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Do you need an anesthesiologist for upper gastrointestinal endoscopy? In the aftermath of Joan Rivers’ tragic death following an upper endoscopy procedure at a New York outpatient surgery center, every news bureau is discussing this topic. Because I have no inside information on Joan Rivers’ medical care during her procedure, I will not judge her physicians, rather I will attempt to answer the specific question:
Do you need an anesthesiologist for an upper gastrointestinal endoscopy?
The answer to the question is: it depends. It depends on 1) your health, 2) the conscious sedation skills of your gastroenterologist, and 3) the facility you have your endoscopy at.
1) YOUR HEALTH. The majority of endoscopies in the United States are performed under conscious sedation. Conscious sedation is administered by a registered nurse, under specific orders from the gastroenterologist. The typical drugs are Versed (midazolam) and fentanyl. Versed is a benzodiazepine, or Valium-like medication, that is superb in reducing anxiety, sleepiness, and producing amnesia. Fentanyl is a narcotic pain reliever, similar to a short-acting morphine. The combination of these two types of medications renders a patient sleepy but awake. Most patients can minimal or no recollection of the endoscopy procedure when under the influence of these two drugs. I can speak from personal experience, as I had an endoscopy myself, with conscious sedation with Versed and fentanyl, and I remembered nothing of the procedure.
If you are a reasonably healthy adult, you should be fine having the procedure under conscious sedation. Patients with high blood pressure, diabetes, asthma, obesity, mild to moderate sleep apnea, advanced age, or stable cardiac disease are have conscious sedation for colonoscopies in America every day, without significant complications.
Certain patients are not good candidates for conscious sedation, and require an anesthesiologist for sedation or general anesthesia. Included in this category are a) patients on large doses of chronic narcotics for chronic pain, who are tolerant to the fentanyl and are therefore difficult to sedate, b) certain patients with morbid obesity, c) certain patients with severe sleep apnea, and d) certain patients with severe heart or breathing problems.
2) THE CONSCIOUS SEDATION SKILLS OF YOUR GASTROENTEROLOGIST. Most gastroenterologists are comfortable directing registered nurses in the administration of conscious sedation drugs. Some, however, are not. These gastroenterologists will disclose this to their patients, and recommend that an anesthesiologist administer general anesthesia for the procedure.
3) THE FACILITY YOU HAVE YOUR ENDOSCOPY AT. Most endoscopy facilities have nurses and gastroenterologists comfortable with conscious sedation. Some do not. The facility you are referred to may have a consistent policy of having an anesthesiologist administer general anesthesia with propofol for all endoscopies. If this is true, they should disclose this to you, the patient, before you arrive for the procedure. A facility which always utilizes general anesthesia means that you, the patient, will incur one extra physician bill for your procedure, from an anesthesiologist.
I refer you to an article from the New York Times, which summarizes the anesthesiologist-propofol-for-endoscopy phenomenon in the New York region in 2012:
One last point: If the drugs Versed and fentanyl are used, there exist specific and effective antidotes for each drug if the patient becomes oversedated. The antagonist for Versed is Romazicon (flumazenil), and the antagonist for fentanyl is Narcan (naloxone). If these drugs are injected promptly into the IV of an oversedated patient, the patient will wake up in seconds, before any oxygen deprivation affects the brain or heart.
Propofol, however, has no specific antagonist. Propofol only wears off as it is redistributed out of the blood stream into other tissues, and its blood level declines. A propofol overdose can cause obstruction of breathing, and/or depression of breathing, such that the blood oxygen level is insufficient for the brain and heart. The Food and Drug Administration (FDA) mandates that a Black Box warning be included in the packaging of every box of propofol. That warning states that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”
Anesthesiologists are experts at using propofol. I administer propofol to 99% of my patients who are undergoing general anesthesia for a surgical procedure. Anesthesiologists are experts at managing airways and breathing. Individuals who are not trained to administer general anesthesia should never administer propofol to a patient, in a hospital or in an outpatient surgery center.
I serve as the medical director of an outpatient surgery center in Palo Alto, California. We perform a variety of orthopedic, head and neck, plastic, ophthalmic, and general surgery procedures safely each year. In addition, our gastroenterologists perform thousands of endoscopies each year. I review the charts of the endoscopy patients as well as the surgical patients prior to the procedures, and in our center, approximately 99% of endoscopies can be safely performed under Versed and fentanyl conscious sedation, without the need for an anesthesiologist attending to the patient.
If you have an endoscopy, ask questions. Will you receive conscious sedation with drugs like Versed and fentanyl, or will an anesthesiology professional administer propofol? You deserve to know.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: