Monday, February 26, 2018

Colonoscopies, Revisited

[“Let Inga Tell You,” La Jolla Light, published Feb. 28, 2018] ©2018
I was genuinely surprised when one of the biggest responses I’ve ever received to a column was to the one about colonoscopies.  (The recent column about high-pressure dentists had a surprising response too but I’ll follow up on that one another time.)  I will merely say that neither gastroenterologists nor dentists fared well.
The Light only allows me 800 words rather than the 20,000 that I could now easily write about colonoscopies but let me say that horror stories abounded.  One reader shared:  I woke up in the middle of it because they decided to discontinue anesthesia when my blood pressure plummeted to 80/40. The nurse told me to stop screaming because I was upsetting the other patients.
Most readers (although certainly not the one above) agreed that the 14-hour intestinal power wash prior to the procedure was the worst of it.  The most commonly used “bowel prep” agent is still an utterly foul concoction called GoLytely but the newer (and only slightly less toxic) Prepopik is gaining ground, more slowly because Medicare doesn’t cover it.  $44-$100 is lot of money to spend for something that gives you explosive diarrhea.
Fortunately a non-invasive DNA test called Cologuard – a stool test that one conducts in the privacy of one’s own home – is on the market but not considered the “gold standard,” which I think means less gold ends up in the pockets of gastroenterologists.  But any fantasies one might have about discreetly pooping into an ergonomically-designed receptacle, sprinkling in a few drops of a testing agent and putting it out for the unsuspecting postal lady to pick up should be disregarded.  A reader noted:  We are in the process of doing the “Cologuard” test and it has taken us the whole morning to just read the instructions in the booklet which is over 35 pages long!!! Each step has to be followed exactly as outlined, specimen bottles have to be correctly gathered, labeled, and preservatives added so they can be mailed successfully.  If one does not follow the intricate steps, the test could become invalid.  
After experiencing both GoLytely and Prepopik up and close and personally, my ever-perverse mind became obsessed: if these were the products that ended up on the market, what about the ones that FAILED? Inquiring minds HAD to know.
Thus, it was a dream come true when I was contacted by a local retired physician who personally knows “Dr. X,” the developer of GoLytely and who provided me with some of the most fascinating and illuminating correspondence I have been privileged to have in my column career. Totally lovely guy.
I emailed him:  I confess that my imagination has run away with itself about the development of GoLytely. Certainly one could imagine beta versions that didn't get the job done, but surely there were versions that did it way too well?  How much did they pay these people?????  By the way, just so your colleague, Dr. X, understands, his burial site will have to be unmarked.  I cannot even imagine the GoLytely-related atrocities that might occur upon it otherwise. I assume he already resides in the witness protection program. Sincerely, Inga
My new local friend sent me an article from Gastroenterology that covers this exact topic. It was not too surprising to learn that the earliest versions of bowel preps, in 1947 and 1953, were tested on rats and sheep.  But this only raised more questions: How did they get the rats to drink it? Was some poor lab technician in charge of measuring rodent effluvia? I’m trying to even imagine rat colonoscopies with a teeny weeny colonoscope. 

But between 1953 and the unleashing of GoLytely on the innocent masses, there were some definite bumps in the developmental road including some chilling descriptions of the “hazards of volume overload.”  I was also intrigued by the experiment that added 80 mmol of mannitol to the test solution only to discover that “fermentation of mannitol by colonic bacteria yields potentially explosive gases.”  Um, are we not talking human intestines here?  This was apparently mostly a risk if “electrocauterizing procedures” were being used.  With the understated charm so endearing to scientific publications, it was noted: “in only one study was an explosion observed.”
My local correspondent referred me, should I desire more information on “the flammability of colonic gas that is expelled” to papers by Mike Levitt who is the world’s authority on intestinal gas. I’ll bet he is a huge hit at school career day. You can see the utter rapture on the face of every male student. “That’s a real job?”
Personally, I’m rooting for the Cologuard DNA test but preferably in a version whose instruction manual is one paragraph. But even more, I'm really hoping that colonoscopies will become a footnote in med student's texts about barbaric procedures once inflicted among the American public. They’ll shake their heads and marvel, “And millions of people actually agreed to this?”

Tuesday, February 13, 2018

Olof On The Mend

[“Let Inga Tell You,” La Jolla Light, published, February 14, 2018] ©2018
As I told my husband Olof as they were moving him from the Cardiac ICU to the Trauma ICU, I wasn’t that desperate for column material.  A week before his recent heart attack-cum-traumatic-brain-injury, I had been wondering aloud at dinner whether after nine years of writing my column I had anything left to say.  Were people just too polite to tell me?  (This is your chance.)
And then Olof goes and almost crumps right in front of me. 
It would not be surprising that this event has shaken both Olof and me to the core.  But I never worried about Olof having a heart attack. Part of it is that he was too busy having cancer. But the cancer was cured and he was just so insanely healthy. No family history of heart problems whatsoever. This violates all rules of nature, never mind medical advice.
Speaking of medical advice, our first week home after he got out of the hospital was with fraught with inadvertently-induced iatrogenic afflictions. Please note that we were absolutely dazzled, amazed, and tearfully grateful for the care that we got at the Prebys Cardiovascular Institute.  I totally recommend that if you are going to have a heart attack, you have it there. 
But in all the confusion between having both a heart attack and a head injury, I didn’t know that Olof was being given Lipitor, a statin.  I know that there are people who think that everyone should be taking statins. But they would be idiots.  For people who tolerate them well, statins are apparently terrific.  But there are a sizable number of people – Olof and I among them – who have serious, and potentially permanent, side effects to them. We have many friends who have had bad side effects of various types to statins as well.
When Olof took statins a decade ago, he developed increasing severe muscle pain over a period of weeks which, since he never complains (including, alas, about chest pain), I wasn’t aware of it until he was too incapacitated for business travel.  It was our pharmacist who clued us in on the likely cause of it.
Olof’s mother, I should mention, has had cholesterol in the 350 range (no, not a typo) her entire adult life.  (She failed with statins as well.)  Did I mention that she is 96 and clear as a bell?
I didn’t find out that Olof had been given Lipitor in the hospital until a prescription bottle of it came home with him.  He was already having muscle pain but assumed it was a delayed symptom of his fall.  But when we got home, the muscle pain absolutely crippled him. He was in agonizing pain, unable to get from sitting to standing – or vice versa – or to stand up straight.  Just what somebody who has just had a heart attack, a neck injury, a smashed up face, and an on-going brain bleed needs. It was heartbreaking to watch.  I flushed those suckers down the toilet immediately.  But it took almost two weeks for the pain to fully subside. That stuff doesn’t leave your system overnight. 
Our house is small so if you fall down, there’s a reasonable chance you’re going to hit something.  I was just terrified Olof would fall again. His arsenal of new meds – eight! (well, seven after I gave the statins a burial at sea) – was making him very lightheaded.  I just wanted to wrap the house in bubble wrap. Or maybe HIM in bubble wrap. 
Our dog Lily was rapturously happy to have Olof home. Even though the neighbors had done a heroic job caring for her, she expressed her distress at Olof’s absence by regularly pooping on the carpet. 
I, meanwhile, thought I was managing the stress pretty well until I realized when I came back from errands in downtown La Jolla one morning that I had been wearing my fuzzy bedroom slippers the whole time.
It was probably not too surprising that I have developed a constant anxiety about having a stroke or heart attack myself.  Olof was (and still is) in tons better shape physically than I am.  So how exactly do you know you have occluded arteries before you drop almost-dead in front of your horrified spouse?  Even the cardiac rehab people scratched their heads and said that Olof had already been doing everything that they normally recommend post-heart-attack patients do. 
So when we went for Olof’s next cardiologist appointment, I booked an appointment for myself. First available for new non-emergency patients wasn’t until March but that will hopefully give us time to get Olof back on track. I realize that obsessive worrying about having a heart attack or stroke is probably not helpful in preventing them.  In the meantime, every time I have the slightest heartburn – Olof’s only symptom – I’m wondering, “Is this it?”