Expert: Ronald Levy, M.D. - 6/11/2008

Question
QUESTION: I have 2 first-degree relatives who have died form colon cancer; I'm, 51 and have some of the symptoms so I scheduled a colonoscopy.  I made it clear that I would not consent to any sedation (for a variety of reasons) and the physician agreed.  Then, just before the test, he calls in a CRNA who wants me to sign a consent for propofol, which I did not since we agreed to no sedation.  The doc says "everyone gets something"; I guess our 1/2 hour office visit specfying no sedation meant nothing.  I know that soe of these exams are done without sedation and that's what we agreed to.  Needless to say, I removed the IV (which the CRNA grabbed and stuck herself with the cannula.and I left.  Now I'm geting messages on my answerng machine asking me to rturn. what gives?

ANSWER: The first question to ask is why you don't want sedation? I have never understood why people want to be awake and suffering (unless they don't trust that the doctor will do what he says). Obviously you have the right to do what you want and if the physician agrees to your plan he should carry it out but you might want to reconsider having sedation. If you have a specific concern that I can answer, I'll be happy.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: thanks-I had a "paradoxical reaction" to versed in addition to breathing difficulties and hives....I'm allergic to eggs so propofol is out..and I guess I got a little mad when the CRFNA tried to push it into my IV despite the red "allergy" band on my wrist, sedation has been a nightmare for me and I just don't want it under any circumstances.  And it's odd that so mant colonoscopies are done worlywide with no drugs at all;  but in the US I guess it's expected..   And yes, I don't really trust the providers who have twice tried to give me drugs that I'm very allergic to...especially after we agreed in advance not to use them.......sorry if I'm sounding a little mad; my sister just died from colon cancer and I can't seem to get this simple screening test done in a manner that is reasonable; ableit probably painful...I may as well jusy skip it...trust the doctor? we spent  a 1/2 hour office agreeing that sedation was not to be used and then he tried to give it to me at the last minute when I arrive......and I was trhe designated driver for my neighbors "sedated" colonoscopy".....the got 4 mg versed and 100 mcg fentanyl and screamed her head off begging them to stop because of the pain...and they thought this was just fine because of the "amnesia" effect of versed...trouble is, now she's starting to remember and beleive me, she would have been better off experienceing the pain rather than having a painful test, hustled out the door, then left to figure out what actually happened..  sorry..sounds like a bad idea...and, she's a 4-year RN so she's no idiot...she needs to have yearly colonoscopies and swears "no sedation" ever again........Well, thanks for listening, I guess that i'm better off cancelling the 3rd one that I had scheduled....

ANSWER: I'm sorry for the difficulties you've had but you should not just skip it. Ignoring a potential problem is no solution. While it is true that in other countries they do these procedures without sedation, that doesn't make it right or even acceptable. I did my medical training in Israel where they did male cystoscopy without anesthesia and (at that time) did deliveries and episiotomies without anesthesia. I listened to these people scream and I would not want that for my enemies. I understand that you are allergic but there are many drugs in our arsenal to PROPERLY sedate you. If your friend was screaming, etc they did not give her the  appropriate dose. One thing you might think about is to have the procedure done at a hospital instead of an outpatient facility. They are better prepared to manage these things, you'll get a real anesthesiologist giving you the sedation and they will be more likely to listen to an adhere to your wishes.

Good Luck,

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston


---------- FOLLOW-UP ----------

QUESTION: Thanks for all of your help; I just returned from another abortive attempt at having this test done; durg-free and the GI doc agreed to this in advance.  On the day of the exam (today), I reported to the hospital, prepped as instructed, in a reasonable good fram of mind, wanting to get this test done, as the GI doc and I had discussed, without drugs.   From themoment that I reported to the hospital's "GI lab, I was hounded by nurses and the CRNA who insisted that i sign a "sedation consent" despite what the doc and I had agreed to!  I don't want to sound like a broken record, but what gives?   Who runs the show, the physician or the nurses?   Try as I might to explain my situation, I was told that, and I quote:  "if you don't want to have the test "our way-everyone gets something", you don't belong here"  so i left.  What is the patient supposed to do?  If the patient and the doctor agree on a reasonable course of action, who in the heck gives the CRNA the authority to change that?    I'm really mad.  Thanks.  New doctor, new hospital, deja vu.........so much for the 3rd time being the charm...........

Answer
If you and the doctor agreed to no sedation, then the CRNA should not have even been in the room. The nurse who assists the GI doc should be the one monitoring your vital signs. When this happened, you should have had your GI doc talk to the CRNA and tell them that he is going to do the procedure without their services. This is not a fight that you should have. This is up to the GI doc and the anesthesia personnel. Let them fight it out. If your GI doc agreed to try the procedure according to your wishes, then he needs to be the one to set the rules in the procedure room.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston