Tubal Ligation without Endotracheal Intubation in Portland, OR
August 1, 2013 12:34 PM   Subscribe

As a professional opera singer, I will not risk vocal-fold damage by undergoing endotracheal intubation. I've read several sources that say it's possible (and even preferable) to do a laproscopic tubal ligation without intubating, but my scheduled surgeon/anaesthetist will not perform the procedure without shoving a tube down my throat. Can you recommend someone who will, or advise me on how to find them?

I'm extremely unimpressed about this; I made my position clear on intubation from the start, but it's only now - a week out from the surgery date - that they're telling me that they won't go ahead without it. They are not willing to use an LMA or a face mask, nor to do the procedure under spinal/local & sedation - both of which I know are viable options from reading the literature.

This will be my sixth surgical prodecure, and I have never yet been intubated; my anaesthetists were always willing to work with me. However, this is only the second one I'm having in the USA, and things are obviously different over here.

The surgery was being done to reduce my risk of getting ovarian cancer as well as for sterilization, so it needs to be done.

Any recommendations on how I go about finding a surgical team that won't insist on intubation for this procedure? Or, if you happen to know one, suggestions for an OB/GYN who will use the alternative methods?

Throwaway email: tubalwithouttubes@gmail.com
posted by anonymous to Health & Fitness (15 answers total) 2 users marked this as a favorite
Keep calling around until you find someone you can work with. My mom had a full hysterectomy with a general and Darvon.

I decided to go the whole route, but I'm not an opera singer.

I agree with you, if you're willing and you can find a gas passer who is, there's no reason to be intubated if you don't want to be.
posted by Ruthless Bunny at 12:36 PM on August 1, 2013 [1 favorite]

Have you considered Essure? It's a permanent birth control option that works by blocking the fallopian tubes rather than cutting them. No surgery or anesthesia required for placement.
posted by quince at 12:46 PM on August 1, 2013 [4 favorites]

Have you considered Essure? It's a permanent birth control option

Essure is indeed surgery-free, but there is no indication as of yet that it will reduce the OP's ovarian cancer risk. (The question has been raised, however, and is likely being researched.)
posted by like_a_friend at 1:32 PM on August 1, 2013

If these are the best surgeons for the job, it's worth addressing them like a consumer. Tell them that you are unsatisfied as a customer and deeply annoyed that they are telling you this now, at this late date. Tell them you'll be forced to take your business elsewhere and never come back. If they do agree to discuss it again and decide to follow your wishes, make sure that there is a signed letter to the agreement not to intubate.

Then I'd ask in your community of peers if they have any recommendations for doctors/surgeons who would agree not to intubate and start finding a new person. It sounds like they are more interested in covering their asses than respecting your desires in this arena.
posted by amanda at 1:59 PM on August 1, 2013 [1 favorite]

Find a new Doctor. My doctor did a full hysterectomy (uterus, ovaries, fallopian tubes, cervix, tightened the vaginal wall, pulled up my collapsed pelvic floor and reattached it. All of this was done during one surgery with an epidural (spinal block) and twilight sleep.

I have a difficult time coming out of general anesthesia, I do not wake up for 5 to 6 hours. It always freaks everybody out, so doctors will avoid general anesthesia unless it is absolutely necessary.
posted by JujuB at 2:29 PM on August 1, 2013

I think you should ask the surgeon you're currently scheduled with for a recommendation. I wouldn't phrase it so much as "I will take my business elsewhere" but rather as "would you rather do this procedure without endotracheal intubation, or would you rather have some other chump do this procedure without endotracheal intubation, or would you rather I just don't get this procedure at all?" and make it eminently clear that you will not be having the procedure if it requires you to have endotracheal intubation, and ask them if they genuinely believe that it is preferable for you to NOT have the procedure rather than having the procedure without intubation, because those are the only options you're considering.

Really, really explain it to them, make it clear that it's about your livelihood, ask them what makes them so reluctant to perform the procedure without the tube (like, if they feel that you have added risk factors) and if they still refuse, cancel the procedure and ask them if they have any recommendations for other surgeons who would take your unique needs into account.

(And if that doesn't work, which, yeah, it might well not, I agree that you should ask around among your fellow singers. I know, it's a bit of a sensitive subject, but they are going to be a good resource for you. Can you post anonymously to any of the opera listservs/boards?)
posted by mskyle at 2:31 PM on August 1, 2013 [1 favorite]

If, after further discussion, this doctor does agree to do the surgery without the endotracheal intubation, make sure you have an advocate (with a signed medical power of attorney!) there to insure your wishes are followed: being the cynical cuss that I am, I could see the doctor agreeing to do things as you prefer, then once you're on the table and unable to object, the endotracheal intubation.
posted by easily confused at 3:21 PM on August 1, 2013 [2 favorites]

What the hell "surgeon/anaesthetist" is this? Because the surgeon's job is to fix your problem but the anaesthetist's job is to keep you alive. These are different jobs with different training and skillsets and I would not want a general performed by the same person for any surgery more complex than dental extraction.

You might drop a MeMail to TedW who is a paediatric anaesthesiologist and would at least be able to let you know if this is nuttypants.
posted by DarlingBri at 4:36 PM on August 1, 2013

Followup from the anon poster:
Thank you all for your answers so far.

To clarify the "surgeon/anaesthetist" confusion - these are indeed two separate people, but I have never had the chance to speak to the anaesthetist. I'm being given the runaround by the nurse of the GYN who would have been doing the surgery; she has said more than once that it's the Gyn/surgeon that refuses to do the procedure without intubation, but has also claimed that she has spoken to the anaesthetists for me more than once and that the refusal is coming from them. Without the ability to speak to Anaesthesiology directly, I don't as yet know where the decision came from, hence my phrasing.

The nurse hasn't returned my call, and apparently just told the reception staff that "she didn't call me" when I called to follow up a moment ago. Argh! By this point, I don't think I trust them to comply with my stated requirements even if they did agree, so I will be finding someone else to do the procedure.

I'm trying not to feel like I'm being one of those terribly demanding Patients from Hell for standing my ground on this. So thanks, MeFites, for affirming that it's okay to be insistent with my livelihood at stake.
posted by LobsterMitten at 5:05 PM on August 1, 2013

I will be finding someone else to do the procedure.

Excellent. Find a surgeon who will arrange for you to have a pre-operative consult with the anaesthetist, where by "pre-op" we mean several weeks out, not sitting there 20 minutes before theatre in a backless gown.

If this is on the NHS or whatever and that isn't possible and/or the anaesthetist is luck of the draw, you can also write to the head of anesthesiology at the hospital where this surgery will take place, cc'ing your surgeon.
posted by DarlingBri at 5:18 PM on August 1, 2013 [2 favorites]

Stick to your guns!

Every major surgery I've ever had (when non-emergency) involved a pre-op consult with the anesthetist.
posted by BlueHorse at 8:14 PM on August 1, 2013

From the OP:
So, in the hope that people are still reading this:

I've spent the morning calling around other gynaecology practices here, and every time I've found someone who does tubals, I've been told that they can't answer the question of whether they can do the procedure without intubation unless I come in for a consultation. That's great for their profit margins, I guess... I've tried asking for nurses or medical/physician's assistants to talk to, but I'm hitting medical gatekeeping all the way.

I'm at my wits' end. Surely there is some way to get this information without having to do a consultation with every gyn in town until I find one who'll work with me?? Any ideas, MeFites?
posted by restless_nomad (staff) at 12:11 PM on August 2, 2013

I wonder if you could start at the other end of the problem and approach anesthesiologists? Surely you could call the major hospitals in your area and ask for their anesthesiology department? A secretary will probably answer the phone, but these hard-working people would probably be happy to help connect you with someone who would look upon your request (opera singer doesn't want intubation? Cool!) as a challenge. She may also know which anesthesiologists are top of their game and approachable. The anesthesiologist then could make a recommendation for a GYN surgeon who would consider your request.

I would suggest you contact a large, possibly teaching University Hospital becuse that's likely to have the largest GYN practice and the most cutting-edge anesthesiologists.

If you could provide your location, people might be able to make more specific recommendations.
posted by citygirl at 12:44 PM on August 2, 2013

The OP's title says Portland, Oregon as location.
posted by guster4lovers at 12:55 PM on August 2, 2013

To anyone reading this post,
It would be foolish to undergo a laparoscopic procedure with an LMA. While this is done in Europe and other places where there is little recourse for patients when they are injured by sub-standard practice, (i.e. high risk to the patient but low risk to the clinician), in the USA no responsible anesthetist would EVER do a laporoscopic tubal ligation without an edotracheal tube. While "open" tubal ligations are routinely done with supraglotic devices (such as LMAs) or neuraxial anesthesia (such as spinal anesthesia), it would not meet the standard of care to use these anesthetic techniques for any laporoscopic procedure.

Using an LMA for a laporoscopy would expose the aptient to higher risk for:
Aspiration pneumonitis (acidic gastric contents entering the lungs)
Acute Respiratory Distress Syndrome
Long term intubation/mechanical ventilation
Ventilator Associated Pneumonia

The risk of vocal cord injury during intubation is very low. Anesthitists do not "shove" endotracheal tubes anywhere. Both CRNA (Certified Registered Nurse Anesthetists) and Anesthesiologists (Physician Anesthetists) do around one thousand intubations every year. They are highly skilled airway experts that intubate under direct laryngoscopy or fiber optic visualiztion. The greatest care is taken in optimizing safety. When your anesthetist refuses to use an LMA for a laporoscopy, they are caring for you. They will take the same care with your vocal cords when they intubate you.
posted by sancho at 8:54 AM on October 8, 2013

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