AboutJohn Thai, MD Expertise Gastroenterology, Hepatobiliary diseases, Infectious Diseases - including Viral Hepatitis A/B/C/D/E/G, liver transplant, surgical procedures including biopsies, pancreatic diseases, bariatric surgery, endoscopy (EGD, colonoscopy, etc), and Nutrition
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Expert: John Thai, MD Date: 4/22/2008 Subject: Colonoscopy
Question QUESTION: How can I find a gastroenterologist who is experienced in and willing to perform unsedated colonoscopy? I have recently had a colonoscopy and based on family history and polyp finding have been recommeded for 5 year follow-up. I have a history of allergies to multiple medications, including Fentanyl and Demerol (I know this is rare, but my youngest child also had similar rxn, so to the extent it might be genetic, I do wish physicians would quit questioning this part of my history). For my initial colonoscopy, I reluctantly agreed to the use of Versed, as the physician indicated that I would need it. However, he failed to provide any information about the amnestic qualities of this medication. He also indicated that I would feel fine and could return to work the following day. I do not remember anything in 36 hour period. From the time I began to remember, I had a horrible headache. I have a sensitive job and needed accurate information regarding use of medications for an elective procedure that I did not receive. This lack of information from the physician could have cost me my license and the abiltiy to earn a living. Fortunately, it is apparent, that I did not engage in any work that left my office during that period. But, I could have.
I thought that something might come up in my records. There is a discrepancy in the records regarding the amount of IV Versed that was pushed in a period of 5 minutes, 6 or 7 mg., with 4 or 5 mg. being pushed in the first 2 minutes, depending on what part of the records is read.
Bottom line, I know it is appropriate to follow the recommendations for a repeat examination. However, based on my experience, I will never again consent to receiving Versed for an elective procedure. I set up an appointment and did speak with this physician in advance. He would not say that he would not do the colonoscopy unsedated. If he had, I could respect that honesty and I likely would have sought out another physician for the procedure. He simply said he would use the Versed to help me relax a little. In my book, relaxing a little is quite different from being immobilized and unable to form and retain memories for the day and a half I experienced.
Any input that you might provide is greatly appreciated.
ANSWER: Hi Doris,
I empathize with your situation. However, I cannot speak nor shall I comment on the actions which taken place as it is unethical. I can only provide you with information that is relevant to public awareness.
As such, I can tell you that many gastroenterologists do perform unsedated colonoscopies with the use of a double balloon enteroscope with an overtube. The problem with using such a method is that it very time consuming and laborious for the gastroenterologist. That is the reason why a few gastroenterologists prefer the traditional method of using larger scopes and sedation as it is a much less laborious and time consuming process.
You always have the right to ask your gastroenterologist to use a thinner scope, like the double balloon enteroscope. However, not all would accommodate such requests.
A problem with unsedated colonoscopy is if you have a polyp or an abnormal presentation that needs to be excised or biopsied. You will feel the pain. Thus, you may elect to stop the procedure if the pain is too harsh.
As far as anesthetics, the reaction differs from one person to another. No individual will have the same effect. A few may need very little and others may need stronger doses. There is a recommended initial dosing of anesthetics; however, the physician increase the dose based on your level of comfort during the procedure. Most of these anesthetics are fast-acting. Complications from these anesthetics vary from one person to another.
To help decrease the time of the procedure, I definitely recommend asking your gastroenterologist for proper recommendations to prep 1-2 days prior to the procedure. A very clean bowel definitely helps him/her fasten the process.
John Thai, MD
---------- FOLLOW-UP ----------
QUESTION: I appreciate your not wanting to second guess the gastroenterologist whose behavior I was describing. And for the record the colon prep was deemed adequate and a pediatric scope was used. I am a licensed health care professional. I am skilled in alternative pain management - hypnosis - providing for others, as well as myself and have successfully used autohypnosis for procedures in the past. My major concern is the risk to my license and the lack of informed consent in regard to the medication/amount of medication used.
As a result, I refer back to the original question that I asked and I feel was not answered....How can I find a gastroenterologist who is skilled, practiced and experienced in performing unsedated colonoscopies, who is thus willing to perform unsedated colonoscopies? I think I called every provider within a two hour radius of my location. If needed, I would prefer to fly across the country to find a provider willing to perform the procedure as I have outlined. However, I do not believe it expedient for me to call every gastroenterologist in the country and presume that there may be ways to narrow the search. Thank you in advance for your response.
Answer As a health care professional, you should be aware of basic medicolegal jurisprudence regarding patient awareness and safety set forth by state and federal regulatory commissions and professional medical associations. As such, it is unethical for any physicians to comment on the professional advisories and/or work performed by another physician unless it is a done in a manner to assist with a pending medical advisory for continual advanced medical care or medicolegal advisory with informed consent to review all documentations of the event in question.
The procedure outlining any medical/surgical procedures indicates that a physician has the duty to protect their patient at all times. Thus, all procedures are done under recommendations adopted, approved, or set forth by regulatory commissions or professional associations. For example, an informed consent application for a surgical procedure would state that a physician is consented to perform all related procedures recommended for that specific procedure, unless otherwise stated by the patient.
Anesthetics differ from one individual to another. It is based on the body mass index and tolerance level. Thus, not two persons are alike. For example, I have a female who weighs 100 pounds and another who weighs 120 pounds. The female who weighed less due to lower body mass index would have been considered to have lower doses of anesthetics because of the pharmacokinetics of the medication. What would be the considering factors which would guide a physician to administer more anesthetics? The answer would be pain and comfort scale during the procedure.
I am providing this service as an educational guide. I do not make professional recommendations or referrals. All physicians have their own techniques which follows the recommendations and guidelines set forth. It is very difficult to create a list of physicians able and willing to perform a procedure of your requests. It is usually "word by mouth" as to whom is good or bad. Your primary care physician would be of better guidance.
The double balloon enteroscope was approved for general use in late 2004.
You may also elect to have a virtual colonoscopy instead of a traditional colonoscopy. The procedure is limited in many ways. In the event there is an abnormal finding, you would be given the option of having a traditional colonoscopy.
