Expert: Ronald Levy, M.D. - 3/1/2008

Question
I truly do appreciate the time and attention that you provided in response to my initial question.  However, your response does not directly address my concerns.  Perhaps that is because I was not clear.  Fortunately, it appears that the short-term memory difficulties have passed.  However, I would like to respond to your response and to see if, based on my clarification, there is any additional wisdom you would be willing to share.

You indicated that most people would find colonoscopy without medication unpleasant.  I have several responses to that statement.  First of all, if a viable medication option could be/would have been discussed which took into account my specific health history, I would be receptive.  Second, I am aware by literature review and communication with colleagues, that in other regions of this country and other countries, physicians either by option or routine, do perform colonoscopies without medication.  Third, in my own training as a health care provider, history lessons indicated that woman were given scopolamine during labor because bearing children without medication was thought to be unpleasant.  During my own education and after, I am not aware of the continued routine use of scopolamine.  As such, for a variety of reasons, trends change.

You also referred me to a teaching hospital.  That is a good idea!  As a licensed healthcare provider and having myself trained medical residents, that was an initial thought of mine.  However, the providers in my own community all practice at the teaching hospitals here and none of them would entertain even discussing medication options, or any options prior to appearing at their site, prepped and ready for the procedure.  The community I went to was one that has a well respected medical school and the provider who did the procedure was recommended due to his experience, skill, research background, and his reported willingness to respond to the needs/wishes of patients.

As I previously indicated, the provider who I did meet with and who did perform the procedure, essentially told me how things were going to be, without listening and without providing accurate information.  You indicated that your practice/facility tells people to put off important decisions for 24-48 hours.  This physician never informed me about the amnestic qualities of Versed.  In addition, given that I am a doctorally prepared, licensed health care professional, with responsibilities in the medical-legal arena, I specifically asked about the half-life of the medication and the related matters of the time period in which I should not resume any critical level of work or decision-making.  His response was, “I had my own colonoscopy and worked the next day”.  He gave every assurance that I would have no medication effects that required any accommodation on my part the following day.  As indicated in my initial question, this was not my experience.

I am aware that you indicated that allergic reactions are rare.  I have a history of asthma and allergies that have been asymptomatic for several years.  I have had reactions to a variety of medications in the past.  I shared with the physician my medical and medication adverse reaction history and recommendations by prior healthcare providers to not receive specific medications.  During past surgeries I have had reactions to Fentanyl and Demerol that were similar anaphylactic reactions I had in response to other allergies.  The treating physicians (now several years and different states removed) told me to not let anyone give me either of these two medications.  I have also had severe dystonic reactions to Compazine, Reglan, and Droperidol which required significant oral surgery, dental work, and orthodontia to correct the damage.  As a result, I was informed that the use of Propofol would be contraindicated due to its potential side effect profile.

I think that the most pressing issue for me is that I trusted this health care provider, and I feel betrayed.  He did other things, such as insisting that I sign some document that “was missed” after I was already prepped in the procedure room, IV running, without glasses, and hooked up to life support/vital sign monitors.  I felt I had no choice at that time but to sign the document he put in front of me, which even then, he did not explain.  After the procedure, I did have the teleconference with an Assistant Attorney General in preparation for a case that involved legal action at that level.  I found notes that I took of that call and a telephone log of 29 minutes, but did not remember making it.  I fortunately did not have any direct contact with any patients of my own or examinees for 48 hours after the procedure.  I was also able to discuss my notes from the telephone call with the attorney after my head had cleared to make certain that I had not acted in any way that had the potential to negatively impact the lives of the public or the person on trial.  The response and advice of this physician put me in a situation where I could have potentially acted in a manner that could have caused harm and could have put my license in jeopardy.  While I do want to comply with reasonable medical care for myself, I cannot allow myself to again be put in such a compromising position.


Answer
OF course I can't speak for what another doctor says and does. I will tell you that Scopalamine is still used but it is actually a much stronger amnestic than Versed. In fact, in those cases where a patient is too unstable for any real anesthetic, we have to use Scopalamine just so they won't remember much of what happened. Without knowing more about  your anaphylactic reactions or what happens when you get Propofol I cannot speak as to what they gave you. It seems like you have never ereceived Propofol but were told not to take it. The formulation of Propofol is not like the other drugs you mention so unless you are allergic to eggs, Propofol shouldn't be a problem. With regard to signing a consent form while sedated, this is inappropriate in all cases and if you were at a hospital, the nurse should have intervened and as far as your GI doc being able to function the next day, absolutely that is possible (and maybe even common) but since it is not true for everyone, we still recommend 48 hours. You need to remember that you are in charge of your body and if the physician does not wish to comply with your desires, then you should seek other physicians. You cannot force the doc to do what they think is incorrect but they also cannot force you to receive a medication you don't want.

I am sorry for the bad experiece you had but please don't codemn the whole specialty for the arrogance of a single individual.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston