Archive for January, 2018

I’ve been absent a while due to a huge surge in both work, and for a short while, my writing career. The latter has sputtered and the former has blossomed, but I’m going to be more diligent about blogging. So, here is a topic that has been a source of stress for me ever since I turned 50…getting a colonoscopy.

Okay, for those who are younger, kind of like every pregnant woman who turns 35, there is this “squall” of medical “issues” that must be dealt with when you turn 50–even if you have no underlying indications of problems. (I know a lot of super-healthy 40-year old first-time moms, and a bunch of smoking, drinking ones who are 30–guess who has better birth outcomes. Seriously, stop smoking). You’ll get an EKG at every annual checkup. Another is a shingles vaccine (no big deal–shingles are pretty awful). The other is a colonoscopy. You’ve heard stories, I’m sure–nightmares driven by our cultural love/hate relationship with preventive medicine. Let me throw in the usual disclaimers–I have a Ph.D., but I’m not a medical doctor. This is my own personal experience, not medical advice. Please talk to your primary care provider about your risks and benefits for anything and everything.

I knew it was coming, and sure enough, my nurse practitioner brought it up. Here’s the gist of it: For about 48 hours, depending on the practitioner, you drink a clear liquid diet (chicken broth, Sprite, light-color Gatorade, etc.) Then you take some laxative pills, fast completely, and swill 4000 ml of this absolutely disgusting concoction that expels liquid out of your rectum (I’m sticking with the proper medical terms). Different doctors like different preps; this solution was Golytely, and it was utterly nasty, a combination that tasted like a blend of dirty sea water and bits of plastic. The “lemon flavor” did nothing to help. 4000 ml is about 1.06 gallons. Since I had an afternoon appointment, I had a “split” prep, which is actually the recommended way by the American Society of Gastroenterology for getting a clean colon. So, the evening before the procedure, I was to take 4 Dulcolax tablets and drink half the solution, 1 cup at a time over the space of an hour starting at 9 PM. Then, about 5 AM, I was to drink the rest. Now, my doctor was super picky about clean colons and said, in a helpful way, that my prep could’ve been a bit better (the nurse whispered to me later that I’d done things pretty well). I think 2 things didn’t help me: a) I could absolutely not finish that last 200 ml of solution the morning of the procedure. I was already choking it down, about to toss it up, using a straw and drinking it ice cold, which is the recommended way, and b) the second dose is best if taken no longer than 5 hours or so before the procedure. However, I was told to drink it at 5 AM over the space of an hour for a 1:30 PM procedure which then was delayed over an hour, so that meant I should’ve drank it around 8-9 AM instead because the early drinking plus the delay meant the colon had time to build up new “bits” of stuff (normal), and that’s not what they want to see. I’ll know better next time…and to ask for a different prep. There are lots of options out there; it’s really physician preference. Also, if you are a barfer like me, the Harvard School of Medicine says 4 mg of Zofran taken an hour before each dose of prep can help nausea–I did this, and it certainly helped. Ask your doctor.

I definitely recommend starting your liquid diet TWO days before the colonoscopy, which is what my PCP advised–it made things coming out an easier process. While time consuming and tiring, it was not that bad to be on liquids for two days. Use baby wipes, have diaper rash cream on hand, and (sorry), wear Depends if you lay down to rest. You’ll be glad you did, and so will your floors and mattress. Anyway, after all this, you go to a facility, get an IV (which, while a bit painful since you’re dehydrated, helps with rehydration), then you go to a room and get a scope up your rectum, into the sigmoid colon, up the descending colon, across the transverse colon, down the ascending colon, and into the cecum. That’s about 8 feet in most people. They check for masses or polyps or anything suspicious and usually take a small biopsy. Then you are done; time to rehydrate (slowly) and eat (slowly) and get your strength back. I recommend resting that day and if possible, the next day  as well. I took a good walk to expel the CO2, but I was worn out from the long three day experience of prep. Seriously, it’s okay to be good to yourself and maybe work from home the day after, especially if your procedure is in the afternoon.

Now, my story…So, for every dang surgery I’ve ever had, including the miraculous Da Vinci robotic ovary removal (almost pain free), I throw up. I’m talking no matter what anti-emetic is used (Zofran works the best for me; the Trans-Derm Scop patch was a nightmare, but it works great for most people), I throw up like the possessed Linda Blair. It’s horrible. If I’m lucky, it’s like an hour puke; if not, maybe 6 hours, and oh geez, that is the LAST thing you want if you have had surgery on your neck or abdomen. But you have to be insistent that this is the case. Here are the things people have told me in hospitals:

  • Propofol won’t cause you to throw up; seriously, that never happens. (So, um, why the whole “nothing after midnight,” to avoid aspirating liquid into the lungs, if it never causes nausea? Hmm. Check out the ASA recommendations from 2015 (Table 1) at the American Society of Anesthesiology. But of course, talk to your doctor, always).
  • The Trans-Derm Scop patch will prevent you from throwing up. (I know it works wonders for many people; dang, I wish it did for me!)
  • Why do you want Zofran before surgery? Most people don’t throw up. You can get it after if you need it. (Um, it works better if taken before nausea starts?)
  • This is a fast procedure; you won’t remember anything, and people usually don’t throw up.

And the other thing that causes me problems is Versed (midazolam). I’ve stopped taking breaths–twice, and also experienced nausea, headache, and hiccups that had me gasping (to be fair, I think the CRNA in one case saw I was anxious and gave me a 4 cc bolus–whoa! Too much!). Here’s what most medical people say:

  • You don’t want Versed? Why?
  • Most of our patients are really happy with the Versed; they don’t want to be anxious. (I don’t like anxiety, either, but I do like breathing).
  • I won’t do the procedure unless you have Versed or something similar (at which point, I changed doctors).

Let me quickly say–if I was having major surgery, I’m not stupid! I’d want the Propofol, pain meds,  and a good anesthesiologist at my side. We’d work together to come with an anti-nausea plan. They are out there, and if you find one (we did), get his/her name, and request them! The two I’ve used and requested were so happy to help, and I’ve recommended them to others. Good folks who do good work, but I’m guessing many people don’t even ask their names. And likewise, Versed has been a life saver for people who are anxious or want the amnesia it provides. Seriously, I am all about do what is best for you. No judgment here!

So, there is the root of my fears and problems: No doctor I could find would do the procedure without sedation (either Versed + Fentanyl, or Propofol, possibly with Versed first). I called about 10 places and even had an appointment and procedure scheduled (he insisted on Valium because no one could possibly stand to do this procedure without some kind of sedation; I really didn’t know what I was going to have to endure, he explained). He had my favorite anesthesiologist on the case, and I probably would’ve went through with it…except the facility was like a stockyard. I took a friend there, and the space provided was gruesome. No one was allowed to be with you during prep (I’m a hard stick on a good day and appreciate a hand to hold). The cubicles were just curtains. I saw people “stacked up” in the hallway, moaning with their sheets off because the center was so busy. Just to confirm, I did call and asked: could my spouse stay with me; what were the cubicles like; and was everyone guaranteed privacy. Answers: No one can be with you during prep, we do have curtains, and we do the best we can, given that we are a “high volume” center. Nope. I cancelled. And I kept making calls.

Having read many peer-reviewed articles about unsedated colonoscopy, I contacted the nearest medical school/teaching hospital to see if they might be doing a clinical study comparing sedated versus unsedated colonoscopy. No, but they had a doctor who did them, and would I like to book an appointment? I asked several questions–can my spouse be with me (yes, of course); what is your privacy like (we have cubicles that have walls on 3 sides and a curtain on one side, and we cover our patients at all times); yes, we see a lot of patients, but we do our best to be considerate of modesty. I booked the appointment.

And to cut to the chase–it went great! Okay, I realize I’m one of a gazillion patients, but at my pre-check in phone call, the nurse said, “You’ll just have to remind everyone, no sedation, because we probably won’t remember.” And we did. Most people looked at me like I had 3 heads, but they were polite about it. One nurse, though, said, “You can do this! You seem determined, and I know you’ll be fine.” The anesthesiologist was courteous, but he was also clear: “You have to make a decision now, before you leave the cubicle; you can’t turn back because I can’t leave a patient who is getting sedation to come to you if you change your mind midway through. That’s not safe for anyone, and I know you don’t want to abort the procedure after your prep.” I agreed–that was fair, and he signed off my chart and went to help someone else. But yeah, kinda scary to hear it.

The same nurse who’d called me was the one who took care of me in the colonoscopy suite, and she was absolutely awesome and supportive. She coached me to breathe through the turns, never left my side, and gave verbal reassurances. The doctor and his fellowship doctor told me “where we are” on the turns and such. We cheered when they reached the cecum. It helped that the doctor had done these before unsedated (he said he’d had to do one on an intelligence officer) and used a pediatric scope. That made a big difference.

Did it hurt? Yes–about 3 times, for about 10 seconds each. I would say if childbirth is an 8 and a kidney stone is a 9, this was about a 6, but brief “stabs” of pain, nothing lasting very long. These were, of course, where the turns were made. I panted my way through, and the pain passed quickly. Six minutes to get into the cecum, near the appendix, where the large intestine meets the small intestine. Eight minutes to get out as they peeked at things and took a painless biopsy. I admit, I didn’t watch the monitor going in because I was so focused on breathing and relaxing. I did on the way out, and it was quite interesting. Could I “feel” the scope? Yes, but barely, like a flutter. Could I feel the gas (CO2)? Not as much as I thought. And then…done! The “I’ve been doing this a long time” tech, who helped things “behind” muttered, “I’ve seen people with the drugs have a heckuva time…that was really amazing.” And at all times, I was well draped.

I got some ginger ale, dressed, and went right home. The check-out nurse giggled and thanked me for making her paperwork easier. The only problems I’ve had have been rehydrating and eating again (I haven’t had a Coke in 30 years–but it cured my headache and settled my stomach. Also, I inhaled a Krispy Kreme donut–hmmm, start with toast and crackers first, I think). No problems getting a good night’s rest, and the coffee this AM was marvelous.

I want to repeat–this is NOT for everyone. If you have fears or anxiety, you will probably be more at ease getting medications (both a good friend and my spouse say that’s what they want, and that’s great for them–know thyself). No judgment! However, if you have problems with nausea or recovering from anesthesia, and you can manage pain with self-hypnosis, breathing, meditating, and/or relaxation–this may be something you want to investigate. Your challenge will be finding a doctor and facility who will do it. I warn you, this (and the crappy Golytely) were the hard parts. You might have to travel (I was ready to go to Minnesota to Mayo) or make a lot of phone calls. Also, beware of bait and switch–get names of who you talk with so there are no misunderstandings later. Your PCP might be able to direct you to someone they know. Why is it so hard to find a provider that will go unsedated? I suspect it’s a twofold problem–one, this makes money if you use sedation. (Sorry, but it’s true–I won’t get an anesthesia bill). And two, probably this is a difficult procedure for many people to consider doing without meds and thus is not a “norm.” Possibly, gastro residents coming out of med school are never trained how to do this unsedated. However, my doctor also said he and his colleagues do it unsedated so they don’t miss work.

I hope this is helpful to someone who is looking for this option–drop me a line if you want more info. And maybe you could tell them you work for some intelligence service and can’t have the sedation? Just a funny thought. 🙂