PEG

I'm having my second ever colonoscopy on Friday. Or I'm supposed to at least.

PEG is such an innocent sounding word. Reminiscent of what is at the moment a sort of ironic song, or an ironic bit of lyrics. "Peg, it will come back to you..." And indeed, it may if what might be coming back (up) is your clear liquid dinner.

Really, it should be PEIG, which stands for "Plastic-like Emesis Inducing Gunk". Why a PE(I)G prep? Why indeed.
From EndoNurse
In a recent attempt to assess which bowel preparation agent is most effective, researchers conducted a meta-analysis by pulling studies that were published between January 1990 and July 2005.2 The meta-analysis discovered that sodium phosphate (NaP) was more effective in bowel cleansing than polyethylene glycol (PEG) or sodium picosulphate (SPS). Patients showed more difficulty completing PEG than NaP and SPS. All three were comparable in terms of adverse events, with PEG resulting in slightly more adverse events than SPS. NaP resulted in more asymptomatic hypokalemia and hyperphosphatemia than the other two, leaving the researchers to conclude that “the biochemical changes associated with a small-volume preparation like NaP, albeit largely asymptomatic, mandate caution in patients with cardiovascular or renal impairment.”

I have no cardiovascular or renal impairment. So, ummm, why am I getting the PEG prep? My theory is that I am getting the prep which is standard when the clinician assumes the patient is likely to be overweight, hypertensive, and possibly older (male). Sorry if that sounds mean. Any hostility comes from my irritation that male is still too often the medical standard, and I have some issues about which populations are sampled and then generalized to in research in general.

Anyhow, I'm not in that set - the set being people who you should give a crappier prep to because the crappiness of the prep is overshadowed by the need to not pump this person full of salt. I'm a skinny, hypotensive mid-thirties woman who fills up so fast she usually can't eat a whole meal at a time and who has a history of low Na levels.

Is this an example of one size fits all medicine or does my GI doctors office know something they should perhaps share? I'm too tired to push the issue. I'm going to try to get this shit down and keep it down, but if I end up not adequately prepped because my doctor's office insisted on a crappy prep for crappy reasons I'm probably not going to be feeling terribly compliant...at least not for a little while since I already asked once "er, do I really have to do the PEG prep?"

My prep instructions tell me that "if vomiting persists, stop the prep and call our office for instructions". When my GI's office calls back about the Donnatal/anticholinergic/antispasmodic issue, I'm planning on asking exactly how many times a person must vomit before we consider it to have persisted.

PGY-?

It's July. This means it's national "how the fuck do I order that?!" month.

As a unit clerk, I dreaded July. Sure, it meant some new fresh folks to replace the ones who had been worn down and frayed by February. But it also meant too many over-eager interns and inflated residents strutting their stuff through our halls, sitting at my computer, walking off with my pen, running away with charts, and sleeping through pages. Overall, I saw July as one big pain in the ass. However, I hadn't really thought about what it meant for the patients until 1997.

Back in 1997, my brother was admitted to a big city hospital, one of those mammoth teaching/research jobs, the first week of July. Depending on your perspective, he presented either a mess or a mystery. That is, there were several paths you could have gone down to try to come up with one explanation for all the symptoms.
Here's the most obvious stuff. He was a recently HIV positive 25 year old male who came to the emergency department with renal angle tenderness, vomiting, diarrhea, fever. Oh and he was quite overtly jaundiced too. I don't know the meds or the lab values - this was years ago now and if I knew this information I've long forgotten it. Long story short - here's the important info which a good history would have elucidated. My brother had spent the weekend before this illness started at a Pride celebration which apparently entailed the mandatory drinking of many Rolling Rocks in the sun for the better part of two days. He had tried to keep up a good (non-alcoholic) fluid intake since one of his HIV meds came with stern warnings about fluids and what could happen to his kidneys if he didn't get enough with the med. However, the intentions for decent hydration were shot when he ate some bad yogurt which resulted in vomiting and diarrhea and fever. Oh and he has Gilbert's syndrome.

Needless to say, my brother's hospital stay was a fucking disaster. He was bounced from one service to the next in the attempt to come up with a single diagnosis which would account for each symptom, sign, and lab value. His primary care doc (ID) was on vacation, a fellow was covering in the office. No one knew who was authorized to talk to whom. The various services couldn't keep my brother's coverage straight, and the nursing staff didn't know which doctor was on what service and what service was on call when. Labs which were ordered didn't get drawn because they weren't ordered right the first time (and sometimes second), peaks and troughs were inverted or totally missed. Unnecessary imaging was performed, biopsies were ordered and then canceled at the last minute. Follow up on any error was somewhat expectedly poor given the many, massive cracks for something as apparently minor as bloodwork or a CT scan on a stable inpatient to slip through. Like I said, fucking disaster. But we stuck it out. We did so by constantly leaning on the primary's office, keeping our own notes about what had been ordered when, and getting to know the interns and residents really well. Yes, we were the pain in the ass family, but keep in mind, my brother's HIV status was still new and his doctors had been going down the path of kidney infection so we were scared. Eventually, the multiple, cascading causes of my brother's presentation were elucidated and addressed (more or less) and after only three false starts ("hey, he's going home today as soon as they do rounds and write the order!"), he was finally discharged.

I'd like to think that hospital and residency administrators had identified the little mini-catastrophe that a service-wide medical staff change like this causes every year, that they'd learned some tricks like staggering schedules so that radiology, anesthesia, internal medicine, surgery, emergency medicine, and infectious disease didn't all completely change staff at the same exact time, but I'm guessing this is more of my boundless optimism. I'm guessing that because my aunt just checked herself out AMA from another (different) big city hospital last night after being juggled, bounced, and rescheduled around for days. She was admitted Friday night for a Monday AM bronchoscopy (looooong history of heavy smoking - PET scan showed a mass). The scope was postponed all day Monday due to a back up. Then Monday night, the team changed its mind and decided on a needle biopsy (placement of the mass), but it was impossible to schedule with radiology through Tuesday. Tuesday evening, a nurse told my aunt "yeah, this kind of thing happens all the time". I understand why she said it, and I expect her intentions were entirely good and even sweet. Unfortunately, my aunt had been cooling her heels inpatient for too many days so she could undergo a procedure to confirm that she has lung cancer - at least this was what was going on in her mind no doubt. And while she waited, patiently or not, she was witnessing the hospital screwery that is July. I think the conversation with the nurse was the last straw and also an excuse to run away. Within an hour she had signed herself out AMA and now plans (or says she plans) to have her primary care doctor set up the biopsy outpatient through Local City Hospital, which has earned the nickname of "Local Shitty Hospital". But who knows, maybe Local Shitty (not a teaching hospital) isn't so bad comparatively speaking, at least in July.

A timely article

Since I was just writing about compliance (to medication regimen), Medea, and Large Marge, this seems to be an appropriate reading for the day. I'm supposed to be writing a lecture on hypothesis development and testing, but ow.

And my attention is less than razor sharply focused.

I've gotta say, after looking over the abstract, I find myself quite curious about the "pictorial blood loss chart" used in this study.

Also, I can't help wondering - where's the imaging man? Here I am looking at stuff on muh-muh-muh-My Mirena (see, it's not just the Macarena it fits with - it's a quite musically handy word) and finding a long term study on side effects of the blasted thing and it seems they didn't collect data on ovarian cyst formation in women using The Device.

Can I get a hearty wtf?

bitter pill

When I was taking doxycycline for my acute Lyme infection many years ago, I developed a serious aversion to it. I had to force myself to swallow each twice daily dose. So great was the desire not to take it that I sometimes gagged on it and had to spit out into my hand, take a moment to visualize that it was a large tic tac, and then pop it in for another go. I often forgot to take it when I was supposed to. There were many, many nights when I had to get up out of bed, eat some crackers, and take the damned pill because I had totally "forgotten" to take it before I brushed my teeth and settled down for sleep. How did I remember after I got into bed? I had finally taped a sign to my bedroom ceiling to remind me to take the pills.

Why was it so bad? Because within two hours of taking it, I would feel HORRIBLE. It wasn't an upset stomach. It's hard to describe...I felt like my brain had been scrambled. My head felt like I had taken a blow from a 2x4 right dead center on the forehead. My eyes ached. I couldn't stand light and sitting up or standing made me feel like I was going to puke and pass out.

This happened every single time I took a pill. The time frame on it might be off. It's been a while since I was on the doxy and I tried so hard to forget the details. Some of them will stay with me for a while I'm sure but stuff like "did it start in two hours or was it peaked and falling off by two?" is information I can and therefore do forget.

When I was on the IV rocephin a year later, I had another sort of odd psychological reaction. This one wasn't based in any physical aversion training. It was the creepiness of knowing that little port not far above my elbow was the leading end of a line that went smack into the superior vena cava. The exact placement of the end of the line was quite apparent to me since for a few days after I had it placed, every time I crossed my right arm over my chest - say to brush the teeth in the left side of my mouth - my heart would go "ka-chu-u-unk" instead of the usual "ka-thunk". I had them pull it back some. (Yeah, like I said, I'm that patient.)

Point is, I knew it was there and I sometimes had to think really hard about not thinking about it so I wouldn't get skeeved out. About the second week in, I noticed that if I successfully accomplished this goal, I'd forget about the line maintenance routine. So it's flushed twice a day, once after the drug and once again about 12 hours later. On the days when I'd managed to not be thinking overly much of my PICC and where it went, I'd forget to bring my supplies with me if I was out. It was sort of a catch 22 - think about it and fret but remember to be prepared to take care of it or not think about it and be so blissfully unaware that I got caught more than once without my syringes.

These days, when I miss a pill or forget if I took one, I can't help wondering if there's some kind of aversion issue happening. The ones I forget now have none of the obvious displeasures associated with the doxy or the PICC line, but there are two in particular which I consistently forget to take or forget if I've taken. Unlike my elavil, which I seem to hardly ever forget to take and never forget if I have taken, I far too often find myself standing there looking at the package of PPIs or bottle of NSAIDs in my hand and wondering "crap...did I take one of these already?" or realizing many hours later (usually when the symptoms get raging) that I can't remember having taken one.

I've considered that there may be some regularity to this pattern. The one which has worked the best and without which have an eventual visible, marked effect (weight loss) is the one I am good about taking. It's not a simple cause and effect thing though. I don't feel immediately or even directly better after I take the elavil. It's a cumulative thing on a much longer time scale than I would have thought necessary to induce such an association. So what's going on with the others then that makes them so readily forgotten?

I was thinking about this today after I got off the phone with a friend who's been doing chemo every other week for about many months now. She's been switched to a once every three weeks course now, but says it still sucks a bunch. I also thought of another friend who had to administer Hepatitis C treatment to herself at home (this woman hates needles) and my brother who's taken various HIV and psych meds, all with various side effects and the occasional adverse event.

How the hell do they face each dose?