Monday, May 17, 2010

Being Regular

One of the more frequent topics of complaint in the ER setting, unfortunately, regards bowel movements. Too many. Too few. Too hard. Too soft. Too watery. The wrong color. The right color but the wrong time of day. No flatus. Too much flatus. Associated cramping. The list goes on and on. And on. And...on.

Anyone who works in medicine and, specifically, patient-care knows exactly what I'm talking about.

When a patient starts going down this road, I am pretty skillful with diversion conversation. Imagine Mrs. Smith, an elderly woman who "just so happens" to have brought me a list of all of her bowel movements during the past two weeks. Lucky me, right? A third of the way in, when she starts to talk about her love of corn and her subsequent change in bowel habits, I have to stop her. I have no other options, really. Well, unless you count plunging a syringe of epinephrine into my heart an option.

"Mrs. Smith," I say, a warm smile on my face, "I don't mean to interrupt you, but you look an awful lot like Betty White. Isn't she so pretty?" When Mrs. Smith blushes and starts talking of her love of "The Golden Girls," I feel victory. I taste victory. I smell victory. But, sadly, it is short-lived. "I wouldn't be surprised," Mrs. Smith says, outsmarting me, "if Betty White loved corn, too." And back to the list she goes.

With all of these conversations and complaints of what could go wrong with bowel movements, I have a big fear that when I become an elder myself, I might obsess about my own BMs. I would hope I wouldn't, but one never really knows. Metamucil? Check. Fibercon? Check. Prunes? Check. Chex cereal? Check. Fleet's Enemas? Check. I can only hope that I'll have my bases covered.

Plus, I love corn. And corn-on-the-cob.

A few years back, I took care of an elderly gentleman, bushy eyebrows and all, who had presented to our ER because he had not had a bowel movement for three mornings.

"I always have a bowel movement after I wake up," he explained staunchly, trying to give some formality to such a subject. "I haven't changed anything, either. I still eat a bowl of Chex in the morning and take my fiber pills at night. I even tried Metamucil last night and still, nothing." After speaking, he gave an exacerbated exhalation for good measure, just to make sure I understood his predicament.

I looked at this gentleman sitting in his gown on the treatment cot. He looked very comfortable despite his lack of recent bowel evacuations. Concern, though, was etched on his face.

"Are you having any abdominal pain, sir?" I asked. "No," he answered. "Any fever? Any blood in your stools?" No and no. "Did you try an enema or do anything different to see if it would help you with your bowel movement?" Most people have some sort of back-up plan (pun intended) for when they are constipated. For me, a strong cup of black coffee does nicely (well, unless I just ate forty pieces of banana laffy taffy).

The gentleman hesitated before finally speaking. "I, um, well," he stuttered, before finally deciding to just spill, "I tried to dig myself out."

Ugh. My eyes instinctively went to this patient's hands. They appeared to be clean. I struggled to spot anything under his nails, but failed. Thank God. I looked down at my own hands, grateful for my subconscious habit of always putting on gloves before shaking a patient's hands.

Now it was my time to stutter. "Um, well," I said, "when did you try to 'dig' yourself out?" Did I really want to know? Just asking, even, made me shudder.

"Last night," the man answered. He paused, and I knew what he was going to say next. Please don't say it, please don't say it, please don't say it, I chanted to myself.

"And this morning, too." Ugh, he said it.

Well, as I said before, I like corn as much as the next person. And, also, consider me a good Boy Scout. I want to be prepared. Always. You're never too old to learn, right?

"Sir," I asked, "can you tell me how you tried to dig yourself out?"

He raised his bushy eyebrows and looked me in the eyes, realizing that I was being serious. And honestly, although I joke, I was being serious, since I would need to check to make sure he wasn't bleeding or had injured himself. "Well," he said, "I got me some petroleum jelly and coated this finger with it (he held up his right index finger) and... ."

You get the idea, I'm sure.

The idea of digitally disimpacting a backed-up patient is not new to me. I've done plenty of them. Most everyone in the medical field can attest to trying to shirk this part of our job, though. It is truly a procedure that rolls downhill. Starting with the lowly medical student. If one isn't available, call the freshest intern on the block. No intern? That's okay, find me a mid-level or senior resident. It's a really bad day in the ER, though, when the attending has to double-glove-up and do it himself. You earn your money that day, for sure.

But to do that to yourself? I wouldn't even consider it. If I hadn't considered self-disimpaction during my laffy taffy crisis, I think it's safe to say that I will never consider it.

Even during corn season.

This elderly patient, he with the clean hands and fingernails, did beautifully. Rarely will I order a soap-suds enema (since this is the nursing equivalent of a disimpaction and gains me no points in popularity), but I did on this patient, since he did have some minor rectal impactions on x-ray and exam.

The nurse schooled me, though. "Doctor Jim," she said, smiling even after giving the enema, "I did the enema but he still needs some help." That explained her smile. "I think with your help," she added, enunciating a bit too much, "we might have some success."

I tried using my charms of conversation. "Have I ever told you, Nurse Bonnie, that you look just like Angelina Jolie?" Maybe, I had thought foolishly, I could work my way out of this one.

"Nice try, Doc," Nurse Bonnie said, now laughing along with me, "but you could look like Brad Pitt (which, I might add, I do) and I'm still going to need you to disimpact my patient."

Humbly, I earned my money that day.

Do me a favor, okay? The next time you are in the ER as a patient and you skillfully bring up your bowel movements (whether they are your primary or secondary complaint), remember that we, in the health field, are people too. We feel your pain. We want you to be regular, trust me, we do. And we want the best for you.

Which is why, in my opinion (and humble charming way), you should see your family doctor for any bowel complaints. Any at all. Trust me, they do a much better job of disimpaction and managing the bowels than any ER doctor I know.

Maybe that's the line I should have used on Mrs. Smith.

As always, big thanks for reading. It seems that we in the medical field have no fear talking about this subject. I can only hope I didn't scare you. Next post will be Wednesday, May 19. See you then...


Jim ( UK ) said...

Well done Jim ; the way , I`m on iron tablets at the moment ( eeewwwwww ) :-)

The Hopeful Elephant said...

The Angelina Jolie line was not good...not good at ALL...


I will never look at corn the same way again.

(Blueberries work well too, I am told...)

The HipCrip said...

If the thought of self-manual evac squicks you out, here's one more reason to thank the gods that you're unaffected by a spinal cord injury/damage (SCI/D).

For many of us, keeping things regular means finding and maintaining the right balance of fiber and water intake; taking probiotics and/or stool softeners; and the use of digital stimulation, manual evacuation, suppositories and/or mini-enemas (not to mention boxes of gloved and gallons of lubricant) during bowel care itself.

A strong cup of hot, black coffee never hurts, either.

AtYourCervix said...

The senior citizen crowd is definitely quite bowel fixated. I even find a few of the younger women who are just as fixated. I recall a very young, prolonged hospitalized pregnant woman that we had once....she was on multiple meds for 'regularity' and was very bowel fixated. This was her regular routine - no medical reason for it either. I also cared for a woman with familial polyposis who was medically managed - but her condition required it. Ironically, she wasn't all that bowel fixated. It was a matter of normality and routine for her.

AtYourCervix said...

And to Jim (UK) - don't forget to take some ducosulate sodium (colace, pericolace) with that iron.

Kate said...

I have a friend who works in hospice care and after a particularly long day yesterday, came over for a backyard barbeque, tired scrubs and all, and announced to the whole group, "There will be NO talk of poop. No jokes. No farting. No ANYTHING! NO POOP!" It is the bane of her existence. Considering she also has three little girls at home who are also poop obsessed.

tracy said...

...yep, the ED (no, not erectile dysfunction!) crowd is pretty obssessed too.....luckily for you, we don't run to the Emergency Department!

soulful sepulcher said...

My daughter had an awful corn-on-the-cob blow out as a teen, and I've never eaten corn since! Not after cleaning up that disaster!

It takes a very unique person to work in an ER is what I'm gaining from reading these stories!

Dr. Woof-Woof said...

This doesn't surprise me. Many people carry their bowel fixation on to their pets as well. Commonly, I have people come in for an office visit with a dog or a cat b/c "they haven't gone 3 times today - they ALWAYS go three times!" Or they went out at 7 am instead of 6:30am so something MUST be wrong. And, I'm with you - I will do anything to avoid going through the list of two weeks' worth of "stool records" that clients bring in. Because it always includes things like "9am - brown (but not quite as dark as normal) and a little bit soft (like soft serve ice cream) and had 3 pieces of grass in it." Now, how do you know it had exactly THREE pieces of grass unless you're digging through each pile??

Oh, and you haven't lived until you have experienced a manual disimpaction on a 120# German Shep. who is blocked up b/c his owner "always feeds him 1-2 pork bones, but this time everyone at the party gave him 1-2 pork bones, and now he can't poop, and there's blood coming out, Doc" - I remember one specific night in the Animal ER when I literally spent 2.5 hours with an anesthetized patient, warm soapy enemas, KY Jelly enemas, and a colon filled with a concrete-like mix of poop, bone, and grass. Oy. It earned me the temporary title of "Rear Admiral" - boy was I glad when THAT nickname disappeared ;)

Leslie said...

Oh my stars, I am speechless! LOL!

Cal said...

We are very lucky in our household regarding poopy matters, but we were tested during potty training! Holding in poop in not good for a little girl; She know that very well now.

Katie Axelson said...

Now, I can clog the toilet just as easily as the next girl, but I'd never dream of discussing such habits with anyone other than the family that has to deal with the repercussions.

So a couple years ago my grandma was in the ER with... just kidding (well, only a little).

And, nope, you didn't scare me with your poo post. :-)

<>< Katie

Maha said...

Constipated old folks are not my friends!

Medical Mojave said...

@Jim--do ERs ever get toddlers in the for poop withholding? I'm just curious about the demographic spread.

My father now calls and 'confesses' his attempts at dis-impaction which uggghhh. But at least I've kept him out of the ER, right?

And in our house, I now make almond flour/ground flax muffins that keep everyone super regular. ;)


BubbleGirl said...

You are the best!

I think you should direct everyone in your ER to:

It's a great site which explains EVERYTHING you would EVER want to know about poop.

My secret... Adding some All Bran Buds to my good-tasting cereal. Works like a charm! ;)

ACZ said...

Oh, Jim... Jim... Jim... may I call you Jim? No? Ok, Dr. J., then. SAY - didn't you have a stellar NBA career before you went into emergency medicine? No? That was some other Dr. J? Oh, well.

It pains me to say this - because up until now, I've thought you a wonderful writer - but lately, and in particular with this last post, your writing has really turned to shit!

When I'm plugged up, the only solution that gets things moving again is Colon Blow. And for those particularly difficult times - such as after ingesting a whole bowl of banana laffy taffy or eating a 5 lb bag of powdered cement, I turn to New Super Colon Blow!

anonymousRN said...

As a student I once walked in to a patient on the ortho floor who was asking for her nurse, as her own attempts to manually disempact herself had not worked. (and might I add that she had long fingernails... ugh!)

I have to admit, I have never ever seen a doctor disempact a patient... I have done it many times as an RN, but it is something that is left to the nurses to do... I should talk to some of your nurses and find out how we could change that. :)

Webster said...

Don't you just recommend Milk of Magnesia for two days with a follow up with their PCP?

Well, I suppose you do have o rule out the various odd things people do to themselves.

Rogue Medic said...

Why does it seem that the bowel babies do not develop dementia and forget their excretory obsessions?

You could retaliate by explaining that the ED is a place where they could pick up some charming C. diff.

Moose said...

You know, I'm fairly anemic, I take a lot of iron pills in a day, and I infrequently take morphine for pain.

Yet I am, for some reason, not at all worried about what comes outta my butt. Doctors are far more worried. "Are you SURE you're regular, when you take all that iron?" over and over and over. Yes. It's called staying hydrated, eating well, and NOT OBSESSING ABOUT MR COLON.

Thank you, and good night.

Anonymous said...

That guy was shit out of luck..
That's some unbelievable shit...
He wasn't shitting, was he..

I hoped he thanked you for the shit!

Val said...

I knew someone who took a dental filling out with his own dremel craft drill... does that count for DIY treatment?

Jill of All Trades, MD said...

Very funny post :) But seriously, no, i think ED docs are DEFINITELY much more skilled at manual disimpactions than primary care docs are...

Chrysalis said...

I was wondering. like anonymous RN, why the nurses didn't do this. It is not a pleasant thing at all, but we had to do it. (One of the things I don't miss.)

Blessed said...

I thought this post was pretty bad, but, well, seems a lot of people also use corn poop to send a message:

of course I thought of you. ; )

Have Myelin? said...

My grandmother was obsessed with her poop and I swear I never will be. Even if I am worried about it. LOL.

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