuming they actually do pay attention. At the end of the day, isn't detecting more polyps the goal of giving routine colonoscopies to prevent colon cancer? In the long run, the use of anesthesiologists in GI will save insurance companies millions of dollars in preventable cancer treatments. But of course it is hard to put a number on a supposed future savings when these companies only count their quarterly profits.

So get the word out. We are not going to win the battle on patient safety when it comes to anesthesiologist monitored endoscopies. But if continue to spread the word that disease detection is greater with us present, then that will hit the skeptics where it counts, in their pocket books.

Open Access Endoscopy. Is GI Following The Same Fateful Path As Anesthesiology?

An open access GI procedure is when an endoscopic procedure is performed on a patient without a full consultation with a gastroenterologist. Some have advocated this approach as benefiting patients by allowing faster scheduling of cases with less paperwork and hassle. In fact, Dr. Thomas Deas, Jr., M.D., president elect of the American Society for Gastrointestinal Endoscopy, has presented an informative article on how to increase open access procedures for GI docs. Some of the advice he gives include finding and working with the a good primary care doctor who you can trust to refer a low risk patient for an open access endoscopy. He says that virtually any healthy patient between the ages of 50 and 80 is eligible for open access. If a patient have chronic issues like diabetes or respiratory illnesses, then they should undergo a full consultation first before having the endoscopy.

Now why does this line of reasoning sound so familiar to anesthesiologists? Because that is the precise logic GI docs use to preclude anesthesiologists from providing sedation for endoscopic procedures. If a patient is relatively healthy, who needs a fully trained anesthesiologist? The gastroenterologists can give the sedation themselves or in the not too distant future, the patients can give their own propofol with the help of a self controlled pump. No anesthesiologist involved to delay a case, cancel a case, or take any money from their surgery centers.

But the GI guys better be careful what they wish for. Open access endoscopy on healthy patients can easily lead to competition from their fellow health care providers. By not doing a full consultation on a patient, the gastroenterologist has basically reduced himself to a scope monkey. Anybody can take a course in endoscopy and do a procedure on a healthy patient. It may not be as perfect as a regular GI doc's but for a screening procedure it should be good enough. With practice, the outcome might even be comparable. Therefore the internist or family practice doc may decide to pad his income by doing the endoscopy in his own office. Or perhaps in the future a nurse practitioner or physician assistant will take a course in endoscopy and do procedures for the internist in his office, bypassing the need for an expensive gastroenterologist to do the same thing. Healthy patients don't need the full expertise of a fully trained MD to watch over them right?

No More Excuses

How did I miss this juicy nugget of information? A paper presented at Digestive Disease Week in May has finally put to rest the canard that anesthesiologists are not needed in an endoscopy suite. The study, conducted by Dr. Brooks Cash of the National Naval Medical Center in Bethesda, Md, looked at over four and a half million colonoscopies performed over a ten year period. Roughly one third of the colonoscopies were performed with an anesthesiologist present.

Dr. Cash's team found that when an anesthesiologist was present, the rate of detecting a colonic polyp was 37.7%. When no anesthesiologist was there, the detection rate was only 37%. While this may sound like a small difference, with such a large sample the difference was considered significant. Similar positive findings were found when accounting for sex and age differences. What's more, when an anesthesiologist was performing the sedation, the rate of detecting colon cancer within three years of the initial colonoscopy was significantly higher, 1.97% vs. 1.71%.

There you have it. Now there are no more legitimate excuses for not having an anesthesiologist performing the sedation in the endoscopy suite. Anesthesiologists increase the effectiveness of screening colonoscopies, leading to higher rates of early cancer detection thereby saving lives and MONEY for everybody involved. Previous studies have already shown that patients prefer to have a propofol anesthetic for their procedure. They will be more compliant with a screening colonoscopy if they knew how painless it can be with propofol. The patients will then refer all their acquaintances to do the same thing. This again leads to early colon cancer detection which will save even more lives and MONEY.

What about patient safety? GI docs will insist that no studies have found that sedation given by an endoscopist has led to any more complications than one given by an anesthesiologist. While that may be true it's like asking whether a Boeing 747 flown by one pilot is just as safe as having the plane also carry a co-pilot (I don't need to tell you who the real pilot in the endoscopy unit is). One pilot in the cockpit will almost assuredly take you to your destination safely, with all the autopilot and other safety measures present. But wouldn't you feel more comforted by knowing there are two pilots taking you on the journey?

So that leaves only one excuse left for why gastroenterologists don't want anesthesiologists in the room. Do I even need to repeat it? It all comes down to MONEY. They think we slow them down which decreases the number of procedures they can do in one day thus costing them MONEY. How shallow of some of these docs to think our careful evaluation of our patients for their ability to tolerate an anesthetic safely is an impediment to their business plans. That is very egocentric thinking. The big picture is that anesthesiologists are saving MONEY by helping the endoscopists detect early colon cancer. This saves the hospital, the insurance companies, and the government an enormous amount of MONEY in the long run. The patients are more grateful for their humane sedation and successful screening. And another productive member of our society will be able to continue to lead a normal life because we prevented him from getting cancer. Isn't that worth the few hundred dollars it costs to have an anesthesiologist present during an endoscopy? Heck ya!

Give Me Propofol, Straight Up

There is a study in Gastrointestinal Endoscopy this month advocating the use of balanced propofol sedation (BPS) over what the authors call conventional sedation (CS). BPS consists of propofol along with the use of midazolam and meperidine while CS is just BPS without the propofol component. The study consisted of 222 patients who underwent therapeutic EGD or ERCP. At the conclusion of the study, they found that there was no statistical difference in complication rates. However BPS was found to statistically improve patient cooperation along with health care provider and sedation nurse satisfaction with the procedure.

Now I have to admit that I've only read the abstract that's available on the Gastro Endo website. I don't have a subscription to the journal. What do you expect, I'm an anesthesiologist. But I found their rate of cardiopulmonary complications quite appalling. The abstract does not delve into their definition of cardiopulmonary complication (hypotension? MI? Aspiration?). For BPS the rate of complications was 8.8% while for CS it was 5.8%. Transient interruption of procedure was 2.9% for BPS vs. zero for CS. Neither sedation caused termination of the procedure or required assisted ventilation.

Again I haven't read the entire article. I'll have to go to the medical library to see if they even subscribe to it. But a 9% cardiopulmonary complication rate seems quite excessive. Even 5.8% sounds high. My question is, why use a cocktail at all? My preferred sedation for endoscopies, including therapeutic procedures like ERCP and EUS, is straight propofol, and nothing but. Let me tell you my experience from giving thousands of sedations for GI docs.

I find that Versed adds virtually nothing to propofol sedation. You might give it for excessively anxious patients in preop or pediatric patients, but most adults can handle the brief 2 minute or less transport from preop into the procedure room. They may say that they need something to calm them down but when you explain to them that Versed will prolong their post procedure stay for up to an hour, most people won't mind a little anxiety before the start of the procedure.

I rarely give narcotics either. Again narcotics add almost nothing to the propofol sedation. Some procedures that are excessively painful, such as biliary or pancreatic duct dilation, may require narcotics during the course of the procedure. In those cases I would only give short acting narcotics such as fentanyl. But giving narcotics routinely for sedation only increases the risk of intraop apnea, hypotension, hypoxia, and postop nausea and vomiting. The last thing you want as a GI anesthesiologist is a PACU full of unhappy wretching patients that the nurses are unable to discharge home.

So this study asks the wrong question. It's not which sedation cocktail is better for therapeutic GI cases. It's whether anything besides propofol is required to sedate a patient adequately for the gastroenterologist to complete his procedure. Trust me. You don't need to complicate your life by giving anything else besides propofol. Cheers.

VICTORY!

The Food and Drug Administration has sided with anesthesiologists and denied the American College of Gastroenterologists their petition to remove from propofol's label the requirement that administrators of the sedative have training in general anesthesia and not be involved in the surgical procedure itself.  Says the FDA, "After considering your [petitioners'] claims and the literature you provided for our review, we conclude that you have not shown that the warning is no longer warranted or appropriate.  In fact, we conclude that the warning is warranted and appropriate in light of the significant risks associated with propofol, and we further conclude that the warning should help ensure that propofol is used safely.  Accordingly, we will not seek to have the warning removed, reduced, or otherwise amended."

This should have been a no brainer for the FDA.  In light of the death of Michael Jackson, it should be self explanatory that propofol is a dangerous drug in the hands of people who have not had proper training in airway and cardiovascular resuscitation.  It continues to puzzle me the ACG's persistence in demanding the right to use propofol sedation.  Why is it not obvious to them that it is inheritantly dangerous for the operator to also be in charge of the sedation? Airway collapse can happen in seconds. Are they going to be vigilant enough to notice?  And if they are how good a job are they doing with the endoscopy? Will they see that flat polyp hiding in the hepatic flexure or the ulcer right behind the pylorus if the patient starts to desaturate or brady? What of all those studies published in GI journals expounding the safety of gastroenterologist administered propofol? Most of them use doses of propofol that are practically homeopathic.  If anesthesiologists gave that small an amount, we'd probably get kicked out of the procedure room for not know how to give MAC sedation. 

What about the ACG's contention that requiring an anesthesiologist present to give propofol increases the cost of the procedure? The FDA's answer in essence is, "How can you put a price on patient safety when it is so easy to make sure they survive the procedure by having an anesthesiologist in the room?" The extra cost is more than justified given the significant risks of poorly administered propofol sedation. How would the endoscopist explain to a patient's family that the victim suffered an acute MI or anoxic brain injury because they were too cheap to hire an anesthesiologist to monitor the sedation? They can't. And now thanks to the FDA, they won't have to. If a medical catastrophe happens, we anesthesiologists are man enough to take the blame.

There's An AAP For That

Gastroenterologists have been pining for the right to use propofol for their endoscopic cases for years.  At the recent DDW conference in New Orleans, there were multiple talks on gastroenterologist administered propofol (GAP) or nurse administered propofol (NAP) vs. anesthesiologist administered propofol (AAP).  Everyone agrees that propofol (while it's still available) is superior to other forms of sedation for endoscopy.  The friction between the professional societies is over who is the most qualified to give it. 

I found this little gem from the American Gastroenterological Association.  It is a guide from the AGA Institute on how to give propofol sedation.  One of its tables describes how best to monitor a sedated patient.

Notice that the AGA Institude recommends that ECG monitoring is optional while capnography (the measurement of expired carbon dioxide) is not necessary.  Really?

By comparison. guidelines from the American Society of Anesthesiology on respiratory monitoring during endoscopic procedures state, "Monitoring for exhaled carbon dioxide should be considered during endoscopic procedures in which sedation is provided with propofol alone or in combination with opioids and/or benzodiazepines, and especially during these procedures on the upper gastrointestinal tract."

If your are a patient, who would you prefer to watch over you while you are sedated and helpless? Dr. GI, please stick with what you know best and leave the patient and airway monitoring to the doctors who do this every day, your helpful and friendly anesthesiologists.  Case closed.

Gastroenterologists and Anesthesiologists--Can't We Just Get Along

A couple of days ago, I mentioned the antagonism shown to Dr. Alexander Hannenberg, president of the ASA, during his presentation at the DDW.  He was trying to lay out his reasoning for why anesthesiologists alone should provide propofol sedation during GI endoscopy.  This naturally didn't sit well in a room filled with hundreds of gastroenterologists. I feel that this animosity is more motivated by money than any legitimate medical reason.  So let me present some logical reasons why anesthesiologists and the use of propofol should be used in every endoscopic procedure.

Improved patient compliance.  Patients' worst fears and the reason many avoid needed endoscopic screening are the perceived pain felt during the procedure.  They hear horror stories about how uncomfortable the procedure is from friends or recall bad memories of previous endoscopies.  But once they've experienced a screening with propofol sedation, many are effusive with praise.  When they wake up, they can't even believe the procedure is already finished.  They have no further hesitation for future endoscopies and highly recommend to their friends and family the virtues of propofol sedation.  Thus more procedures and money for the gastroenterologists.

Improved examination.  When the patient is well sedated with propofol by an anesthesiologist, the patient has minimal movement compared to a versed/fentanyl moderate sedation.  The gastroenterologist is free to take his time to examine the GI tract thoroughly at his leisure instead of telling three people to hold the patient down before he falls out of bed.  A better examination leads to a better reputation which leads to more referrals, which again means more money for gastroenterologists.

The gastroenterologist can concentrate on his exam.  Two sets of eyes watching the patient during a procedure is better than one.  Sure a nurse can give the sedation and chart the vital signs and assist the doctor and monitor the patient's airway for impending obstruction.  But isn't it safer to have another physician who is a trained expert in all those activities in the room?  If the patients loses his airway and codes, guess who is going to get sued? The sedation nurse and the gastroenterologist.  And the nurse's lawyer will punt the responsibility to the MD in charge of the room.  If an anesthesiologist was present the GI doc's lawyers could legitimately say that the airway is not his concern and is the onus of the anesthesiologist and we would agree. Why does an endoscopist want to risk a malpractice lawsuit from a patient that becomes hypoxic and possibly get an MI, stroke, or even dies on the table when there are plenty of anesthesiologists willing to help out to prevent such a tragedy? Fewer lawsuits, more money.

As you can see, there are plenty of monetary incentives for GI docs to use anesthesiologists in the endoscopy suite.  There are now papers that document increased satisfaction from patients and endoscopists with propofol sedation.  In this era of evidence based medicine, the gastroenterologists should abandon their traditional ambivalence and embrace anesthesiologist-administered propofol for endoscopy.

The Propofol Burn

One of the least desirable effects of propofol is the burning sensation a patient feels when it is injected into the vein.  I've had many patients complain about the irritation from a previous anesthetic experience.  Being in GI anesthesia, I've had much experience with this as a consequence of the high turnover of patients and the near universal use of propofol.  After years of trying different methods to reduce the pain, I've had great success with a protocol of lidocaine followed by a propofol chaser.

It's very simple.  When the patient is ready for induction, I give 30 mg of lidocaine and immediately follow that with 30 mg propofol.  I then wait 30-60 seconds and then give another bolus of propofol of 30-40 mg.  Continue this cycling of propofol boluses until the desired level of sedation is achieved.  I've found that this eliminates the propofol burn greater than 90% of the time.  The key I think is the small amount of propofol injected each time.  The first bolus given as a 1:1 ratio with lidocaine seems to give good relief from vein irritation.  Waiting 30 seconds before giving the next bolus allows the patient to achieve some level of sedation so that they have less awareness of the burning with the subsequent boluses.  Another advantage of giving small intermittent boluses is decreased risk of having the patient go apneic, which can happen if they are given a large initial amount of the drug.

Why not give a benzo like Versed as a sedative?  In GI the cases are very quick.  Even though Versed is short acting it is not short enough.  You wind up with a recovery room full of patients sleeping off their Versed.  Patients achieve alertness much faster after using only propofol.  Versed induced amnesia is also inconsistent; some patients still remember the pain while others are amnestic five seconds after Versed is given.  Patients are also happier when they wake up faster from anesthesia.  Many patients complain of being drowsy for hours when they go home after being given Versed.  They report feeling alert and normal when only given propofol.

Fentanyl has also been advocated as a preop sedative to alleviate the burn.  My experience has been that narcotics have an unpredictable effect on respiration, especially when given with propofol.  Some patients do fine while others go into prolonged apnea when propofol is given.  And again the patient takes longer to wake up in recovery.  There is also an increased risk of post operative nausea and vomiting when adding a narcotic to your anesthesia. PONV is something patients find extremely unpleasant and want to avoid at all cost.

Of course there are some instances where this intermittent bolusing of propofol doesn't work.  If you are trying to achieve a rapid sequence intubation, screw the burning pain.  Just inject and go.  The pain is the last thing you should be worried about.  Also patients who have tiny veins will almost always have pain with injection no matter what protocol you use to prevent it.  They just have to live with it for a few seconds until they fall asleep.

Obviously there is no scientific basis for this method of induction.  It was arrived through years of propofol injections.  But give it a try.  I would like to hear how other anesthesiologists minimize the amount of burning when they give the milk of amnesia.