Friday, July 11, 2008

Sign Here, Please


I have a confession to make.

I don't believe in informed consent.

Or rather, I believe that informed consent is occasionally possible (and should always be the goal/intention), but also that achieving true informed consent is rare.

Even if I spend an HOUR talking to a patient about every possible common effect or complication of every drug and piece of equipment I use, maybe even if I get to the UNcommon things, I don't think I can adequately convey the amount of information that would enable anyone except another trained anesthesiologist to give me genuine, fully informed consent for an anesthetic. Fairly well informed consent I can get, probably, but not fully informed.

If an orthopedic surgeon spends a very long time explaining the ins and outs of, say, a radial head resection to me, I'll get a general idea, perhaps even a very good idea, of what I'm in for if I need the surgery, but I won't have his or her years of experience witnessing and doing the procedure and dealing with all the possible events it might generate. Even with medical school under my belt and some surgical experience, the intimate knowledge that comes from hard-earned expertise will never be mine.

That's why I don't want my orthopedist to just list statistics about possible complications for me. I want advice. I want medical guidance in light of the knowledge and education I lack. I want HELP making the decision that's the best fit for me and my problem.

For this reason, just as I believe a paternalistic approach to doctor-patient communication is wrong, I believe the "independent choice" model, in which patients are given information but not recommendations, is wrong: a disservice and a failure to provide the patient care we took an oath to provide when we all promised we'd try to be good doctors. I favor a more collaborative approach that allows me to put my expertise to the service of another and also preserves my patient's right to make decisions in as informed a way as possible.

I do not think of patients as customers. I think of patients as patients. Customers buy things they want for themselves. Patients seek help that they lack the knowledge, skill, and expertise to provide for themselves, and often that help comes in the form of experiences they really don't want but which might be necessary in order to recuperate or preserve their health and safety. That is, unless they are truly unwilling to experience those unwanted things and would literally rather die than undergo those experiences. If someone is competent to come to that decision, I am duty-bound to respect his or her wishes. But if patients are willing to let me offer the help I know how to offer, then sometimes I have to put patient safety ahead of patient comfort, though I always strive for both.



I studied basic principles of medical ethics in med school. There are four principles written about extensively by Beauchamp and Childress that have given medical practitioners a common language to use in discourse and practice, regardless of differences in cultural background, value systems, and religious or moral views. These principles or ethical goals are

  • Patient autonomy
  • Beneficence
  • Nonmaleficence and
  • Justice.
I never think much about the way I am confronted daily with small ethics issues, but lately I've been noticing that they're actually a pretty prominent part of my practice of medicine, especially the first principle: patient autonomy. My job actually entails taking away people's autonomy entirely, at least temporarily; once they are anesthetized, they have little control over the treatment decisions I make. But usually there's a chance to discuss the important points beforehand, and during those discussions I try to respect patient autonomy while also expressing my preferences and plans.

An example: a woman whose preop history I was recording asked me if she would be given the drug Versed (generic name: midazolam) without being told before her surgery. I told her that I personally never administer it without making sure a patient wants to receive it and knows of possible effects such as memory loss of events around the time of the drug's administration. Very rarely, patients report experiences with this drug that are so awful for them that there's even a website on which hundreds of vitriolic comments (including some exceedingly ignorant and bigoted ones) against anesthesiologists have been posted, one even comparing us all to people who commit date-rape. While I try to be as thorough as I can about explaining my anesthetic plan, I do think it's unrealistic, not always useful, and often downright impractical for us to give patients a full run-down on every single drug we administer as part of the anesthetic.

Another example: a morbidly obese pregnant woman needed to have a cesarean delivery for a fetus in breech position. She adamantly refused to have an IV inserted. My colleague informed her that he absolutely could not and would not provide anesthetic care without IV access and would have to have her sign a form stating she was refusing care and aware of the risks. She eventually agreed to an I.V. He also tried to explain the relative danger of a general anesthetic versus a spinal or epidural for the procedure, but she would have none of it - she wanted a general anesthetic, no regional anesthetic, but she wanted to be woken up as soon as the baby was pulled out of her body and she wanted her husband to cut the cord. He had to tell her that this plan just would not be possible. Sometimes full patient autonomy is not only impossible but also inadvisable.

Another: a mother at Children's once told me that under no circumstances did she want a breathing tube inserted in her child. I told her that we would have no choice but to cancel, or at least postpone, the surgery. An un-secured airway was just not an option for the procedure; proceeding without one would have constituted malpractice. She then relented a little and began to ask questions - why the tube was necessary, what it meant for her child, whether her child would experience discomfort from it. I answered all her questions as thoughtfully as I could, and in the end she gave us permission to take care of her child.

One more: a former nurse refused to give consent for a general anesthetic for a procedure we most commonly performed under general. She told me she would cancel and go home if she couldn't have a spinal. I told her I could safely provide a spinal anesthetic but was professionally and ethically obligated to inform her of the possible complications before we proceeded. When I started explaining these, she was irritated at first, saying, "The other anesthesiologist I talked to in the preop clinic didn't tell me any of this!" In the end, though, with some investment in a thorough conversation, she felt reassured, and happy that I respected her wishes despite the fact that it wasn't the usual m.o. at our institution for her surgery.

I'll listen intently to what's important to my patients, and I'll do everything in my power to provide the experience they want if I can do so safely. I won't force a patient to submit to something against his or her will. But I won't practice bad medicine against my will either. My patients' safety matters too much.

55 comments:

rlbates said...

So very well said, T.

Anonymous said...

Hi,
You're a very eloquent writer! Well done! I also have always thought that informed consent is not so informed and stating complications in laymans terms is not that informed. Eg. We would like to take some blood from you and there are some risks associated with this such as infection, a fever and death which is very rare....let's just string it all in one sentence...
I sent you an email at the gmail address that you provided anesthesiobiost@gmail.com. I was wondering if you got a chance to come by it?
Don't worry I'm not a wierd stalker...just a student inspired wondering if you could help me?
Thx, E :)

T. said...

Thanks to both of you for your kind remarks!

Anonymous/E - I haven't received your email. You may have a typo in the address line - could you resend it? The address is anesthesioboist@gmail.com. Thanks, and thank you for stopping by!

Resident Anesthesiologist Guy (RAG) said...

Accurately portrayed impossibility at informed consent. Being a new intern I had to get informed consent on a procedure to which I was wholly new. Trying to list all the compications for an informed consent when I, the doctor performing the procedure, didn't know enough to actually guess what the most common complications could be? How informed could that honestly be?

I really liked the Ortho analogy. I still don't get open and closed fixation and I've had it explained a few different times.

Anonymous said...

You know my medical mind read boist (like your oboe) as biost (like biologist) all along I thought you must also have a love for botanicals...sorry about that :)
Just sent you another email with the correct address!
Thank you for being so responsive!
E

Anonymous said...

Just curious -- what is the relevance of the patient's morbid obesity to the second story you relate?

T. said...

Morbid obesity is an automatic red flag to most conscientious anesthesiologists because of the potential for a) difficult airway - an anesthesiologist's worst nightmare and b) difficult IV access.

Separately, a pregnant woman is an automatic red alert for ASSUMED difficult airway.

When we have a pregnant patient who is ALSO morbidly obese, most of us feel, "Please, please, please don't need a general anesthetic, because I really don't want the airway risk."

There are few things for which we have greater concern than a pregnant woman's airway, especially if additional risk factors for airway difficulty exist. Having been on the intubating end for a pregnant woman who was NOT obese but needed a general anesthetic for a stat C-section, I can honestly say it was one of the more memorably concerning moments of my clinical practice. A good anesthesiologist would never adopt a "cowboy" / smug attitude about such a situation, ever.

Anna said...

I agree with you about the collaborative approach. I recently had to make a medical decision on my own - further tests vs. conservative tx. No guidance, no recommendations, no discussion of the relative merits of the options. I suspect this is happening to many patients - not necessarily because the physician doesn't care, but because the time constraints are so intense. There just isn't the time to really discuss things with patients anymore.

To me, part of the informed consent procedure isn't just about risks and complications. It's also about why the surgery/tx is necessary, what it will entail and what it's supposed to fix or ameliorate.

As a layperson, I probably don't need to understand all the technical details, but I do need to know the total context.

I have mixed feelings on how much patients should be told about the risk of rare complications. On the one hand, you don't want to unduly frighten your patient or burden him/her with a ton of indigestible information. On the other hand, patients can feel totally blindsided if they end up being that outlier, especially if the risk was downplayed or glossed over ahead of time.

Been there, done that, bought the soundtrack. :( And I got really tired of hearing, "Gee, this is really rare, we almost never see this." Believe me, I did not feel special.

P.S. I see we like a lot of the same movies! I don't think I know anyone else on the planet who has seen The Trouble With Angels. :)

- Anna

Mitch Keamy said...

that's right.

T. said...

Mitch! I've missed you! Thanks for stopping in.

Anna - sometimes I bring TTWA with me on call to cheer myself up during "down time." I still laugh every time Mother Superior exclaims, "Mr. GOTTSCHALK! I asked you to lend BAND uniforms!...This is a Catholic SCHOOL!"

Thanks for your perspective on this tricky stuff.

Theresa said...

Excellent post. I agree the idea of fully informed consent is not possible. You are doing a great job of dispelling misinformation among your patients. Unfortunately, this task falls under the heading of cognitive services that don't get fairly reimbursed by CMS. Still needs to be done. Kudos!

Matt said...

Awesome post! I have been throwing this around in my head but probably couldn't articulate it as well as you have- the best I could come up with is holding informed consent up as a recognized ideal, knowing that we can never truly achieve it but we should still strive for it. Sort of like how a curve approaching an asymptote never will touch the imaginary line however it is our duty to try to make the distance between the two imperceptibly small.

T. said...

Theresa and Matt - thanks! I appreciate your taking the time to visit and read.

Matt, what a brilliant analogy! (Your curve approaching the asymptote.)

Supremacy Claus said...

T: There is no longer any such thing as lack of informed consent.

Everyone has a duty to Google their procedure. They may then repeatedly review professional grade information about their decisions on their own time, up until the very start of the procedure. Everyone in the US has access to the internet. The latter should end all claims of lack of informed consent. These should be dismissed as frivolous per se, and without any evidence.

As a patient, I don't care about informed consent. I want relief, not a surgical education. When I fly, I want to arrive. Pilot training would disturb me. Why would anyone want to know all about the surgery?

Informed consent is just another bogus, lawyer gotcha in bad faith.

Supremacy Claus said...

Another opportunity on the Internet that is impossible in the surgeon's office? Chat rooms. Spend hours with a multitude that has undergone the same procedure.

Anonymous said...

T., unlike the other people who left comments above, I find your post to be troubling, especially the idea that an anesthesiologist would "not believe in" informed consent. Also, as regards your opinion that it's "unrealistic, not always useful, and often downright impractical for [anesthesiologists] to give patients a full run-down on every single drug [they] administer as part of the anesthetic"—I must respectfully and completely disagree. The very substance of your profession centers on administering potent, brain-disabling chemicals to patients, and you're essentially saying that it is impractical to make those same people aware of all of the risks (even rare ones) associated with said chemicals. From whose point of view do you suppose that it's impractical? The person who is about to have his or her central nervous system assaulted, or the person who pushes the plunger of the syringe enabling the assault? I find it horrifying that a medical practitioner would hold such a viewpoint. It presupposes that medical practitioners always know best. The sad truth is, they do not. I realize that that's a difficult pill (pardon the pun) for the medical profession to swallow, but it's true. Anyway, if I were a patient, I'd prefer to be made aware of any and all risks associated with a drug that I'm about to be administered, no matter how rare a given risk might be. And, despite the comments posted above, I do not think that I am alone in that sentiment. I would imagine, for instance, that the tens of millions of people who were prescribed Vioxx (not an anesthetic drug, of course) by doctors with "intimate knowledge that comes from hard-earned expertise," would sharply contest the impracticality of having drug-associated risks, even rare ones, explained to them. The ones who are still alive, I mean.

Supremacy Claus, concerning your comment that "[e]veryone in the US has access to the [I]nternet," and that that circumstance should "end all claims of lack of informed consent"—things aren't quite so cut and dried. What if, for example, a person who has never had surgery before becomes ill, is rushed to the emergency room, and is told that he or she needs to have emergency surgery. To my knowledge, there generally are no Internet kiosks to be found alongside the various EKG machines and IV racks in an ER. So in that scenario (hardly a rare one), the only actual mechanism by which the patient would be able to learn about a particular procedure, or about the risks associated with anesthesia, would be interaction with the medical staff. If the members of that staff are too busy, bothered, unqualified, or unwilling to provide thorough and accurate information concerning possible risks, then they might want to consider shedding their incredulity over the prospect of a patient being dissatisfied with the quality of care that they extend to him or her.

T. said...

Anonymous - by "impractical," I meant that it is often impossible to predict exactly what combination of drugs will given during the course of any given anesthetic, and therefore impossible to discuss in detail every single one of the drugs that may end up being administered. Just at induction alone as few as two and as many as six drugs may be given rapidly through the IV in quick succession, depending on the particular circumstances of the induction. During the anesthetic, drugs are given at various times depending on what the physician or nurse anesthetist feels is helpful or protective at any given moment during surgery. So when I use the term "impractical," I am thinking of those many moments in the middle of surgery when it would be ill-advisesd and medically improper, to wake a patient up and tell him/her, "I've just decided that for your safety you really need some phenylephrine right now because your blood pressure is sagging. May I have your permimssion to give it?" Administering an anesthetic involves a number of different possible drugs at different times, the use of which may not be foreseeable at the outset.

What I do think is reasonable is time spent explaining the predictable elements of the anesthetic. "I will be giving you propofol, one of the most widely used anesthetics in the country if not the world, to induce anesthesia prior to intubation. To maintain your state of unconsciousness I will then administer a gas called (sevoflurane / isoflurane/ desflurane). Both of these agents do have a tendency to drop your blood pressure, for which I will have drugs on hand to boost your blood pressure if necessary. In addition, I need to forewarn you that in the elderly, some post-op confusion is not uncommon after a general anesthetic..." etc. But to submit that it's reasonable or practical to give a detailed account to each patient of every possible drug that MIGHT be used during their operation? I don't see how. There are hundreds on the list. Paralytics. Narcotics. Antidotes for both. Things that increase heart rate, things that decrease it, things that increase it but pose less risk of triggering bronchospasm than some other things that increase it...it's a seemingly endless list. Any of those drugs could be deemed appropriate at any time during the operation, for SAFETY reasons...or they could remain unused.

There's no recipe for a given anesthetic, and very often different anesthesiologists will make very different anesthetic choices for the same operation. It's a dynamic art consisting of multiple real-time decisions intra-op, and unlike most other fields of medicine, it's the one field that can't always allow for a great degree of patient participation in the decision-making, though most of us do care about patients' preferences beforehand if they have any.

T. said...

I just reread the post and want to reiterate this:

"My job actually entails taking away people's autonomy entirely, at least temporarily; once they are anesthetized, they have little control over the treatment decisions I make. But usually there's a chance to discuss the important points beforehand, and during those discussions I TRY TO RESPECT PATIENT AUTONOMY while also expressing my preferences and plans."

I agree that doctors do NOT always know best. But there are few people outside of anesthesiology, other doctors included, who know ANYTHING AT ALL about providing good anesthesia; by its very nature, anesthesiology lends itself LEAST to patient-doctor collaboration. Despite this, I still believe what I already wrote in the post, earlier: that a collaborative approach is usually best and should be respected as much as possible.

Supremacy Claus said...

"What if, for example, a person who has never had surgery before becomes ill, is rushed to the emergency room, and is told that he or she needs to have emergency surgery."

A threat of death ends all informed consent. I am short of breath, or have a knife sticking out of me. Am I going to ask for a second opinion, or choose to ride it out, see how things work out without treatment?

T. said...

My obsessive-compulsive side is compelled to correct a mis-write above, which should read, "Things that increase heart rate, things that decrease it, things that decrease it but pose less risk of triggering bronchospasm than some other things that decrease it..."

Sorry - an ill-crafted, confusing portion!

Anonymous said...

Hi T,
I am one of those people that has problems with versed/midazolam, but I don't have anything against anesthesiologists (or anyone else) who prescribe the drug to patients who understand and desire the amnestic and sedative effects of it. I also have no problem with clinicians "overriding" a patient request in an emergency situation.

I do have a problem with any clinician that decides to ignore a patient request in favor of what is convenient to him/her in a completely elective procedure. This is most frustrating when the explanation given is: "We did what was 'best' for you."

Just as you say, it is impossible to have truly informed consent, clinicians must recognize that it is also impossible to get a "complete" patient history. Sometimes clinicians need to trust that if a patient says he/she doesn't want something, that he/she may have a good reason, but not feel comfortable discussing it with someone he/she just met. If the reason is critical to the care of the patient, this should be explained.

If you were my anesthesiologist for general anesthesia, and I told you I did not want versed because the amnesia is very upsetting to me, I would hope you would treat me with respect. I would want you to describe possible experiences I may have in general terms (i.e. you may have periods of feeling paralyzed, or hear sounds, feel pressure, but should not feel pain) and ask me if that was Ok with me. I hope you would not say, "Ok, I will give you propofol instead."

Thank you for your blog. You seem like someone who really cares about your patients.

Anonymous said...

I want to say that I am one of the so-called "bigots" who have recieved Versed against my wishes to facilitate a general anesthetic, also against my wishes. I carefully explained why I didn't want any of the debilitating drugs, and my anesthetist assaulted me with the patient control drug Versed. He didn't do me any favors and I have zero respect for Doctors and nurses of any kind now. I have developed a bias against them based on this stunningly insensitive and agressive treatment at the hands of a control freak CRNA. While I could care less what those "rapid succession" drugs are OR their dosage I feel that I should at least have to give my consent for them to be used in the first place. Don't tell me you won't do a GA and then put a drug like Versed in my veins to gain compliance. I would never have allowed even the smallest dose of Versed for ANY reason if I had been informed. Informed consent is the very bedrock of patient care. It makes me very nervous when you say otherwise...

Anonymous said...

I signed a consent for sedation after it was explained to me that I was going in for a nap and would wake up in recovery and in a hour could go home. Some how I have a hard time relating the words "nap" and "wake up" with the amnesia that was actually caused by the drug Versed that was put in me. The drug was put in me without even telling when the were injecting it in the IV and the next time I was aware of anything was sitting at home in a chair. The resulting confusion caused by the drug triped off a panic attack so severe that I ended up in the ER. I had never had a panic attack before in my life. It took a year of consuling to finally stop the resulting daily panic attacks and ptsd. I realiize now why it is so easy for a CNRA or anesthesiologist to lie to the patient or make promises they never intend to keep. After the drugs are given and the procedure is over these people are able to slip away into the background never to be seen again! If complications happen as a result of the drugs put in us during the procedure we tend to lay blame on the recovery room nurses and the Drs. The person that should be responsible for our full recovery from the drugs is the person that put them in us. I know now that in the future if I ever need any procedure requiring a anesthesiologist that I am going to tell them up front that if they are going to put drugs in me then I am going to hold them personally responsible for getting the drugs fully out of me no matter how long it takes. You can never trust someone that lies to you when it comes to your personal health and safety.

T. said...

Please refrain from referring to CRNA's and anesthesiologists as "these people." By suggesting that they are all liars you accuse the entire profession of intentional duplicity which is completely untrue and irrational.

I am very sorry for the effects you experienced after sedation, but a year of panic attacks is simply not an expected or, I would suggest, not a widely-known effect of Versed (or, perhaps more precisely, of the amnestic effects it produces). Over 300 people have commented on versedbusters.blogspot.com that this drug has produced traumatic ill-effects, but since CRNAs and anesthesiologists administer the drug to THOUSANDS of patients every year who report being HAPPY with their care afterward, it is seen by-and-large as a useful and helpful drug.

To resent an entire group of people based on one exceedingly rare outcome and accuse them of INTENDING harm when the intent was the opposite - to help and to provide comfort - is unjust. It's like resenting ALL people of color or ALL people of a certain religion or ALL people from a particular country simply because ONE individual caused you grief - without meaning to, at that.

I for my part always try to get a full understanding of a patients' wishes and concerns, especially if there is a particular drug they strongly feel they don't want. The last time I tried to engage a patient in a dialogue about this in the hopes of promoting clarity and making sure I had the opportunity to listen well to my patient's wishes, the patient's husband lashed out at me in the preop area, interrupting this very important conversation and yelling, "Why do you people keep on asking her questions?! Just do what she wants already!"

Well, I DO do what patients wish, for the most part. But I also try to take time to do the responsible thing, which is to TALK to patients and LISTEN to patients so we can have a fruitful collaboration about their care.

Anonymous said...

T., concerning your above comment...

"To resent an entire group of people based on one exceedingly rare outcome and accuse them of INTENDING harm when the intent was the opposite - to help and to provide comfort - is unjust."

...while we're on the topic of "unjust," there are a couple of things you might want to consider:

First, the gravity of any negative medical outcome arising from the administration of a drug—regardless of how "exceedingly rare" you happen to feel that that outcome might be—needs to be taken into consideration. In the first few years of Versed's use on humans, the drug caused the deaths of more than forty people who received it, as reported in this New York Times article. And, by your own estimate, it has also caused intense and ongoing emotional suffering in approximately 300 people who have posted comments to the Versed Busters Web site. Still hundreds more have posted about their horrific experiences with Versed on this page from Askapatient.com.

Now, you and many others in the medical profession may be inclined to reflexively and conveniently dismiss such comments with a sanitary adjective like "anecdotal," but doing so does not negate the reality of these patients' experiences. Nor does it diminish the gravity of those experiences. These people are not talking about a case of hiccups, they are describing intense mental anguish.

Also, since you've chosen to refer to such experiences as "exceedingly rare," it's worth noting that that's a subjective assessment on your part. I, for one, cannot view anything with an incidence in the hundreds to be an "exceedingly rare" thing. More importantly, though, for you to encapsulate such clearly grave effects with the phrase "one exceedingly rare outcome," absolutely trivializes their gravity. Now, THAT is unjust! For over forty people to have died, and for hundreds (if not untold thousands) more to have to deal with intense and ongoing emotional suffering, as the result of being administered a drug, is simply unacceptable.

One, or a combination, of three entities is directly responsible for these regrettable outcomes—either: (1) Hoffmann-La Roche, the makers of Versed; (2) the FDA, who approved and continue to allow its use; or (3) medical practitioners who continue to administer the drug to patients in spite of its clear history as an unsafe drug. Since Versed does not appear to be going off the market any time soon, an important responsibility lies with medical practitioners such as yourself—namely, that of notifying patients of all of the drug's potential risks. Based on your original post, you appear to already be doing this in your practice, and that is commendable. But many anesthesiologists do not, as is clear from the hundreds of patient comments posted on the aforementioned Web sites. There is something deeply wrong with that circumstance, and the responsibility of correcting it rests solidly with members of your profession, not with their patients.

A second crucial thing worth considering here is the actual need to administer Versed. Its use is simply not necessary for either the induction or maintenance of general anesthesia. Other anesthetic drugs that do not produce the aforementioned "exceedingly rare" complications can satisfy either of those criteria equally well. Versed is likewise not necessary for diagnostic procedures like colonoscopies or endoscopies. Therefore, it is not unreasonable to conclude that Versed is so heavily favored by the medical profession not because it is of any particular benefit to patients, but because it benefits medical personnel, in that it makes patients more easily manageable. To trade potential months or years of patient suffering for minutes of convenience for doctors or nurses, however, is not a fair trade, in my view.

Alternately stated, when one weighs the profound severity of some adverse health effects associated with Versed—be they "exceedingly rare" or otherwise—against the near-complete nonnecessity of the drug’s use, for people like you to continue to routinely administer it—again, THAT is unjust.

T said...

I have made it CLEAR both on the comment board on versedbusters.blogspot.com and in many places on this blog that I would never wish to trivialize or negate the reality of anyone else's suffering. EVER.

Stating an impression - for example that a rare occurrence is indeed rare - in no way diminshes the fact that for those who experienced the rare occurrence, life was horrendous. Even for more common things - we quote the incidence of headache after a spinal as 1% - it's great if you're in the 99% of people who don't get one, but if you're in that 1%, clearly the incidence for YOU is basically 100% and it's an awful state to be in. But merely stating that the incidence of spinal headache is 1% does NOT mean we think we can be dismissive and blow off the situation of those who wind up with one.

The article you cite about deaths attributed to Versed was discussing a highly concentrated formulation of Versed that even an anesthesiologist, who presumably would be accustomed to and comfortable with having to be super-cautious with drug concentrations and dilutions, found objectionable. This is why it's important to have physicians handling drugs who are trained to examine labels EVERY TIME they draw a drug up and use it; trained to make dose calculations on an individual basis; trained to change the drug concentrations so they are safer to administer; trained to judge whether a patient should get a few micrograms of, for example, epi, or a whole amp. Who's to blame in that example? The drug company for manufacturing such a high concentration? Or the physicians for not diluting it out when they were about to use it? Both, perhaps, if you're the type that insists on the blame game (which, by the way, has been found to be a FRUITLESS agent for change in many research studies on medical error), but not the drug itself. An ill-used drug does not make a bad drug.

People on both sides, clinicians and patients both, dream of a brain-altering drug that will affect ONLY consciousness of pain and leave alone other brain functions like memory, emotional regulation, sexual drive, cognition, etc. But I wonder if such a drug is even POSSIBLE in light of the interconnected structures and functions of the brain. Maybe someday...

You're right that in most cases there's no compelling NEED for Versed, which is why I do NOT administer Versed "routinely." No one should assume or PRESUME they know what I choose to do on a case by case basis in my practice. Your insistence on assuming I give a particular drug routinely seems to be one way in which you can keep me in that label box - "Those doctors, THEY'RE ALL like that, THEY ALL do that." Well, it's a wrong assumption, totally disconnected with reality, so it renders completely invalid your judgment about my practices as "unjust."

When I DO administer Versed at a patient's request or with a patient's consent, it's usually in doses so small that patients usually continue to chat pleasantly with me and ask me when I'm going to start their sedation.

Anonymous said...

Hi T,
I am sorry that you are feeling attacked on the issue of versed. I think it is very difficult for people who have suffered medication errors and/or patient abuse--which is how I would describe what has happened to most of the posters on the versed busters site--to be able to believe that there are good doctors/nurses/CRNAs/anesthesiologists out there.

This is unfortunate, especially considering that most of what the above group of posters experienced was over-generalizations of medical staff towards them (i.e., everyone likes versed, you would be too scared to not have general anesthesia, nobody wants to remember their procedure).

I would suggest that people who have suffered injuries due to medical errors or patient abuse could find more satisfaction in using their energy (or outrage) getting involved in the patient safety movement rather than directing it at an individual who had nothing to do with their specific injuries. A good place to start is Consumers Advancing Patient Safety (CAPS) http://www.patientsafety.org/

Anonymous said...

T., the actual wording of my earlier "routinely" comment was, "for people like you to continue to routinely administer [Versed]...." By that, I simply meant other anesthesiologists. If I'd intended to express the idea that you specifically routinely administer Versed, I would have instead said, "for you to continue to routinely administer [Versed]...." If you reread my comment, you'll see that I did not say that. I also hardly think that my actual comment could be said to amount to any "insistence" on my part, on anything.

Anyway...

...if you don't routinely administer Versed, I think that that's great.

Unfortunately, the same cannot be said of other medical personnel who administer anesthesia. Take, for example, an online poll that was recently conducted on the Nurse Anesthetist Forums, a Web site that describes itself as "The Nurse Anesthetist Resource Site." In the poll, members of the site were asked to indicate whether they either: (1) "usually always give preoperative Versed"; (2) "give [Versed] sometimes if the patient needs it"; or (3) "rarely give preoperative Versed." Of the 73 respondents to the poll, approximately 66 percent indicated that they "usually always give preoperative Versed." The poll results and accompanying discussion can be viewed here.

As concerns your belief that you would never wish to trivialize or negate the reality of anyone else's suffering—I think that that's great, too.

Again, though—and again, unfortunately—the same cannot always be said of others associated with your profession. For instance, in this reply to the above-linked Nurse Anesthetist Forums poll, a student registered nurse anesthetist (SRNA) describes the Versed Busters Web site as "amusing." Given the existence of comments like that—posted in a public forum, no less—I really do think that practitioners of your profession should reconsider being so surprised and/or aghast over the idea of patients being distrustful of anesthesiologists.

(By the way, for the sake of clarity, only two of the previous "Anonymous" replies above are mine—specifically, the one from November 4th and the first one from earlier today, November 8th.)

Supremacy Claus said...
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T. said...

"People like you?" That's supposed to be an acceptable way to refer to me and/or members of my profession? Would you refer to black people as "people like you," or Jews, or any GROUP? It's a little presumptous, in my opinion, and smacks of preconceived notions based on prejudice rather than on reality. You don't know me, so you don't know what people would BE like me or not.

The example you cite most recently involves ONE S-CRNA. ONE. Why is it that many people seem to be willing to generalize based on ONE bad comment / person/ interaction but not based on one, or even many, thoughtful, caring physicians? If one physician or nurse is nasty or unprofessional, why does that automatically translate into ALL physicians and nurses must be nasty people? Yet if a physician is thoughtful and compassionate, why is it people won't extrapolate and say, most physicians must have their hearts in the right place?

I'll tell you why. It's because for some people it's much too satisying to hate, be suspicious, and spread hate than it is to try and see both sides of an argument or see another's efforts as well-intentioned and born of compassion. It is much easier to resent, accuse, and assign blame in the face of imperfection than it is to try and understand where people are coming and the multiple factors that might have contributed to an undesired outcome. Yet the latter is far more helpful to all concerned and more productive than the former. Go figure.

Anonymous said...

As a follow up to my single post on 11/8 2:40 am. After ending up in the ER, the next day I called the office of the Dr that performed the procedure on me and two times during coversation with the receptionist I asked her to please tell the Dr that I was having a problem and went to the ER. I never heard from that Dr ever again. I then called the hospital in an attempt to find out what was done to me so I could make sure it never happened again. I was passed around to four different nursing stations, and at the last one told to call my family Dr. The only way I was ever able to find out what happened to me was with research on the internet! It was later explained to me that no one would talk to me because they were afraid of being sued. I had no such intentions, all I wanted to do is find out. Maybe this attitude is why they get sued.
You indicated that by the use of the words "these people" that I was indicating that all medical people are liars. That is not true, but I still have to ask how do I tell the difference from good and bad? Do you wear different colored lab coats. I have never felt so unsafe in my life as I did after being put out the door without even being able recover enough realize I was leaving the hospital. As I said before you can never trust someone that lies to you when it comes to your personal health and safety.

John said...

As a person who at one time posted vitriolic comments on the VersedBusters website, and who has spent countless hours pondering the possible reasons for my adverse reaction to my Versed experience, my thoughts may be of interest, especially because I believe my reaction was very likely the result of the lack of any 'informed consent'.

I'm a 52 yo man with a good, happy life and no history of any mental problems. I went in for a fairly routine colonoscopy having been told only that the conscious sedation would relax me. I was told I was being administered fentanyl but not midazolam. In the days following the procedure I became obsessed with finding info about midazolam which I now knew had been administered based on my medical report. I was having panic attacks, nightmares, insomnia and thought obsessively about what had happened as my mind unsuccessfully attempted to remember the procedure. It very much seemed like symptoms of PTSD. A number of weeks later, while thinking about it, and after having a bit more to drink than is normal for me, I became homicidal. I don't mean I had homicidal thoughts, I mean I was homicidal. If the persons who had administered this drug to me had been present, I have no doubt I would have killed them without hesitation. This was crazy, powerful stuff for someone who up to that point hadn't had any serious issues beyond the normal ups and downs of a typical life. The next day I made an appointment for mental health counseling, went to one session, came home, my body had a powerful shudder and emotional release much like crying, and as inexplicably as I had been afflicted, I was cured. And i've spent the last year and a half wondering what happened to me. Here is my best guess: I had felt violated in very much the same way a woman feels after raped. What is a benign, or for some people a pleasant drug experience for some people, was for me a serious violation of my autonomy due to the lack of information I had been provided about Versed's amnestic effects. Yes I was duly informed that a tube would be inserted several feet up my colon, but no one felt it important enough to inform me that the most intimate part of my body, my mind, would be chemically manipulated in what, for me, was a extremely disturbing way.

I understand that you have a legal burden to explain risks in a way that provides an individual with the ability to make a judgment about what happens to their body. I work in environmental regulation where we must attempt to explain risks and benefits to community groups. We accept it as a given that many people are poor risk evaluators. When you combine this fact with a lack of technical knowledge, its easy to question the value of these efforts and I suspect the recognition of this communication gap is the basis for your post.

However, the point i'd like to make is this: the time you spend informing your patients about what will be done to their bodies and minds (even when they don't truly understand much of it) can have a powerful mental impact. And the failure to adequately do so can be devastating. Maybe we should change the term to 'informed and consented' to better recognize an important therapeutic need for this discussion (in addition to the legal one).

Supremacy Claus said...
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T. said...

I keep having to repeat myself on this subject, as if it were not clearly posted on the main blog page, but here goes, AGAIN:

PLEASE DO NOT NAME-CALL OR INSULT OTHER COMMENTERS ON MY BLOG.

Even if you have made good/valuable points that might help us learn a little something, I WILL DELETE them if they are disrespectfully made.

It IS possible to be emphatic and even forceful without name-calling or using nasty descriptors. I have ALREADY asked this of commenters before; if you can't abide by it, see ya.

Supremacy Claus said...

That is the way of the left wing ideologue from Boston. Censorship and suppression.

T. said...

Supremacy Claus, you seem completely UNABLE to make strong points without name-calling. I won't begin to guess how someone arrives to adulthood without acquiring more adult behavior, but I WILL suggest that such a habit completely undermines any effectiveness you are hoping to achieve with your commentary.

I'd also like to remind everyone here that hate speech, as best as I can recall, doesn't fall into the freedoms protected by the First Amendment, whether you're left-wing OR right-wing.

Finally, this is MY blog. I have CLEARLY state MY rules many times: say it courteously, or I won't put up with it. Yes, I will censor and suppress you if you attack my readers, most of whom are coming here to participate in a mature, civilized discussion. If you don't like my blog and my rules for it, DON'T COME.

Supremacy Claus said...

"If the persons who had administered this drug to me had been present, I have no doubt I would have killed them without hesitation."

Death threat by obsessive, disgruntled doctor hater. Not a problem here. Not censored.

Sarcastic parody in defense of clinical care. Big problem here. Censored.

And hate speech is fully protected in this country, one has to remind the left wing ideologue.

Here, Doctor, the suggested remedy of the ACLU.

http://www.aclu.org/studentsrights/expression/12808pub19941231.html

The death threat is forbidden.

That prohibition is by the law. You possess this blog, and may do as you please with it. You are just being unfair.

Anonymous said...

In Beauharnais v. Illinois,relying on dicta in past cases, the Court upheld a state group libel law that made it unlawful to defame a race or class of people.

Supremacy Claus said...
This comment has been removed by a blog administrator.
T. said...

Perhaps my writing is at fault, and I have not been clear the, oh, HUNDRED times I've had to reiterate this on the comment boards despite its display on the main page:

I. WILL. NOT. ALLOW. DISRESPECT of me or my readers here.

DISAGREEMENT, by all means. That's how we learn and grow. Forceful candor, sure.

but

If I don't like
your TONE,
your DISRESPECT,
your INSULTS,
your ATTITUDE, OR
your NAME-CALLING,

your comments won't be welcome here.

PERIOD.

For the umpteenth time.

If you lack either the reading comprehension (which might be suggested by the inability to differentiate between a confession of past emotions and a threat of future actions) or the character and maturity to abide by my wishes for this forum, please DO NOT COME.

Or, as brilliant writer Sid Schwab wrote on his blog at http://sidschwab.blogspot.com:

"I've sometimes exercised my right as a blogger to toss comments. Some, of course, see that as wanting only agreement. Surprise: they MISS THE POINT once again. I ENJOY thoughtful discourse; when people disagree respectfully and in ways that propel the discussion forward, I love it."

But when people can't lose the tone and the attitude, and childishly need to insult other people to get their points across, I won't tolerate it.

I don't know how many more times I can repeat the above or how much more explicitly I can restate these remarks. If they are somehow still unclear, well, tough.

Anonymous said...

Dear anesthesioboist, I hear your frustration with those of us who lump you all together, good and bad anesthetists. I am sorry for that. I too have had major problems explaining just how devastating the Versed experience was. The surprise injection of Versed has completely fractured my personality. Previously I was bright, confident and secure in who I was. I believed in God and was ever so grateful to Him for giving me a strong mind that could deal with ANY adversity, pain, I was even raped as a 12 year old and STILL maintained the sanctity of my person. A simple chemical turned me into a compliant zombie who obeyed the medical personnel as if my life depended upon it and did exactly as they commanded me, even though I objected. I lay there trapped in my own mind confused as to why I was sooo obedient, which is not something I would have been, given that they were doing things to me which I had declined. I don't believe in God anymore. The bedrock of fairness has been removed from my life. I know now, that I won't be rewarded for a life well lived, and murderers and child rapists WON'T get what is coming to them in the end. I am not the person I thought I was. I am NOTHING but chemicals. Can you hear the despair? I'm not a real person anymore and a CRNA is responsible for this. He gave me this poison against my will and without warning because he obviously thought I was stupid, ugly, fat, old and he didn't like my cheerful cooperative self. I can't fathom the disdain he felt for me. I am just a worm to be dealt with like you would deal with any uppity ameoba who won't go along with the program. Does this help? I am blaming the CRNA who did this to me and then laughed at my unhappiness later. I also blame every single person who has access to this drug and uses it indescriminately. I didn't even rate an informed consent! I sooo wish I had just gone home without the surgery, but by not giving me an informed consent my CRNA closed that door on me as well. I would have signed out AMA rather than have an amnesia drug and general anesthetic...

T said...

Dear Anonymous 11/17/08 @6:55 -

I am saddened by the experiences you have described. It sounds like the combination of being rendered suddenly over-compliant along with the distressing sensation of amnesia has caused you profound suffering that I can't begin to imagine.

I think intentions are everything, and I will never know enough about your CRNA's intentions to know what to think about the decisions that were made, but I do know that most of my colleagues and I care deeply about keeping our patients safe and comfortable.

As for the concept of us as just chemicals that can be manipulated via other chemicals...believe me, it's an idea that has been one of my greatest challenges too. I encountered the idea that we are nothing but chemicals, or we are at the mercy of our chemicals, as a medical student, and it's constantly holding itself up in my mind against concepts of faith and free will. I do understand the struggle that particular idea can generate. Wish I had more answers...

Anonymous said...

This is for Santa Claus. The idea that we should google our prospective procedure is a good one. However, it will never take the place of INFORMED consent! Obviously all of the variables are not listed for each procedure. In my case I expected to receive a nerve block for the limb in question, something for pain like Fentanyl and an antiemetic. This was clearly shown as an option. I have had many surgeries for broken bones over the years as I have a hobby that puts me at risk for these things. Through trial and error, I have discovered that I respond best when not knocked out. I explained all of this to my arrogant little CRNA, but unknown to me (here is where an informed consent comes in) he had another plan which involved those very things which I had forbidden him to do. For my part I did NOT research anesthesia drugs as I wasn't going to allow them. So much for that! An informed consent would have alerted me to the fact that my CRNA was on some other planet from the one I was on. I needed to know the SPECIFICS of what the CRNA had planned so that I could get the hell out of there!!!! It is NEVER ok to second guess a patient without informing them, ESPECIALLY FOR AN ELECTIVE PROCEDURE. Lawyers are hopefully keeping at least some medical professionals under control so that what happened to me is rare. (no offense anesthesioboist!) An informed consent is not a lawyer gotcha it's a CRNA gotcha, and payback for this attitude is fair and right. If you get a signed informed consent it just may save your bacon. This is the true reason informed consent is used anyway. It's not really for the patient, it's a hold harmless agreement for the medical people, right? So in order to protect YOURSELVES you need to do a good job of being truthful with your patient, whether you feel its a waste of time or not.

Supremacy Claus said...
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Anonymous said...

You know what? I have been thinking about the premise of having no "informed consent" any more. I was absolutely against this and felt that the "informed consent" was the contract which insured that the patient was allowed to select which treatments, if any, the patient accepted the risk for.

Unfortunately "informed consent" has devolved into a hold harmless agreement for the medical practitioners. It isn't working as it should. Informed consent is just one more paper to sign in the hospital or medical center indemnifying the practitioners.

Get rid of the "informed consent." Let the patients know that there is nothing to protect them from over zealous Doctors et. al. "Informed consent" only lulls the patient into a false sense of security.

Most patients believe that by signing the "informed consent" that they have been honestly told the risks, side effects, the possible problems, the use of drugs and the effects of same, etc. They believe that the doctors have told them the truth about their prospective procedure. In my experience this is not what is happening.

Selective divulging of pertinant information is the norm. So while the patient believes they are protected by "informed consent" and they know what to expect and what will be done to them, nothing could be farther from the truth.

I believe that patients would be more vigilent about their treatment if they knew that there is NOTHING to protect them once they are on medical turf. Patients would be more wary about what their treatment entails. Patients would do as Supremacy Claus says and research more if they knew that anything goes in the hospital! If they knew that they couldn't trust the medical people to tell them the truth many would find it on their own.

Maybe it would be better to remove ALL semblances of patient protection from the medical assembly line. Get rid of informed consent! Take away the phony patient rights laws. They aren't followed anyway! Let patients know they are on their own in any medical setting. Let people know that there is no recourse if something goes wrong or wasn't identified by the practitioner as a potential problem. In the real world you can't sue a Doctor anyway as they are very well protected by law.

Anonymous said...

T. I like your thoughts and attitude...There is no way every detail (ie. what size scalpel or exactly how many stitches would be used) can be placed on a consent form..or even discussed with apatient. You sound honest...and I suspect you be honest with any question I would have as well as being more forthcoming on ideas of alternatives. And I think you would be more receptive to any reservations I had about th esurery or parts of it.
leemac

Anonymous said...

We are not asking what size scalpel or how many stitches. It might be nice to know where the incision is going to be, we would like to know about AMNESIA drugs that leave us walking, talking and screaming. If you want to use ga to make your life easier it would be nice if you asked our permission and/or accepted our decision. It would be really nice to know the risks of surgery, like, what are the chances of being crippled by this surgery... I think I should know if student Doctors are going to be perfecting their technique with my body. You guys play pretty fast and loose with a patients most precious possessions, their body and mind don't you? It's like "who the hell cares about the stupid patient, any and all risks should be assumed by the patient because what the hay, we were only trying to help. Why should we have to explain anything anyway? The patient should be quiet, accepting and under no circumstances ask questions or decline any part of our medical procedure." If you want information you will be ridiculed by such as the previous post which equates the size of the scalpel and the number of stitches with Versed, ga and surgical complication. How insulting.

Anonymous said...

I had a paradocical rxn to versed in the past and told the anesthesiologist that I didn't consent to receiving it, ut the CRNA gave it to me anyway. I remember her smirking as she patted me on the shoulder and told me that: don't worry about any problems, you can trust me". Really professional. When the procedure was over, the CRNA was red-faced and begging me to consent to a blood draw fo HIV/Hep C; it seems that after she pushed the Versed into my IV I had another paradoxical reaction and she got bit and stuck as I ripped my IV out. I told her no and she said that my anesthesia consent permitted this, I told her and the surgeon: "I hereby revoke my consent to any blood draws or further treatment since you administered a drug that the anesthesiologist agreed not to use". Suddenly the CRNA got very quiet. My wife told her: "don't worry about any problems honey, you can trust him"......My wife has had enough clinical experience to know that consent can be revoked at any time and she asked how the CRNA felt now. I told her that I have to live with the Versed side-effects and that she has to live with the consequences of exposure. Interestingly enough, my surgeon was totally supportive; when I saw him 2 weeks later I told him that I would have agreed to a blood test if the CRNA wasn't such a jerk..he said let her worry about the consequences. And I got a formal apology from the anesthesiologist.

Anonymous said...

Wow: You sound like the doctor that I would want to administer my anesthesia. For me, Versed is a nightmare drug (previous terrible experiences, but guess what: most docs still give it).....I had the wonderful experience of having severe burn debredementafter an airplane crash and I told the anesthesiologist: "no Versed"...she gave it anyway. I ended up in the ICU with a severe airway problem and significant memory impairment (1 year later after Versed)..am I a nutty Versed-hating patient? nope; I'm just a slob who flys jets for the USAF..but, my wife is an MD and I have a Ph.D. in biochem...whay do some in your profession push unececessary amnestic benzos on patients (Versed) when we clearly refuse them? Cr*p, I want to trust my anesthesia doc, but I no longer do.............I'm sure that most docs would laugh at my horrible Versed experience; my burn scars aren't pretty....but they are nothing compared to the Versed damage........

Anonymous said...

Oboist: Great blog;I wish that we had more docs like you. I do drug research for a living; I only see patients when my boss drags me out of my lab. Many patients have undergone screening colonoscopy per my recommendation and I always felt that these tests saved lives and did little or no harm. As I have reviewed many patient complaints about midazolam side-effects, I have to conclude: "an unacceptable number of patients who receive midazolam (Versed) for routine colonoscopy experience severe and long-lasting effects from this agent". I no longer recommend colonoscopy unless an anesthesia provider is available to administer propofol. I had previously felt that the thousands of "Versed horror stories" were bunk..that is until a bright, vibrant, fairly young MD at our facility got a colonoscopy (4mg Versed/100mcg fent) and immediately developed PTSD, nightmares, hostility and long-term memory loss. This person is no tinfoil hat person. Additionally, I doubt that many patients are harmed by the scant doses of Versed administered by anesthesia providers. Contrast that with the 4mg that was carelessly squirted into my friend's IV by a GI nurse who can't spell, much less perform "titration".

Anonymous said...

Just found out that I need yearly colonoscopies and this blog has convinced me to refuse midazolam or other amnesia drugs. I just retired from the military (I'm 57) and have been in several wars, but none has scareed me as much as the carelessly administered/poorly consented anesthesia drugs such as midazolam. I'm not a total tinfoil hat person, but I'm no doctor (my kid is in medical residency)..

EJH said...

Do you believe Pelvic exams while under anesthesia at teaching hospitals were done with informed consent?

This is one of many news stories by reputable outlets:

http://www.foxnews.com/health/2012/10/05/pelvic-exams-while-under-anesthesia-sparks-debate/

You may know the human body better than the average person, but you DO NOT know my body better than ME.

I am sure that you agree with the following statement:

"It is MY body, and NO means NO."

You say you won't force a patient, but will you advocate if you see something that defies common sense (like students lining up to perform pelvic exams on an anesthetized patient)?

T. said...

Pelvic exams should only be performed with patients' consent. "No means no" doesn't work in matters of the airway. If I have to intubate someone because the alternative is unsafe then I have to - NO ONE has a choice.

What does that mean, "You do not know my body better than me?" My gynecologist is the only person who has seen my cervix. My anesthesiologist is the only person who has seen my glottis. You may have no idea how your body will react under anesthesia, so how can you say you truly know your body? NO ONE knows EVERYTHING about themselves, physiologically, and in some cases, a clinician WILL know more than a person about his/her body.

Finally, if not even The Atlantic can get an anesthesia story totally right, then Fox News is certainly not going to be entirely reputable either. Most articles have to resort to some sensationalism to make bucks. That's not to say that the issue raised of unethical pelvic exams doesn't occur or isn't a problem (though again, I don't recall ever having seen it), but I'd have to hear from a much wider range of clinicians and patients to feel I have an adequate understanding of the actual situation.

Sometimes I let the surgeons or paramedics-in-training intubate patients but I always obtain the patients' permission beforehand and document on the consent form that the patient is willing to allow someone other than myself or the nurse anesthetist working with me to perform the intubation. I believe any such departure from the norm warrants explicit consent.

Never Again said...

T. What do you do or what would you do if a patient (such as me) refused the services of the crna? I have zero intentions of ever letting an advanced practice nurse do any "doctoring" on me. How would I enforce this if I'm to be knocked out? Bring a video tape?

T. said...

Specific preferences about which you feel very strongly should be explicitly added to / documented on your consent form before you and your physician sign it. The consent you give should be sufficiently binding.