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My Extremely Fancy Colonoscopy

THE QUEST TO BE POKED AND PRODDED BY THE BEST OF THE BEST OF THE BEST
by James McManus
Illustrations by Tony Millionaire

My Extremely Fancy Colonoscopy

James McManus
14 Snaps

Because of my age, positions of influence, birth order (first of seven) and other factors, I tend to trust those in authority. Whether I’m buying a car or a puppy, a novel or a computer, I’m content to deliver myself into the hands of an expert. Instead of spending decades learning Russian with run-of-the-mill comprehension, I count on Richard Pevear and Larissa Volokhonsky for versions of Anna Karenina and The Brothers Karamazov more subtle and poetic than I could ever in a hundred years hope to come up with on my own. The time I save not trying to parse Count Lev’s upper-caste syntax or Fyodor Mikhailo­vich’s born-again Slavophile ravings, to say no­thing of the Cyrillic alphabet, al­lows me also to read The Mahabharata, the Iliad, My Name is Red, and Love in the Time of Cholera, albeit in translation. Not that the world wouldn’t be a better place if I mastered Sanskrit, Ho­meric Greek, modern Trojan, and Colombian Spanish and thus partook of those cultures directly; on the other hand, bro, life is short. It’s for much the same reason I don’t cram for the MCAT, attend and pay for medical school, then do a six-year gastroenterology residency when I come down with diverticulitis: because any board-certified specialist worth her sodium chloride knows infinitely better than I ever could what sort of shape my intestines are in, better still how to heal them.

One obvious downside of this way of thinking is that millions of postmenopausal women who took estrogen with progestin were following the same logic, and they were often fatally misled. We found this out only in July, 2001, after the Department of Health underwrote the Women’s Health In­itiative’s randomized control trial, which showed that the numbers who developed breast cancer, heart attacks, strokes, or blood clots in the lungs were higher on the E Plus P regimen.

Likewise the Cardiac Ar­rhythmia Suppression Trial in 1991 re­examined the conventional wisdom that certain antiarrhythmia drugs helped prevent second heart attacks. The trial involved 1,500 heart-attack victims: half received antiarrhythmics while the other 750 were slipped a placebo. These mortally vulnerable patients thus had the same odds of getting the lifesaving therapy as they’d get on the pass line of a craps table. How darned unfortunate, then, to be randomly shunted into the placebo group, condemned to crap out by a computerized roll of the dice! Yet researchers have to break eggs to make omelets, right? And so, in the interest of medical science, the trial was scheduled to run for at least two years. The early results were so dramatic, however, it was halted after only ten months for the health of the unlucky guinea pigs. Those patients knocking back a sugar pill each morning, in the innocence of their already damaged hearts, were found to be about two and a half times more likely to survive than those ­ta­king the antiarrhythmic.

Two generations ago, doctors smok­ed cigarettes in TV commercials, and people with my genes and habits bought the farm even younger. It also turns out that if you were born in the Northern He­misphere during the month of May, you’re 13 percent more likely to develop multiple sclerosis. Better to be born in November, according to Professor George Ebers of the Radcliffe Infirmary at Oxford Uni­­versity. In other words, if you have a family history of MS, it’s best to make procreative love during February. On Valentine’s Day, for example, after exchanging cards dappled with pink hearts and ­cutely drawn demyelinated nerve fibers.

In the meantime, though, I have flown to Minnesota for a three-day executive physical (which would include, because of “my little gastrointestinal adventure,” a colono­scopy), at the Mayo Clinic. As the Mayos and their architects anticipated, no healthy person, let alone someone who’s mortally ill, wants to traipse through a Minnesota winter from appointment to ap­pointment, so they put in a subway system and fitted it with chandeliers, Chihuly flowers, and enormous glass panels near the top, facing south to let in extra sunshine, while in August the mega AC compressors make everything pleasanter for that patient, such as myself, who is about to have a digital video ca­mera launched up his rectum.

*

One of the brightest guiding lights of modern Western medicine, Wil­liam Worrall Mayo, studied science in his native England under John Dalton, who in 1803 had form­ulated the atomic theory of chemistry. Be­fore Dalton reorganized the pe­riodic table according to the atomic weights of the elements, edu­cated people understood atoms in terms of characteristics observable with the five senses: soap atoms were thought to be slippery balls, acid stung because it was made up of barbed hooks or triangles, air consisted of miniature springs, and so on. Dalton and students like Mayo eventually helped us make several huge leaps in our understanding of the chemical nature of health.

After sailing to New York in 1845, Mayo was hired as a pharmacist at Bellevue Hospital, where he dispensed things like castor oil and leeches and was paid so little he was forced to supplement his in­come with work as a tailor. Four years later he moved his burgeoning family to Lafayette, Indiana, where he undertook Dr. Elizur De­ming’s sixteen-week course at the Indiana Medical College. Mayo and his hundred fellow students were forced to share a single microscope; this put them one up, however, on students at Harvard Medical School, which wouldn’t pro­vide its first microscope for an­other twenty years.

Mayo’s education spark­ed a lifelong passion for chemical analysis, with what might be found looking deeper—or just to the west. Traveling by horse and buggy in 1854, he left the malarial climes of Indiana and lighted out for the brisker weather of Minnesota Territory to set up a practice. Known as the “Little Doctor” because of his five-foot-four-inch stature, he was also the only one around who used a microscope to make diagnoses. In much the same spirit, he pioneered ovariotomy—making ab­dominal incisions to determine whether tumors were present—and other techniques of what was all too accurately called kitchen surgery. By 1863, Mayo had been appointed an examining sur­­geon of draftees and volunteers for the Union Army in the southern half of the new state of Minnesota, whose draft board was headquartered in Rochester. He soon moved his family there and set up a practice in which he was eventually joined by his sons Will and Charles. When a tornado struck the town in 1883, destroying most houses and commercial buildings, the Mayos worked with Mother Alfred Moes and her Sisters of St. Francis to provide shelter and medical care for the victims. Rochester had no infirmary, so they turned the only dance hall left standing into a surgical ward. Making do, they kept Minnesotans alive. Once the crisis passed, ­Mother Alfred raised $60,000 to build a hospital and lassoed Dr. Mayo and his sons into serving as its physicians. Saint Mary’s, their twenty-seven-bed institution, op­en­ed in 1889. As other doctors at­tached themselves to “the Mayos’ clinic,” the peculiar idea of a group of specialists caring for patients en masse began to take shape. Common medical records were established by 1907 to serve the five thousand people who flocked there each year. A network of conveyor belts was designed to move X rays and paperwork more efficiently, in conjunction with one of the world’s first telephone paging systems.

Doctors from all over the world began to visit to study, leading in 1915 to the Mayo Graduate School, the first institution devoted to training medical specialists. (The three interlocking shields of its logo represent the mutual dependence among clinicians, researchers, and ed­ucators.) Among hundreds of other salutary accomplishments, Mayo clinicians received a Nobel Prize, for the use of cortisone, in 1950. In 1994 they pioneered a study of endothelial dysfunction and chest pain, sparing millions of heart patients terrifying ambulance rides and hazardous angiograms. More recently, Mayo scientists de­veloped genetic therapies to repair atherosclerosis and began programming stem cells to generate new, healthy blood vessels.

The Rochester campus now has 1.4 million outpatient visits and 321,900 inpatients a year, all of them under the care of 1,626 physicians and scientists, 1,636 residents and fellows, and a staff of more than twenty-six thousand. Eighty percent of these patients come from the upper Midwest, two percent from outside the U.S.; about a third are on Medicare. At more than fifteen million square feet, the clinic is almost three times the size of the Mall of America, the Gopher State’s less useful mecca. Satellite campuses in Scottsdale and Jacksonville bring the total number of inpatients to 503,000 per year. But Mayo’s influence emanates  much more widely. Today, just ab­out anywhere in the world, if you’re having blood drawn for chemical analysis (not let to rebalance your humours), awaiting the results of a biopsy, having genetic material examined through an electron microscope, or simply lying on something besides your kitchen table while being treated by a specialist, you are benefiting from the Little Doctor’s pathfinding spirit.

*

Seven o’clock Monday mor­ning, I present myself at the Executive Health Program desk on the seventeenth floor of the Mayo Building in downtown Roch­ester, just across the street from our hotel. The EHP costs $250 more than a regular physical, with the extra fee covering what the brochure calls “a streamlined yet comprehensive exam designed to be completed in the shortest possible time.” Like all Mayo physicals, it will include preventative screening tests, a comprehensive me­dical history and examination by an internist, and referrals (if necessary) to subspecialists, as well as health risk and lifestyle assessment for physical fitness. A friendly wo­man hands me an appointment fol­der: printed schedule, test instructions, plastic jar for a urine sample. I’m to go when I can, then drop it off at Station S in the subway connecting the hospitals.

My first appointment is for 7:30 at Desk C of the Subway Level, for Venipuncture Specimen Collection. I’ve been fasting since last night at 7:15, and I’ve taken no aspirin or iron-containing vitamins for a fortnight. My instruction sheet also has a fifty-point exclamation mark to remind me of my co­lonoscopy Tuesday morning. No solid food for another twenty-four hours—twenty-seven, actually, since I won’t come out of anesthesia till tomorrow afternoon. By then we’ll be talking almost two full days, two empty days, without eating. Black coffee, tea, JELL-O or clear chicken broth are OK, but forget about cranberry juice or anything of similar hue. “These liquids show red in the colon and can be confused with blood,” warns the sheet.

By 8:04 I am two blocks away in the Gonda Building for an electro­cardiogram. I line up outside the long row of cubicles with two dozen well-fed executives in their fifties and sixties, all of us shirtless and hungry as electrodes are stuck to our chests. Then it’s back to the Mayo Building for earwax re­moval. I tell the otorhinolaryngological nurse, Lisa Thoe, that my hearing has deteriorated in the previous decade or so. I can’t always tell what my students in the back of the room are saying, and my wife complains she has to repeat herself half the time. Nurse Thoe has me sit back in what looks like a dentist’s chair, complete with overhead klieg light and trayful of gougers and diggers. And then in she goes: crunch, rasp-rasp, scrape, chisel-chisel…

“No earwax in here, Mr. McAnus.”

I patiently correct her, then ask, “Are you sure?”

“Sorry. But nope, none at all, Mr. McManus.”

“OK…”

She swings her chair and tray around to check my left ear. Same result. Must be eardrum degeneration, not hygiene, so I’m sent across the hall for a hearing test. Greg Smith, the tall, blond technician, fits me with headphones that have light wands springing out like an­tennae. Looking through a window and speaking by intercom, he tells me to press a button when I hear the “isophonemes” he’ll shoot me.

Turns out I have excellent hear­ing, “above normal” levels for healthy young ears. My right ear has 100 percent recognition at 40 dB, my left 95. I have a hearing threshold level of 10 dB at 250 Hz, and under 5 as the frequency moved into the 4,000–6,000 Hz range. “My wife says the same thing,” Smith confides. “It may have to do with our ability or willingness to concentrate on what’s being said.” Which my wife Jennifer will be un­shocked to hear, at whatever Hertz level I speak at.

*

For my chest X ray, I wait on a bench with a senator from a northern plains state, a genial guy around my age who prefers not to be identified. He seems to be following me from test site to test site, unless it’s the other way around. I’m able to say he looks a lot different in a knee-length powder blue bib from the way he does in the dark, rumpled suits he favors for TV appearances.

Is the executive program elitist? Depends who you ask. (I don’t ask the senator this, mainly because it’s clear his focus today is quite personal.) Those whose hard-earned in­surance allows them to come here would tend to say no, I will guess, while the obverse would also be true. America seems not to want socialist flatness, wherein everyone gets mediocre health care at best, but nor will we tolerate too wide a gap between haves and have-nots. Most of us accept that certain members of every culture get cared for more lavishly than others, and that this is not always the worst of all possible worlds. Only czarinas and counts got to flush away “night earth” two hundred years ago, but the steady development of royal technology is why just about every­one now gets to sit on a porcelain throne fitted with copper plumbing and triple-ply Charmin. R&D can take years, even centuries, but eventually the benefits trickle down to the rest of us, though I’m the first to admit that this might not be the most fortunate metaphor. Even Honest Re­publican Abe used an outhouse for most of his life. It wasn’t until 1860, decades before Thomas Crapper brought us the Silent Valveless Water Waste Preventer, that Mi­chael Flannigan invented the Fecal Banishment Apparatus, also known as the Ablutions Assistant. Lincoln himself gave it a test drive in 1862. “Tar nation!” he declared. “Mr. Flannigan’s engine could pull the feathers off a goose at twenty paces. For a man standing to relieve himself from a fair distance, this contraption makes it darned near im­possible to miss! The lady folk will be most appreciative of that.” The president, however, soon had what he believed to be a clairvoyant night­mare in which the device swal­lowed his son Tad, and he de­cided against installing one in the White House. Tad’s eleven-year-old brother Willie had just succumbed in February to typhoid fever, al­most certainly caused by pol­lution of the capital’s water system; many historians also believe General George McClelland’s near-fatal bout with the disease almost sank the Union’s cause. So even at the top of our social pyramid, people died of such things fairly recently.

A couple of summers ago Garrison Keillor, a registered NPR-type, found the Mayo to be quite democratic. While it’s famous as the clinic where, as he put it, “the Ex­alted Nawab of Lower Rawal­pindi’s fourteenth and fifteenth wives go in for a chest X ray,” Keillor noted that it also quietly serves most of southern Minnesota. His only complaint was that during his checkup he had to wait a lot, and he recommends bringing a book—Dante or the Book of Job. But he called this “the Lourdes of the North.” (Time 8/28/00). For an extra $250, the price of a half-de­cent Weber or a WSOP Super Sa­tellite, senators and corporate VPs and credentialed reporters don’t have to wait quite as long.

*

“Turn to the right and cough.” I comply. Nothing like knobby male fingers probing your scrotum to mitigate guilt about privileged white maleness. No, sir.

“OK, that’s good.”

The doctor in charge of my over­all checkup is Donald D. Hensrud. From the earliest days, each Mayo patient has been assigned a personal physician who coordinates access to all clinic services and follow-up treatments. Hensrud’s job is to initiate my chart, check my vitals, perform a comprehensive history and physical exam, decide which further tests are appropriate, then integrate the results into an overall prognosis and treatment plan. He has no vested interest in testing for every last thing or in skip­ping the pricey tests, either. In this he is following “the spirit of the clinic” established by William J. Mayo in 1921: “Group medicine is not a financial arrangement except for minor details, but a scientific cooperation for the welfare of the sick.” All Mayo doctors receive a salary unrelated to the number of exams and surgeries they perform or lab tests they order, and the clinic proudly continues as a not-for-profit, charitable public trust.

“Please kneel down there and lean forward.”

Oh, boy. Hensrud has almost freakishly wide blue eyes, pale skin, and silver hair parted in the middle, combed back. Midnight blue suit, crisp white shirt, glinting yet sober blue tie. For an extra dash of color, he’s wearing a mauve rubber glove, with which he points to a pullout ledge near the bottom of the ex­amining table. Kneeling down with my back to him feels extra peculiar, perhaps, because he’s wearing that suit instead of a lab coat, especially as I tender myself to his application of a cool smear of lubricant. Ew. A moment ago we were having a civilized man-to-man, two fully clothed guys with young children, bi­cycles, wine, and our writing in common. Now Dr. Hensrud has a long, knobby index finger way up my rectum, feeling around to gauge, he informs me, the dis­tended­ness of my prostate. ­Finally, finally, maybe twelve seconds later, it’s over. “Absolutely normal,” pronounces my violator as he peels off his maculate glove. “No nodules or enlargement.”

“Great,” I say, assiduously av­oiding eye contact. “Yeah, great.”

As I lie faceup on the table, he de­termines that my venous pressure and jugular reflexes are normal, my carotids without bruits, my lungs clear, my flesh free of edema, and that pulses are palpable in my distant extremities. Once I’ve pulled up my boxers, Hensrud di­rects me to the changing room in the corner. Yahoo! Back in my clothes, I emerge a new man through the curtain, ready to re­sume our conversation as though no orifi have been penetrated.

The fact is, Hensrud’s modesty and gravitas make him seem almost saintly—Alyosha Karamazov in pin­stripes, with a wallful of high-powered medical diplomas instead of a monastic faith in Orthodox Russky miracles. Two M.A.’s in public health, medical degrees from four universities. He also serves as the medical editor in chief and lead writer of Mayo Clinic on Healthy Weight, a book I’ve been reading all summer.

He pointedly asks whether I’ve had family or work problems related to alcohol.

“You mean like tavern brawls, wilding…”

Patient smile for the defensive patient. “DUI arrests and the like.”

“No DUIs, no.”

“That’s good. How much do you drink?”

Even while grilling me, Hensrud’s tone remains formal but warm, with a throw-his-head-back-to-laugh sense of humor. He makes direct, friendly eye contact, hears out my answers, and speaks in complete sentences and paragraphs. Not that I always want to li­sten. “When you have family members who develop heart disease this young, especially with your grandfather at thirty-five, we’re of course more concerned about it. The fact that your father was a smoker and had Type II diabetes certainly increased his risk. When I see a family history like this, I ask about other things we maybe haven’t checked yet. Homocysteine, for one, a protein in the blood that acts like cholesterol—the higher the homocysteine, the greater the risk of heart disease. Lipoprotein (a)—kind of like cholesterol in that it increases your risk. Another one is C-reactive protein. We’re going to check these to see if they might be elevated.”

Thinking of David Letterman’s by­pass, I ask, “Isn’t there some machine that can gauge, you know, blood flow?”

“Right now there isn’t a noninvasive way to check for narrowing of the arteries. But we’re not going to order angiograms on anyone without symptoms, much less somebody who’s young and healthy.”

I wanted to hug him but managed to restrain myself, in no small part due to the freshness of our proc­tologic encounter. “What ab­out someone like me, though, who’s got the family history, ain’t so young anymore, and sometimes feels twinges?”

“Well, first we characterize the chest pain, then we do diagnostic studies. And we emphasize prevention and controlling risk factors, because that’s the bottom line anyway. You’re not having symptoms, so you aren’t a candidate for surgery based on what we think the anatomy might show. Otherwise
I would order an angiogram.” He picks up a life-size heart model, which I find hard to look at—as if it might cause a myocardial infarction psychosomatically. “We’d in­ject dye into these three arteries to see how much blockage there was. That’s the gold standard, though it’s highly invasive. And without any symp­toms at all, we just don’t do angiograms. They’re a pretty big deal, which is why they’re performed in a hospital. The benefits don’t outweigh the risks. You do enough of them, you’re going to cause problems in somebody where none had existed before.” He puts down the heart. “What we’ll do is a coronary calcification study, an ul­trafast spiral CAT scan of the heart that looks for calcification in these arteries.” He points to the center of his chest, two-thirds of the way up the blue tie. “As plaque builds up and narrows the artery, it calcifies.” He knows
I got scanned at the University of Illinois five years ago, and he picks up their printout, which I mailed in with the lengthy questionnaire
I filled out one month before my appointment. “This is good. You were at the fortieth percentile. Fiftieth percentile would be average, of course, but for heart disease, you don’t want to be average be­cause one of three people will die of it.”

“Roger.”

I’ve read in the Mayo Clinic Heart Book that cardiovascular disease is the country’s No. 1 killer. Not cancer? Not guns or DUIs? Nope, and it’s not even close. Heart problems kill more of us than the next seven leading ­causes combined. Sixty million Am­ericans are on track to go out in this manner.

“What’s good,” Hensrud says, “is despite your risk factors, high cholesterol, and family history, you were better than average on this, but you have to remember this test looks at calcification indirectly. What we don’t know is whether the plaque has built up in a critical area, or whether it’s likely to rupture. It’s an imperfect test, though it does give us good information, and in your case it gives us a baseline. We’ll give you another one now, compare it with five years ago, and see if there’s been major progression.”

Next subject: diet. Shamelessly deploying flattery as a goad, Hensrud tells me, “You’re already on the right track.” Pregnant, professional pause. “I would cut down on your portion size. I hate to say this, but you should also cut back on the pasta, increase the vegetables and fruits…”

It’s a privilege, of course, to be ex­amined by a doctor who’s a leader in his field: who has research ongoing, who publishes his findings in authoritative fo­rums like Car­diology: Today and To­morrow (May 2002) and The American Journal of Cardiology (July 2002). Even two-year-old re­search can be much less useful these days, when the state-of-the-art is ad­vancing so rapidly. It matters less to me that Hensrud also consults for ABC News, Fortune Magazine, and Blue Shield of California than that he literally wrote the book about how a person with my cardiovascular issues should eat and take care of himself. Like most people, I don’t require the steadiest (and priciest) surgical hand guiding a laser through my ventricles—yet. I need to be told by someone I re­spect what to eat and drink and what not to, and which medications to take. Not that a lesser doc would scan my test results and put me on a diet of deep-fried chi­michangas and blue agave tequila, but when a Mayo clinician is doing the nudging, the message may finally get through.

*

In my room at the Kahler Grand Hotel Monday even­ing, I knock back my first dose of Fleet Phospho-Soda, a putatively ginger-lemon-flavored oral saline lax­ative. That is, I try to. After mixing 1.5 oz into a half-full glass of water, I take my first sip. If the Dead Sea’s a 2 on the icky continuum and King Oscar sardine juice a 3 1/2, Fleet Phospho-Soda is at the very, very least an 11. The trick is to get as much of it down my throat while tasting as little as possible, mainly by pouring it past the more sensitive taste buds near the front of my palate. I plop in four ice cubes and click on the television, settling back with my cocktail of little barbed hooks. So as not to tempt dear old dad, Jennifer and our two daughters are dining downstairs in the restaurant; our suite also provides separate bedrooms, an excellent thing for reasons I’ll address in a minute. The girls had a wonderful day exploring Rochester and environs, especially the old-time movie theater converted into a Barnes & Noble with a vast children’s section. The only downside, according to Jennifer, was the heartbreaking horror show of terminally ill children being wheeled back and forth between hos­pitals. She had a lot of hard questions to answer.

One place they probably won’t want to visit tomorrow is the Roch­ester Federal Prison, a ­“cou­ntry-club facility” (according to my complimentary issue of Ro­chester Magazine) just up the road that until recently housed longtime Chicago congressman Dan Rostenkowski. Other guests have in­cluded perennial candidate Lyndon LaRouche, nut-job evangelist Jim Bakker, broomstick-wielding rapist Justin Volpe, the only FBI agent ever convicted of first-degree man­slaughter (Mark Putnam, for strangling an informant) and Clyde Bellecourt, who occupied the Bureau of Indian Affairs in Wounded Knee, South Dakota. Currently on hand in the facility is Sheik Omar Abdel-Rahman, the blind colleague of Osama bin La­den who sanctioned the Islamists who gunned down Anwar el-Sadat, de­tonated bombs outside our em­bassies in Africa, targeted landmarks and humans all over New York and Cairo, and managed to strike the World Trade Center in 1993 and 2001. Many of these attacks must have been spiritually encouraged from his comfy cell right here in Rochester. Mayo doctors and their unholy Western medicine continue to help Abdel-Rahman avoid further deterioration of his eyes and internal organs, though it cannot be easy for them. It has been reported that one doctor placed a hand gently on his shoulder, her usual way of establishing rapport with blind patients. When the sheik wrathfully brushed her off, she ap­ologized, adding that she’d meant it only as a gesture of friendship and respect. “If you respected me, you would know that a woman in my culture would never dare touch a man!” Wincing and sipping my Fleet,
I try to imagine the human touch a violently rabble-rousing Christian or Jewish cleric would re­ceive in a Muslim penitentiary.

If their numbers along Mayo cor­ridors and on sidewalks downtown are any indication, Arabs and Muslims are certainly made to feel welcome in Rochester. This hotel has a five-page menu of Middle Eastern cuisine printed in Arabic. Hanging with the Stars and Stripes in the dome above the rooftop pool are the flags of Saudi Arabia, Jordan, Oman, United Arab Emirates, and Turkey, along with those of Mexico, Australia, and the Seychelles. The cable TV package includes four Arabic stations. Right now Channel 63 has a huge crowd swirling around a black glyph in what must be Mecca, with closeups of worshippers chanting their prayers; the station’s logo on the screen’s upper left is a palm tree emerging from a pair of crossed scimitars. Al Jazeera is on Channel 64. Next time I click there, enraged Palestinians are bearing a bloodied young man on a stretcher.

Watching this helps pass the time between limping sprints to the bathroom. By 8:37 I’m down to short blasts of ginger-lemon fizz and shorter, more parched emanations—or as Dante wrote of another inferno, ed elli avea del cul fatto trombetta (“and he made a trumpet of his ass”). Meanwhile, Arabest News on Channel 65 has mountainous battlefield footage from what must be Kashmir. Channel 66 has a soap opera: men without beards, women in chic clothes and hairstyles. An anchor in a Western business suit reads the news on Al Jazeera next to footage of Vladimir Putin.

Our own president, as it happens, underwent a colonoscopy by a Navy GI a few weeks ago at Camp David. Two benign polyps had been discovered while he was governor of Texas, and this last procedure was part of the standard follow-up. Gi­ven a choice of local anesthesia and mild sedation or a general anesthesia with Propofol, Mr. Bush chose the latter regime. Before going under at seven a.m., he invoked the 25th Amendment, transferring power to Vice President Dick Cheney just in case, for example, Saddam or Osama took the opportunity to lob a few Scuds at the Halliburton derricks in the exurbs of Riyadh or Fort Worth while the “‘“real”’” commander-in-chief was sedated. The only previous in­vocation of this amendment came in 1985, when Ronald Reagan had surgery for colon cancer and George H. W. Bush, not Alexander Haig, damn it, was in charge for seven hours and fifty-four minutes, paving the way for H. W. to become, in a sense, a two-term president himself. It remains to be seen whether the same colorectal pretext will work for Mr. Cheney.

Naval colonoscope was withdrawn from presidential sphincter at 7:29, and Mr. Bush came to at 7:31. Most doctors check their patient’s post-anesthesia alertness by asking who the president of the United States is, but we’re told Mr. Bush’s GI, Air Force Colonel Richard Tubb, chose an equally obvious question, though we haven’t been told what it was. Perhaps he asked, “What’s the capitol of Grecia?” or “Wasn’t Cruise awesome in Top Gun?” In any event, by 9:24, after tossing a ball for his dogs and scarfing a plate of waffles, the president was back, so to speak, in the saddle, ready to bushwhack any godless stem-cell research, sign a more fair and balanced tax code, then—saving the best for the last—de­cide who gets to be the ace of spades on his cool desert-camouflage poker deck.

*

Tuesday morning at 4:45 my wake-up call an­nounces it’s time for my second round of Fleet. This time
I cheat by diluting the stuff with twice the recommended volume of water, but it still ain’t the perkiest beverage to help you greet Dawn’s rosy fingers, let alone your gastroenterologist’s.

After ninety minutes of CNN, Fleet, Al Jazeera, no breakfast, and a shower interrupted by my ump­teenth scalding sit-down, I hustle four blocks to the Eisenberg Building, check in, and dash to the men’s room. Reemerging eight minutes later, I submit to yet another blood-pressure cuff and digital ear thermometer, declining advice about a living will before dashing to the men’s room. Soon I am ushered into a deeper, more sterile waiting area, which has its own men’s room, thank God.

My only fellow waiter this mor­ning is a large, chatty man from Kansas City. As naturally as if we’re placing the Royals and White Sox on the abysmal continuum, we start shooting the… breeze about colon health, HMOs, Fleet preps. The young man—he tells me he’s ­thirty-six—shakes his head in wonder to hear that I had to down only one glassful of Phospho-Soda per session, for a total of two, then makes me repeat myself to see if he heard right the first time. For some reason, his prep required one glassful every fifteen minutes for three and a half hours. Worse, this is his “ninth or tenth” colonoscopy. His father and two of his uncles died early, and he himself has already had “dozens” of polyps removed. He does not use the C word but says that, depending on what they discover this morning, the Mayo GI team will probably advocate re­moving his entire colon, which will mean “wearing the bag” for the rest of his life. A string of clichés about “these days” and “all their advances” is the best I can ma­nage to encourage him. When they call his name first, we shake hands, don’t smile, and wish one another good luck.

Ten minutes later Lawrence Szarka is looming above me in the chrome and glass dazzle of en­doscopy suite No. 2, because what other room would they put me in? We’re surrounded by EKG and vi­deo monitors, a pneumatic tube por­tal for biopsy specimens and right here, up close, atop Szarka’s instrument table, a colonoscope coiled like a silvery Mapplethorpe bullwhip. Am I ready for this? We will see. I lie on my side, semifetal, with my back to the doc, watch the nurse pump 100 mcg Fentanyl and 5 mg Midozolam into the back of my hand, and wake up thirsty in the recovery room.

Wha happeh?

What happened was that, soon after I passed out at 8:10, a second nurse, Marcia Ward, applied a liberal dose of Novaplus lubricant to pa­tient McManus’s anus, through which Dr. Szarka inserted the Ol­ympus PCF-160AL variable stiffness pediatric colonoscope. For the last two years, he and his fellow GIs at Mayo have been using kiddie co­lonoscopes on most mature pa­tients. The PCF-160 is leaner and more flexible than the standard adult model, but in the right hands it still gets the job done. Guided by the camera and lamp at its tip, Szarka advanced the scope into my ce­cum, which he identified on the monitor in front of him by the presence of the appendiceal orifice and the ileocecal valve. Clean and clean. He intubated my terminal ileum (also known as the Sac of Troy) for a distance of 5 cm and observed it was normal. The mu­cosa in my sigmoid colon (named, of course, for the Viennese punk power trio founded and disbanded in August 1973 by the radical grammarian Hans X) had scattered small diverticula, also normal for a person my age. He also observed that my bowel preparation was excellent, thank you very much, and that so far I was tolerating the procedure quite manfully. If I could have, we would’ve touched fists.

The a-ha moment came after Szarka had reached an anatom­ically difficult hairpin turn in my sigmoid colon, in which he spotted some protuberant tissue. No, not my head. Just a polyp. Assisted by Ward, he passed an electrocautery snare through the scope, positioned it above the polyp, and lowered the lasso loop over it. Ward pulled the snare’s other end until she and Szarka could see on the monitor that the lasso had tightened around the base of the polyp. By pressing a foot pedal that sent twenty Joules of energy through the snare, Szarka cauterized the base of the polyp while pulling the rest of it away from the wall of my colon. When he told Ward to cut, she tugged on the trigger device, which snipped off the polyp by closing the snare all the way. Szarka then suctioned the damn thing back out through the channel and into the light. Fifteen millimeters long, it was about the size and consistency of a shitake stem pickled in sake. He drop­ped it into a specimen container, which Ward slid into the tube portal behind her, from which point it was sucked over to the Department of Laboratory Medicine and Path­ology in the Hilton Building, three blocks away. Data gathered during these procedures are trans­mitted electronically, of course, but you still need a three-dimensional tube to convey bio­logical specimens. Mayo’s pneumatic pipeline was in­stalled in the 1930s to more efficiently relay files and lab samples around the campus; these days the system is controlled on Windows NT on a Pentium platform. Over in Patho­logy, a technician sectioned the polyp and applied a stain of hematoxylin-eosin; without the stain, such tissue cannot be visually distinguished from an adenomatous polyp, the sort that can become cancerous. Following once again in the footsteps of W. W. Mayo, pathologist Susan Abraham was scheduled later today to slide the specimen under a microscope and make her diagnosis. In the meantime, back in Suite No. 2, Dr. ­Szarka found the rest of my colon, including a retroflexed view of my rectum, to be normal, though the PCF-160 provided only circumscribed views as to whether or not I was anal.

Once the IV was removed from my hand at 8:36, an orderly wheeled me down the hall to re­covery, where I came to a little be­fore nine. No,
I could not have some water. I’d been warned in ad­vance that my memory might get a bit dicey; it did. I may have fallen asleep again, too, but at some point a glance at my schedule reminds me I need to have blood drawn again before eating. Released from recovery at 10:26, I resume my executive powers.

Excerpted from Physical: An American Checkup, to be published by Farrar, Straus & Giroux in December 2005. © 2005 James McManus.

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