Preparation is everything

WARNING: this blog deals with a variety of subjects that people might find distasteful. If you find descriptions of poop distasteful, read no further.

All right... you've been warned.

I went to the preadmission clinic (PAC) at the hospital where I will have surgery earlier this week. Exactly one week before my surgery, to be exact. But I had already had bloodwork (twice), a chest/abdomen/pelvis CT scan with contrast, a pelvic MRI, and a physical from my GP. I had met with my surgeon to discuss my surgery, and had already been given a package of information about what would happen when I was admitted. So what possible purpose did my visit to PAC actually serve?

Well, admittedly a lot of what they did was either pointless or was redundant. I got a chest X-Ray (CXR), for example. While I was getting it done I asked the tech what the CXR would show that the CT with contrast didn't.

"Nothing," he said. "Some anesthesiologists won't intubate you without one though. I could document that you refused if you want."

"No, it's okay," I said. Thirty seconds later my CXR was finished. If I hadn't asked my question I would have been done and out of medical imaging before I had even finished asking the question in the first place.

I also had bloodwork done. A lot of it was a repeat of the bloodwork that I had already had drawn, but I did need to be cross-matched in case I happened to need a blood transfusion during or after my surgery. The chance is slim, but if I do need it I will appreciate the fact that the hospital is ready. The fact that some of the blood work was redundant is unimportant when I consider that.

I saw the enterostomal therapy (ET) nurse as well. I know her fairly well - we work together on my unit, after all. She was sweet and surprised to see me and did a great job as she marked the spot on the right side of my abdomen where my diverting ileostomy - if my surgeon decides to create one - will exit. This will be temporary and allow the anastomosis - or union - between my sigmoid colon and what's left of my rectum after surgery in order to let the anastomosis heal fully without dealing with fecal matter. She found the ideal location that won't be interfered with by the waistband of my pants and isn;t in a natural fold in my abdomen, then injected a small amount of methylene blue dye under my skin, tattooing the area so the surgeon can see it easily.

I got a 12-lead ECG. As a pilot, I have those done every few years anyway. It's several minutes of preparation as a technician applies electrodes to my chest, left leg and arms followed by ten seconds of letting the monitor work followed by a minute of the tech removing all the electrodes. There's virtually no chance that it will show anything that is of concern.

I needed to see the anesthesiologist, but really only so he could be sure that I had had surgery and hadn't had any negative reaction to anesthetic. He listened to my chest and heart and looked in my mouth - assessing my airway for when I am intubated during surgery - and explained all the things about anesthetic and post-op pain management that I already know.

I saw a very helpful nurse who explained the things I can do to recover quickly and get home as fast as possible. And I also saw a pharmacist which was really ironic. On two counts.

First, the pharmacist I saw is a friend of mine. Their eldest child went to school with our eldest and we've worked together for over a decade.

Yeah... that's the second part of irony. I'm a pharmacist too. So the interview went quickly, but more than most preop patients I recognize the importance of having an accurate Best Possible Medication History (BPMH) on any patient undergoing surgery.

All of this preparation was important, making the steps I would have to follow before and immediately after my surgery go more smoothly. It was kind of a pain and it took three hours, but preparation is important.

And while we are talking about preparation, it also meant that it was time for me to start my bowel prep.

Sounds crazy, right? Bowel prep a week before surgery?

I'm not trying to clean out my bowel. Not yet. But I needed to start the process. And I needed to start then because it can take an average of  about four days for anything I eat to be excreted. If I get constipated or my bowel transit time is longer than average, whatever I take in will still be there on my surgery day. And that will mean it's a bad day for me and for my surgery.

I have already mentioned about needing to prepare for my colonoscopy. It may not be a surprise if you think about it (although why on earth would you have thought about it?) but in order to see the inside of your bowel it is critical to clean it out so that the gastroenterologist can visualize your bowel and nothing else, if you get my meaning. That involves dietary restrictions for a week before, clear fluids the day before, and a variety of different means of cleaning out your bowels.

For my colonoscopy, I had to use a Colyte bowel prep that involves drinking 2 litres of stuff the afternoon before and 2 litres the morning of your colonoscopy. If you don't already know, quickly drinking 2 litres of anything is a struggle and CoLyte isn't the most palatable stuff on the planet. It's best to drink this stuff when it's really cold otherwise it can be a little nauseating (trust me, I left one glass out for about five minutes and almost gagged when I drank it) and also best to drink about 250 mL rapidly every ten to fifteen minutes. It took me two hours, but I got through the two litres of Colyte.

Then the fun started.

Colyte works by pulling water into your large intestine (or bowel) to clean out the usual contents. Because I had not been eating high residue foods (things with stringy fibres, red meat, seeds, nuts) for a week and hadn't had any solid food in 24 hours the only stuff in my bowel was pretty easy to dissolve. About an hour after I started I had my first bowel movement. It was softer than usual but nothing really that different.

Ten minutes later I had another. It was noticeably softer. And ten minutes later it was softer still, then five, and so on.

I had about a dozen bowel movements that night and by the time I went to bed there was no solid poop at all. Think of your worst case of diarrhea - that is pretty much what it was like. But I hadn't had any Colyte for a few hours before bed and things settled down. I went to bed and set an alarm to wake up six hours before my procedure the next day to start the whole process over again.

Oh yeah... you're not done after drinking just two litres of the stuff. A full bowel prep requires four litres of CoLyte. Pro tip - have your colonoscopy scheduled for early afternoon so you don't have to wake up at 2:00 AM to start your second prep cycle.

By 10:00 I was passing nothing but clear water when I had a bowel movement. I had done an excellent job of prepping for my colonoscopy.

I also had a flexible sigmoidoscopy as both workup for my colon cancer and to allow my surgeon to tattoo the tumour site so that it was easier to see when he did surgery. He wanted me to use two sodium phosphate enemas, one the night before and one the morning of my sigmoidoscopy. They did not do a particularly good job of cleaning out my bowel.

Trust me - you don't want me to go into further detail than that. Plus - and maybe this is just me - I much preferred drinking 4 litres of liquid to using two enemas.

I have a different bowel prep for my surgery. Like my colonoscopies, I need to have a low fibre diet (no raw fruits or veggies, no popcorn, nothing with seeds, no nuts) for 5-7 days prior to surgery, then a clear fluid diet WITHOUT any red or purple-dyed liquids for 24 hours before surgery. The reason for no red or purple liquids is because they might dye the colon and make it look like there is bleeding or inflammation that doesn't actually exist. And I need to take liquids that have sugar because having low blood sugar will cause problems for surgery. Up to that point the preparation for my colonoscopies and my surgery are the same, but after that the actual preparatory process will be different.

I will start by taking a laxative called bisacodyl. This is a stimulant laxative that will increase the rate of contractions in my large intestine. I will then take a slightly different form of CoLyte, drinking half of the mixture the evening before my surgery. I will also take two antibiotics - neomycin and metronidazole - to help reduce the amount of bacteria in my colon. I have to use a surgical scrub on my entire body before going to bed, dry myself with a clean towel, and then go to sleep on clean sheets and wearing clean pajamas so that the bacteria on my skin are reduced. Because my surgery is early in the morning, I have to set an alarm for 2AM and get up and start the whole process over again; more CoLyte, so many more bowel movements until basically nothing but clear water is coming out, and finally another surgical scrub shower after I'm fairly certain that I am done with my bowel movements. Then I will get dressed (again in clean clothes) and let my wife drive me to the hospital.

And then I will have my surgery.

I will be prepared. Physically.

But emotionally? I think I will, but I'm very much trying to live in the moment right now so I can't say with certainty. But I know I will go through with the surgery even if I am nervous or anxious at some point in the next few days.

So... yeah. I am prepared, in every way that matters.