Expert: JM Starkman, MD - 7/30/2009

Question
QUESTION: I recently ran into a problem with outpatient surgery anesthesia.  A year ago I had elbow nerve surgery on my left arm and had to have it redone last month.  The first time it was done with the block with novacaine (?) and the bloodpressure cuff without any of the IV sedative drugs (which I had a problem with in the past); the anesthesia was fine with just the block just ucomfortable at the end which was fine.  2 months ago I had to have the same arm redone, same procedure and I requested the same block only; basically the CRNA told me that she would do what was appropriate and she thought that sedation was a good idea; when I declined she verbally told me "o.k." but then proceeded to administer 45mg doses of diprivan throughout the procedure despite my repeated requests for her to stop.  I react badly to this stuff and it made the procedure misearble.  Afterwards I complained to the anesthesia epartment and they said that sedation was given "because I was moving my arm during surgery" which my surgeon said was not the case; in fact the largest doses were given before I even got to the O.R.  When I pointed this out, the anesthesia head CRNA then changed her tune and basically said: "all patients sign a blanket consent and we can give what we feel is appropriate".  So basically they do what they want regardless, I guess.  Now I have to have the same procedure on the other arm.  My question is:  how do I prevent them from doing this again?  A verbal promise obviously means nothing. What if I write on the consent "bier block only, no sedation or  general anesthesia and have the anesthesia doc sign this?  Seems like a lot to me, but what does it take?  My surgeon is furious, but he said that the CRNA's are a contract service and rotate in and out. I would appreciate any suggestions.

ANSWER: Ask your surgeon to reschedule your case at another facility where he practices (he'll hate this if he's a part-owner of the $urgery center you mentioned----but their 'contract' anesthesiology department has no respect for your wishes, so go elsewhere.  Send the surgery center's administrator a letter explaining same.

I'd make my consent explicit next time, requesting and consenting to a Bier block only.  In unusual events the anesthesiologist may be forced into moving into a general anesthetic.  But I really think if a patient consents to one thing and gets another it is not just a violation of physician-patient trust---it's battery.

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

QUESTION: Thanks for the candid and informative reply; I just sent a letter to the administrator of the surgi-center and had the surgeon reschedule the case at a hospital. I spoke with the hospital's anesthesia department about marking the consent "bier block only, no sedation or general anesthesia",  and I'll be asking the anesthesia doctor to also sign this on the day of surgery.  They sort of made me feel unreasonable about asking for this.......thanks

ANSWER: Good work.  If they continue to "sort of make you feel unreasonable", I'd sort of let THEIR administrator know what's going on.  I'm really sorry that people calling themselves doctors are treating you this way.

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

QUESTION: Thanks again for the help and I actually got a pre-op meeting with anesthesia this time,  One more question, as if you haven't answered enough.  They agreed to Bier Block/no sedation which was great; but the anesthesia doc strongly suggested sedation, and when I politely declined she told me that it might be ainful (o.k. with me), but I was confused when she told me that I couldn't get any painkiller (fentanyl) if I refused the sedtion(propofol)..I can't see the connection between the two, but if that's the way it's done, o.k.  Does this make sense?  thanks again....

Answer
No sense. There is no contraindication to small, conscienciously dosed amounts of fentanyl during bier block without the use of a sedative like propofol.  This is an ego play by the anesthesiologist who wants to be the "boss" and has no respect for patients playing a more active role in treatment.  Too bad. Perhaps you can show this series of questions to your surgeon and elicit his aid in resolving the matter---but if you do have problems with small doses of propofol I'd expect small doses of fentanyl are not a very good idea for you either.

Good luck with your elbow operation.