June 21, 2007 - What the Right Hand Doesn't Know

This morning I go to Ocean Medical Center for a colonoscopy. This is a routine “wellness” test – the obligatory 50th-birthday look-see by a gastroenterologist. Inasmuch as this is a screening test for colorectal cancer, I suppose it falls within the purview of this blog (even though it has nothing to do with lymphoma).

Do not fret, gentle reader. I promise to spare you the grisly details. Suffice it to say that the test itself isn’t bad (I slept through most of it). It’s the fasting-and-purging regimen of the previous day that’s the worst part – as any colonoscopy veteran will tell you. Yet, even that doesn’t live up to the negative hype.

The most significant aspect of this colonoscopy, to me, is its timing. It happens to take place a few days before my excisional biopsy (which is scheduled for this coming Monday, June 25th). With all my anesthesia woes during my last two surgical experiences – the pain I felt during my core-needle biopsy in December of 2005 and during my port-implantation surgery a month later – I'm looking on the colonoscopy is a sort of practice run: a chance to work out any communication difficulties among my doctors.

That’s the theory, anyway. The reality proves to be very different. Here’s what I did, in a vain effort to try to prevent the communication snafu that did, in fact, happen:

1) I informed my gastroenterologist, Dr. Aaron, that when I had my port-implantation surgery a year and a half ago, I woke up on the operating table, feeling pain. I told him I have sleep apnea, and use a BiPAP machine every night. He told me I ought to speak to the anesthesiologist, to make sure that doc’s informed of my history. (And who will the anesthesiologist be, I asked? Search me, says Dr. Aaron. It’s a group. You don’t meet your anesthesiologist until the morning of the surgery. But, he says, if I call his office the day before, maybe one of his staff can scope it out.)

2) Earlier, I'd scheduled an appointment with Dr. De La Luz, my pulmonologist, to consult about anesthesia issues (this, with my biopsy surgery in mind). Because that appointment was already scheduled for a few days prior to the colonoscopy, Dr. Aaron suggested I ask him about that procedure as well. When I saw Dr. De La Luz several days ago, he repeated what he’d said to me some months before: there’s no reason you can’t use a BiPAP machine in the operating room. Dr. De La Luz scribbled a prescription for me to give to the anesthesiologist that morning, listing my BiPAP settings. Should I try to talk to the anesthesiologist ahead of time, I ask him? No need, says he. You don’t know which one you’ll get, anyway. Just give the doc this slip. They have BiPAP machines on hand. All the respiratory technician has to do is calibrate it to your settings, and you’re good to go.

3) I call Dr. Aaron’s office, anyway, the day before, to see if I can get an anesthesiologist’s name. No luck – they have no idea which one it’s going to be. Based on what Dr. De La Luz told me, though, I don’t worry any more about it.

Sounds good in theory, right? Wrong! When the scrubs-clad anesthesiologist (I’ll call him “Dr. B”) comes in to see me in the outpatient-surgery prep area, he picks up Dr. De La Luz’s little missive that's clipped to my chart. What’s this, he asks?

I’ve got obstructive sleep apnea, I explain. This is so you’ll be able to hook me up to a BiPAP, so I won’t slip into an apneic episode, so you won’t scale back the anesthesia, and so I won’t wake up in flagrante surgico, as happened the last two times I had surgery. (Truth to tell, I wasn’t so glib at 7:30 in the morning, after a day subsisting on clear liquids, jello, and a 64-ounce bottle of laxative – but, a story like this one does gain in the retelling.)

Dr. B. furrows his eyebrows. I’ve never seen a machine like that used during a surgical procedure, says he. Then comes the real kicker: “What’s a BiPAP, anyway?”

Uh-oh, I think to myself. I’m in trouble. My anesthesiologist has never heard of a BiPAP machine.

Non-medical types are more likely to have heard of the more-common C-PAP – the BiPAP’s kissing cousin – but I’m surprised to meet an anesthesiologist who isn’t familiar with it. (And Dr. De La Luz had been so confident: all I had to do was hand over his little note, and everything would be fine!)

The thought crosses my mind that maybe I ought to just get up, go home, reschedule the colonoscopy, and start all over again: making a more energetic attempt to breach that impregnable, bureaucratic wall that keeps anesthesiologists from communicating with their patients in advance.

No, I say to myself. Think about this carefully. A colonoscopy is more of a diagnostic procedure than a surgical operation. Sure, it’s invasive, but – except for the possible removal of a polyp or two, deep within my intestines where there aren’t so many pain receptors – I’m not going to be cut. Besides, I’m not crazy about the idea of trudging back to the pharmaceutical barkeep for another of those jumbo laxative cocktails.

Dr. B explains his reservations. If I should have a problem with acid reflux in the operating room, while my gag reflex is suppressed by the anesthesia, the positive airflow from the BiPAP could cause me to aspirate some nasty stuff into my lungs, causing pneumonia.

Well, then – says I to him – I’m confused. Could you help me understand why a pulmonologist – an expert in BiPAP machines – would tell me it’s common to use it as a piece of operating-room equipment, to ward off apnea?

Hold on just a minute, says Dr. B. Let me talk to a respiratory technician.

Sure enough, the respiratory tech shows up a few moments later – wheeling in a BiPAP machine. She leaves it at the foot of my gurney, ready to go. Dr. De La Luz must have been right, after all, I think to myself.

But, not so fast. I’m still not out of the woods. Who should show up next but the head respiratory technician? There’s a problem, she says. They don’t have the same sort of face mask I use at home. The home version covers the nose only. The hospital version covers both nose and mouth, and is actually used more for emergency resuscitation than for keeping the airway open during routine surgery. You’ll have the mask strapped very tightly to your face, she tells me – more tightly than your BiPAP mask at home. As you’re drifting into or out of consciousness, you might feel disoriented and try to rip it off. And that would bring the whole procedure screeching to a halt.

Nasal C-PAP or BiPAP mask

Moments later, Dr. Aaron shows up, looking concerned. He’s evidently been talking to the other two. He tells me he strongly recommends against the BiPAP machine. The risks are just too great. He’s done hundreds of colonoscopies, many of them on people with sleep apnea, and he’s never had that kind of problem. The procedure is brief, the anesthesia is light, and it will all be over before I’m likely to have any breathing difficulties.

With that, I give up. I’ve run up against an all-too-typical problem of hyper-specialized American medicine: dueling doctors, with the patient caught in the middle. The right hand doesn’t know what the left hand is doing. How do I decide?

Well, at this point it’s is two docs against one – and the chances of tracking down Dr. De La Luz for a confab, at this early hour, are probably nil. Yes, I’m scared to repeat my previous, waking-on-the-operating-table experience. But, I sure don’t want to repeat the colonoscopy prep at some later date, either.

Just forget the BiPAP, I tell them. Let’s go ahead without it. With the procedure being so short, I think I can probably get through it.

It all turns out OK. I do open my eyes at one point, and twist around to look at the monitor. There, I catch a glimpse of a cavernous-looking orange tunnel that is my large intestine – but, I feel no discomfort. Moments later, I hear a voice telling me to settle down, and I close my eyes and go back to sleep (I expect Dr. B may have given me another squirt of sleepy juice, through my IV line).

Later, back in the recovery area, Dr. Aaron stops by to tell me things looked pretty good in the ol’ intestines. He did excise a couple of “innocent-looking little polyps” and is sending them off for a precautionary biopsy, but he doesn’t think they’re likely to be cancerous.

I’m relieved by the results, but a little rattled at how the medical bureaucracy foiled my best efforts to try to head off a very real problem, one I’d experienced twice before. I’m really not trying to second-guess the doctors. I just want to be sure the doctors do talk to one another. Is it too much to expect that the right hand will know what the left hand is doing?