Expert: JM Starkman, MD - 8/1/2010

Question
Hi Dr. Starkman:  I just returned from a deployment in the Middle East and I need to have some shell fragments removed from my forearm; no big deal just shards of mostly copper (they migrate to the surface and sort of turn green); painful but tolerable and I would like to have them removed.  I declined having the surgery done at a military hospital overseas. I scheduled with a surgeron and the problem seems to be anestheisa; please bear with me because I'm not a medical person (my wife is a nurse)...I was told that regional anes could be tried (ax block, I think) or gen anes.  I was basically told that with regional anes I would be more or less awake, more or less comfortable and might or might not remember the surgery.  This is supposed to be the "safer" option.  The gen anes option is painfree but "more dangerous" and nauses/vomiting are possible. I tried to get the anesthesia person to explain what they were going to do beforehand, but was told that I could ask on the day of surgery.  Fine.  On the day of surgery I asked for the anesthesiologist and was only able to speak with a nurse who told me to sign the consent and that they would choose for me.  Is this normal? She said that the regional option with conscious sedation was safer and that I woould be awake but probably not remember the surgery and any pain.  What?  One nurse told me that she had surgery with this "twilight" and she felt and remembered it all and it was horrible.  In terms that a layman can grasp, is being awake and given drugs to make you forget the pain (maybe) really as good as being asleep?  This sounds risky and possibly very traumatic. My wife had a colonoscopy with this twilight sedation and I heard her screaming; they had to stop the procedure and she will never go back. Is this common? The anesthesia nurse also told me that my anesthesia would be done by a nurse not an anesthesiologist (my surgeon didn't tell me that).  So, just before surgery I was told: you may have regional and may or may not be awake, in pain and may or may not remember the surgery.  Or you may have gen anes and it's more risk and you may be quite sick afterwards.  And your anesthesia will be done by a nurse not an anesthesiologist (some days they have one sort of supervising and on other days they do not).  Too many maybe's, so I postponed; the surgeon was apologetic but wasn't much help.  I'm 45, no medical problems and I'm not on any meds; these stupid pieces of metal will probably grow out on their own, but it's unsightly and not comfortable so I would like to have them removed.  I would appreciate any suggestions that you might have.  Insurance isn't an issue; mine pays for any type of anesthesia and anesthesia provider (I figured that an anesthesiologist is better than a certified nurse since the price is the same; when I mentioned this the anesthesia nurse was offended and told me that the two providers did the same job. Huh?)  Thanks.

Answer
I'm sorry this has taken me so long to answer, but I copied your message and let a few colleagues look it over:

Both the nurse anesthetists and anesthesiologists who looked at the message thought the nurse anesthetists you spoke with treated you rudely and inappropriately. Both were surprised that being a healthy 45 year-old having minor surgery would somehow place you in a "dangerous" category of anesthesia care, irrespective of what method was chosen to keep you safe, comfortable and provide adequate operating conditions for your surgeon.

"Too many maybe's"---I agree.

That your surgeon wasn't much help is another real surprise. If he can't quickly call the anesthesiologist or head nurse anesthetist and get any of these matters quickly settled then you are at the wrong hospital or surgery center with the wrong surgeon.

So, without knowing anything else, I'd say start over.  Call your local county medical society and ask for the name of a board-certified general or plastic surgeon.  When you meet him ask where he operates and if a board-certified anesthesiologist will be there in advance to formulate an anesthesia plan that is acceptable to all....before the day of surgery. That should do it.


And send a copy of ALL OF THIS to the chief administrator of the hospital or surgery center where you went to initially.

And good luck!