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...