Expert: JM Starkman, MD - 8/6/2009

Question
I recently had a colonoscopy to check on my FAP and the procedure was somewhat of a disaster because of the drugs that were administered (fentanyl and midazolam); they didn't do anything except cause agitation and difficulty breathing.  The gastroenterologist told me that "anesthesia" would be administered, after a brutally painful exam and lots of nightmares, I found out that the "anesthesia" was really sedation administered by the gastroenterologist.  She told afterwards that I could have requested real anesthesia but they do not like to schedule it because it wrecks their schedule.  O.k., I learned my lesson, it's the patient's responsibility to research each procedure beforehand and question everything. Fine; when I got the pathology reports I found out that I need colon surgery. Trying to avoid another debacle, I tell the surgeon that I want an anesthesiologist to perform the anesthesia, not a nurse (crna) and he says that this is o.k.  On the day of surgery I ask to speak with the anesthesiologist who will be performing my case and I'm told that a nurse (crna) will be doing it.  The crna tells me that she's as qualified as an anesthesiologist and that the anesthesiologist will supervise the case; I finally spoke with the anesthesiologist asked him if he would be personally supervising the case but got no answer. Surgery was cancelled.  Can one anesthesiologist supervise more than one case at a time?  If so, I don't understand how.  I'm an airline pilot and often act as an instructor, but I'm always sitting next to the student and we have full dual controls.  Safety is never compromised.  I was told that one anesthesiologist can "supervise" several crna's at the same time performing in different O.R.'s.  This seems analogous to me supervising a student flying NY-Paris and Pgh-London at the same time.  I would appreciate any light that you could shed on this crna/anesthesiologist supervision; it seems unsafe at best.  I'm now scared to have the surgery; am I wrong to want my anesthesia to be done in totality by an anesthesiologist? Thanks.

Answer
Your question brings up so many important issues that I hardly know where to start. (That's why it's taken me so long to reply--my apologies.)  As I've previously mentioned to others in this forum, gastroenterologists acting as anesthesiologists are often not providing the same modern standard of anesthesia care as a board-certified anesthesiologist can.  Thumbs-up to your gastroenterologist for not mincing words and readily admitting that her version of corner-cutting is due to scheduling matters.  Ironically, when an anesthesiology group does regularly get involved with gastroenterologists there is a considerable efficiency realized to the benefit of all parties involved with respect to scheduling, patient volume, production pressure, early discharges and patient satisfaction!  The model has been slow to become universally adapted by GI practices;  some third party payors do not reimburse for separate anesthesia...can you hear the fight yet?: "You want  ME to take the risk, purchase anesthetics, show up, work.....and NOT GET PAID because you accept THAT insurance for your lousy colonoscopies??!?!?!  So one "bad" insurer can throw a wrench into the machinery for all.

Your concern about CRNA supervision and safety is most insightful.  In many hospitals and anesthesia  practices the "supervision" of up to 4 CRNAs by one MD is typical. (It used to be unlimited!!!!! until third party payors finally put a cap on it) The practice is mostly safe because CRNAs are about the most conscientious and well-chosen group of professionals out there. In many non-urban places they are the only anesthesia providers around and manage simple and complicated cases as well.  I know many CRNAs that I'd let anesthetize me............BUT..........I am not a high risk patient (I don't believe from what you've written you are either), I know who's good and who's not and there's that dirty little "anesthesia secret":  when doctors, anesthesiologists or surgeons have their OWN surgeries they have MDs do the anesthesia 1:1.  Many liability insurance policies have lower premiums if anesthesiologists do their own cases and do not supervise CRNAs;  the "risk experts" recognize a difference in claims, obviously.  Appalling or insulting, depending on one's position, is the fact that (I'm not kidding) anesthesiologists like to compare themselves to airline pilots when discussing 'vigilance' and safety matters! (no kah-kah!) Your industry clearly takes the high-road/high-state on this one.

Many anesthesiologists work one-on-one with their patients, not supervising others.  And I believe that if that is what you are most comfortable with, having researched the matter, that is what you should receive and your surgeon should see to it. You're not wrong;  it's what I'd do.  I do not know of any instance of a third party insurer/payor/contract which would deny coverage for same which is a typical modern excuse not to do certain things.  Arrange a preanesthetic interview with the anesthesiologist who will do your case 1:1 to discuss your history and concerns. Review his credentials. See to it that your surgical/anesthesia consent states the anesthesia will be 1:1.

I'm sorry your FAP has gotten so bad that surgery is now indicated.  Please get a second opinion to see if there's another option or a way to minimize the extent of resection. DON"T HAVE ROBOTIC SURGERY! Too new. Too many (top secret) complications. Watch out for low-flying helicopters.  Let me know how you do.