Regarding procedures where patient is likely given a hypnotic/general anesthetic, it is best that a Medical Directive be available preop and the request for a no-blood technique be made to doctor,surgeon and anesthesiologist. Good if patient is in a Transfusion-free Medical/surgical Program in the hospital; his wishes will be respected. But if he happens to be in a hospital where there is no such program and doctors/nurses are not cooperative, then a problem arises. He still has to get the doctors' promise/assurance not to give blood.

In the hospitals where I work as active or visiting consultant anesthesiologist, I have requested all the doctors to respect patients' Medical Directive even when they are unconscious. I'm happy that there has been a palpable change in the attitude (negative to positive) of many of my colleagues here in this part of the Philippines. I don't see any negative or violent reaction from our nurses when patient refuses BT.

It's true that the anesthesiologist usually gives the blood transfusion but most often upon the order of the surgeon. I have heard of stories made by some doctors that they gave blood when patient fell asleep despite patient's refusal during the preop visit. I tell them that they can be sued for such action. When I give lectures on blood transfusion (BT) alternatives, I always emphasize that issues on BT are no longer just a religious issue as many non-Witness patients are refusing blood.

Regards,

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Angelina A. Gapay, MD

Thank Dr Gaypay and to all others who helpd me to get my last colonoscopy without the possibility of blood_it was easy following your instructions)...and after getting a ransfusion of platelets from multiple donors at a universitry hospital, being assured that the blood supply was "safe" I get a letter from the American Red Cross stating that the platelets that I received were not tested for HIV or Hep C. I now have a letter in my chart and every time I have a procedure , the doc signs it to acknowledge my wishes. Thanks again!. My question is about colonoscopy (I have at have another one, pretty much immediately), my issue was not wanting sedation and I finally convinced the hospital that did my last one to do it without sedation (no versed/propofol etc) and reluctantly agreed to a small amount of painkiller fentanyl is what they use) if the doctor thoughtthat it was absolutely required to complete the test. Didn't ask for it, which was a mistake on my part, it hurt a lot. But no big deal. Since then, I have moved and told the GI dept that I didn't wan't sedation, they were very reluctant to schedule the exam, but did. I did the prep and the nurse called last night and told me: if you don't consent to the sedation, then we won't give you any painkiller (fentanyl)....I reported for the exam this morning and they had an anesthesia nurse waiting for me; she bluntly told me that it was her professional judgement that this exam would be doen under sedation with propofol and fentanyl if needed..I told her that I had bad experiences with sdation, and just plain didn't want it, but would accept the option of a little painkiller if absolutely rewired to finish the exam. She told me flatly: "we don't just give IV narcotics without sedation "on demand"..........so I reluctantly left.......I understand the synergy between sdatives and narcotics, but if I can di o the exam with neighter, or just a little fentanyl, why insist on propofol? AM I missing something?A nurse told me that the "insist" on versed so the exam is faster and the patient has amnesia or propofol so that the anesthesia nurse has to give the propofol and it's a separate fee. This is a new hospital for me, and I already have the doc calling me yelling at me for leaving. (I ask her if she would like being the option of pain control if needed and she would not answer). Any ideas? thanks. you guys realy helped me before.

In the first place, why would you undergo another colonoscopy a few months after the first one? Were there findings in the first one that need confirmation by another colonoscopy?

I suspect that the administration of either midazolam or propofol plus fentanyl is the standard operating procedure for colonoscopy in the facility where your test would be done. In fact, in our hospital it is the SOP. I used another technique, that is, fentanyl and parecoxib without sedation, in a patient (nurse) who requested no sedation. She had a high tolerance to pain. In your case, you might have to look for another anesthesiologist who would agree to your wishes, or give in to their wishes for you to accept propofol/fentanyl. I agree with you that there is great synergy when narcotics and sedatives are used together. Heart rate drops significantly and respiratory rate and depth drop too. If your nurse anesthetist is good/skilled, you should have no problem.

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Angelina A. Gapay, MD

Thanks Dr Gaypay-yes, they want to repeat the procedure because there was some sort of procedural error in processing the original biopsies and they have to try to get a number of patients to come in for repeat tests. Lucky me, but nobody is perfect; they have really been asking me to return (no charge for the test and they even offered to pick them up and take me home when I told them I didn't have a ride)......The Chief of Anesthesia called me on 12-29-08 and said that the CRNA who told me "no sedation meant that you won't get any fentanyl if needed" was totally out of line..but that they prefer to use propofol/fentanyl (don't have parecoxib yet).....The test was painful before with nothing, but I told them that I would prefer to endure the pain rather than being "cared for" by people who seem to be incapable of telling the truth. I'll be doing the prep next week and the exam; the gastro called me and assured me that an anesthesia doc would be present (and they actually called me)..I just can't seem to get them to undestand that I don't' want their services since they lied to me about the fentanyl, which seemed to me to be a reasonable standby if things got too painful; but after the CRNA told me "NO", and the gastro doc basically agreed, then they discover that they messed up the original colomoscopy and suddenly the chief anesthesia doc calls me and says "the CRNA was wrong, you can just ave fentanyl". Would a reasonable person trust these people? Gosh, I wish that I still lived in the Phillipines, I would gladly pay whatever it took to have you, Dr. Gapay, present for this exam. I can tell that you are trustworthy. have a great new year, and thatns for your continued suggestions; otherwise, I would never have this exam erpeated (and I'm getting the feeling that there is something seriously wrong that they aren't telling me). thanks

Thank you very much.
So, they have to repeat procedure because they messed up with the original tissue biopsy. Anyway, it's a good thing they offered a repeat procedure at no cost, plus a free ride. However, please insist on getting a pain reliever like fentanyl from your doctor-anesthesiologist because severe pain during colonoscopy can induce a neurogenic shock (fainting spell) which is no good either. Or you may have a small amount of propofol ,say, 4-5 ml, to take away the anxiety, prevent rises in heart rate and blood pressure; not really to put you to sleep.

Hope you get it done without problems. Regards.

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Angelina A. Gapay, MD

DR Gaypay_I'm writing this as an inpatient at a university hospital (USA)...and my primary care doc (a wonderful woman) told me to thank you for life-saving advice.....I had sedationless colonoscopy (and the lost the biopsy-everyone is human, it happens)..so they insisted that I come in for a "free" repeat colonoscopy..and everyone from the GI doc to the pathologist called me and expressed their sympath that I had to have the test repeated (since the seemed to have lost the biopsy),,,,,,I attended West Point and the Phillipine Military Academy and just retired at 53....they are pretty sure that I have colon cancer in an early, cureable stage, and without your advice I would have NEVER had a repeat colonoscopy if they insisted on sedation. Yesterday, we did the colonoscopy. the CRNA who said: refuse seation and you won't get painkiller was there and said that she "mispoke".........I told then to do the exam with nothing and didn't sign a sedation consent.......which was ok with the scope doc, but she said the same thing that you did: it's going to hurt........bad idea, I guess...then the "chief anesthesia doc" show up and asks if she can handle the case, and before I know it I got 100mcg fentanyl (didn;t do much) then they did the exam. painless until the end (air) and I got propofol..........next thing I remember was the CRNA removing a rectal tube (to get of the air) and she put someting in my IV and I slept for a long time.......anway..dr Gapay-thanks!.......................

Dr Gaypay and to everyone on this board-you must be sick and tired of hearing about my recent "medical misadventures" but I'm back in the hospital and just had to say that-you from the bottom of my heart to all of you for your support-it turned out to be lifesaving. With your advice, it was easy to get a "no blood" agreement, even though I'm not a J. Witness.....but Dr, Gaypay, your advice about getting the repeat colonoscopy saved my life..Briefly, I tried to get them done in the past w/o sedation, nobody would do it, my favorite answer was from the CRNA who said: don't sign the sedation consent and I won't give you any fentanyl.....I had fentanyl before, didn't want it unless it was necessary, but you can see from my previous posts what happened (human error-happens to anyone).anyway; yesterday, I got the second scope (with the chief anesthesia doc present and the CRNA) and they even got me a ride to return to the hospital since they lost the biopsy. MY wife said: I would never go back there..they lied to you (they did)....anyway, the second scope went well with 100mcg fentanyl, no propofol (which I thought that I got-but didn't ask for so they didn't give it)...the biopsy was cancerous and luckily didn't penetrate the gut wall (so tomorrow, I get colon surgery which should be curative)...........DR Gaypay: without your advice, I would have never returned for the repeat exam...the CRNA said that she "insisted" on sedation because she wanted me "comfortable".......and she was there yesterday after the exam holding my hand and sing a tube to get out the painful air (a job that CRNA's probably don't usually do! Anyway, now we are friends.........good thing; tomorrow they will be doing the colon surgery and other than not eating for several days, I feel fine. No blood will be given.........., the CEO of the hospital asked me (he was a classmate in college) why I wasn't really mad....well, colon cancer isn't going to kill me (thanks Dr Gaypay)..and I'm grateful. thanks a million!