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Robot Performs Surgery For Obstructive Sleep Apnea: Is It Over The Top?

I came across this article the other day regarding use of the daVinci robot to perform base of tongue surgery for obstructive sleep apnea.

For those who don’t know, the daVinci robot system made by Intuitive Surgical is a robotic system whereby the surgeon directs the arms of the robot to perform surgery in difficult-to-access areas of the body.

My feeling is that using a robot to perform sleep apnea surgery is way overkill akin to using a $50,000 sniper rifle to kill an ant on the wall.

Everything the daVinci robot can do can also be done without the robot with equivalent patient outcomes. In fact, Read more »

*This blog post was originally published at Fauquier ENT Blog*

Variations In Retrieving A Foreign Body From The Stomach

I have observed extreme variation in how my colleagues manage GI foreign-body retrieval from the stomach. Some always use general anesthesia and endotracheal intubation; others (myself included) use conscious sedation. Some use an overtube to withdraw the object into if possible; others simply pull it up to the endoscope and use the endoscope to guide it through the esophagogastric junction and upper esophageal sphincter. The reasons for this variation are clearly related to the perceived risk of airway compromise or gastrointestinal wall injury during withdrawal of the object from the stomach.

So my questions to you are:

1)      When do you ask for endotracheal intubation during foreign-body retrieval?

2)      Do you use an overtube when removing foreign bodies from the stomach, and, if so, always or in what situations?

3)      If you don’t use an overtube, what technique do you use during withdrawal of the object?

4)      What is your favorite “tool” or endoscopic accessory to grab objects from the stomach?

I look forward to hearing your thoughts on this issue.

*This blog post was originally published at Gut Check on Gastroenterology*

True Story: An Anesthetist Attempts To Sabotage A Surgeon

There is a sort of love/hate relationship between the surgeons and the anesthetists. Neither one can survive without the other. We supply them with work and they get the work to lie still while we cut and dice. Yet their job is to keep the patient alive while we challenge their ability to stay alive. At the moment of surgery they play good cop and we play bad cop. Of course after surgery the good cop is suddenly the surgeon through and through. But that is another story.

I really appreciate a good anesthetist (I‘ve had bad ones) and to tell the truth these days I’m spoiled by the quality of the gas monkeys that I work with. However many years ago I remember a case where the anesthetist and I had a misunderstanding about time frame.

I was doing a laparotomy in Kalafong. The gas monkey was a long term medical officer. Read more »

*This blog post was originally published at other things amanzi*

Is IV Sedation Over-Used?

We criticize alternative medicine for not being evidence-based, and they criticize conventional medicine in turn, saying that much of what conventional medicine does is not based on evidence either. Sometimes that criticism is justified. I have run across a conventional practice that I suspect began because it sounded like a good idea, but that never was adequately tested and is not carefully thought out for individual patients.

I recently had a bone marrow aspiration. The written instructions said not to eat or drink for 6 hours before the procedure, to bring someone to drive me home, and to expect an IV. I suspected from these instructions that they were planning to use IV sedation, and I was right.

I questioned the need for sedation. I am prejudiced about bone marrow aspirations. I observed several and did one myself during my internship. When I had finished, the patient asked me when I was going to start. We did the procedure at the patient’s bedside in a multi-bed ward with no sedation, only local anesthesia. So my prejudice was that the procedure was no big deal and was not terribly painful.

I can imagine that some patients may be terrified by the idea of a needle going into their bone and may want to be sedated and not remember the experience. But I was not anxious about it, and I saw no need for the fentanyl and Versed they wanted to give me. I figured it would only prolong my time in the hospital, produce amnesia, expose me to a small risk of adverse effects, and leave me groggy; so I asked to opt out. They readily agreed – although they did keep asking me if I was really sure I didn’t want it. They would not have offered the option of no sedation if I had not known to ask.

The pathologist doing the procedure told me the injection of local anesthetic into the skin was the most painful part of the procedure. He was wrong. It was the ONLY painful part of the procedure. The penetration of bone and the aspiration of marrow produced only a pressure sensation.

This study reported that 85% of non-sedated patients had intense pain. I find that hard to believe, based on my personal experience and the experience of the pathologist that the local anesthetic was the worst part of the procedure. I wonder if those patients were anxious and were expecting intense pain. At any rate, I think giving me IV sedation would have been the wrong thing to do.

I had a similar experience with an excisional breast biopsy. They offered me general or local anesthesia and I chose local as presumably the safer option. Then they said they would use IV sedation along with the local. I asked why. They said to relieve anxiety. I told them I wasn’t anxious so if that was the only reason for sedation, I didn’t want it. I finally prevailed. I was comfortable, alert, had a good time chatting with the anesthesiologist, and was able to leave the recovery room much sooner than sedated patients.

I’m not saying that IV sedation is not indicated for some patients, but I am convinced it was not indicated for me. Has it become a knee-jerk reflex to sedate everyone as a general principle? Why? To avoid complaints and keep patients more cooperative during procedures? Are we paternalistically deciding that it is better if the patients don’t remember the procedure? I wonder: if minor procedures are not remembered, might the mystery increase anxiety and fear of the unknown for future procedures? We must ask seriously whether IV sedation is done more for the patient’s benefit or the doctor’s. The answer will vary with the procedure and the patient.

Rather than sedating every patient, why not use some judgment? Even if the patient is anxious, perhaps a non-drug option could relieve that anxiety without risking the side effects of drugs. Surely some anxiety is due to fear of the unknown. Would it help to show patients a video of someone comfortably undergoing the procedure without sedation, with an explanation of exactly what was happening? Would simple reassurance or personal attention from a patient advocate be helpful? Worth looking into? I think so.

Doctors are frequently accused of prescribing unnecessary drugs out of habit or reflex. I suggest that IV sedation for minor procedures is an example of over-prescription that is based more on custom than on good evidence.

*This blog post was originally published at Science Based Medicine.*

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