Wednesday, September 15, 2010

Pipe Cleaning

I usually work two or three shifts a month at a small, rural hospital about two hours from where I live. Why? Mainly, the small hospital is less than ten miles from my childhood home, where my widowed father still resides, and thus provides me an opportunity to catch up with Dad as well as four of my siblings and their families, all who live within five miles of Dad.

I also thoroughly enjoy the different ER setting that working in a small hospital provides when compared to the trauma center I have been a part of for fourteen years. People are more appreciative, it seems, and less demanding. People are respectful. There seems to be a more heartfelt connection between the small town folks and the ER staff versus the big city dwellers who demand everything on their terms with our trauma center staff. I have yet to be asked for a turkey sandwich, a warm blanket, an extra pillow, or internet access at the smaller facility.

It is, simply put, refreshing.

Still, I have a hard time drawing the line between how emergency medicine should be practiced in a small town versus a big city. Should there be a difference, even? I'm not sure if there should be. I like to think I extend myself and my staff quite well to each and every patient, whether I'm in Smalltown, USA, or the big city.

During my last round of ER shifts near Dad's, an energetic, spritely 80 y.o. woman came in complaining of constipation. By her tightly wound perm, I should have seen that she would be a hard patient to please. She typically had a bowel movement everyday. Unfortunately, the day before she came to see me, she had not had her typical movement. The next day, upset about skipping a day of evacuation, she came to our ER demanding to get an enema.

"Maam," I asked, after introductions, "do you have any abdominal pain?" "No," she answered. I continued. "Do you have any fever? Do you have any urinary complaints? Do you have any vaginal complaints? Do you have any nausea or vomiting?" To each question, she answered a resounding "no."

"Maam," I said, quite honestly, when I had finished a perfectly normal physical exam, "I am trying to figure out why you came to the ER if you otherwise feel alright. Did you call your family doctor about your constipation?"

"Why would I do that?" she asked, "they don't do enemas in the office. And I need an enema."

"Well, maam," I confessed, "I don't require our nurses to give enemas to people unless they medically need one. Without a fever, abdominal pain, or any other changes to your health, I don't even feel you need an enema for just skipping one day of your regular movements."

"You mean you aren't going to order me an enema?" she asked, incredulous. "Have you had an enema here before, maam?" I asked, curious as to why she was so focused on getting an enema. "No, I haven't," she said, "but I know lots of people who come here to get one when they need one."

While the patient went to the bathroom to "try to go again," I left her room to question the nursing staff about their enema practices. "Oh no, we don't do enemas unless we really have to," the nurses said, almost in unison. What other answer was I expecting? Of course, nobody in their right mind was going to volunteer to give an enema to a healthy, non-distressed patient.

The woman returned from the bathroom. "No luck," she said, smiling as if to say "so there," as she comfortably walked back to her room and easily jumped up into her cot. "Well," I said, "I think we have a plan for you, maam." I then explained how I approach constipation in the otherwise healthy patient. I explained that she needed to make sure she ate enough fiber in her diet and drank enough liquids. She needed to be physically active which, judging from her energy, wouldn't be a problem. We talked about her taking something to "keep her regular," from FiberCon to Metamucil to MiraLAX, as she needed.

Finally, I talked to her about the meat of her problem. "Maam," I said, "although I don't suggest it right now, if you feel you are constipated and want to aggressively treat it, then use a Fleet's enema. If you don't have relief in one hour, repeat it. And if that doesn't flush you out within four hours, drink a half bottle of magnesium citrate." I went over this twice, actually, as she nodded her head.

When I was done, she got quite snippy with me. "You mean I won't be getting an enema here in the ER today?" "No, maam," I said, "I'm sorry if you are disappointed with that, but I wouldn't make my staff give you an enema I'm not sure you even need."

"I'm not giving myself an enema," she yelled now, "I never did and I never will!"

I assured her that the instructions that come with Fleet's enemas are very good, including pictures of how to go about things. As a side note, if you want a good laugh sometime, spend the dollar on an enema to see the cartoon drawings in the instructional pamphlet.

Well, she wasn't buying what I was selling. "You mean my husband and nephew have been waiting in the waiting room for nothing? I came here for an enema and I am not happy I'm not getting one."

She then requested if home-nursing would come by her house to give her an enema. Having an important connection with the home-nursing team (my sister Chrissie is a nurse who heads that department), I called Chrissie to get her input. After reviewing the patient's complaints and exam, she mirrored my thoughts. "Does she even need an enema, Jim?" No, I assured her, she doesn't. "Then just have her follow up with her family doctor in a day or two and if she is not successful by that time, we can send someone out to help her. It would be hard to justify sending home nursing in at this time." I love my sister Chrissie, no bones or bullshit with her approach. Just like mine.

I went back in to the patient and explained my conversation with Chrissie to her. The patient was not happy. But she was healthy. Healthy and a little constipated.

After she left, threatening to go to a neighboring rural hospital an hour away where "I'll bet they'll give me an enema," the nurses gave me a round of applause. I felt kind of bad, actually, for having this patient leave disgruntled, without her enema.

"Thank you for separating an emergency enema from a non-emergency enema," said the charge nurse. I nodded my head to her as she continued. "You are the first doctor who ever said 'no' to that demand."

This whole incident got me to thinking. At the big trauma center, I would never have considered giving this patient an enema, no matter how much she thought she needed one. We are just too busy to not utilize our time more efficiently. In the small town, however, people seem to expect that extra "oomph" of kindness. But a line has to be drawn at some point. Incidental constipation without symptoms does not, in my book, demand an enema "just because" the patient is obsessing over her bowel movement patterns. Or because they happened to sign into an ER to be seen.

Something tells me this kind lady will not be baking me an apple pie as a thank-you. Which sucks, since I love apple pie. But at least, whether it's in a big city or a small town, I feel I treated the patient correctly.

As always, big thanks for reading. See you Friday...


Empress Bee (of the High Sea) said...

oh! my mother in law rose from the grave to visit you? she was the exact same way! once she was in intensive care for a heart attack and asked me to sneak her in some suppositories. sigh... good job saying no doc!

smiles, bee

CeeCee said...

New here. Don't even remember how I came across your blog.

What is it about 80+ year old folks and their bowel movements? My in-laws (whom I adore) feel perfectly free to discuss trips to the doctor and their bowel habits with just about anyone. I really, really hope to remember these days when (if) I'm 80. Sometimes one wonders if all they do is go from doctors visit to doctors visit.

I'm quite sure the truly needy patients in your small town ER appreciate what you did. Maybe one of them will bake you a pie. :)

DT said...

She may not bake you an apple pie, but the nurses might!

Heather said...

No...the word so many people struggle with their whole lives.

Anonymous said...

Ladies, just wait. Your words are going to come back to haunt you in a few years!

BubbleGirl said...

As a 23 year old female with various health problems, I often try to fix myself before I see a doctor. Once I had gone for at least a week and a half without a bowel movement. I started drinking prune juice, and eating All-Bran cereal, and lots of fruits to see if that would help. After days of that not working, I went to the pharmacy and got a laxative. When that didn't help, I went to the walk-in clinic and had something prescribed to me. I think this is about the most reasonable way to solve this sort of problem.

At what age do we lose our common sense? (assuming that we have it in the first place)

coulrophobic agnostic said...

Never stand between an old person and their bowel habits.

Cal said...

I tried looking up the instructions for the fleet enema online, but no luck. My daughter had a book called Everyone Poops... it helped her through potty training.

Katie said...

Tell her to stop eating banana Laffy Taffys.

<>< Katie

Karen said...

When we were teens, my family lived next door to an older woman who would always ask my older sister to give her an enema because she "hadn't gone since yesterday". My sister *hated* to do it, and I'm not sure now why she didn't just say no, but we still laugh about it today. She was the Enema Lady. LOL

Tiffany said...

Ok. Seriously. WTF?!?!? Who does this?!?! Obviously this lady, but like, omg, I cant imagine ever asking for an enema!!! 6 months ago I needed to have a flexible Sigmoidoscopy, and I just about died of embarrasement when I was told I needed one. Never mind having to go to the pharmacy and by the fleet enema and the magnesium whatever. Oh, and the cartoon pic's of the fleet enema are hilarious, I laughed my but off when I read them. Then When I had to get a flexible sigmoidoscopy, I was dreading that day and almost died of embarassment. I couldnt imagine ASKING some stranger to stick some fluid up my butt to make me go poo just becuase I havent gone in one day!!! Pigs would fly before I would ever do that!!! I really hope that I am NEVER like that when I'm old....Good for you for sticking to your No. Funny Post!!! Thanks!!

Anonymous said...

I think the obsession in older people develops from a combination of cultural expectations and a rapidly decreasing number of things the person can control, along with a the realization that as one gets older and frailer, minor ailments can get serious fast.

I'm a much younger person with some health problems. They can take over one's life, and there have been weeks where I've gotten to the end of a day and realized that about all I managed to do was to get to a doctor or therapist or two, and I cannot deny that it can be disconcerting, starting on a week or two of narcotic or anti-cholinergic medication of some kinds and just *knowing* that there are going to be issues.

So, I'm sympathetic to the bowel obsession, but I still don't really want to hear about it nearly as often I do from some of my older clients!

type1medic said...

It is nice to see you didn't do or should I say make a nurse do an unneeded enema. WTG Dr.

EDNurseasauras said...

How refreshing, a doc who cares more about medical necessity than "customer service". Well done.

Besides, there is a special place in hell for ER docs who order enemas in the ER.

Winking Doll said...

"You are the first doctor who ever said 'no' to that demand."

As EDNurseasauras @September 16, 2010 6:18 PM pointed out, it's refreshing to have a doc who cares more about medical necessity than "customer service". As a nurse, I thank you for not making nurses do the medically unnecessary just to make client happy. Unfortunately, I have been guilty of administering the medically unnecessary as ordered by doctor(s), because "customer service" is NUMBER 1 in private hospitals. I know of an ER doctor who quit because his hospital's management put customer service/abuse above medical necessity and staff welfare.

Yes, if the lady insists on it, she should buy and enema and administer it herself (or ask her husband, or whoever). What a waste of medical resources, esp ER staff's time!

Anonymous said...

I did a google image search for fleets enema hoping to see the instruction sheet and oh my goodness I saw some things I really didn't need to see, LOL.

I am glad you didn't give in to the patient's unreasonable demands.

Anonymous said...

Ewwwwwwww! I can't imagine going to the ED for an enema, let alone self-administering one at home. There are so many more pleasant ways to relieve constipation, which don't include Fleet Phospho Soda or mag citrate, two of the vilest substances known to man. (Colonoscopy prep is just plain nasty.)

Regularity was quite the thing when I was a kid. My late mother used to feed my sisters and me prune juice if we had not had a BM that morning. After my father passed away, all of us gleefully recycled the prune juice bottles my mom had kept all those years. Needless to say, none of us eat prunes!

Search WhiteCoat's blog, and you will find a recipe for a raisin-date-senna leaf bar he used to prescribe to cancer pts on opioids. Granny Enema could probably use half a pan daily, as she sounds as though she may be full of feces, regardless of whether she has a daily BM.

Anonymous said...

You know, there are foods from select resturants that would solve her problem in a matter of hours...

Anonymous said...

unfortunately another perspective for this story is that there are people in emergency need of enemas when medical "professionals" refuse to administer them. not quite as funny.