A coat-hanger round an old sock

It occurs to me that I haven’t blogged much on the actual subject of colonoscopy – it is my sole paid occupation of the moment. It is probably, to most people, a distasteful subject. Those who have some inkling of what it consists of usually assume a gas mask would be necessary, along with some borderline crazed personality fixated on faeces. A faecophile-dominated profession. In fact the bowel is pink and clean if you have a patient who can read the information leaflet (despite the multi-ethnic population of our city, our hospital sends them out only in English, on the understanding that “there’s usually someone who can translate in the family”), and has not been forced to take the bowel preparation as an inpatient where they forget to give it you, then feed twice the dose to you four hours before, having not allowed you to drink or eat for 12 hours. Of course this inhumane experience for the patient is also a disaster from our end: a dehydrated patient with a poo-filled gut leads to some very exasperated operators of the flexible friend, and doesn’t often get us any further with a diagnosis. The main point of it all, after all.

I am inspired to write because for the last two hours in between breastfeeding my teething baby back to sleep, I’ve been filling in the details of my colonoscopies of the last few months on an Excel spreadsheet. Mind-numbing, hence the break. However, it has set me thinking. I had a break from even this for a year to have my baby. At present I am entering the data from before I left to have her. My success rate is quantifiable - and I have just, after 3 months, made it back to pre-baby levels.
The colon is a long loopy thing. Passing this bendy tube round it is just difficult enough to be a challenge (luckily for the patient, or not, depending on your view). It is akin to trying to pass a coat hanger through a very long sock with your eyes shut. And, like surgery, you don’t mind doing the same thing again and again if it is complex enough, as there is a satisfaction to doing this well, and a motivation to keep improving and making it more efficient, or more elegant. I remember timing my appendectomies until I had done one in 25 minutes from first incision to finishing sewing up. After that, I felt cutting the time down further would be a triumph of bravado over safety so I stopped timing. The next challenge came with perfecting the size of the incision, and then with training others. I have spoken to some old greybeards who say that it all palls in the end. And all you are left with is the money. But that would be cynical.

The process of learning is predictable. There are known, anatomical bends in this thing and they are like markers of your learning curve. First, get out of the rectum my dear. This is particularly hard in women who’ve had a hysterectomy (so they say... this may just be the kind of surgical folklore which is brought in to buttress up one’s ego after failing at something). Indeed, one of my first bosses used to give me 3 minutes (the time he could, bravado all the way, make it all the way round in) at the beginning of each colon. I spent 3 months up the recta of half the population of that small seaside town before I ever made it out of a rectum... And so it goes on. Splenic flexure, hepatic, and that final hurdle, the ileocaecal valve. Despite being at separate ends of the scope, with very different opinions as to whether it should be advancing or withdrawing, you and the patient jointly cheer when it gets to the end – the delightful sight of the only recognizable bit of bowel drawing into view like a long-awaited harbour: the caecum. I even don’t mind a bit of the brown stuff here (very un poo-like and liquid. The scope ensures there is very little smell, and when you turn the hepatic corner into the last lap, often with difficulty and a sense of triumph, the poo has also, you note, been struggling to make it round the corner. Its lakes are a welcome sight of homecoming.)

Perhaps I haven’t mentioned colonoscopy because its outer reaches (inner reaches) are not for the faint-hearted. Indeed, they might make you think I was weird.. Well, I am glad to say that for once I was joined the whole trip round by a patient who was just as weird the other day. He’d had some of the usual jollop which I often suspect is over-dosed in order to render the patient a proper, asleep well-behaved patient who doesn't interrupt. Only, occasionally it has the paradoxical effect of inducing intense garrulousness. One of the recognised jobs of the endoscopy nurse is to take over talking to the talkative patient so that you can get on with the test. Serious. This patient, however was different. He was interesting. At least, many may be interesting only one doesn’t have time for small talk when one is wrestling with the splenic flexure. But he was interested in what he was seeing. So are many patients of the well-informed, not hung-up variety. But this bloke was just free-forming. Never has the inner landscape been so variously described and discussed. It was an alien territory. It was – as I explained, commonly referred to by us as looking like a Toblerone – the transverse colon. He was ecstatic over that idea and all forms of chocolate were dredged up and became parts of the colon: the Roses green triangle, Curly-Wurly, the inside of an easter egg... We passed the liver - give us a wave! And detected all his recent abuses of that organ. We were underwater, pot-holing, finding caves over little pink crests of bowel. Like the inside of an accordian. We were – somewhat like the part of the Tracey Emin film “Top Spot” where a girl is lost in endless tunnels with a carnivorous predator spotted padding forward – we were in tunnels. Trains, buses (the bendy buses of course). He wanted to know what everything was, every little ridge and vessel and streak of tomato. I’d found a fellow enthusiast. We could have been a team. Only his colonoscopy – thankfully one twinge only at the splenic – was normal. He had no indication for one again in the forseeable future. Sigh. A perfect partnership briefly twinkled, and was gone.