is this one right here, because this is what you're all worried about, probably. So when you go out into practice on your first day, this is what's gonna make you sweat, is not am I going to have a complication, it's when am I gonna have a complication and what do I do when that happens? And so this is something that if you haven't been taught in your fellowship, again, I think this is a really, really important topic. The cool thing about having our faculty here to the left as well as they can chime in and give some of their perspectives as well. But because this is a somewhat smaller group, please feel free to interrupt. Please feel free to have questions during the talk. And then I'm hoping, feel free to take pictures of anything. You're also welcome to have the PDF or PowerPoint from these slides as well. I put in some slides that I hope will help you have a framework so that if you go to a practice that maybe doesn't have a morbidity and mortality conference you have a framework off of which to operate. These are really important things, just as important as keeping an ergonomic practice so that your practice can survive a long time. You need to have a practice where you can mentally deal with the problems that are gonna come up in your practice. That's just a fact of endoscopy. So these are my disclosures. Again, first do no harm. And I put a question mark, we'll talk why. Informed consent is an important thing to know about, particularly now that you're going into independent practice. We'll talk a little bit about acute management of perforations and bleeding, but that's what fellowship is about, and that's something you're working on on the wards all the time. I could show you lots of videos of neat little tricks for managing things, and we'll do a couple, but for the most part this is something that you'll learn along the way. Learn from your mentors, find mentors locally, even in practice. You'll continue to learn, as my colleagues have all mentioned. After the fact of a complication, and this is where it gets tricky, because for the most part you've been protected from this. So you are not the point of the spear when it comes to managing the complication afterwards, in many cases. And so we'll talk through a couple different strategies for communicating and evolving yourself through these really difficult situations that can come up. So endoscopy procedures, as you all know, have changed quickly. So what used to be a very diagnostic tool with the first fiber optic gastroscope, where they were kind of pulling the buttocks apart and just looking up the anus a little ways, have evolved quite a way from the 50s, all the way through now till the 80s when they were doing diagnostic EUS, to then electronic video scopes, so we're not sharing tubes to look down together. Although occasionally we'll use our pediatric ERCP scope, and if the video scope is broken, we'll have to go back to the old fiber optics and add a little share channel for the fellow. Variceal ligation is not that old, right? Self-expanding metal stents in the 90s. And then it's really been over the last 15 to 20 years that we've seen this rapid growth in therapeutic endoscopy. What used to be done in private practice is very different than it was even 10 years ago. So we're seeing use of lumen-opposing metal stents and therapeutic EUS and some of these very risky, novel and asthmatic procedures being performed in practice and expected in practice. And so the risk of endoscopy has also changed accordingly. So I think it's probably unfair. I know the spirit of this statement, but the thought of first do no harm is really, it's sort of an unfair statement for a, or an expectation for a procedural physician. You've chosen this procedural specialty, and if you haven't experienced a complication at some point, you will. So while we're all aspiring to have low or no complications, again, it's eventually gonna come up, and knowing how to manage that is gonna lead to a happier, healthier, longer career for you. So informed consent is clearly the cornerstone of an ethical procedural practice, and I was fortunate to work with Doug, thank you very much for having me today, but we worked on a guideline for the ASGE talking around some guidelines for informed consent in endoscopy. And we have a unique practice as endoscopists because a lot of tools that we use, even down to our snares, are not often indicated, FDA indicated, for what we use them for. And so we're doing a lot of off-label stuff, a lot of things that take on risk for ourselves. We also have very high-volume practices, and so again, statistically, you're gonna run across that patient who is gonna have a problem in anyone's hands. So again, informed consent, critically important, it's this legal doctrine that protects patient self-determination and autonomy, an absolute necessity for every single procedure that you perform, every single patient, even, you know, this was something that came up, it's not just procedures you perform, it may even be procedures you don't perform. So when you recommend not doing something in a way, you're also getting informed consent from a patient, consent not to proceed. And so again, this is gonna include that discussion, understanding of the condition, the proposed treatment, risks, benefits, and alternatives to that procedure, and then again, the risk of not proceeding, and importantly nowadays, consent for blood transfusion as well as needed. So these are all a part of that informed consent process. You have to know your local and state regulations. I think Doug and I were both a little surprised by how state-by-state it is very different, and even hospital-by-hospital within a state, the expectation for informed consent, what that includes, how you obtain it, who contains it, obtains it, could be different from a state-by-state or even hospital-by-hospital basis. So other things that I consider when I'm talking with patients through an informed consent is the use of off-label, either devices or techniques, non-FDA-approved devices and techniques, which will come up now and again, documenting consent even in emergencies. So I do my very best to get in touch with Next of Kin as you all do as well, and then document when I'm unsuccessful or that I have, that we've talked through those risks for their loved one. Use of video and other supplementary information can be helpful, and I think we're seeing increasingly in order to keep things efficient and in order to prevent some of the calls to our fellows, to our nurses, whoever's answering those phone calls about the prep, that having video and other supplementary information for patients can be super helpful. So one of my mentors would always say that chance favors the prepared and really put a big emphasis on this in terms of why he thinks he has many less complications or issues that come up in endoscopy as compared to his peers. He says, again, if you're thinking through procedures in advance, not just showing up that day with what do I have on my table, but thinking through procedures in advance can be super helpful. He, for example, will have a little pre-rounding session. I think you've heard this as a recurring theme, meet with your anesthesia team, meet with your nursing team ahead of time. This gives you an opportunity to tell that anesthesia provider, hey, we're gonna do some banding today on this third patient, and it's probably gonna hurt. Last time, they needed a whole bunch of narcotics in recovery, and they were on viscous lidocaine for two weeks afterwards. They had just, and we sent them for a cardiac workup because their chest pain was so bad. So think through those things that can come up, try to anticipate them. On that second procedure, now that you know that's a patient who's gonna have chest pain after a ligation, maybe they chase the sedation at the end with a little bit of narcotic or something. So your anesthesia team can work with you to keep that throughput, but also, again, to help your patient have a better experience. So think about allergies, anticoagulant medication, special requests. On my list for the day, I have those written out for each individual patient. So I take the 15 minutes the evening before to make sure that I have a good plan, the scopes that we're gonna use, the likely complications that could occur during a procedure so that we have those devices and tools in the room and available. Inform patients what to expect. So I think this also goes a long way with an endobariatric procedure, with any other therapeutic procedure, like we'll use the banding as an example. Let patients know you might have some chest pain when you wake up, that's to be expected. Let them know about dietary changes up front so that you're not spending 30 minutes chasing the benzodiazepine and telling, being invited back to the room to give that diet recommendation four more times. Make sure that that's discussed ahead of time and well-documented. Have those rescue devices, like we talked about, accessible and know how to use them. So general endoscopy complications, fortunately, are within endoscopy, mostly limited to bleeding and perforations. So in another standard of practice committee guideline that Doug was a part of as well, again, while we do procedures and while complications are inevitable, fortunately, I start my consent with telling every patient, you know what, endoscopy is pretty safe, but there are risks to anything. These are the risks. EGD, bleeding for a diagnostic scope, very rare. For a PEG or foreign body removal, the percentage goes up maybe to two in 100 people. Perforation, incredibly uncommon with diagnostic EGD, such that I personally don't talk about this as a risk for a diagnostic EGD, but I also recognize that some of my mentors, David Lauren, for example, tells every patient they could die during endoscopy. He and I openly debate this. I think that's wrong. I think that makes people scared. I have a more of a paternalistic approach to consent and to medical care, but I can acknowledge that it's true because if we talk through the main risk, and Dr. Adler mentioned this, the main risk in endoscopy is actually not something that you directly are going to do with your scope. It's a cardiopulmonary event, so up to 11% of complex EGD in colonoscopy can be complicated by aspiration, desaturations that require intubation. So this is really where you need to always be aware. Because we are training in our practice mostly a propofol-monitored anesthesia care practice with a CRNA, I always worry for my fellows as they go out into practice, if they're doing a lot of conscious sedation, that they remember things like elevating the head of bed, things that our CRNAs are always thinking about, always taking care of. That's something you need to keep in mind is how can I prevent this, especially when you're the only ACLS provider in the room. So the cost of transfusion is big. So even though it's rare to bleed, this is something that I think is important for us all to recognize because our procedures can cause bleeding, particularly colonoscopy with polypectomy. So if you've ever seen a patient with transfusion-associated lung injury, they feel like they're drowning, they feel like they're dying, sometimes they do. And these allergic reactions, pulmonary edema, and development of antibodies are all risks of transfusion. So as much as we can help people avoid blood transfusion, it's a big thing. So while your Boston Scientific Resolution 360 clip might cost 250 to $400, depending on your local contracting, the risk of these things also adds up and I think needs to be part of the equation. So fortunately, there's some guidelines here to guide us. Doug Rex, the former ASGE president, has said the question's not whether to close after polypectomy, but when. Because with coagulation, there's a five to 10% risk of hemorrhage with greater than two centimeter right-sided colon lesions and use of antithrombotic medications, becoming comfortable with the clips that you'll use in the skill session and other devices for closing mucosal defects is an important skill to have. Unfortunately, even with experts, through the scope clips are not always gonna do it. And so there are other tools available. And again, in the skill session, you'll have an opportunity to use some of those. Other closure strategies, I really like the over-the-scope clip. So I think this is a really nice, if you had one rescue tool, that might be the one that you would have in your practice. It closes small perforations. So if you have a perforation while retroflexing in the rectum, if you have a bleeder that has rebled despite clips, often the over-the-scope clip is a really nice kind of nuclear bomb to drop on that issue. And it will take care of a lot of those things. I personally went into GI because of endoscopic suturing. I like tissue remodeling and I liked suturing when I saw it. So the overstitch device is my go-to for a lot of those bigger complications, big bleeds, overstitching an ulcer or vessel, and perforations. But there are increasingly options, right? Large size clips like the Mantis and others, the X-TAC device for through-the-scope suturing. There are increasingly these options for you. Fortunately, industry is great about coming to you and teaching you these things in person. I'm always skeptical of having a rep in the room, and I personally don't let them in my room just to talk. But if I'm learning a new device or if we're trialing a new device in our practice and we want to know if it works well, I can guarantee you they're very anxious to come see you. And I think if you set expectations with them, hey, I just want to learn about X-TAC today. They won't try and pitch you on these other things. And just make it clear up front what you're looking for from them. And they'll usually respect that. So this was a colleague's duodenal polypectomy several weeks afterwards. And unfortunately, bleeding can occur a long time after your mucosal resection. So this is another device you can trial in the skills session. This is Olympus's Endoclot. I don't use this often. I don't like hemostatic sprays because they feel kind of ineloquent to me. But I will admit, if it wasn't clear where the bleeding was coming from before, now it is. So it does give you this interesting view. Of course, it doesn't work is part of the reason I don't love it. So it feels like a Band-Aid, which in a way it is. And oftentimes doesn't work. But it did give us a view of where the bleeding was coming from. And in this case, again, that nuclear bomb over the scope clip. And there's lots of varieties, several companies that offer them. I just heard that Microtech is going to start selling one soon as well. So they'll be even cheaper than they were. So lots of options for the over the scope clip. And often that'll take care of business. Perforation repair. This is another skill that you'll be able to learn in the skills lab. So this was a procedure I was called in because a colleague during a retroflexion in the rectum of a patient who had IBD saw that they had caused a perforation. And so we have a suturing response or a perforation response team who can come do stenting or suturing. So if you are the person, it would bring a lot to a practice. If they don't have someone who can use endoscopic suturing, it would bring a lot to any practice to have someone who feels comfortable doing this. Lots of studies, but this was the first from Sergei Kantsevoy in Baltimore where he showed that in a private practice he was able to prevent patients from going to surgery when they had perforations during large polypectomy. And so again, this has been around for quite some time. I think a reasonable device to consider learning. There's ASGE suturing course and some other courses through the ASGE that could get you experience and even some certificates in using the overstitch device. It's also important to know when not to act, right? So that first do no harm is a two-edged sword. So let's say this is a 55-year-old woman who presented for a screening colonoscopy, had a two-centimeter hepatic flexure polyp that was resected with a snare with some coagulation. So it was not a cold snare, importantly. And then an hour after the procedure, she has severe abdominal pain and recovery. Your anesthesia team can't get her out of the pre-post area. And she's showing some kind of early peritoneal signs with rebound. So you send for a CT appropriately. You have to have a high index of suspicion for perforation in this patient, even though you think the polypectomy went well. The red flag for the board question here is that you used coagulation with the snare. Maybe something that we wouldn't do anymore for a two-centimeter hepatic flexure polyp, depending on its presentation. But no free air or contrast extravasation. You can see it's a really nice contrast exam, contrast enhanced exam here on the CT scan. So what's the diagnosis? Yeah, post-polypectomy syndrome. So thermal injury to the bowel wall, fever, leukocytosis, peritoneal inflammation. And this is a case where if the patient goes to the OR and has surgery, there may be some legal precedent for the patient to sue for an unnecessary surgery. So as much as you can block that from happening, this is an opportunity, again, to help your patient, but also your team. So protect this patient from the OR. In general, most small, even microperforations, can have a shot at being managed conservatively. So if a patient is stable, bring them into your service. Put them with a hospitalist, perhaps, that you trust, someone who has your cell phone number, and just keep in close contact. Again, complications are inevitable. So you will experience these. And I think that's the most important point of this talk, is that eventually things are going to happen to you and to your patients. And again, it all comes back to everything you need to know you learned in kindergarten. When you do something wrong, you apologize, right? And I think we all expect that of each other as human beings. But complete, transparent disclosure is and should be your top priority. So there's legal precedent for this. But you want to say, I'm sorry. This is what happened. This is what we're going to do. Be very transparent. What's interesting to me, aside from maintaining the patient-physician relationship, which is critically important, it actually will decrease the risk that that patient or family is going to come at you legally. It also, in many states, protects you from that information being used in a court of law. So by disclosing, this is what happened, I am sorry, this is what happened, this is what we're going to do to fix it, document that in the chart. In many states, that's going to be inadmissible in court. And in general, is a show of goodwill that's critically important for any future discussion around that case, again, in a courtroom. The Morbidity and Mortality Conference is in my, so that's your first stage of healing, is talk to the patient. You're going to feel incredible weight off your shoulders when they, often, they're apologizing to you or giving you that hug, like, it's OK. We'll get through this. The Morbidity and Mortality Conference is the second stage of healing. And this is where you can start to have some quality improvement projects for your hospital, your team, your practice, yourself. The M&M Conference is a hospital standard of practice since 1916 at Mayo Clinic. It's required by the ACGME, actually, in all surgical residencies and fellowships since 1983. Interestingly, GIs not made it definitely a part of their program. So internal medicine lists it as a requirement that there be an opportunity for you to be able to express issues with the program, safety issues for patients. But having a formal Morbidity and Mortality Conference, in my opinion, should be a part of your future practice. There should be a place where you can discuss this in a safe place with colleagues. So again, it's to improve patient care and education, not to be punitive, not to shout at each other, not to yell at colleagues or get upset, but to really learn from each other, to have a confidential, protected, almost certainly not comprehensive and not punitive opportunity to chat. And so this is how I do it. We start our conference saying those things from the former slide, and then we'll say, by the way, this is a conference that's just for clinical care providers. This is a safe space for everyone who takes care of patients. Everyone else, please get out of here. And then, again, you have that safe place. We also then run through our typical M&M questions. Was the procedure indicated? Was the timing appropriate? Did patient preparation, sedation, or monitoring contribute to the issue? Was it endoscopic technique? What might have been done differently? And then was the complication recognized promptly and treated appropriately? And again, if you ask yourselves these questions with every complication, you'll probably come up with some quality improvement initiatives for your team. And then we'll jump into that first case and let the first presenter take off. And again, if you want your practice to buy into this, it needs to be non-punitive. This needs to be, again, a safe place where people can talk about the issues that they've had and game plan together what can be done. And then at the end, thank everyone. I always copy my chair or somebody high up in the division to make sure that I'm acknowledging the team who's come and shared an experience that was inevitably a negative one for them. Finally, helping yourself. So I've seen no colleague die from anything except depression and burnout. And I've literally seen colleagues die from that. So you want to prevent yourself from having injuries. You want to prevent yourself from legal action. But more than anything, you need to take care of yourself mentally. And none of you went into medicine to hurt people, but it'll come up. So when you have complications, initially, you may feel totally numb to the situation. But especially once you are the attending and you are responsible for what happened, it's going to start to eat at you. And everyone reacts differently. And it's totally normal and acceptable that you feel angry or that you feel like you want to quit or that you feel like, well, it wasn't my fault. But acknowledge something went wrong. Acknowledge that you need to talk about it. And again, everyone copes differently. Some people will want to develop a quality improvement project. Go find your chair, your supervisor, someone who you know will listen to you as you talk through the problem. And often there's confidential hospital counseling through most practices. For sure, there's suicide and crisis lifelines, which hopefully things would never come to. But the CDC also, I think one other good thing that came out of COVID, aside from wearing PPE during colonoscopy, is that there are more tools, more recognition of provider burnout than ever before that COVID brought to light. So the CDC and many others have free tools available to us as medical providers. That's what I've got. Thanks, guys. Take a couple questions. I would just say that the other thing I routinely, even though we have fellows and I've been in hospitals where the nurses do all the consent, especially, although I do it for everybody, meet the family beforehand, meet the patient beforehand. Because if you come in afterwards and tell them there was a complication, they're just meeting you for the first time. And so, again, I don't know how that works in some of these busier practices. But again, when I was doing some of my training, the nurses would do the consent, and doctor might wave hi, and that's about it. So I think certainly having that, even if it's a very quick discussion about the specific risks, having that relationship. And if you think you're doing something super high risk, bringing them to clinic beforehand. I certainly have done some cases where you've never met them before. You talk about patients being transferred by ambulance and coming back. You're going to have very limited relationship with that patient, and they're probably really sick if they're being transferred. I don't know, Doug, if you comment on that. I mean, we do a very large number of round trips in our practice. Every single day, we do round trips from hospitals all across Denver. And so we've had a conversation with the doctor at the other facility, but we don't meet the patient until they run in. And because of the way the nature of ambulance transfers is, the patient's always alone. There's no family with them. So we meet them right there, go over everything, and then we do the procedure. It's tough. It gives and it takes, that model. Probably take it a lot. Any other questions from the audience? The last talk? One question about novel procedures that we generally discuss about, how do you take consent for those procedures? Because you don't know what the complication rates would be for them. Do you mean for regular procedures? Like procedures like G-Palm, you said you started doing more last year. Yeah, I mean, there's pretty good data on them. So I mean, we just talk about the risks. G-Palms, I meet in clinic first. So G-Palm, I don't do open access, because you have to weed out the crazies. I'm being serious. Some of them are crazy. So G-Palms, I have to meet them in clinic and look them in the eye, and we have a fairly detailed discussion. I can tell you, and Andy can back me up here, there is very limited data, and there's very limited literature at all, not just data, on the use and the consent process in these patients. We've made the recommendation, but there is essentially nothing. And in the surgical literature, there's a little bit, but there's actually almost nothing in GI. And then the last thing I'll say, because it's the basis for a much bigger discussion, is that your consents offer you extremely limited legal protection. Like you are deluding yourself if you believe that your consent offers you any meaningful protection, and lawyers are extremely skilled at dismantling your consents.

informed consent

complications management

transparency and disclosure

Morbidity and Mortality Conference

physician-patient relationship

self-care and mental health