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Editor's Page
The Economics of Endoscopic Sedation
Dan O'Connor
Publish Date: October 10, 2007

This month's cover story attempts to explain why nurses and gastroenterologists are scratching and clawing to wrap their hands around the propofol syringe in the endoscopy suite. It's more a turf battle for them and anesthetists than a patient safety debate, even though RNs who've passed their nurse-administered propofol sedation training course and GI docs who've completed a weekend seminar are eager to put their sedation and airway management skills and training up against an anesthesia provider's.

IFFY PROPOSITION We haven't wavered from our position that no one other than trained anesthesia providers should push this drug ("Keep Propofol in Trained Hands," August, page 8). And we fully expect the FDA will deny the American College of Gastroenterology's petition to dilute propofol's warning label when it gets around to Docket # 2005P-0267. The ACG's claim that there's no increased risk when non-anesthesia personnel administer propofol sits on a house of cards:

  • If a properly trained GI doc is supervising ...
  • If an RN staff is properly trained ...
  • If that staff adhere to a stringent established protocol including ACLS certification and airway management training ...

If these three things happen in every case in every GI suite in the country, then it's safe.

ECONOMIC INEQUITY? Anesthesiologists administer propofol sedation 6 million times a year, says Marc Koch, MD, president and CEO at Somnia Inc., an office and ambulatory anesthesia service company. We can see why an office-based GI doc who must pay an anesthetist $140 out of his bundled fee, $476.07 for CPT 45378 (colonoscopy) and $632.04 for CPT 45385 (colonoscopy & polypectomy), could use a more affordable alternative.

Here's an idea for a product that could end the catfight over who besides trained anesthesia professionals should administer propofol during endoscopy. It's really quite simple: Inside a sterile pouch we'd pack a tiny bottle of bourbon, like the ones they serve on airplanes, and a small hunk of wood. Patients would down the bourbon and then bite down hard on the wood right before the scope is inserted. We'd call it the John Wayne Endoscopy Sedation Kit, in honor of how the Duke would psyche himself to use a rock to hammer the arrow stuck in his chest out his back.

We'd rid endo suites of gallons of propofol, of RNs pretending to be anesthetists, of GI docs doubling as anesthetists and of anesthetists billing as anesthetists. Just booze and tree bark. Close your eyes and grit your teeth. Patients may not like it much, but it'd be safe and cheap.