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Unsedated? Not Here! unsplash-Piron Guillaume

Unsedated? Not Here!

Why the Excitement?

News reports say the Ontario government may cut anaesthesia-assisted colonoscopy. Some reports say "It is unthinkable to have a colonoscopy without sedation,” and others just call it a "freakout.” If you're about to have a colonoscopy, how will this matter to you? First, read the stories here and here.

The best question is, "how many doctors will be at my colonoscopy?" One or two? After these changes, the answer will almost always be one. Before these changes, the answer was usually one, but sometimes two. It’s not a big issue most of the time.

If there is one doctor, then this is the endoscopist. He or she is usually a general surgeon, like me, or a gastroenterologist. This is the person who advances the colonoscope through the bowel, takes out polyps and makes diagnoses based on what they see in the colon. If there is just one doctor, then this is also the person who bears responsibility for the patient’s comfort and sedation. The sedative medications are usually given by a registered nurse, who works under the direct supervision of this doctor.

If two doctors are present at colonoscopy, then the second doctor replaces the registered nurse. Before you get the impression that this is just a doctor doing a nurse's work, the second doctor is an anesthesiologist who is skilled at putting people to sleep and waking them up again. They have skills in keeping people comfortable during full-on surgery that is much more invasive and pain-inducing than colonoscopy. They are skilled at hooking people up to ventilators and at keeping patients comfortably sedated in the intensive care unit, sometimes for weeks at a time. They have a skill set that goes far beyond what’s needed for colonoscopy sedation. Having one of these doctors present is much like using a printing press to write a word when a ballpoint pen will do.

Yet, sometimes it is helpful to have that second doctor. The anesthesiologist can use a medication called propofol, that in Ontario the endoscopist is not allowed to use. Propofol can be more dangerous and so an anesthesiologist needs to be at the bedside. Propofol often results in patients being completely asleep during their procedure and waking up a bit faster after it. The risk of sedation is small whether propofol is used, or whether the nurse and endoscopist are giving sedation with midazolam and fentanyl. With propofol however, the risk of breathing complications is a bit higher. Otherwise, the two approaches are not significantly different.

The one exception is patients who don’t sedate well with midazolam and fentanyl. Typically these are people who may have high anxiety, or who take anti-anxiety medication, or who have chronic pain and need long-term narcotics. For them, propofol usually works better. For their sake, I hope that OHIP would continue to provide funding on an exceptional basis. For everyone else, midazolam and fentanyl tend to work just fine when given by an experienced endoscopist and registered nurse working together.

I didn’t yet mention unsedated colonoscopy. This too can be had if someone really wants it. But it’s not for everyone. Some people have a short and straight bowel and moving a colonoscope through them is relatively pain-free. Some people experience less discomfort than others. Maybe a person is really curious to see inside themselves. Whatever the reason, unsedated colonoscopy is possible. About 10% of my patients choose not to have sedation. Even so, if someone starts their colonoscopy without sedation, it’s always possible to add sedation partway through to keep the proceedings civilized.

Let’s hope the civilized proceedings don’t stop at the endoscopy suite but extend all the way to Queens’ Park.

This article is written by Dr. Mark Reimer. He is a general surgeon and medical director of The Reimer Clinic. He has performed about 12,000 colonoscopies in a decade of practice. Outside of his medical work, Dr. Reimer manages a home care company called Freiheit Care Inc.