Wednesday, August 16, 2006

Anesthesia Alert

Every day, patients hear physicians speak the following words -- "It's a simple procedure that we can do right here in the office." The number of office-based surgical procedures has increased by an estimated 93% since 1996. Approximately 25% of all surgeries occur in doctors' offices, and that number is expected to rise to 35% within the next few years. At first glance, that doesn't really seem like a bad thing since, for most patients, an in-office procedure is convenient, less threatening and, in general, faster than the same procedure done at a surgical center or hospital... but it's also riskier. A study published in Archives of Surgery compared surgeries conducted at ambulatory surgical centers in Florida with those done in doctors' offices, and found a tenfold increased risk for adverse incidents and death in the office setting. According to Frederick Ernst, MD, coauthor of Now They Lay Me Down to Sleep... What You Don't Know About Anesthesia and Surgery May Harm You, many of the complications and deaths are tied to the anesthesia used in office settings. "The complications occur primarily because the people who give sedation are not trained and certified in anesthesia delivery," he says. "We've had reports that office managers and secretaries are administering intravenous (IV) sedation while the surgeon does the procedure and tries to monitor the patient at the same time. That is absolutely ludicrous."
These days, most in-office IV sedation involves the use of the drug propofol (Diprivan) because it acts quickly and patients can recover from it quickly. But it can be unpredictable -- in some cases, propofol-anesthetized patients even stop breathing. Because of that unpredictability, the US Food and Drug Administration (FDA) says that propofol should be "administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure." Unfortunately, that doesn't always happen, either because the surgeon feels that an anesthesiologist isn't warranted or because he/she plans to use the anesthesia at a lower dose for conscious sedation -- meaning that the patient retains his/her swallowing reflex and can respond to verbal commands. (Many states do not require that an anesthesiologist be present for conscious sedation.) The problem, according to Dr. Ernst, is that there is essentially no such thing as conscious sedation using propofol. "A lot of these guys will tell you, 'Oh, we're just going to give you a little bit,'" Ernst says. "But that's a crock. It is unconscious sedation, period." Among other potential complications, such as respiratory and cardiac arrest, when unconscious sedation is used with any drug there is a loss of the protective swallowing reflex, so anything that comes up from the stomach can cause an airway obstruction or make its way into the lungs, causing aspiration pneumonia. So what's driving the decisions? The answer is simple: cost. "Insurance companies love office-based procedures because the facility fee for office surgery is less than that for a surgery center, which still is less than that for a hospital," says Dr. Ernst. "Surgeons love it because, if they do the surgery in their offices, they get the professional fee, the facility fee and a fee for the anesthesia, so they're making money on three fronts instead of one."
The good news is that it's easy to protect yourself from unnecessary risks when it comes to anesthesia -- you just need to ask the right questions before you agree to a procedure and be prepared to take action if you don't get the answers you want. According to Dr. Ernst, there are four basic areas to cover before you agree to an in-office procedure that requires any type of sedation, including diagnostic procedures such as colonoscopy and endoscopy.
Ask about privileges. Your doctor should be approved to perform the procedure at a nearby hospital. Ask your doctor point-blank: "At what nearby hospital do you have privileges to do this procedure?" If he doesn't have an answer, don't do the procedure in his office.
Check for certification. Make sure that your surgeon is board certified, which means that he has passed a medical specialty examination. Also ask if the office is accredited, which means that a state or national agency regularly inspects the office to see that minimum standards of patient care are met.
Get an anesthesiologist. If there is going to be any kind of IV sedation, general anesthesia or major work such as an epidural, insist that a board-certified anesthesiologist or nurse anesthetist administers and monitors sedation.
Prepare for trouble. If the answers to all your other questions have been satisfactory, there's one more hurdle to cross. What happens if something goes wrong? "Make sure that there is a transfer agreement in place in that doctor's office," says Dr. Ernst, "so that if you get into any kind of trouble, there can be immediate admission to a nearby hospital -- and that hospital should be within 10 miles." That said, safer yet is to insist that a procedure that requires anesthesia of any kind be done in a hospital unless absolutely necessary.
Remember, no insurance company can force you to have surgery in a doctor's office instead of a hospital or surgical center. If you ask for an anesthesiologist, and the doctor says one isn't available -- push to have the surgery done at another location. Or push for another doctor. Don't stop pushing until you get what you want. "You may have to be really aggressive," explains Dr. Ernst. "And that goes for dealing with the insurance company, as well. Right now, an insurance company cannot force you to have surgery in a doctor's office. Be strong, stick to your guns. The insurance company will know that you know what you're talking about. After all, your life is on the line."


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