The Ostomy Files: Sharing What Comes Naturally

Common sense is in medicine the master workman. – Anonymous

A (Not Untypical) Case

  A 50-year old male patient underwent emergency surgery for a ruptured diverticulum with peritonitis.

A diverting transverse loop colostomy was established. He was visited postoperatively by an ostomy nurse and instructed on self-care. He chose to use a two-piece, closed-end pouching system to manage his temporary colostomy. Three months later, preceding closure of the colostomy, he presented as an outpatient for a barium enema to evaluate the distal colon. Shortly after the radiology technician began to instill contrast medium, the physician informed him the medium was incorrect. A second bag of contrast medium (barium) was hung and successfully administered via the patient’s rectum. At the completion of the procedure, the patient was told to go to the bathroom and expel any remaining barium via his rectum. He did so and left the hospital for the drive home. Several minutes later, he noticed that his ostomy pouch was extremely full, overly inflated, and leaking white liquid onto his clothes and the seat. Completely surprised by this and without any extra pouches, he was forced to pull the car over to the side of a residential street and empty the overflowing, closed-end pouch out the car door. This humiliating event prompted a letter of complaint to the hospital’s CEO.

  What happened here? Where did the breakdown occur among the patient, technician, physician, and ostomy nurse? This embarrassing and unnecessary event could have been avoided with better coordination, communication, and education of all vested parties. Unfortunately, this scenario may not be as unusual as one might think. After checking several online ostomy chat rooms, this author found examples of similar experiences from people with an ostomy who underwent various types of radiological examinations. “I remember the nurse emptying my bag before going downstairs for the scan and then when I got back to my room about 30 minutes later, the bag needed to be emptied again. When I told the nurse about it, she said ‘No, it’s fine. I just emptied it.’ She was shocked when she saw the bag was actually full again.” Another patient reported, “You can imagine my surprise when a local gastro doc suggested I take a bowel prep before having an ileoscope (sic) done. . . . needless to say I lost all faith in the man.”

Common Sense Education

  The scope of specialized ostomy nursing practice includes education of the entire healthcare team – purchasing agents, bedside nurses, nursing aides, OR staff, physicians, radiology technicians, billing agents, discharge planners, home care nurses and nursing aides, volunteers, patients, their families, and other ancillary services or individuals. Consider all the people and services (in- and outpatient) who may come in contact with your patients at some point along the rehabilitation process. Tailor information and educational content so it meets the specific knowledge and hands-on needs of the individual or department representatives at that point in time. Teach only is needed to manage the patient appropriately.

  For example, the staff in radiology should understand the anatomy and physiology of each type of ostomy surgery (eg. loop, transverse, end) because of the impact on specific bowel preparations and post-study elimination of barium, gas, and other radio-opaque dyes. The department should have some extra ostomy pouching systems on hand or at least know where to obtain them, how to determine an appropriate appliance for each patient, or how to reach the ostomy nurse specialist. Due to an often overwhelming case load, specialized ostomy nurses frequently overlook transferring their knowledge to include diverse members of the healthcare team. However, it is one of the best ways to help patients avoid humiliating and emotionally traumatizing events.

Preventing the Preventable

  What could have been done to prevent the patient’s negative experience in the radiology department? Ostomy nurses can play an important role with physicians, labs, and other testing departments by assisting with the development of written instructions for a variety of diagnostic studies for patients with various types of ostomies. Below is a brief list of what information might be included in each instruction sheet:
    • Pre-procedure education; what the study is designed to examine; why it is necessary; bowel preparation and/or dietary changes required
    • What to expect (eg, explanation of what is to occur; discomfort; injections/anesthesia; route of entry [rectum or stoma])
    • What supplies to bring (eg, extra drainable pouch, clip, and skin barrier)
    • Need to stay at the facility for 30 to 45 minutes after procedure to empty rectum and/or ostomy pouch (if indicated)
    • Use of colostomy irrigation sleeve and/or high output/fistula pouch to manage high output during or after the procedure
    • Dietary/fluid instructions before and after procedure
    • Contact information should problems arise.

Using Education as the Master Workman

  Often, as in other disciplines and facets of life, we find that the simplest approach is often the most effective but frequently the most overlooked. Specialized ostomy nurses intuitively know what has been outlined in this article. However, what can be misunderstood is that what comes “naturally” to specialized clinicians is not apparent to other non-specialized clinicians. The transfer of ostomy care knowledge with a common sense approach expands exponentially across the healthcare continuum. At the end of such a continuum is a person with an ostomy who has been treated with quality, state-of-the-art care, empathy, and respect.

The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.