November 17, 2018

Surgery without sedation and a question about charity.

"Most cataract surgeries are performed using a local anesthetic as well as 'conscious sedation,' which involves an anesthesiologist putting patients into a sort of twilight state. But some practitioners will do the procedure without the sedation. Although not for everybody, surgeons say, this approach is worth asking about if you’re a calm patient. It can be especially appealing if you don’t have someone to help you get home, or your insurance doesn’t fully cover the cost of an anesthesiologist."

From "What Doctors Don’t Tell You About Cataract Surgery/Patients should know about choices to be made about the procedure and postsurgery adjustments that may be unexpected" (WSJ).

I don't like that headline, because based on my experience, doctors do tell you all those things. Maybe some doctors don't tell you, and I'll bet some patients don't understand or remember what they are told. But I didn't know that "some practitioners will do the procedure without the sedation." That surprised me. A tough person who hates sedation might like this option, but I think it's terribly sad if someone picks this option because they don’t have anybody to help them get home or because they can't cover the cost of sedation.

I suspect that not having someone to help you when it is required for a medical procedure is a troublesome problem for many aging people who are proud of living independently. It would be nice if there were an easy, Uber-like service for this need.

And yet why am I so sad about this? I know that extremely low-cost cataract surgery is provided to millions of people in other countries. I've researched some of the charities that do this work, and they say $25 is all it takes to remove one person's cataracts. Presumably, sedation is a luxury. Maybe we comfortably squeamish Americans should be asked if we would forgo the sedation if it would cover the cost of cataract surgery for 100 individuals in poor countries.

59 comments:

Eleanor said...

I was scheduled for some day surgery with a doctor I had a good rapport with. He suggested I do the surgery with local anesthesia and a valium. He'd block my view of what was going on, and we could chat about things we often talked about. The surgery itself would take about 20 minutes. Without the anesthesia I could go home in a couple of hours, stop on the way home for some lunch, and resume my life immediately. No headache, no nausea, no fasting ahead of time. I agreed. When I arrived at the hospital, a whole contingency of staff descended upon me to try to change my mind. I didn't, and the procedure went smoothly. There was no pain. I felt a tug, and it was over. I was at work the next day. I think a lot of small surgeries could be done with less anesthesia if doctor and patient have trust.

stlcdr said...

wrt. Not having someone to help them get home.

This is the sad state of affairs of a modern technical society. This sort of thing is the whole point of family, and to a lesser extent, friends (specifically, friends you spend time with, not social media friends).

Reliance on strangers widens a gap between the haves and have nots. This leads to the slippery slope of someone (the government) should do something.

Sydney said...

Anesthesia is a luxury. It is my understanding that in Europe most colonoscopies are done without anesthesia, making them cheaper by a factor of 10. Here in NE Ohio it is impossible to find someone willing to do them without sedation.

gilbar said...

It would be nice if there were an easy, Uber-like service for this need.
for my last surgery, they EXPLICITLY told me that i Could NOT be picked up by a cab
One of my friends had to take time off of work to walk me out the door.

This is ENTIRELY because of lawsuit stuff. MOST of what we in the States pay for medical stuff is Really lawsuit stuff.

AllenS said...

When I have a colonoscopy procedure done, I request a very light sedative. You need some sedation because when they shoot that air into you, it can be painful as I learned when I had a flexible sigmoidoscopy performed with no sedation. Plus, I like to watch the journey.

Ann Althouse said...

"It would be nice if there were an easy, Uber-like service for this need.
for my last surgery, they EXPLICITLY told me that i Could NOT be picked up by a cab"

I know.

My idea is a service that would be a person you hire to come with you in the same way that a friend would.

Bart Hall (Kansas, USA) said...

Perhaps consult with opthamologists Drs. Ron Paul and Rand Paul, who have performed many surgeries in the developping world.

Ann Althouse said...

When you live alone, you may find it very hard to ask someone you know to help you. You may not have cultivated friendships with that kind of personal intimacy, and even if you have friends who would say yes, you may really hate to ask. I think it would be nice if there was a service where you could hire someone to accompany you for a medical procedure. There are many services for hiring people to do things that someone in your family would help you with if you didn't live alone — for example, moving furniture around or walking your dog. It's a shame if people get drawn into assisted living too early, because of occasional things they need help with and a lack of nearby family and friends.

Otto said...

Best wishes for your impending cataract operation.Both?

Tank said...

@Althouse

That’s what I did for my colonoscopy. We have a guy in our community who drives, but is not Uber. For $50 he drove me there, waited, and drove me home. Mrs. Tank is not allowed to drive, and I didn’t want to ask a friend to drive me at 5:15 AM.

wild chicken said...

"My idea is a service that would be a person you hire to come with you in the same way that a friend would."

My fear is that a service like that would start out great, with nice trustworthy employees, then deteriorate until you don't know what kind of lowlife ex con weirdo you're depending on.

But here at least the senior companion program I think fits the bill.

Francisco D said...

Two years ago, I had laser surgery for narrow angle glaucoma on both eyes. No anesthesia, no problem.

Five years ago, I had a colonoscopy. The pain medication kept me comfortable, but I was fully alert. No problems.

I don't recommend avoiding anesthesia for many operations, but it is not always necessary. Your mileage may vary.

iowan2 said...

My MIL has been in nursing homes and assisted living for two years. Before that started she was 100% self sufficient. We asked her way she did't allow friends, which she has many, some offered help. While she herself was constantly fixing a casserole, driving others to Dr's, picking up groceries, etc, she would accept returned offers of favors.
We asked why she did so much for others? She said because of the good feelings she got. We told her it wasn't very nice to deprive those feelings to others. Didn't help. Oh well. Small towns are great for having a host of good friends who will lend a hand at moments notice.

rhhardin said...

Ride your bike to your surgery.

rhhardin said...

I never get anaesthesia at the dentist, even local. I was brought up on slow low speed dry drills and can stand anything.

High speed water-cooled drills are why there are no men in modern America.

Seeing Red said...

Maybe we comfortably squeamish Americans should be asked if we would forgo the sedation if it would cover the cost of cataract surgery for 100 individuals in poor countries.


Or lower the cost of insurance or charity begins at home. How does one prove the charity will do what it says? Do we sponsor the patient and get a follow up letter?

EDH said...

Maybe we comfortably squeamish Americans should be asked if we would forgo the sedation if it would cover the cost of cataract surgery for 100 individuals in poor countries.

That's the altruistic argument for not spending $30k+ to support an immigrant family in the US when that money could instead fund a clean water project for the whole village in the country from where they came.

Ann Althouse said...

"That’s what I did for my colonoscopy. We have a guy in our community who drives, but is not Uber. For $50 he drove me there, waited, and drove me home. Mrs. Tank is not allowed to drive, and I didn’t want to ask a friend to drive me at 5:15 AM."

So you had a guy (but he needed to be paid). What if you didn't know of that guy? How would you find a guy?

Phil 3:14 said...

The sedation for cataract surgery is more about avoiding the fear reactions of seeing surgical instruments etc approach the eye. The anesthesia removes the pain (as is true with dental procedures). I assume the problem for the Opthalmologist and the surgicenter is giving you a choice and still having the ability to give sedation if you (or they) change your mind as the procedure begins.

Its all about time and speed.

Ann Althouse said...

"My fear is that a service like that would start out great, with nice trustworthy employees, then deteriorate until you don't know what kind of lowlife ex con weirdo you're depending on."

That's what the Uber-like company would work on. I'm still hesitant to use Uber, because I'm not trustful, but you'd have to trust even more to rely on someone to get you to a really important appointment like surgery and to deal with you when you are drugged!

Ann Althouse said...

I once opted to have a tooth removed with just novocaine and nitrous oxide and it was a nightmare! The tooth broke midway and it took much longer than anticipated and I'm sure the doctor had a much harder time with the complication because my head was right there suffering under his hands.

Ann Althouse said...

"The sedation for cataract surgery is more about avoiding the fear reactions of seeing surgical instruments etc approach the eye"

Yes, you cannot look away. You can't predict how awful that experience might be. And there is the destruction of part of your eye that has to take place. You don't know how that might disturb you and you don't want to make it more difficult for the surgeon.

tcrosse said...

You may save a few bucks by skipping the anesthetist, but then you still have to pay a couple of guys to hold you down.

Fritz said...

When my second cataract surgery went slightly wrong, and they needed to take out the vitreous humor in the eye, the retina surgeon warned me ahead of time that during the operation they would bring me out of it to the point that they could talk to me, and they did.

It was pretty weird, laying there knowing they had at least three different probes sticking in there. But the muscles are nerve blocked so they can't twitch, and I was so full of don't-give -a-damn juice that I could discuss with him the pros and cons of attaching the new lens to the iris semi-rationally (no, he didn't). But it wasn't awful.

Two hours later I was walking to the car.

Fernandistein said...

I had a detached retina (that's a real road to blindness, unlike cataracts), when they (pretty much) fixed that they filled the eye with gas, which your body eventually replaces with some fluid, but the fluid causes cataracts, so I had the cataract surgery without sedation. It was kinda creepy and hurt for a couple of seconds at one point.

Rob said...

You don’t need someone to accompany you to surgery; a taxi or Uber is sufficient. It’s the pickup that requires someone to get you. And there are, at least in my area, car services in which the driver will come up to the recovery room to retrieve you. I used one for a minor procedure that wasn’t worth bothering a friend about. The doctor’s office had given me the name of the car service, so they were okay with it. Cost about $25 more than a taxi would have. It wouldn’t be my choice for something major, but it worked fine.

Amexpat said...

Anesthesia is a luxury. It is my understanding that in Europe most colonoscopies are done without anesthesia, making them cheaper by a factor of 10.
First time I had a colonoscopy here in Norway, the doctor suggested that we try it first without a sedative and he'd give me one if I later needed it. It was more uncomfortable than painful, like the extreme bloat you get eating way too much at Thanksgiving. I decided to continue without the sedative as it was interesting watching the procedure on the screen.

The next time I went I asked for a sedative. Whatever they gave me was great. Woke up very content. I did it because there was no cost - I wouldn't pay the actual cost for it out of my pocket if I had too.

However, I gladly pay out of my pocket for Novocain when having a cavity drilled at a dentist.

CWJ said...

Althouse -

Do the surgery. I've had both eyes done and was amazed how quick and out the door it was. Some details. The only anesthetic I had was whatever was necessary to keep me calm. I was aware and responsive throughout the procedure. I chose the laser option, and had my own 2001 light show for no more than 30 seconds. The only surprise was Dr. M announcing it was done when I thought we were only half way through.

As for driving home, I wouldn't trust myself, but mostly for the heavy dilation and sensitivity, rather than the drugs. Each time, they gave me these "cool, ever so stylish" blu-blockers to wear outdoors for a few days.

Etienne said...
This comment has been removed by the author.
Etienne said...

When I had my right eye done, they gave me a little pink pill. It was the size of an aspirin. I said "is that my sedation??"

Yes, it's just to relax you, because you will be immobile in a sitting position. I was awake during the procedure and it was very enjoyable.

Having someone drive you home is not an option. Even if you decline the pill, their insurance doesn't allow them to release you to drive.

There is a professional service called "patient sitters". These are very basic trained nurses (CPR and health techniques). They pick you up, drive you to the clinic, and then drive you home.

The service is not expensive. The one my sister used was like $16 an hour, and her procedure took three hours home to back home. About the same as grocery shopping. She had a friend willing to drive her there and pick her up, but the clinic required the person to stay there during the procedure. I mean, people have jobs!

William said...

It's a fact that red haired people need more novicaine than others to avoid pain during dental procedures. Sadly this fact is not taught at dental colleges. Many dentists are ignorant of this extremely important fact.......I wonder if this holds true for eye operations. The eyes are in the same general neighborhood as the teeth, and I wouldn't be a bit surprised if they shared some neural paths. I'm also due for a cataract operation. I'm not sanguine about the procedure or its results.

Tim Wolter said...

I've had both sides done. The first was with IV versed. Only vaguely remember any of it. This was back when you had to have an eye patch on for 24 hours. I was so sure that when I took it off I'd have a glowing red Terminator eye. Darn.

Second one was with a small dose of liquid versed. Swish it around, it absorbs faster under the tongue than in the stomach. It tastes vaguely like bourbon. Maybe bourbon with cough syrup. I was awake during the procedure but did not care. It was like observing from another reality. At my follow up visit the next day I asked the Ophthalmologist, a friend btw, "Hey, did I actually use the word phacoemulsification in a sentence while you were working?"

"Yes, you did".

Versed. Ask for it by name. Wears off much faster than Valium.

And best of luck.

TW

rcocean said...

Its not really the pain, its the boredom and discomfort.

I liked the colonoscopy - out like a light and woke up in bed an hour later.

My wife picked me up, and I felt so good, I went to the lake and fished.

Must have gotten light anesthesia.

Narayanan Subramanian said...

fear reactions of seeing surgical instruments etc approach the eye"

Lois Bujold has torturer scene discuss this in Brothers in Arms

JimT Utah said...

Eyes are not especially sensitive to pain; rather the reverse. On the other hand, the fear factor is patient-dependent, and is unknown until the procedure begins. I've had cataracts treated more than once (given time, they can grow back), and a membrane peeled of my retina. No pain, ever, but the doctor kept telling me not to watch what he was doing. I find it very hard not to watch. You don't see something like eye surgery from the inside every day, but the doctor really doesn't want you to move your eye while he's working

The Cracker Emcee Rampant said...

Can you sit still for a teeth cleaning? Then skip the secondary anesthesia’s like Valium and Versed ( especially Versed and it’s variants). They’ll just make you tired and hamper the all-important post-surgery self-care. If they don’t provide them at the ASC, get your prescription for post-surgery meds filled before the procedure. Don’t have the procedure done by an ophthalmologist with an Eastern European surname. You’re going to be amazed at how fast (20 minutes is very long for an expert surgeon, unless there are complications) and simple the procedure is.
The $25 dollar figure is absolutely laughable. That doesn’t even begin to cover your provider’s cost for a decent lens, never mind the rest of it.

The Cracker Emcee Rampant said...

Oops, didn’t read carefully again. The $25 was in reference to something else.

NorthOfTheOneOhOne said...
This comment has been removed by the author.
NorthOfTheOneOhOne said...

I suspect that not having someone to help you when it is required for a medical procedure is a troublesome problem for many aging people who are proud of living independently. It would be nice if there were an easy, Uber-like service for this need.

There is (kind of) one; it's called Veyo. It's not available in all states and they only do medical transport, no home health services.

The Cracker Emcee Rampant said...

Oops, I was right the first time. Charities can do the surgery for $25 ($50 is more accurate) because they’re using donated/expired lenses, equipment, and meds and operating for free in Third World charity institutions. And forget about aftercare. Infinitely better than nothing but not what the average Madison citizen would expect.

NorthOfTheOneOhOne said...

See if they'll give you propofol, my nurse anesthetist sister-in-law calls that 'milk of amnesia'. You're awake, but in a disassociative state so you won't have any memory of the procedure. I had it for my last colonoscopy. There no grogginess afterward and I didn't spend the rest of the day napping.

Ironclad said...

I have had both lens replaced for cataracts and I can tell you the only reason that they want someone to accompany you is that the valium they give you to relax you makes you too drowsy to drive yourself. I could see fine but I was goofy for a few hours after the procedure.

As far as the anesthesia goes - they deaden your eye with a local so you feel nothing - just you see a bright light for less than a minute and it's done. For me - the first time I had a lens replaced the extension that locks the new one in did not extend properly so they removed it and put another in (seems like that happens occasionally) If the doctor had not said anything I would have never know.

Being totally knocked out usually means your memory gets messed up for a time after you come around. I had surgery once and I cannot remember several hours even though I was told that I was lucid and chatty during that time.

Gabriel said...

@Ann:I once opted to have a tooth removed with just novocaine and nitrous oxide and it was a nightmare! The tooth broke midway and it took much longer than anticipated and I'm sure the doctor had a much harder time with the complication because my head was right there suffering under his hands.

I had four wisdom teeth out that way. The oral surgeon scolded me about refusing anesthesia and said if I had a miserable time he wasn't to blame.

Halfway through he took a break and I told him that while the experience was not very pleasant, I was not suffering. Feeling more like a hooked fish. He said they prefer to put people out because it gets "medieval and barbaric" (his words).

But I saved half the cost. The issue was that it was quite possible my insurance would deny coverage because there wasn't that much wrong with my wisdom teeth; in the end the insurance did pay. But I didn't feel hard done by.

Trumpit said...

Vision is more precious than all the tea in China. A word of advice: Make sure your eye surgeon doesn't have Parkinson's. A man who is his own surgeon has a fool for his patient.

Inga...Allie Oop said...

“The sedation for cataract surgery is more about avoiding the fear reactions of seeing surgical instruments etc approach the eye"

“Yes, you cannot look away. You can't predict how awful that experience might be. And there is the destruction of part of your eye that has to take place. You don't know how that might disturb you and you don't want to make it more difficult for the surgeon.”

This simply does not happen. The only thing you see is a light, no hands, no instruments. I was very alert during my cataract surgery and heard the machinery and the surgeon and staff. It was all very interesting. No pain, and no scary things to see.

Ralph L said...

It is my understanding that in Europe most colonoscopies are done without anesthesia

I find that unlikely--maybe just not a general. I had one without anything (the doctor had failed to schedule it after the throat-poking endoscopy I'd just had). It was so painful, I started convulsing and screaming before then he knocked me out. The cortisone shot in the knee I had the same year was no fun either.

Between 10 and 18, I had 3 sets of teeth pulled, 4 at a time, with a general, and I'm glad I missed it, particularly the barely exposed wisdom teeth.

Two years ago, I had 1,000 laser flashs to staple 2 retina tears. It took hours on 2 days because I had to look up as far as I could and hold my eye still. The flashing in the other eye was not pleasant, but only some of the zaps hurt.

I'll pay a lot extra for drugs, but insurance should cover it, regardless of the high malpractice insurance premiums.

Inga...Allie Oop said...

Surgeries, plural. No need to be scared.

Ralph L said...

When I had a lymph node lump removed from one arm with a local, one of the 3 or 4 people present did nothing but hold my other hand to keep my calm, I guess. That was 1980, before medical costs went out of sight.

Inga...Allie Oop said...

What can I see during my cataract operation?

Inga...Allie Oop said...
This comment has been removed by the author.
Inga...Allie Oop said...

Bottom line, you see nothing but lights or colors during your surgery, not because of the sedation you get in your IV, it’s because your optic nerve gets anesthetized, as I understand it

Ralph L said...

They hadn't warned me before my laser zaps that I would lose all vision in that eye temporarily, but it was only a few seconds of freaking out. The consent form said there was a very small chance it could be permanent.

Sebastian said...

"they say $25 is all it takes to remove one person's cataracts"

They say $1 is all it takes to deliver a lecture on constitutional law or evidence.

Bad Lieutenant said...

A tough person who hates sedation might like this option, but I think it's terribly sad if someone picks this option because they don’t have anybody to help them get home or because they can't cover the cost of sedation.

The rules on resting/escort after sedation are too tough thanks to, er, lawyers, so that's on you, Emerita. Time was, for my 'scopies, the doc would shoot me up with a syringe of Versed, which was literally the best thing ever, I would get up after, talk to the doc, grab my coat and head out for work. Driving or walking or taking the train.

Now, it has to be propofol, which works a treat, sure (though no fun like Versed), but a) the anaesthetist doesn't take my insurance, b) there's all the waiting and no driving unless you lie to them, and anyway you have to wait so long that the meter expires.

So one day I was in a hurry, and I said, yeah, skip the anaesthetic. I mean the sedation, I got the cetacaine to numb my throat, but I did have a bit of unpleasantness as they put the fiberoptic probe down my throat. It was all over quickly enough and I strolled right out. Wasn't the worst thing in the world. Wasn't "sad."

Bob said...

Trumpit, good advice.

Olya said...

For Medicaid and Medicare patients in my state there is a medical transportation service for these situations. Basically contractors from cab services who go through some extra vetting and are reimbursed by the state.

When one of my kids was not quite 2 years old she had to have a minor procedure done on one of her eyes. The doctor promised to sedate her but we could not go back with her. When we heard her screaming agonizingly for far too many minutes, my husband stormed back and asked a nurse what had gone wrong. They had lied to us and proceeded without sedating her, and she was "being naughty"--that is, quite reasonably terrified and in pain and resisting because she was too young to comprehend why this was happening to her. She had a phobia of "white coats" and confined spaces for quite some time after that.

Etienne said...

"they say $25 is all it takes to remove one person's cataracts"

When I worked for Northrop, it was said I got $1 an hour for what I knew, and $56.69 an hour for my security clearance.

Alas, at 22 trillion debt, I had to get my piece of the pie.

Nancy Reyes said...

you write: Maybe we comfortably squeamish Americans should be asked if we would forgo the sedation if it would cover the cost of cataract surgery for 100 individuals in poor countries.

You're joking, right? So you take the money saved and poof, the eyeball fairy takes the money and sends it to the jungles of Africa and poof, the person there now can see.

why do people use these arugments on why to give lousy treatment to the elderly, but one rarely hears it to argue why Fido or kitty cat shouldn't get treated, or why rich people shouldn't get plastic surgerty.

Fyi: Outreach charities send in a team and do a bunch of eye surgeries in isolated clinics. Google Rand Paul.

We had these come to our hospital in Africa 30 years ago.

they may take out a cataract for 25 dollars, but the cost of the logistics is a lot higher than that.

Unknown said...

I have had both laser eye surgery for a retinal tear and later on other eye cryo surgery for the same thing. The only medication I received for both was local anesthetic. It was all fine, and I was relaxed. Would have had no need for twilight sedation. I did, however, trust and have faith in the surgeon and doctors, as I was at a renowned Eye Clinic in a top hospital in the USA.