Although a bit of a personal issue, I’m known for my transparency and I’m happy to share the experience so that others approaching 50 know what to expect.
The preparation is the hardest part. Three days before the procedure, it’s recommended that you reduce the quantity of high fiber foods you eat – fruits, vegetables, nuts etc. For me that was particularly challenging since my entire diet as a vegan (who tends to avoid white flour, white rice, and white sugar) is high fiber. I moved to soups and brown rice. A day before the procedure (really 36 hours), you move to a clear liquid diet – apple juice, broth, and tea. In my case I drank a cup of vegetable broth and apple juice every 3 hours.
At 7pm the night before the procedure, the real challenge begins. The bottle of magnesium citrate reads “a pasteurized, sparkling, laxative”. Sounds so appealing. The first dose is 15 ounces. The bottle warns that the maximum therapeutic dose is 10 ounces in 24 hours for adults, but colonoscopy is a special case. The 15 ounces of laxative is followed by 24 ounces of clear liquids over the next 2 hours. Keep in mind that you have not eaten any solid food for 24 hours at this point. Sparkling laxative followed by broth and apple juice is not Chez Panisse.
A few hours after the laxative, the intestinal rumbling begins. You’ll have a rocky night with an urgency to jog to the nearest bathroom every few hours. By morning the intestinal cramping will have subsided and then you get to repeat the process! Six hours before your procedure, you’ll drink another 15 ounces of mag citrate followed by 24 ounces of clear liquids over 2 hours, then nothing by mouth for the final 4 hours. Given the 36 hours without solids and 30 ounces of mag citrate there’s nothing really left in your body, so you’ll move the clear liquids through your system quickly. You’ll arrive for your procedure just as all the cramping has stopped.
The procedure itself is the easy part. There are multiple sedation options – nothing at all, versed/fentanyl, and propofol/monitored anesthesia.
I received propofol, which works quickly and clears quickly. I have no memory of the anesthesia, but when I awoke I thought I had just come in from chopping wood on the farm. The nursing staff were very understanding. In a few minutes, I was walking, dressed and back on the iPhone, doing conference calls and answering email. I did avoid work with chain saws and signing a new will.
The Boston Endoscopy Center, where I had my procedure, uses an electronic record called Gcare, which captures images and reports. The BIDMC enterprise systems are fully interfaced to Gcare, so all endoscopy information is immediately available to patients and providers. By the time I returned home, I had access to all the images above. The report was simple and to the point
“Medications: MAC Anesthesia
Pain rating: 0/10
Indications: Screening for colon cancer
Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. Moderate sedation was initiated by the physician. Continuous pulse oximetry and cardiac and blood pressure monitoring were used throughout the procedure. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position.The digital exam was normal. The colonoscope was introduced through the rectum and advanced under direct visualization until the cecum was reached. The appendiceal orifice and ileo-cecal valve were identified. Careful visualization of the colon was performed as the colonoscope was withdrawn. The colonoscope was retroflexed within the rectum. The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications.
Mucosa: Normal mucosa was noted in the entire colon
Impression: Normal mucosa in the colon
Otherwise normal colonoscopy to cecum
Recommendations: Colonoscopy in as long as 10 years as per the recommendation of Medicare. If you develop symptoms such as bleeding, or if a relative develops colon cancer, this interval would change. Get regular checkups with your primary doctor to check for hidden blood in the stool
Additional notes: The efficiency of colonoscopy in detecting lesions was discussed with the patient and it was pointed out that a small percentage of polyps and other lesions including colon cancer can be missed with the test. Degree of difficulty 2 (5 most difficult).
FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology.”
Done for another 10 years!
As July draws to close, both Kathy and I are celebrating. We’ll have a high fiber vegan meal and welcome the simpler August ahead of us.
John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. He’s also the author of the popular Life as a Healthcare CIO blog.