11/22/2008 Mike D'Orazio, ET1 Weird or Arcane Ostomy and Other
Info Some myths, some facts and some things to ponder courtesy of
Mike ET Slide 2 Mike Ostomate ET 11/22/2008 Mike D'Orazio, ET2 1963
- USN 1970 - ET 1985 2006 WOCN Conf. Slide 3 11/22/2008 Mike
D'Orazio, ET3 A priori housekeeping concerns Ostomies are trade
offs! Disease vs. non disease & problems vs. problems Potty:
Defecation and excretion are dynamic processes that flow in a net
unidirectional way (mouth to anus and kidney to urethra) and any
event that impedes such homeostatic flow is troublesome in the long
run. Ostomy diversions, continent or other wise, may well perturb
the natural cephalad to caudad order of things. In other words,
anatomic, metabolic & stasis concerns can arise! Skin: Is a
chronic concern for all as we age, with or without an ostomy. Slide
4 Ostomies as tradeoffs How are ostomies or other diversions
presented to prospective patients? Do the ostomies live up to the
hype? Is there a balance point? For some, ostomy is a blessing,
early on. For others the ostomy is less well received. Time and
comprehensive assessment of experiences (a.k.a. lived experiences)
are the best arbiters of ostomy outcomes. 11/22/2008 Mike D'Orazio,
ET4 Slide 5 11/22/2008 Mike D'Orazio, ET5 Lets query the audience
Stomas and nerves? Anatomy & hernia risks? Bowel physiology?
Adequately hydrated? Gas and odor issues; a gender issue? Pee
breaks? Pouch wear times? Historical tidbits? Is your skin in the
game? Defunctionalized organ behaviors? Pharmacy in the loop? Are
you a boy/girl scout? The Art of Ostomy Potty? Slide 6 11/22/2008
Mike D'Orazio, ET6 Do stomas have nerve endings? What say you? What
say the medical folks? How can we know for ourselves? What makes it
tick? What makes it move? What makes it pee & poop? Slide 7
11/22/2008 Mike D'Orazio, ET7 Stomas have no nerve endings This is
a bald-faced lie! It is also a myth that will not die! Until now,
hopefully! Okay, smarty, how do we clarify? What say you? What say
I? Slide 8 Bowel nerves book references 11/22/2008 Mike D'Orazio,
ET8 Slide 9 11/22/2008 Mike D'Orazio, ET9 The nerve of that stoma!
There are more than 100 million nerve cells in the human small
intestine, a number roughly equal to the number of nerve cells in
the spinal cord. Add in the nerve cells of the esophagus, stomach,
and large intestine and you find that we have more nerve cells in
our bowel than in our spine. We have more nerve cells in our gut
than in the entire remainder of our peripheral nervous system. The
Second Brain by Michael Gershon, M.D. page Xiii Slide 10 11/22/2008
Mike D'Orazio, ET10 Muc = mucosa SM = submucosa CM = circular
muscle MP = myenteric plexus Lm = longitudinal muscle John B.
Furness, Wolfgang A. A. Kunze and Nadine Clerc. Am J Physiol
Gastrointest Liver Physiol 277:922-928, 1999. Slide 11 11/22/2008
Mike D'Orazio, ET11 The nerve of that stoma! The discoveries of the
Law of the Intestine by Bayliss & Starling in 1899 and the
Peristaltic Reflex by Trendelenberg in 1917 describe the pressure
induced propulsive (mouth to anus) activity of the gut, which is
not dependent upon any connection to the brain or spinal cord,
i.e., a completely autonomous local nervous mechanism which is now
known as the enteric nervous system (ENS) of the gut. The Second
Brain by Michael Gershon, M.D. page 3 Slide 12 11/22/2008 Mike
D'Orazio, ET12 The nerve of that stoma! So, why is it that the
stoma feels no pain when cut or cauterized? This is the question
and observation that has contributed to the erroneous statement
that the stoma has no nerve endings. Slide 13 11/22/2008 Mike
D'Orazio, ET13 The nerve of that stoma! most of the information
carried by gastrointestinal primary afferent neurons is not
consciously perceived. This is nicely demonstrated by tests on
fistula patients who report no sensation when the healthy stomach
is probed or in patients that have had the intestinal lining cut to
take a biopsy. Am J Physiol Gastrointest Liver Physiol 277:922-928,
1999. John B. Furness, Wolfgang A. A. Kunze and Nadine Clerc. page
G924 Slide 14 11/22/2008 Mike D'Orazio, ET14 Alas, stomas do have
nerves! So, now let us put to rest the misstatement about the bowel
and nerves. There are nerves; but the sensory nerves of the bowel
between the esophagus and the rectum, for certain types of painful
stimuli, such as cutting or cautery, are either very low in number
and caliber or the brain is not readily able to perceive the pain.
Of course, one can still be a pain in the ass; however, this is a
topic for other times and places. Slide 15 11/22/2008 Mike
D'Orazio, ET15 Arcuate line vs. parastomal hernias? The arcuate
line is a defined anatomical landmark that shows the demarcation of
the various abdominal wall layers from fully layered to partially
layered as one examines the length of the anterior abdominal wall
fascial layers. The other interesting finding is that this line is
not universally positioned across or among all patients. Above the
arcuate line, the rectus abdominis (the six pack muscle group) is
surrounded by an anterior layer of the rectus sheath and a
posterior layer. Thus, it begs the question whether or not
parastomal hernias would be affected by location of stomas above or
below the arcuate line. Slide 16 Parastomal hernia 11/22/2008 Mike
D'Orazio, ET16 Slide 17 Variations of the rectus sheath In a study
of 40 cadavers the shape and position of the arcuate line were
neither symmetrical nor constant, and neither was the arrangement
of the nerve supply to the rectus abdominis muscle or to the
overlying skin. Monkhouse WS, Khalique A. Variations in the
composition of the human rectus sheath: a study of the anterior
abdominal wall. J Anat. 1986 Apr;145:61-6. 11/22/2008 Mike
D'Orazio, ET17 Slide 18 11/22/2008 Mike D'Orazio, ET18 Arcuate line
anatomy 1. Posterior wall of rectus sheath 2. Arcuate line 3. Linea
alba 4. Rectus abdominis 5. Inferior epigastric vessels
http://www.med.umich.edu/lrc/ coursepages/M1/anatomy/htm
l/atlas/abdo_wall61.html Accessed 10/25/2008 Slide 19 11/22/2008
Mike D'Orazio, ET19 Physiology Osmosis When two aqueous solutions
of unequal concentrations are separated by a membrane permeable
only to water, the water migrates through the membrane to equalize
the concentrations of the two solutions. Osmosis describes the net
water flux. Think diarrhea associated with lactose intolerance, and
making urine! Diffusion? High to low concentration migration of
gases. Think farts and other odors! It is why, along with the
olfactory nerves, we can smell! Slide 20 Osmosis: The Goldilocks
Principle Hypertonic is too much Isotonic is just right! Hypotonic
is too little 11/22/2008 Mike D'Orazio, ET20
http://campus.queens.edu/faculty/jan
nr/cells/cell%20pics/osmosisMicrogra phs.jpg Slide 21 Diffusion:
The Nose Knows 11/22/2008 Mike D'Orazio, ET21 I hope this doesnt
smell like my ostomy bag!! Slide 22 11/22/2008 Mike D'Orazio, ET22
Water & electrolyte absorption The duodenum & jejunum are
the major sites of water absorption, which can be explained by the
relatively large pore size (8 angstrom radius) and consequent low
flow resistance to water movement across the mucosa, whereas water
movement across the ileum is more restricted due to smaller pores
(4 angstrom). Clinical Gastrointestinal Physiology by Granger,
Barrowman & Kvietys. W.B. Saunders, Phila 1985. page 151 The
total daily water load (1-1.5 liters ingested & 6 7 liters from
secretions of salivary glands, stomach, pancreas, liver and
intestine) presented to the small intestine is roughly 8 liters
& approximately 80% is absorbed. N.B. An angstrom is the unit
of measure of wavelengths; one one-hundred-millionth of a
centimeter or 10 -8 centimeter. Slide 23 11/22/2008 Mike D'Orazio,
ET23 Vitamin B 12 concerns The terminal 18 ( 50 - 60 cm) of the
ileum is critical for vitamin B 12 (cobalamin) and bile acid
absorption. It is prudent to reassess B 12 levels for any suspect
patients since it takes 2-4 years to deplete B 12 reserves in the
liver. Trading off some measure of continence with urinary or fecal
reservoirs at the expense of some loss of essential nutrient
absorption. Slide 24 11/22/2008 Mike D'Orazio, ET24 Fecal
diversions and urinary stones Compared with controls, ileostomy and
J-pouch patients had significantly lowered urinary volumes and pH,
higher concentrations of calcium and oxalate, and an increased risk
of forming uric acid stones. Christie PM, Knight GS, Hill GL.
Comparison of relative risks of urinary stone formation after
surgery for ulcerative colitis: conventional ileostomy vs. J-pouch.
Dis Colon Rectum 1996 Jan; 39 (1): 50-4.
http://www.urostonecenter.com/evaluation.asp Accessed 10/16/2008
Slide 25 11/22/2008 Mike D'Orazio, ET25 The air we breathe
including farts Fart recognition cycle Air gas fart noise (Fx
restriction & pressure) Tight or stenotic stomas are more
likely to make louder noises Think of the balloon letting out air
Laplaces Law: Tension = Pressure x radius (restriction) or P = T/r
Two essential ingredients tend to give us away smelly and noisy
farts. Ladies take no solace because your farts tend to stink more
than mens; even though men tend to fart more in volume. Ostomy bags
can be helpful hiding us. Until we either open up the bag or the
filter fails to do its job. Slide 26 11/22/2008 Mike D'Orazio, ET26
Gas, flatulence or farts Subject condition Number of daily farts
Approx. daily volume in liters Swallowed air/gas Gut produced gas
non smelly Smelly component of gas Normal10 +/- 12 N 2 (16%) O 2
(3%) CO 2, (10%) H 2, (9%) CH 4 (18%) Sulfur groups H 2 S 95%
reduction in fecal H 2 S release. The ability of bismuth
subsalicylate to dramatically reduce H 2 S could provide a
clinically useful means of controlling fecal odor and / or flatus
and of decreasing the putative injurious effects of H 2 S on the
colonic mucosa. Fabrizis, Suarez, Furne, Springfield & Levitt:
Bismuth Subsalicylate Markedly Decreases Hydrogen Sulfide Release
in the Human Colon. Gastroenterology 1998; 114: 923-929 Bismuth
subgallate (C 7 H 5 BiO 6 ) is found in Devrom . Slide 29 Pee Break
11/22/2008 Mike D'Orazio, ET29
http://images.google.com/images?hl=en&q=little+boy+eeeing&btnG=Search+Images&gbv=2
Slide 30 11/22/2008 Mike D'Orazio, ET30 Pee break:
Ureterosigmoidostomies AuthorYearEvent John Simon1851First urinary
diversion Thomas Smith1878First direct ureterointestinal
implantation Karl Maydl1892Implantation of the trigone into the
sigmoid George Fowler1896First antireflux ureterointestinal
implantation Robert Coffey1911First successful antireflux
ureterointestinal implantation Wyland Leadbetter1951First
ureterointestinal implantation avoiding reflux and stenosis The
History of Urinary Diversion. D.T. Basic, J. Hadzi Djokic, I.
Ignjatovicl. Urological Clinic, Clinical Center Nis. Institute of
Urology and Nephrology, Clinical Center of Serbia, Belgrade Serbia.
Slide 31 11/22/2008 Mike D'Orazio, ET31 Pee break: Cutaneous Ileal
conduits Eugene Bricker established the use of the ileal conduit in
1950. However, the first ileal conduit was performed by Heinz
Haffner from Brickers group. Afterwards, Bricker reported a series
of 307 patients, with lethality rate of 12.4% and only 3.4% related
to procedure. Since the metabolic shortcomings associated with the
ureterosigmoidostomy have been overcome, Brickers technique became
the gold standard for the next 35 years, without substantial
changes until today. The History of Urinary Diversion. D.T. Basic1,
J. Hadzi Djokic, I. Ignjatovicl. Urological Clinic, Clinical Center
Nis. Institute of Urology and Nephrology, Clinical Center of
Serbia, Belgrade Serbia. Slide 32 11/22/2008 Mike D'Orazio, ET32
Hautmann, R E; Stenzl, A; Studer, U E; Volkmer, B G Methods of
Urinary Diversion. Deutsche Arzteblatt 2007; 104(16): A 10927.
Mansoura is in Egypt & Lund is in Sweden Slide 33 11/22/2008
Mike D'Orazio, ET33 Hautmann, R E; Stenzl, A; Studer, U E; Volkmer,
B G Methods of Urinary Diversion. Deutsche Arzteblatt 2007;
104(16): A 10927 Slide 34 11/22/2008 Mike D'Orazio, ET34 Hautmann,
R E; Stenzl, A; Studer, U E; Volkmer, B G Methods of Urinary
Diversion. Deutsche Arzteblatt 2007; 104(16): A 10927 Slide 35
11/22/2008 Mike D'Orazio, ET35 Metabolic abnormalities continent
urinary diversion Metabolic and histological complications in ileal
urinary diversion: Challenges of tissue engineering technology to
avoid them. C. ALBERTI, European Review for Medical and
Pharmacological Sciences 2007; 11: 257-264 Slide 36 11/22/2008 Mike
D'Orazio, ET36 Metabolic abnormalities continent urinary diversion
Metabolic and histological complications in ileal urinary
diversion: Challenges of tissue engineering technology to avoid
them. C. ALBERTI, European Review for Medical and Pharmacological
Sciences 2007; 11: 257-264 Slide 37 11/22/2008 Mike D'Orazio, ET37
Urinary reflux and stenosis Oosterlink W. Lobel B, Jakse G,
Malstrom PU, Stoeckle M, Sternberg C. Guidelines on bladder cancer.
Eur. Urol 2002; 41: 105-12 Slide 38 11/22/2008 Mike D'Orazio, ET38
Detubularized diversions J-pouch, neobladder, coloplasty*, etc
Detubularized or reconfigured diversions for urine or stool suffer
similar trade offs. Achieving continence with internal reservoirs
results in lower pressure systems, which may benefit the continence
and storage aspects at the expense of increased residual or
incomplete emptying aspects. Pressure = tension / radius (Laplaces
Law) Volume of sphere = 4 / 3 r 3 C *..plasty = changing shape of
an organ Slide 39 Detubularized diversions 11/22/2008 Mike
D'Orazio, ET39 Laplace's Law The larger the vessel radius, the
larger the wall tension required to withstand a given internal
fluid pressure. For a given vessel radius and internal pressure, a
spherical vessel will have half the wall tension of a cylindrical
vessel. http://hyperphysics.phy-astr.gsu.edu/Hbase/imgmec/lapl1.gif
Slide 40 11/22/2008 Mike D'Orazio, ET40 Pouch wear times (50 years
ago) Number of daysNumber of respondents 2 weeks19 Lenneberg and
Rowbotham The Ileostomy Patient: A Descriptive Study of 1425
Persons published by Charles C. Thomas of Springfield, Illinois in
1970. Page 45. Essentially, this book describes their targeted
research on pouch wear times and reasons for changes for
ileostomates from the period of 1958-1962 and comprises the
tabulated results of 1355 ileostomy only participants. Slide 41
11/22/2008 Mike D'Orazio, ET41 Pouch wear times (today 2008) Stoma
typeNumber of participants PercentAverage wear time
Colostomy20336.94.55 Ileostomy23843.35.01 Urostomy10919.85.02 Total
n = 551 JWOCN Vol 35/No 5 September/October 2008 Richbourg et al,
page 507 Slide 42 11/22/2008 Mike D'Orazio, ET42 Pouch wear times
assessed It would appear that the durability of the average pouch
wear times has held relatively constant over a half century, and,
in fact, the Lenneberg study was much more useful since it limited
its study to only drainable ileostomy pouch wearers, and also
identified reasons for complete appliance removal from skin during
pouch changes. The Richbourg study included all ostomy types and
failed to distinguish between closed end or drainable pouches, one
piece or two piece, wafer vs. pouch changes and also failed to
identify reasons for changes. Slide 43 11/22/2008 Mike D'Orazio,
ET43 Historical turning points Incontinent Stomas Brooke, Crile
& Turnbull - early 1950s Reusable Pouches Strauss/Koenig 1936
Gricks 1939 Orowan 1963 (convexity) CIRA > UOA >ETs >
WOCNs >UOAA Disposable Pouches (1950s onward) Coloplast (Sweden)
- one piece adhesive & Conseal Plug (1980s) Marsan - multi
piece adhesive or karaya wafer Hollister - all-in-one pouch &
karaya wafer E.R. Squibb Orahesive dental bandage > Stomahesive
Continent Outcomes (with and without stomas) Slide 44 Historical
Koenig & Orowan 11/22/2008 Mike D'Orazio, ET44 Slide 45
Coloplast Conseal Plug-1980s 11/22/2008 Mike D'Orazio, ET45 Slide
46 11/22/2008 Mike D'Orazio, ET46 Historical turning points -
pouches Slide 47 Ostomy pouch oddities 11/22/2008 Mike D'Orazio,
ET47 http://monstercrochet.blogspot.com/2005/0
7/you-crocheted-what.html Slide 48 Davol pouch in use 11/22/2008
Mike D'Orazio, ET48 Slide 49 Davol pouch before, during, after
11/22/2008 Mike D'Orazio, ET49 Slide 50 11/22/2008 Mike D'Orazio,
ET50 Historical tidbits outer space No astronaut has defecated on
the moon; however, urine was left in the lunar module descent stage
on the moons surface. In a closed cabin, flatus was annoying;
however, the Apollo crews took out their emergency O 2 masks and
used them frequently for protection against the obnoxious odor. In
the Gemini flights a small fecal bag with an attached finger cot on
the side was adhered to the perineum. Lomotil became the drug of
choice to minimize stooling. Gemini XII flight and Gemini Program
Summary. Fact Sheet 291-1, NASA, Dec. 1966. Slide 51 11/22/2008
Mike D'Orazio, ET51 Czechoslovakian father of loop colostomy
(12/28/1883) Karl Maydl 1853-1903 Oliver Pfaar. Karl Maydl. Dis
Colon Rectum 2001; 44(2): 280-283. Slide 52 11/22/2008 Mike
D'Orazio, ET52 Quiz time, again Which organ system has the greatest
exposure to the outside elements? Is it the skin? Are you sure of
your answer? Or, is it the GI tract? Drum roll, please GI tract!!!
Slide 53 Bowel Surface Area 11/22/2008 Mike D'Orazio, ET53
http://images.google.com/imgres?imgurl=http://www.colorado.edu/intphys/Class/IPHY3
430-200/image/villi.jpg&imgrefurl=http://www.colorado.edu/intphys/Class/IPHY3430-
200/020digestion.htm&h=371&w=660&sz=97&hl=en&start=1&usg=__DcANUpgpWvK
QCxiheQK9vC1LJwc=&tbnid=q2tm0ZmML9B65M:&tbnh=78&tbnw=138&prev=/images
%3Fq%3Dneural%2Banatomy%2Bof%2Bthe%2Bintestine%26gbv%3D2%26hl%3Den
%26sa%3DG. Accessed 10/29/2008 Slide 54 11/22/2008 Mike D'Orazio,
ET54 Speaking of skin The intestinal surface area is approximately
100 times the skin body surface area, that is, it is in the order
of 200 m 2 (an adult body skin surface area ranges from 1.5 to 2 m
2, typically 1.75m 2 ). Max E. Valentinuzzi. Understanding The
Human Machine: A Primer for Bioengineering. World Scientific, New
Jersey, 2004. page 152. N.B. a tennis court is approximately 228 m
2,and not much larger than the area of the intestine.
http://en.wikipedia.org/wiki/Tennis_court Accessed 10/17/2008 Slide
55 11/22/2008 Mike D'Orazio, ET55 Comparative surface areas Lung
area Skin area Intestinal area
http://www.vendian.org/envelope/dir2/lungsout.html Accessed
10/17/2008 Slide 56 11/22/2008 Mike D'Orazio, ET56 Skin graphic
Slide 57 11/22/2008 Mike D'Orazio, ET57 Skin has layers Slide 58
Skin layers lost to tape removal trauma 11/22/2008 Mike D'Orazio,
ET58 Slide 59 11/22/2008 Mike D'Orazio, ET59 Skin: peristomal
contours Slide 60 11/22/2008 Mike D'Orazio, ET60 Some more skin
questions Why do some barriers irritate more so than others? ICD
(irritant contact dermatitis) vs. ACD (allergic contact
dermatitis)? How to decide rigid vs. flexible selection? Why does
scratching cause a skin flare? Slide 61 11/22/2008 Mike D'Orazio,
ET61 Some skin answers Why do some barriers irritate more so than
others? Idiopathic predilection (behavioral & genetic) Barrier
ingredients Mechanical & related factors: Pressure Friction
Duration Too wet or too dry skin state pH alkalinity increases
risks Age Cleansing and prepping products & techniques Slide 62
11/22/2008 Mike D'Orazio, ET62 Some more skin answers Traumatic or
irritant adhesive dermatitis The greatest number of skin reactions
which are observed in relation to the wearing of adhesive tapes or
barriers are of a mechanical nature. Shearing at the tape-skin
interface & edges Plugging of follicles and sweat pores The
dermatitis caused by trauma usually remains strictly localized to
the site of contact with the adhesive, while allergic reactions
tend to spread beyond the area of actual contact. Slide 63
11/22/2008 Mike D'Orazio, ET63 ICD versus ACD ICDACD Diseased
skinAll exposed areasOnly sensitized areas Concentration dependency
Dose effect & duration all or nothing Subjective
qualitiesBurning, stingingItching Objective qualitiesErythema,
edema, bulla, necrosis, desquamation Erythema, papule, vesicle
Diagnosis (dx)No dx testPatch test Gebhardt, Elsner & Marks.
Handbook of Contact Dermatitis. Martin Dunitz, London, 2000. table
4.1 Slide 64 Dermatitis book references 11/22/2008 Mike D'Orazio,
ET64 Slide 65 11/22/2008 Mike D'Orazio, ET65 Rigid versus flexible
pouch/wafer This is more art than science Many factors to consider
Body habitus and lifestyle concerns Comfort level or perceptions If
peristomal skin planes are very challenging then skillful
assessment is needed, and flexible or rigid may be in order there
are no hard and fast rules here! Slide 66 11/22/2008 Mike D'Orazio,
ET66 Scratch an itch and make it worse Note that some people are
itchers while others are not Koebners Phenomenon The Koebner
phenomenon is the development of isomorphic * pathologic lesions in
the traumatized uninvolved skin of patients who have cutaneous
diseases. It refers to the fact that in persons with certain skin
diseases, especially psoriasis, trauma is followed by new lesions
in the traumatized but otherwise normal skin, and these new lesions
are clinically and histopathologically identical to those in the
diseased skin. http://www.ijdvl.com/article.asp?issn=0378-
6323;year=2004;volume=70;issue=3;spage=187;epage=189;aulast
=Thappahttp://www.ijdvl.com/article.asp?issn=0378-
6323;year=2004;volume=70;issue=3;spage=187;epage=189;aulast
=Thappa. Accessed 10/23/2008 * Isomorphic = different ancestry but
same appearance Slide 67 Koebner = Psoriatic flare 11/22/2008 Mike
D'Orazio, ET67 Slide 68 11/22/2008 Mike D'Orazio, ET68 Scratch an
itch and make it worse Lewis wheal effect Sir Thomas Lewis, in
1927, described the triple response to a blunt instrument, such as
the handle of a reflex hammer, being pulled firmly across the skin:
a relatively narrow red streak develops in the path of the
instrument, followed by a red flare extending several centimeters
out, and finally elevation of the skin (wheal formation). The
elements of the triple response involve respectively capillary
dilation, arteriolar dilation, and exudation into the extravascular
space as histamine is released from mast cells and basophils. In so
many words, the firm pressure on the skin produces an acute
inflammatory response.
http://findarticles.com/p/articles/mi_qa3841/is_/ai_n9138879http://findarticles.com/p/articles/mi_qa3841/is_/ai_n9138879.
accessed 10/23/2008 Slide 69 tape > irritant contact dermatitis
(ICD) > severe itching > aggressive scratching + pouch >
maceration > contributes to yeast overgrowth + Skin Prep wipes
> increased chemical sensitization > vicious cycle of trauma
and insult (Lewis Wheal effect)!!! 11/22/2008 Mike D'Orazio, ET69
Slide 70 11/22/2008 Mike D'Orazio, ET70 Diverted or bypassed organs
Although an ostomy diversion now functions for the detoured GI or
urinary tract, any remnant structures will likely still produce
their own accumulating physiological debris, such as mucus, blood
and other shedding cells. E.g., do not be alarmed if you still feel
the urge to take a poop or a pee as before! Slide 71 11/22/2008
Mike D'Orazio, ET71 Pharmacists need to be your ally The
complexities of an altered GI & GU tract and the myriad
advances and characteristics of medicines really demand a close
liaison with you, the prescriber and the knowledgeable pharmacist.
You must take the initiative to inform about your ostomy
circumstances and work with the prescriber and the pharmacist they
do not read minds! Slide 72 11/22/2008 Mike D'Orazio, ET72
Ostomates motto Borrow the wisdom of the scouts and always plan
ahead and be prepared for all possible contingencies. Back up
supplies readily available? Murphys law accounted for? Have extra
supplies, will travel? Comfortable in your ostomy role? Others know
what to do for you? Now, get on with pottying as well and as
normally as you can!! Slide 73 11/22/2008 Mike D'Orazio, ET73 The
Art of Ostomy Potty Once Upon A Throne Slide 74 11/22/2008 Mike
D'Orazio, ET74 Foreground (pre ostomy) check Toilet check!
Cleanliness check! Location check! Toilet paper check! Wash up
check! Out of here ASAP! (unless you use the throne for secondary
gains) Slide 75 11/22/2008 Mike D'Orazio, ET75 Potty Patterns B.O.
(Before Ostomy) Slide 76 11/22/2008 Mike D'Orazio, ET76 Potty
Patterns P.O. (Post Ostomy) Slide 77 Toileting survey asks Front
facing sitters? Rear facing sitters? Side saddle aficionados?
Kneelers? Stand ups? Slobs? Neat freaks? Procrastinators?
Expediters? 11/22/2008 Mike D'Orazio, ET77 my preference Slide 78
11/22/2008 Mike D'Orazio, ET78 Toilet police wants to know How much
toilet paper? How many flushes? Do low flush toilets work well for
fecal ostomates? Who fits or not upon the throne? Who whistles? Who
hums? Whos uptight? Whos carefree? Slide 79 11/22/2008 Mike
D'Orazio, ET79 Remember, Ostomy = tradeoff I hope this little
presentation helped enlighten and entertain you and brought
additional insights to aid your understanding of ostomy tradeoffs.
Thank you, and continued ostomy potty success! Mike ET
