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Recommendations for pain management during colonoscopy
Letters to the Editor
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dation for upper gastrointestinal endoscopy. Aliment Pharmacol Therap 1990;4:103-22. Standards of Practice Committee. American Society for Gastrointestinal Endoscopy. Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures. Gastrointest Endosc 1995;42:626-9. Bell GD, McCloy RF, Charlton JE, Campbell D, Dent NA, Gear MWL, et al. Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy. Gut 1991;32:823-7. A Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology 1996;84:459-71. Stoneham MD, Saville GM, Wilson IH. Knowledge about pulse oximetry among medical and nursing staff. Lancet 1994;344:1339-42.
Recommendations for pain management during colonoscopy To the Editor: I recently underwent a colonoscopy which proved to be terrifying and extremely painful in spite of sedation. Having searched the literature in an effort to understand why this procedure was so traumatic, I was encouraged to find that current research in the field addressed the issues of patient pain from and dissatisfaction with the procedure. 1 - 7 However, because none of the articles I have read dealt with my reasons for dissatisfaction (which I believe are fairly common), I would like to offer some suggestions for ensuring increased patient satisfaction. My colonoscopy was performed at one ofthe best known and most prestigious hospitals in the country by an experienced gastroenterologist who was assisted by a well-trained nurse. I had been informed. by my doctor that the procedure would be relatively pain-free because I would be receiving sedation. Before the procedure I was administered 2 mg midazolam and 30 mg meperidine intravenously. As the procedure began, I started to experience pain and the sedation was increased to 4 mg midazolam and 50 mg meperidine. In spite of the sedation, the procedure was still so painful that I felt as if my stomach were going to explode. Given my sedated state and inability to articulate my pain, I expressed it as best I could by moaning. While I was moaning, neither the doctor nor nurse did anything to comfort or reassure me. Rather they engaged in social chitchat in the midst ofthis. Because I had signed an informed consent form which stated that there was a possibility of various severe complications occurring as a result of this procedure including loss oflife, the seeming inattention ofthe doctor and nurse resulted in my feeling abandoned and terrified. Fortunately, no polyps were found and my procedure ended. I do not believe that the doctor or nurse meant to be 210
GASTROINTESTINAL ENDOSCOPY
insensitive. Their emphasis, however, on the medical procedure to the exclusion of my emotional well-being left me extremely upset. Schutz et al. 4 concluded that patient satisfaction is increased when a discussion of expectations occurs before the procedure; Aabakken et a1. 5 suggested increased information in advance of the procedure by means of a pamphlet to reduce patient anxiety. Based on my experience, I would like to recommend that informing the patient in advance that the procedure might be painful in spite of sedation would help prepare the patient for any possible pain. Providing reassurance to the patient who is expressing pain during the procedure such as telling him/her to breathe deeply to facilitate relaxation would enable the patient to have some control over the pain. Furthermore, I understand that there are certain standards of behavior in the endoscopy room (Boyce and PalmerS) and engaging in social conversation is a violation of them. It would provide more compassionate treatment of the patient to keep any conversation focused on the patient. If these suggestions were followed, I believe that patients would experience less stressful procedures and more satisfaction. Judith Natkins, MS, MA Cambridge, Massachusetts
REFERENCES 1. Froehlich F, Thorens J, Schwizer W, Preisig M, Kohler M, Hays RD, et al. Sedation and analgesia for colonoscopy: patient tolerance, pain and cardiorespiratory parameters. Gastrointest Endosc 1997;45:1-9. 2. Cataldo P. Colonoscopy without sedation: a viable alternative. Dis Colon Rectum 1996;39:257-61. 3. Seow-Choen F, Leong AFPK, Tsang C. Selective sedation for colonoscopy. Gastrointest Endosc 1994;40:661-4. 4. Schutz S, Lee JG, Schmitt CM, Almon M, Baillie J. Clues to patient satisfaction with conscious sedation for colonoscopy. Am J Gastroenterol 1994;89:1476-9. 5. Aabakken L, Baasland IL, Osnes M. Development and evaluation of written patient information for endoscopic procedures. Endoscopy 1997;29:23-6. 6. Williams CB. Comfort and quality in colonoscopy. Gastrointest Endosc 1994;40:769-70. 7. Herman FN. Avoidance of sedation during total colonoscopy. Dis Colon Rectum 1990;33:70-2. 8. Boyce HW Jr, Palmer ED. Techniques of clinical gastroenterology. Springfield: Charles C. Thomas; 1975. p. 6-7.
Colonoscopy and missed colon cancers To the Editor: Missed colon cancers are every colonoscopists' coldsweat nightmare. This was nicely reviewed in the recent editorial 1 in response to the article by Haseman et a1. 2 that analyzed 27 "missed" and 20 "not reached" colon cancers. Colonoscopy-wise, we evolve personal technical styles; each "doing it my way"! The question, Why do trained individuals miss life threatening lesions, suggests a need for deep self searching. Does speed equal misses? Is it possible to be just "too fast"? One member of a seven VOLUME 47, NO.2, 1998
10.
11.
12.
13.
dation for upper gastrointestinal endoscopy. Aliment Pharmacol Therap 1990;4:103-22. Standards of Practice Committee. American Society for Gastrointestinal Endoscopy. Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures. Gastrointest Endosc 1995;42:626-9. Bell GD, McCloy RF, Charlton JE, Campbell D, Dent NA, Gear MWL, et al. Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy. Gut 1991;32:823-7. A Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology 1996;84:459-71. Stoneham MD, Saville GM, Wilson IH. Knowledge about pulse oximetry among medical and nursing staff. Lancet 1994;344:1339-42.
Recommendations for pain management during colonoscopy To the Editor: I recently underwent a colonoscopy which proved to be terrifying and extremely painful in spite of sedation. Having searched the literature in an effort to understand why this procedure was so traumatic, I was encouraged to find that current research in the field addressed the issues of patient pain from and dissatisfaction with the procedure. 1 - 7 However, because none of the articles I have read dealt with my reasons for dissatisfaction (which I believe are fairly common), I would like to offer some suggestions for ensuring increased patient satisfaction. My colonoscopy was performed at one ofthe best known and most prestigious hospitals in the country by an experienced gastroenterologist who was assisted by a well-trained nurse. I had been informed. by my doctor that the procedure would be relatively pain-free because I would be receiving sedation. Before the procedure I was administered 2 mg midazolam and 30 mg meperidine intravenously. As the procedure began, I started to experience pain and the sedation was increased to 4 mg midazolam and 50 mg meperidine. In spite of the sedation, the procedure was still so painful that I felt as if my stomach were going to explode. Given my sedated state and inability to articulate my pain, I expressed it as best I could by moaning. While I was moaning, neither the doctor nor nurse did anything to comfort or reassure me. Rather they engaged in social chitchat in the midst ofthis. Because I had signed an informed consent form which stated that there was a possibility of various severe complications occurring as a result of this procedure including loss oflife, the seeming inattention ofthe doctor and nurse resulted in my feeling abandoned and terrified. Fortunately, no polyps were found and my procedure ended. I do not believe that the doctor or nurse meant to be 210
GASTROINTESTINAL ENDOSCOPY
insensitive. Their emphasis, however, on the medical procedure to the exclusion of my emotional well-being left me extremely upset. Schutz et al. 4 concluded that patient satisfaction is increased when a discussion of expectations occurs before the procedure; Aabakken et a1. 5 suggested increased information in advance of the procedure by means of a pamphlet to reduce patient anxiety. Based on my experience, I would like to recommend that informing the patient in advance that the procedure might be painful in spite of sedation would help prepare the patient for any possible pain. Providing reassurance to the patient who is expressing pain during the procedure such as telling him/her to breathe deeply to facilitate relaxation would enable the patient to have some control over the pain. Furthermore, I understand that there are certain standards of behavior in the endoscopy room (Boyce and PalmerS) and engaging in social conversation is a violation of them. It would provide more compassionate treatment of the patient to keep any conversation focused on the patient. If these suggestions were followed, I believe that patients would experience less stressful procedures and more satisfaction. Judith Natkins, MS, MA Cambridge, Massachusetts
REFERENCES 1. Froehlich F, Thorens J, Schwizer W, Preisig M, Kohler M, Hays RD, et al. Sedation and analgesia for colonoscopy: patient tolerance, pain and cardiorespiratory parameters. Gastrointest Endosc 1997;45:1-9. 2. Cataldo P. Colonoscopy without sedation: a viable alternative. Dis Colon Rectum 1996;39:257-61. 3. Seow-Choen F, Leong AFPK, Tsang C. Selective sedation for colonoscopy. Gastrointest Endosc 1994;40:661-4. 4. Schutz S, Lee JG, Schmitt CM, Almon M, Baillie J. Clues to patient satisfaction with conscious sedation for colonoscopy. Am J Gastroenterol 1994;89:1476-9. 5. Aabakken L, Baasland IL, Osnes M. Development and evaluation of written patient information for endoscopic procedures. Endoscopy 1997;29:23-6. 6. Williams CB. Comfort and quality in colonoscopy. Gastrointest Endosc 1994;40:769-70. 7. Herman FN. Avoidance of sedation during total colonoscopy. Dis Colon Rectum 1990;33:70-2. 8. Boyce HW Jr, Palmer ED. Techniques of clinical gastroenterology. Springfield: Charles C. Thomas; 1975. p. 6-7.
Colonoscopy and missed colon cancers To the Editor: Missed colon cancers are every colonoscopists' coldsweat nightmare. This was nicely reviewed in the recent editorial 1 in response to the article by Haseman et a1. 2 that analyzed 27 "missed" and 20 "not reached" colon cancers. Colonoscopy-wise, we evolve personal technical styles; each "doing it my way"! The question, Why do trained individuals miss life threatening lesions, suggests a need for deep self searching. Does speed equal misses? Is it possible to be just "too fast"? One member of a seven VOLUME 47, NO.2, 1998