I worked quite a bit the last two years of my career sedating patients for colonoscopy with Propofol. Good stuff.
I had a flexible sigmoidoscopy in my early 50's as that is what insurance would cover at the time. No sedation, no polyps, same prep. Not fun.
At age 56, in 2004, I had a colonoscopy with Demerol and Midazolam sedation. Went fine. Same prep, no polyps. The doctor gave me a ten-year pass.
Eighteen months later my dad was diagnosed with colon cancer, specifically a tumor of his cecum, after a time of declining health. It had already spread to his liver and lungs and elsewhere. He died 15 days after diagnosis. He had refused colonoscopies. He also had a history of ulcers and refused to have his stomach scoped to check on those as well.
For the next three weeks I went to work and listened over and over as the gastroenterologists I worked with explained to patients that, due to their family history, they needed to return in 3-5 years, even if they had a negative exam. It never dawned on me that they were referring to me. After all, I had a ten year pass.
You know those cartoons when the light bulb goes up over someone's head? Well, that was me one day in the middle of work, I just heard the doctor say that in my head and bingo, I realized that I would be having colonoscopies more frequently than I had anticipated.
I called my own GI doc, the office agreed this was the case, and said to come in 3-5 years after my original colonoscopy. I think I scheduled it at about four and a half years.
This time it was a better prep, (half Golytely, taken in split doses, five eight-ounce glasses at night after two Ducolax and three eight-ounce glasses three hours before I was to arrive at the clinic). My prior prep required me drink the full gallon in the past which wasn't as pleasant. This time prep was a piece of cake, comparatively speaking.
I also had Propofol, and the procedure went well. Surprise. I had two polyps, and several days later got the letter that I had to come back in three years. In general they tell you that if your polyps are benign you get a five-year pass; if they are pre-malignant you will be back in three years. Amazingly enough, the larger of the two polyps they found in my screening was benign and the teeny tiny 2mm polyp was pre-malignant. Given enough time, that could have grown into full-blown colon cancer. Now it was gone, never to return.
My husband, who has a history of thyroid and prostate cancer and a GIST tumor of his stomach, was with me that day. His screening history was the same as mine. Flexible sigmoidoscopy in his early 50's, negative colonoscopy a few years later, a ten-year pass. When our doctor saw him and found out about the recent prostate cancer, he suggested he come in the next spring to have both his colon and his stomach looked at. It turned out my husband had four polyps, and at least one was pre-malignant, so he will also be on the three-year screening schedule.
I believe in screening, I have regular pap smears, mammograms, and bone density tests. So a colonoscopy was just an add-on to that list. I am not terribly concerned about polyps because I know that these are slow growing tumors, I WILL catch any future polyps early, and they will not have the opportunity to grow into cancerous polyps. Further, if they ever tell me that I need to be screened more often, I will know that they have a good reason.
That said, I tend to ignore the occult blood screenings that my primary physician gives me. I don't know their value in light of my frequent colonoscopies.
My patients woke up feeling refreshed and unaware of the procedure, with a big smile on their faces, telling me that that was the best sleep they have had in years. This was such a daily consistent that we just had to chuckle, as each one gave us the same speech. We wonder at the amount of insomnia in the world. Many of these people went to sleep miserable the night before from the prep (rightly so), and then bingo, all was forgotten! At the time it was funny but they would ask me if I could come out to their homes. My co-worker and I would joke that we were considering starting a business, brown bag in hand and go around providing this refreshing sleep to the masses. But we always made sure they knew we were joking, that this was a powerful drug, and in no way shape or form could it be used in the home.
When the Michael Jackson scenario was revealed, we could not get to the phone fast enough to discuss among ourselves what had happened to him. We knew that it should not have happened. I actually have a former co-worker who, although administering Propofol on a daily basis, actually chose to "bite the bullet" and have her EGD and a colonoscopy with no sedation. The doctor told her that if she wanted it that way next time, she would need to find another doctor. It took more than twice as long. Patient comfort means a patient who is lying still, lessening the incidence of perforation, so I would encourage some form of sedation for everyone. Many of our patients were repeaters, as we all will be if we are following guidelines, and they had some combination of Valium or Midazolam and Demerol or Fentanyl. After their experience with Propofol, the vast majority if not all said they would prefer this newer sedation in the future if it were available. Some said they would insist!
Since we are as nurse anesthetists are bedside and just giving small boluses prn, we can titrate to perfect effect while the scope is inserted. We then back totally off as they have finished doing a thorough exam and are slowly removing the scope. Often the patient awakens just as the scope is removed, we only give more if a biopsy is needed to give the doctor a few more minutes to complete the procedure, and then in very small amounts.
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