Bone Marrow Biopsy Indications & Sedation

[Dr. Aaron Fritts]
…let's talk about what the conversation is like with the patient because you'll see the patient. Usually, they're waiting outside the CT or they're waiting outside. Rarely you have to maybe go up and talk to them, the family before, or especially when they're outpatient, you go talk to them in the waiting room to get consent. What's that conversation like?

[Dr. Chris Beck]
One, it just seems like such a terrible setup to have to go talk to the patients out in the waiting room. Is that where you have to talk to your patients?

[Dr. Aaron Fritts]
Sometimes. When it's an outpatient. There's a rule at one of our hospitals where, if they're getting sedation, you have to see them in their pre-op waiting area.

[Dr. Chris Beck]
Oh, okay. It's like a pre-op area, like there's a bay or something.

[Dr. Aaron Fritts]
Pre-op. Yes, it's a bay. Exactly. Yes.

[Dr. Chris Beck]
Okay. Nevermind. That seems okay.

[Dr. Aaron Fritts]
It used to be, they just wheel them back and talk to them right at the bed, before they jump on the table. A lot of that's changed now. They want to make sure that they're properly talked to, all questions are answered. It's not like a speedy, get them on the table and get them done.

[Dr. Chris Beck]
I actually like that. I like that. I was thinking for some reason you're out in the waiting area, where before they get called in. You have, a dedicated area where they're on the monitor or something, or a nurse has already seen them.

[Dr. Aaron Fritts]
Yes. These are pretty much 100% of the time getting sedation fo rbone marrow biopsy in my practice.

[Dr. Chris Beck]
Same. We also see them back, I think we just call it, pre-op holding. I'll go do a brief H&P, and I'm just checking for labs, sedation, basically risk stratification for sedation, which we also use sedation, not always, but maybe 90% of the cases and checking for allergies. Just a basic, very standard H&P and a brief physical exam. The conversation that informs consent is what takes up the majority of the time. What I really try and do is briefly talk about the risks. I think the risks are low, so I don't want to oversell it, but I do give a nice informed consent.

Then I spend a fair amount of time talking about the sedation for bone marrow biopsy and just managing expectations about what that's like, only because, at least in my experience, that there are certain patients that are expecting, zero pain. Sometimes that can be a little bit difficult due to the speed of this procedure. You don't have all the time in the world to get the anesthetic on board to where it's an absolutely painless, you're totally out procedure. I just do a little bit of expectation management in that regard. A lot of the conversation, a little bit of-- not a little bit. Full informed consent, brief, but then a lot of time talking about, how this procedure is going to feel, how it's going to go, how much time it's going to take, and recovery afterwards.

[Dr. Aaron Fritts]
Totally agree. I think that is the key. A key piece of doing this procedure is managing those expectations, because some people think, oh, I'm getting anesthesia, I'm going to be out, I'm not going to feel any pain. You're exactly right. That's why I tell the patient, I say, "Look, the advantage of doing this here with us and not in the office with the Hemonc doc is that you're going to get sedation. Which means that you're going to be much more comfortable than just local anesthetic in the office." Because that's the way they do them. That's the way they do them in the office.

They might give them a little bit of an anxiolytic, but that's it. They're not doing sedation for bone marrow biopsy in the office. What I like to tell them is, hey, show them where we're going. You can feel that big posterior iliac spine in the back. I said, "That's a nice big chunk of bone, and it's very superficial so we can get to it easily, but we do use imaging guidance, right? That helps speed things along. Because of how fast the procedure is, it is challenging to get you completely asleep. The goal is for you to just feel pressure. If you can feel pressure while we're doing the procedure, you'll hear us talking, but before you know it, we'll be done and we'll be getting you back in your room." I think that people like that. It's like offering one thing over another. It's like, "Okay, I'm not going to be fully asleep, but at least it's fast and I'll be getting out of here fast." They seem to like that.

[Dr. Chris Beck]
You must be just a better negotiator of people than me. I feel like in my practice, we're a little bit teed up for failure, and that the oncologists almost universally tell the patients that they were going to be completely asleep. Also because like in where I'm at, in the suburbs of New Orleans, a majority of these are still done by oncology and maybe some pathologists who aren't using sedation. There's this small referral of oncologists who were like, "Oh, you don't want to have it. You want it to be painless. Here, let me send you to interventional radiology where they're going to put you to sleep." These patients come with an expectation that it's going to be lights out.

I just find that that's a little bit hard to unwind. I do my best. I think these patients, ultimately just want to get this biopsy and move on. There's a fair amount of conversation around that. I really do. We try to get on top of it. I'll sometimes give a cocktail pre-procedurally. I'm sure you have a cocktail too, which you use for like the pre-op holding area for some super anxious patients.

[Dr. Aaron Fritts]
Yes. It's called Benadryl.

[Dr. Chris Beck]
Yes. I do that.

[Dr. Aaron Fritts]
I like to make them sleepy with the Benadryl. We talked about that one with Vishal, another episode I recommend people go and listen to, because we're talking about a lot of the same things.

[Dr. Chris Beck]
Right. Yes, exactly.

[Dr. Aaron Fritts]
Throw a little Benadryl in there, and a lot of times, they do just fall asleep, and then they just wake up when you're getting that core, and they're like, "Oh, okay, well that wasn't that bad."

[Dr. Chris Beck]
Yes. I like the Benadryl, Ativan/Valium and Zofran combo.

[Dr. Aaron Fritts]
Okay. Yes. Zofran is always good too. Right. Yes, man, I think that is one of the most challenging parts of it. Because it's technically-- we're going to talk through that technically. It's not a very challenging procedure. It depends on what tool you're using, but in terms of getting a good sample. The pain thing, I think, is key. What's nice, what you were just talking about is how sometimes these patients have already had one done in the office, and they have that to compare to. That's fantastic, because then you're like, "Well, this is going to be better than that. I can guarantee that."

[Dr. Chris Beck]
Yes, exactly. This is better than that. Yes. Exactly.

[Dr. Aaron Fritts]
That usually makes them happy. Even if they were expecting to be lights out, it's just like, look, I can make you lights out, but that's going to keep you here another hour afterwards. What would you rather?

[Dr. Chris Beck]
If I could make people lights out, I would. It's not that I don't have the patience to do it, but I just found that the hardest patients to get to fall asleep are the patients who want to be asleep and are very, very wound up about it. That's just my experience in my patient population. Those are the patients that tend to fight it, and they're like, they'll keep telling you, they're like, "I'm not asleep. I'm not asleep. I'm not asleep." We do a lot of tricks.

Sometimes I'll do what's called the silent procedure, where there's minimal talking throughout the staff. Just like, there's no external stimuli for them to anchor onto. We'll put a washcloth over their eyes, dim the lights, like a lot of things. Try and keep the room very quiet and subdued. Sometimes that works. These are all just little anesthesia tricks.

[Dr. Aaron Fritts]
That's a good idea. I go the opposite sometimes where I'm like, look, "I'm here, I'm going to talk you through every step. I'm going to let you know when you can expect a sting and when--." That way there's no surprises, because they are face down, remember. That adds some anxiety. You're right, I try to minimize chat, like people talking about what they're going to have for lunch or stuff like that.

[Dr. Chris Beck]
Exactly. Yes.

[Dr. Aaron Fritts]
I think that walking them through it, being like, " Here, I'm putting the light away now." "Okay. Here, you're going to feel some pressure here." That to me seems to help a little bit if they are still awake.

[Dr. Chris Beck]
I think you're right. I think there's some patients-- I'll just say that there's some patients that want to hear it, and there's some patients that don't, but I agree with you. I think there's definitely some patients, as long as you're talking them through it, and they know all this is expected, then they're very okay with that. Absolutely.

[Dr. Aaron Fritts]
They just want things to go as expected. According to plan.

[Dr. Chris Beck]
You're exactly right. For sure.