The Secret Language of Doctors

by Brian Goldman

  I’ve already described the term Code Blue, the very common designation for cardiac arrest requiring a medical team—sometimes called a code team—to rush to the patient’s bedside and begin immediate resuscitative efforts. Code Blue is an example of medical argot that was developed as a neutral way to announce on a hospital intercom that a patient is in cardiac arrest and needs help—without frightening visitors and other patients. TV shows including ER and Grey’s Anatomy—eager to make their stories as realistic as possible—have adopted the term. And once that happened, Code Blue entered the public vernacular and ceased being argot.

  At my hospital, Code Pink means a newborn is in need of immediate resuscitation. Code Red refers to smoke detected somewhere in the hospital. Code White means a patient is missing. There is no international convention in colour-coding. Different countries use different colours to connote different medical emergencies.

  In some hospitals, Code Brown signifies an environmental emergency or one that involves hazardous materials. But it’s also known almost universally as slang for a patient poop emergency.

  “It’s the perfect default label,” says Dr. Erin Sullivan, a registered nurse who went back to school at the University of Limerick in Ireland to become a physician. “When you’re giving report [at nursing handover], if there’s family members around or there’s people milling in and out, you’re not going to say the patient was shitting himself the whole night long, even if you know that’s what was happening. If you say it was a Code Brown, it makes it maybe a little more professional sounding if other ears were to hear it.”

  As a doctor, my usual relationship with Code Brown is olfactory. I step onto a ward and it hits my nostrils like a dog kennel just after breakfast. I switch to mouth breathing, and head in the opposite direction—testing my nostrils now and then—until the smell is down to an acceptable level. But if you’re the nurse looking after the patient who emits the Code Brown, it might well be your professional obligation to run—not away from the scene but right toward its smelly epicentre.

  I see Code Browns, but other than changing my kids’ dirty diapers, I have never had to clean one up. But nurses do, and that’s why they remember Code Brown patients in pungently nauseating detail. One nurse told me about a patient who kept soiling himself throughout an entire shift. “He was about 400 pounds,” the nurse recalls. “He couldn’t move at all, even from side to side. He just had constant diarrhea. It was unrelenting. At nighttime, there was only one other nurse in the department, so it was my job the entire twelve-hour shift to try and turn him as much as I could, pull the sheet out, put a new sheet down, turn him on the other side, pull the old sheet out, pull the new one across. Then the process would just start over again.” The nurse says she remembers getting through the experience with “a lot of sweating and cussing.”

  Doctors refer to a loss of bowel control as fecal incontinence. A study published in 1995 in the Journal of the American Medical Association pegged the prevalence of fecal incontinence at 2 to 3 percent. There are many reasons for fecal incontinence. Some people are born with it. Bowel diseases such as Crohn’s, anal surgery and even trivial anal conditions such as hemorrhoids can cause it. A vaginal birth—the most common cause of incontinence in young and otherwise healthy women—can damage the anal sphincter or the nerve that controls it. Medical conditions such as diabetes, stroke, even a slipped disc can damage the sphincter’s nerve supply.

  The vast majority of patients who inspire Code Brown stories are elderly—and it’s more common in women than in men. Older patients often have a condition called sigmoid volvulus, an intestinal disorder in which the lower part of the large intestines called the sigmoid colon gets blocked. The way to unblock the sigmoid colon is to insert a short endoscope called a sigmoidoscope through the anus; once the scope is in place, the doctor inserts a long plastic rectal tube about the diameter of a garden hose through the scope and into the intestine until it reaches the blockage. The tube becomes the conduit through which trapped poop and gas are expelled.

  This procedure is invasive enough that most nurses are not permitted to do it. If you’re the doctor inserting the tube, the most important thing a thoughtful mentor teaches you is to stand as far away as you can from the end of the tube protruding from the anus—to avoid the nearly inevitable mess that ensues when the intestine stuffed with feces and gas is rather suddenly decompressed.

  Dr. Nathan Stall, a resident in internal medicine, knows what’s at stake. The first time he tried to insert a tube, a more senior resident was watching. “The rookie mistake is to not connect the rectal tube to the bag,” says Stall. “The senior was raising his hand to warn me but it was too late. There was like a ‘ping,’ and the stool shot across the room and hit the curtain. The senior resident actually had to jump out of the way so as to not be hit with this high-velocity stool flying across the room. It was hysterical to us, but you have to try and maintain some professionalism. I’ll never forget to connect the bag to the rectal tube should I ever have to do that again.”

  One mentor who is kind enough to put his young charges in the know is Dr. Marcus Burnstein, a veteran colorectal surgeon at St. Michael’s Hospital in Toronto. “The old joke in medical school or in general surgical residency is that when you find a patient in the emergency department with a sigmoid volvulus who needs this procedure, it’s the perfect opportunity to bring the third-year medical student down and get him or her to do it to see if they can get outta the way fast enough,” says Burnstein.

  “In the intensive care unit (ICU), when we had a Code Brown, everybody would go in, gown up and put masks on,” says Megen Duffy, an American ER nurse who blogs as Not Nurse Ratched, a reference to the cold, heartless nurse in One Flew Over the Cuckoo’s Nest.

  Duffy remembers a particularly gruesome Code Brown on a patient admitted to the cardiac ICU. The patient had Clostridium difficile (we call it C. diff), a hospital superbug that has been linked to deadly outbreaks. It’s a potentially life-threatening intestinal infection that causes profuse, foul-smelling diarrhea. “I spent the entire night putting on gown and gloves to go in there and clean up his stool and wash his hands with soap and water, because that’s the only thing that kills C. diff, and hang antibiotics and hang his feedings and clean around his Foley [catheter],” recalls Duffy. “By the time I did all that and took off my gown and went and took care of my other patient, it was time to go back in there. I think I went through fifty of those isolation gowns. It was awful.”

  For some residents, the fact that Code Brown is usually the nurses’ problem gives them an outlet for schadenfreude—enjoyment in seeing the troubles of others. “I’ve seen residents chuckle when the nurse who has been giving them a hard time or paging them for things that probably they didn’t need to be bothered for has to go clean that up,” says Duffy.

  Paramedics have their share of dealing with Code Brown emergencies too. Morgan Jones Phillips, a nine-year veteran paramedic with Emergency Medical Services in Toronto, won the NOW Audience Choice Award at Toronto’s SummerWorks Theatre Festival in 2008 with his first solo play, The Emergency Monologues, a series of stories inspired by his career as a paramedic.

  “This is kind of mean, but it’s always a little bit satisfying when it happens to the fancy people that go clubbing downtown,” says Phillips. “They’re all dressed up super nice and fancy. Guys have shaved their chests and they’re all super ready to score. But then they have poo running down their legs. There’s a special horror that comes when a woman poos while wearing nylons.”

  The horror is even greater when a Code Brown happens in the back of the ambulance. “It happens lots of times while driving that the patient—especially if they come in with stomach flu or they come in with diarrhea or tarry stool [also known as melena, a thick, oozy, formless bowel movement whose black, tarry consistency is caused by gastrointestinal bleeding]. If we think they’re about to have diarrhea or they say they think it�
�s going to happen again, we flick the lights on and try and get to the hospital as fast as we can.”

  I don’t blame paramedics one bit for trying to get Code Brown patients to the hospital as quickly as possible. If the patient defecates in the back of the ambulance, it’s the job of the paramedics to clean it up.

  * * *

  If you have to endure a Code Brown experience, there is at least one compensation: you have a good story to tell colleagues.

  Marc Burnstein says telling Code Brown stories is a way colleagues bond. “It’s that dark humour,” he says. “If we tell each other stories and have a little laugh about it, maybe it takes away some of the unpleasantness.”

  Scrubsmag.com, which bills itself as “the nurses’ guide to good living,” has pages of posts filled with Code Brown stories. Here is one from 2012 by a registered nurse named Amy Mickschl; she remembers one patient who produced loose stool almost continuously: “I was changing her soiled bed one night and was just getting ready to put a new brief on . . . when she coughed and sprayed diarrhea all over the bed, wall and me. Thank god it didn’t hit me in the face!”

  Mickschl goes on to describe home remedies to deal with the smell—sucking on cinnamon-flavoured Altoids, putting a dab of Vicks VapoRub under the nose, even wearing two surgical masks with a squirt of toothpaste on the inside—anything to counteract an aroma that can be overwhelming.

  Talking about that Code Brown with colleagues the next morning was all about a different sort of code—giving fellow nurses on the day shift a heads-up about what duties lay ahead. “The nurses knew which patient I had been working with the night before,” writes Mickschl, “so, of course, the next thing that happens is that everyone’s arguing over who has to take that patient that day. No one wants that patient that day. It’s like, oh, god, you would do anything not to have that patient.”

  Imagine for a moment the chilly reception Mickschl would have received from the nurse on the day shift who ended up caring for the woman with diarrhea if Mickschl hadn’t given her a heads-up.

  For nurses like Amy Mickschl and paramedics like Morgan Phillips, these shared stories speak to the powerlessness they feel about having to do a clean-up job most of us would rather avoid.

  But even that is changing. “Are Student Nurses Too Posh To Wash?” asked the provocative headline on an article published in 2009 on nursingtimes.net. Author Gabriel Fleming quoted a nursing student who was reported to have told a staff nurse: “I keep being asked to do things which won’t help me learn—clear up poo, mop up blood, give patients tea and toast. I realized that I needed to be more focused to learn, and I don’t do those sorts of things now.”

  Laura Servage believes this attitude is part of a larger phenomenon. Servage is a PhD candidate at the University of Alberta who focuses on educational policy studies, as well as on learning, training and the impact of post-secondary education on society. She writes a blog titled My So-Called Career. In a post from March 2010 titled “All About Bedpans: How Credentials Stratify Work,” Servage argued persuasively that as nurses aspire to higher education and higher professional credentials (something she referred to in her blog as credentialization), some—like the nursing student in Gabriel Fleming’s article—may think differently about the meaning of their work.

  “It’s not a frivolous question,” wrote Servage. “What I’m thinking about here is something akin to an unrecognized caste system, which is entrenched both through professionalization and, in many cases, unionization. Basically, the more thoroughly we are able to describe work—name positions and place boundaries around the nature of tasks that will and will not be performed—the more opportunity there is to segregate ‘good work’ from ‘not so good work.’”

  Nowadays, there are several different castes (as Servage put it) of nurses. A registered nurse (RN) in the U.S. or Canada is a graduate of a nursing program at a post-secondary institution who has passed a national licensing exam. One level below the RN is a licensed practical nurse (LPN), the term used in both countries for a nurse trained at a vocational or technical school or a community college. LPNs care for patients under the direction of physicians and registered nurses. They take vital signs, prepare and give injections, keep patients comfortable and assist with bathing, dressing and personal hygiene.

  One level above RN is a nurse practitioner (NP). This is an advanced-practice registered nurse who has completed a graduate degree (a master’s or doctorate). Unlike RNs and LPNs, NPs have an enhanced scope of practice that permits them to make certain types of diagnoses, order tests and start treatment. Because they have a scope of practice independent of physicians, NPs are permitted to see and treat patients on their own.

  It certainly makes one wonder just which of those three types of nurses have the task of changing bedpans. None of them, says Servage—not even the LPNs. “It is not the licensed practical nurse’s job to clean bedpans anymore.”

  It turns out the system has created a whole new type of health-care worker to do the job: the nursing assistant. Nursing assistants help patients with physical, mental and cognitive impairments with health-care needs that include activities of daily living. “They do the heavy lifting and change the bedpans,” says Servage.

  And what about the nurses? “They want to do the more intellectual work that comes with nursing,” she says.

  This thinking isn’t just going on inside the minds of individual nurses; Servage argues it’s happening at the professional and union levels as well. “If occupations have different status, then there’s all sorts of incentives to make your job not the job of emptying bedpans.” Servage worries who will be left to do that job—and how well they’ll be trained to do it. “How many layers of professions can we have before we hit the wall? Who is cleaning the bedpans? Who is taking the vocational courses to work in health care?”

  This is no idle concern. In Canada in 2011, the Cape Breton District Health Authority in Nova Scotia had an outbreak of C. difficile; thirty-two of forty-one cases were hospital-acquired. A factor in the outbreak was the improper cleaning of bedpans: hospital personnel cleaned bedpans in patient bathrooms rather than in separate utility rooms.

  One professional who shows no reluctance to clean up Code Browns is Nicole Donaldson, a licensed practical nurse in British Columbia. She says she hates it when registered nurses she works with don’t feel the same way. “I had a lady who had cancer and the RN who was trying to change her colostomy was retching,” Donaldson recalls. “The poor woman was absolutely sobbing uncontrollably because this nurse was making such a theatrical fuss about the smell. I really felt sorry for that lady and I think from that day forward I always thought to myself, ‘If you can’t do it, then you get somebody in that can do it.’”

  So far, I’ve told you stories about Code Browns as recounted by the doctors who witness them and the nurses, nurse assistants and paramedics who clean them up. What’s missing is the perspective of the person most affected by a Code Brown: the patient. That Nicole Donaldson even thinks about the patient in the midst of a Code Brown is exceptional. What’s striking about Code Brown stories is that they usually ignore the patient’s point of view. It’s almost as if we blame patients for pooping uncontrollably—as if they wouldn’t do almost anything to avoid it.

  Just ask Sholom Glouberman, a health policy insider who experienced an embarrassing episode of fecal incontinence several years ago. After his surgeon removed a non-cancerous polyp from his large intestine, a post-operative infection nearly cost Glouberman his life. As a result, he co-founded a national organization dedicated to bringing the perspective of the patient to all aspects of health care.

  Glouberman told me a Code Brown story from his point of view. As part of his diagnostic workup, Glouberman was given a CT scan of the abdomen, for which he received an injection of contrast, the dye that radiologists use to spot abnormalities such as tumours. Glouberman says he was informed about the risk of
radiation from the scan. He says he was also told in detail about the possible side effects of the dye—with one exception.

  “They didn’t tell me that I might shit my pants,” Glouberman says. “First of all, it’s very shocking to suddenly feel that you can’t control yourself. You feel horrible and you feel a little bit violated and a little bit ashamed, and you feel a little bit like you are imposing. And after the shit has come out all over everything, they come and clean it up as if it’s nothing.”

  Obviously, the experience was humiliating. Spelling out all of the risks in advance, including the possibility of fecal incontinence, should be Medicine 101. But health professionals might argue that cleaning up incontinence as if it’s nothing is our way of trying to be kind to patients like Glouberman by not making a big deal out of it. Talking about it would call attention to it, which might double patients’ feelings of humiliation.

  On the other hand, we need to appreciate just how mortifying the loss of bowel control is to a patient. This control is a fundamental characteristic of personal autonomy. Losing it is nothing to laugh at.

  Another man who has learned to see things from the patient’s point of view is colorectal surgeon Marc Burnstein. He says he wasn’t always that way: “I hope I wasn’t cavalier when I was younger.” What does Burnstein think of Code Brown stories today? “Any laughing is, hopefully, going on at a considerable distance from the poor patient who generated it, because they have embarrassment,” he says. “It may have been part of a painful experience.” He says many of these patients “are older, frailer and sometimes not entirely with it. It’s a very sad situation.”

  Code Brown is no longer amusing to Burnstein for another reason: seldom, if ever, is it self-inflicted. Over the years, I’ve seen lots of patients induce vomiting. I’ve seen the occasional patient defecate in the corner of the ER waiting room as a deliberate tactic to gain attention. But I have never seen a patient pretend to have fecal incontinence. I’m not prepared to say it never happens, but I can’t find it anywhere in the medical literature.