The Role of the Expert in Team Colonoscopy KIEVERS CUNNINGHAM, MD CAROLINA COLONOSCOPY CENTER

Objectives  To outline and discuss team versus solo colon0scopy  To outline and discuss the roles of ‘The Expert’ in team colonoscopy

Traditional Colonoscopy  Performed by a single physician with the assistance of a nurse.  Technique-scope is held in one hand(usually left) and advance into the colon with the right hand all while maneuvering the controls with the thumb and index fingers of the left hand with occasional solicited assistance from a nurse  Anesthesia- usually administered by the assisting nurse and consists of Demerol/Versed or Valium IV to achieve “conscious sedation”  Documenting/Instrumentation operation- Documentation has to be remembered and done by the solo endoscopist at the end of the procedure. Instrumentation is mostly operated by the solo endoscopist with the aide of the nurse.

Traditional Colonoscopy  Steerer/Camera operation- done solely by the endoscopist  Potential pitfalls  Increased turnover time with the use of traditional conscious sedation  Retrograde amnesia  Patient grogginess for a prolonged period  Potential errors in documenting  Increased potential of missing a polyp- only one set of eyes on the video monitor

Team Colonoscopy  Pusher/Driver Technician- a trained nurse/tech advances the scope with twisting or spinning motion  Anesthesia- Propofol is administered by a CRNA-who is much more highly trained in airway management than a nurse.  Improved analgesia  Decreased post procedure recovery  Documentation/Instrumentation Technician  Additional technician(s)- usually another trained pusher/driver  Records locations and sizes of polyps/lesions/findings real time  Assists with polyp retrieval/lesion biopsy/etc.  Multiple eyes on the screen

Team Colonoscopy  Steerer/Camera Operator- this is the role of the PCP/endoscopist  Maintains the view of the lumen with “gentle” movements of the controls  The driver/pusher is responsible for the bulk of the scope manipulation consequently this skill set is more easily acquired by the novice physician  Gentle circles are performed in concert with the spinning of the pusher/driver resulting in increased lumen interrogation(The Dance)

Expert Role  Requirement- has completed endoscopies and has an ADR>30  Medical director/assistant medical director  Works directly with the PCP during their training phase(<140 colonoscopies) as the pusher/driver.  Assists ‘skilled’ endoscopists with difficult cases  Provides advice on the best way to retrieve a polyp(lifts, snare, piecemeal, ablation, referral)  Reviews all pathologies and the associated cases and makes recommendations on follow up/etc.

Questions/Discussion