Sunday, September 23, 2012

Well Written E-mail From a Reader

"Remember, I am no medical authority, and information is hidden from us patients, so listen to your doctor, but here goes with my opinions.
Over 30 years ago, as part of a job I had in a JCAHO (then JCAH) accredited hospital, I was tasked to convince people to undergo surgery. I worked closely with the medical staff, surgeons,  nurses, technicians, etc. We always arranged for informed consent. Our mantra for explaining such procedures was that if we told you you were going to be helped by an arm operation we also had to let you know that there was perhaps an 8% chance that you would die or a 12% chance your arm would fall off. We also informed them about pain. It is disturbing that I received none of that before or at my recent colonoscopy.
What would I tell people now? It appears that anesthesia has changed since 'my day'. Putting you out was always dangerous. The doctor or nurse (we used to call them 'gas passers' as they used gas) had to be skillful, but they put you out for many big procedures. They also gave you tranquilizing drugs like Valium (diazepam) if you were not to be put totally out, to relax you. 
It appears that has changed. Instead of putting you to sleep they block pain in various areas, more often perhaps then they did in the past.  But the real change is that they use certain drugs deliberately so you will not remember what they did, specifically midazolam AKA Versed and Propofol (Propofol's nickname is Milk of Amnesia). To repeat, they use these drugs specifically because the wipe you memory of ‘the procedure.’
 For example, as far as I can tell, colonoscopies are always painful, either a little, or moderate, or a lot. They can give you pain medications, but if they do, how much, who knows and who remembers, as there is no recording or independent monitoring of these ‘procedures.’ And the drugs they use for ‘twilight sedation’ appear to be chosen because they wipe your memory of what they did, as well as to incapacitate you from resisting as opposed to being out of pain.  It also seems that Versed (Midazolam) does not wipe the memory of some people (like perhaps you) and they remember what happened. Do you feel pain if your memory of it is erased? I think you do. How did you feel lying there perhaps in great pain, following their commands or trying to fight them, enduring it, yet knowing this memory would probably all or partially be wiped out, or would it come back to you some night? Some people therefore refuse to be ‘sedated’ for colonoscopies. It appears that this forces the medical people to give adequate pain medication and to treat you well as you will remember it.
One of the Law and Order Special Victims shows features versed in an episode wherein the criminal assaults a woman who cannot then fight back, and dies I think, or could not remember it enough to testify. Star Trek Enterprise has an episode called twilight that addresses issues of having one’s memory erased.
I was lucky with my endoscopist, a GI doctor with decades of experience. It was done at the office but an anesthesiologist was present, and I had Propofol. Propofol is better I think. President Bush II had it. (Obama had a virtual). I have had no psychological problems. I have not found the complaints on the web about Propofol that I see about versed. I have read it is very painful going in, but all I remember is something going into my arm and then being asked to dress and leave.
You really are at the mercy of the practitioner. There is so much profit that the general practitioners have been approved to do it. The insurance companies do not want to pay the extra costs for propofol, which can mostly put you out (it worked for Michael Jackson, mostly), and for which some states require the presence of an anesthesiologist.
And the better choice seems to be a hospital or surgical center as they would have the better pain meds and CRNA and anesthesiologist services to give you propofol like Bush II got, i.e. Milk of Amnesia, with real anesthesia possibility and instant sick free wake up. And a less private place where rumors might start as they see many clinicians.
Some of my favorite references: From the wonderful Center for medical consumers
A spectacular site that does not appear to be always updated, but has terrific information on colonoscopies and other stuff
“let’s think about the setting and your frame of mind when you arrive for a procedure. First of all, … the colonoscopy preparation procedure requires fasting as well as hours spent in the restroom so that one’s bowels are clean. Then, you generally either have to get up at the crack of dawn or well before dawn depending upon where you live, the traffic, and the time of your procedure, and finally when you arrive exhausted at the hospital or surgery center, you are then checked in, placed in a room, told to remove all your clothes, and put one of those very attractive hospital gowns on, and asked to sign a multitude of papers. Your glasses and personal belongings may even have been removed so that you are signing papers which you can’t even see, but in your tired and hungry state you may be so focused on getting out of the hospital that you’re not too concerned about what you are being given or the documents you are signing. The next step after you’ve handed over your glasses, stripped out of your clothes, and are possibly nervously awaiting your procedure, is that you will probably be approached by a nurse who comes in with a huge smile and pokes you in the arm to start your IV. You are probably then approached by either the same smiling staff member or another member of your medical team with an equally large grin that you will be “given something to relax”. Not one to want to ruffle any feathers and certainly wanting to be a  “good patient” you probably simply say “ok” and may be totally oblivious to what happens next. 
It’s primary use is that of an amnesiac drug, or a drug that will cause you to forget. What many patients are not aware of is that if you are given Versed it does not necessarily mean that you will not have pain, but it may cause you to forget pain.”
How about the Mayo clinic: “Midazolam is used to produce sleepiness or drowsiness and to relieve anxiety before surgery or certain procedures. Midazolam is also given to produce amnesia (loss of memory) so that the patient will not remember any discomfort or undesirable effects that may occur after a surgery or procedure .
“The most common drugs used in date rape …include … Midazolam…  See also Law and Order special victims season 5 episode 5 The episode is entitled "Serendipity.”
From the US National Library of Medicine: “Midazolam is given to children before medical procedures or before anesthesia for surgery to cause drowsiness, relieve anxiety, and prevent any memory of the event.” /
“We conclude that midazolam, given in small incremental doses, in combination with meperidine, produces effective conscious sedation for colonoscopy and exceeds diazepam in its amnestic effect”.
For fun, watch Dr. Oz’s colonoscopy, the second or third video if it is still up. He does not appear to be having a good time. He thought about it all summer I think. And he did not follow up as ordered until much later. Now he, I am told, is an enthusiastic proponent of the procedure.
From a blog, almost an exact quote: ‘While it is true that versed and fentanyl are common and acceptable drugs for outpatient GI procedures these drugs are not as effective as propofol. Additionally, these drugs are generally given by an RN who does not have training in anesthesia as a Nurse Anesthetist or Anesthesiologist would. This limits how far they can go in dosing which is likely what happened with your neighbor. Having said that, many people have GI procedures daily with versed and fentanyl without incident. It is rare to have a patient crying and screaming with these drugs. So the answer is that yes there is a risk of under-sedation with any drug but the risk is much lower when you have a nurse anesthetist giving you propofol.’ Mike MacKinnon MSN CRNA
This shows you are fully awake. FULLY AWAKE!!!  “Under procedural sedation, you remain fully awake and can respond to questions and instructions. … You typically won't remember the procedure or the short period of time following it.”
I have removed salutations from this letter and corrected the spelling of one word.  Otherwise this e-mail is exactly as I received it. 

No comments:

Post a Comment