Expert: Ronald Levy, M.D. - 6/15/2009

Question
QUESTION: Hi Dr. Levy: I'm 55 without any current medical problems.  My doctor took a biopsy during a flex-sig that she did a few weeks ago and the pathology report prompted her to schedule me for a colonoscopy which I wanted to have done without sedation.  She told me that most people get sedation, but that an incerasing number are having the exam done without it and referred me to a recent Wall Street Journal article that indicated that the majority of patients who underwent colonoscopy without sedation preferred it to the sedated exam with Versed. A website "askapatient.com" has hundreds accounts of bad experiences with versed and they sound credible; I would really rather skip the sedation and gladly endure any pain.  The endo center nurse who gave me the prep said that they have done unsedated colonoscopies, but this is infrequent.  When I reported for the exam, they insisted that I sign a sedation consent despite the fact that I wasn't getting sedation.  When I objected, the GI doctor got mad and told me not to believe the versed horror stories; he also told me to hire a CRNA if i wanted Diprivan, but that everyone getting a colonoscopy gets sedation.  This can't be true.  He said that my preference for the unsedated exam slowed them down and that he didn't appreciate my request despite my being told that they did the exams unsedated and it was either consent or leave.  As I was getting dressed to leave, one of the nurses told me that they have had a lot of patient complaints about versed and that a number of employees at that hospital had colonscopies without sedation, it was just not something that they did for everyone. Now my primary doc is fuming that I didn't get the test done because of the pathology report from the flex-sig.  I got a call (and a new prep rx) from the endo center stating that they would do the exam without sedation, but that I would still have to get an IV and sign a sedation consent!  This isn't reasonable, is it?  The same nurse who told me that they do indeed do a fair nmber of unsedated exams said that if I sign a sedation consent that I would undoubtedly get sedation, no matter what they agreed to verbally.   Her suggestion to avoid sedation if to arrive without a driver.  Isn't this a little unreasonable; maybe this is the best way out.  This is my first experience with a test involving any type of anesthesia and now I don't want to go anywhere near the place.  Thanks.

ANSWER: Let me start by saying that the GI doc was wrong to get mad at you and give you an ultimatum. That was wrong in every regard. That being said, let me agree with him that most of the Versed horror stories are untrue. Let me explain. The majority of Versed complaints have to do with the amnestic effect of the drug. A lot of patients don't like the feeling of not remembering what happened. The fact is, this is an expected (AND desirable) effect of the drug. He is also wrong about the Diprivan in that it is also a sedative and it also causes amnesia. Surgery (and procedures) are scary and having amnesia for that (and it only lasts as long as the procedure) is a good thing. I have had Versed for dental procedures and while the dentist (a friend) told me I was squirming and moaning in pain, I don't remember any of it. For me it was a pleasant nap. He is also correct that it probably slows down the day and (right or wrong) they plan out their day based on that so other patients won't have to wait. Colonoscopy, unlike flex-sig, can be a more difficult procedure for the GI doc (depending on how easy YOUR colon is to navigate) and can be very uncomfortable. As for the IV, as an anesthesiologist I like to have an IV because IF something should go wrong (a patient develops chest pain, etc) I have immediate IV access to treat it. If you sign a written consent for no sedation and they give you sedation, that is battery! Just make sure it is in writing. The idea of coming without a driver could backfire if they say we can't do the procedure without one so I wouldn't do that.

So in summary, while I realize that many people are afraid of anesthesia, I would stll recommend getting the sedation. About 20% of the questions I answer here are about this topic. Several of the people I have given this suggestion to have written back afterwards and thanked me for giving them that advise. But if you are really insistent on having the procedure unsedated, sign the consent as such (and realize they may have to cancel the procedure mid-stream if the pain is too great for you). If they insist on an IV (and can't be argued with) accept, but remind them of the written consent that no sedation be given (and you can even have them sign a note to that effect).

Good Luck,

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston

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

QUESTION: Thanks Dr Levy for such an informative answer and for sharing your personal experience with Versed; the CRNA mirrored what you said in that most people find the Versed fine, but that there is a percentage who don't and that's the reason that she gets called in to do diprivan.  As you stated, I can skip the sedation and accept that it will be uncomfortable.  Fine, I will do the unsedated exam.  Here is the problem that I didn't explain well:  they agere to do the exam without sedation, but they still want  me to sign a "consent for procedural sedation" (not a consent for an unsedated exam).  I have no problem consenting to the exam (of course) and they verbally agree to do it unsedated.  The nurse warned me not to sign a "consent for procedural sedation" unless I am actually consenting to sedation; she did agree with you that having an IV was a good idea (after doing the prep and getting dehydrated, it would have been welcome).  My doc said that she prefers that get the exam from this GI doc due to his expertise and that hse didn't think that requesting an unsedated exam was out of line.  What it comes down to is that they agere to the unsedated exam, but want me to sign a "consent for procedural sedation" (totally separate from the procedure consent-I got a copy to review) anyway. This one thing makes no sense to me and has me totally nervous.  When I asked the nurse for clarification, the doc interjected that I should just sign the consent and  trust them.  Any opinions?  Sorry to ask so many questions. Thanks again, I value your input highly.

ANSWER: I don't see any reason to sign that consent unless you are agreeing to sedation. My guess is that they are using this for the case that it IS too uncomfortable and they want to be able to finish the procedure. At that point, they can't ask you to sign a consent, so they want it on file. As long as you are willing to possibly have an incomplete exam (and tell them so), there is no reason to sign that form.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston


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

QUESTION: The GI doctor called me back to clarify the sedation consent issue.  He told me that their verbal agreement to do an unsedated exam meant essentially nothing and that once the sedation consent is signed and the IV started that sedation will be given-again regardless of any verbal agreements.  He said that a number of patients specify unsedated exams but that sedation is his decision not the patients. He asked me why I wasn't rescheduling the exam (after causing them to lose a slot in their schedule) and I asked him if his routine disregard of a verbal promise seemes a little dishonest; he said this was a way to get patients screened who would otherwise not get the exam.  At least I got a straight answer and I won't get a colonoscopy.  Dr Levy-thanks for listening and for your help; I wish that every doctor was as candid and honest as you are.

Answer
I would actually consider reporting this doctor to the local medical board. What he is doing is wrong and bordering on criminal. You need to find another doc to do your GI procedure however.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston