The patient with fecal incontinence doesn’t ask for it any more than the patient with cerebral palsy asks for garbled speech. Laughing at either should no longer be welcome in the culture of modern medicine.
* * *
There’s overcoming one’s disgust at dealing with feces. Then there’s getting past one’s discomfort with dealing with the part of the body from which feces emerge. Sooner or later, all physicians have to learn how to do a rectal examination. The slang term used by many urologists (who are checking the prostate for enlargement and for a nodule suggestive of prostate cancer) is the finger wave. Burstein has done thousands of rectal examinations during his career. He still remembers the first one because of what his teacher did to arrange the opportunity.
“I have to say I don’t think it would pass muster today as a way of introducing it to a medical student,” Burnstein says. “But in 1977, when I was a medical student, I was at a clinic with a couple of other students and a surgeon. We were assessing a young man whose complaint was a hernia.”
An inguinal hernia (sometimes called a rupture) is a noticeable lump in the groin caused by protrusion of the wall of the abdominal cavity with or without a part of the intestine poking through the inguinal canal. Although a rectal is considered an important part of the physical examination, it was probably not that essential in the case of the young man. Nevertheless, Burnstein recalls, every student in his group did a rectal on him.
“I thought having several digital rectal examinations done on a young patient for our education, taught by the fellow who is about to fix your hernia, is not really a free-will, informed-consent situation,” says Burnstein.
The notion of a patient being subjected to repeat rectal examinations by students is not new. It even has a piece of slang to describe it: BOHICA, which is short for “bend over, here it comes again.” According to Wikipedia, BOHICA is a military acronym that came into regular use during the Vietnam War. Commonly understood as a reference to being sodomized, it apparently signified that “an adverse situation is about to repeat itself, and that acquiescence is the wisest course of action.”
It’s not surprising that this piece of military argot found its way into the world of medicine. A surgeon who doesn’t want his name mentioned and who works in private practice in the Pacific Northwest told me that when he was at the U.S. Veterans Administration (VA), “the veterans who attended the urology clinic would often be guinea pigs for learning residents. BOHICA was the phrase for the prostate clinic. If a patient had a big prostate, the surgeon would be like, ‘Come over and feel this.’ You would often get one patient who would get three or four or five rectal examinations by different people. The veterans were joking about it. They would say, ‘I’m here for my BOHICA clinic.’ Like it was funny because they came up with it themselves.”
The surgeon says that both the practice of multiple examinations and the nickname continue to this day. He says he has friends who are urologists who describe where residents do general urology training as “the resident BOHICA clinic.”
That is as cringeworthy as it is puerile.
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The three most offensive bodily fluids health professionals have to deal with are feces, vomit and pus. Of the three, I’d say I’m sickened the most not by the sight but by the smell of pus oozing from an abscess.
“Pus is much worse than poop,” agrees Marc Burstein. “It’s stinkier and it doesn’t wash off as easily.”
Burnstein says the worst abscesses he has to drain are known as ischiorectal abscesses, which originate just inside the anus and spread to the buttock. “God bless us, in North America we have lots of big buttocks,” says Burnstein. “And you can collect a large amount of pus. Personally, I have not thrown up, but I have had to step out for a minute or two and take a bit of fresh air before I come back in the room. I have seen others whose eyes watered at the odour that you can encounter in these situations.”
Nicole Donaldson, the licensed practical nurse has learned not to be fazed by the appearance or the smell of any particular bodily fluid. For eight years, Donaldson worked as a nurse at the Vancouver Island Regional Correctional Centre in Victoria. The people who work there still call it the Wilkinson Road Jail. When she worked at the jail, Donaldson recalls, she was asked by her supervisor to see an inmate who had been transferred to the facility.
“This fella had a pair of shorts on, with very hairy legs. Here I am, trying to pull out stitches. I pulled one stitch and then another. When I pulled the third one, a little pus came out and I was all excited. And he says, ‘Oh, wait. Let me show you pus, nurse.’
“He put his left hand underneath his thigh and his right hand on the inner thigh, and he pushed. Pus came out of orifices I didn’t even know were there. Pus came out of every stitch. I probably had like a cup of pus with one push. The jail guards knew he was going septic, so they got him to us. We discharged him straight to the hospital for intravenous antibiotics.”
For paramedic Morgan Jones Phillips, it isn’t pus but vomit that makes him hurl. Beyond hurling and puking, it’s difficult to find medical slang for vomiting alone. There are bits of slang for vomiting in combination with diarrhea. In the United Kingdom, DNV stands for “diarrhea and vomiting” and OBE for “open both ends.” Phillips doesn’t have slang for a patient vomiting in the back of an ambulance. But he does have an epic story.
“We loaded [the patient] onto the stretcher and were taking him to the hospital,” Phillips recalls. A veteran paramedic, Phillips was riding with the patient in the back of the ambulance. He positioned the man on his side so that he wouldn’t choke on his own vomit. Protecting the stretcher and the floor of the ambulance from the man’s vomit was another challenge altogether. “I was standing up and I had my back to him. Normally, when someone’s vomiting, you hear it coming.”
When that happens, Phillips is as proficient at reaching for a barf bag and placing it in front of a patient’s mouth as Wyatt Earp was with a gun in the Old West. This time, Phillip’s patient was unconscious. That meant he didn’t make a gagging sound or give any indication of what was about to happen.
“I looked down and he was vomiting,” says Phillips. “And I’m right beside him, and it’s splashing and it’s on my legs. I’ve never seen vomiting like this. He’s already got a big pile on the floor. I put the bag under his mouth, and he fills up the bag, which I have never had happen before. The bag is full, and so I throw the bag into the garbage. I don’t have a second bag. I usually carry two, so I must have used one on a previous call and forgot to put a second one in my pocket. So I have to climb over him to get to the shelf to get another bag.”
Meanwhile, the patient continued to throw up onto the floor of the ambulance.
“It was probably a good eight inches high and sort of spread like a pyramid and it smelled awful. I was afraid that I was going to throw up. I started to retch.”
Phillips got his partner, who was at the wheel, to flick on the lights and sirens—paramedics call them cherries—and get to the hospital as quickly as possible. His partner drove as fast as he would have had there been a child choking to death in the back of the ambulance. Unfortunately, he drove so fast that the neat pile of vomit began to spread all over the ambulance floor.
“As we got to the hospital, we went up this big ramp and then he slammed the brakes on,” Phillips recalls. “This tsunami of puke came flying across the back of the ambulance. I jumped onto the bench like a seven-year-old girl seeing a mouse. We ended up being out of service for hours after that because the vomit was everywhere. It was on the walls, it was on the floor. It took forever to clean it up.”
With a story like that, it’s a wonder anyone would want to become a paramedic.
* * *
There is a condition of the lower intestines that attracts its share of stories. Unlike with Code Brown, there is little restraint on the storytelling—and even less empat
hy for its victims.
We label the condition with the odd euphemism social injuries of the rectum. An American colorectal surgeon, Dr. Norman Sohn, first coined the term in an article published in the American Journal of Surgery in 1977. The article reported eleven patients with injuries of the rectum and sigmoid colon that were caused by the insertion of a clenched fist—a practice known to men who have sex with men as fisting. Six of the patients in the study sustained cuts to the rectum and four had perforations that required repair in the operating room. One suffered a torn anal sphincter and ended up with incontinence.
Social injuries of the rectum is a lovely bit of medical argot because it can be spoken anywhere. The words are innocuous; only those in the know grasp their true meaning. “I love that expression and I wish I could take credit for it,” says Marcus Burnstein, who, like Sohn, trained in colorectal surgery at the Lahey Clinic in Burlington, Massachusetts.
The usual reason people put something through the anus into the rectum is autoeroticism—using the anus and the rectum as organs of sexual gratification. “It’s usually somebody doing these things on their own,” says Burnstein. “Although we have had patients come in where it was part of a group sex-and-drugs event and somebody did something to somebody else that they would not have done to themselves. These tend to be difficult injuries to treat.”
Inevitably, the conversation among health practitioners turns to what objects have been inserted by the social injuries enthusiast.
“Every now and then we’ll have somebody come into the ER who has inserted a golf ball or roll-on [deodorant] or zucchini,” says Burnstein.
“I’ve certainly removed lots of strange objects,” says Dr. Sid Schwab, a retired general surgeon and author of Cutting Remarks: Insights and Recollections of a Surgeon. The book is about his training in the 1970s in San Francisco, where he saw scores of patients with social injuries.
“I had a guy that had inserted a candle,” recalls Schwab. “It was at least a foot long and maybe three inches in diameter and it was this hard wax. I just couldn’t get purchase on it because anything you tried to grab it with you’d have to spread the jaws so wide that when you tried to close them, it would just sort of slip away. It was so long that, feeling it through the abdomen, it was actually up above his ribs. So I couldn’t really push down on it.”
Unable to retrieve the candle despite several tries, Schwab got so desperate he began to entertain suggestions. “We just had a parade of people coming in with their ideas on how to grasp it—orthopedic clamps, trying to pass catheters above it and blow the balloon up and pull it back. Nothing worked.”
Finally, Schwab did what he was trying to avoid from the outset: he took the man to surgery and removed the object under general anesthetic. “I had to make a little incision in his belly and then I could reach in with my fingers and sort of stabilize it and push it downward and then grab it and pull it out.”
There is a certain degree of competitiveness between surgeons as to who has the most elaborate story of what was inserted and how it was removed.
“My own worst experience was a man who came into the emergency department with a large billiard ball in the rectum,” recalls Dr. Marcus Burnstein. “A billiard ball is very hard to grasp. We sedated him and couldn’t get it out in the emergency department, so we had to take him up to the operating room and give him a general anesthetic to relax the pelvic floor muscles and the sphincter.”
Two assistants tried to remove the billiard ball—one pressing on the abdomen and the other trying grasp the ball from inside the rectum using forceps ordinarily used on pregnant women in labour. Their efforts were to no avail. The ball remained stuck inside the upper portion of the rectum.
“Just as we were starting to bring the ball down, the patient coughed,” the surgeon recalls with a shudder. “The forceps, the billiard ball, some blood, some gas, and some stool ended up in my lap. We got the ball out, but it was a messy experience.”
That is Burnstein’s most vivid experience in a long career, but it’s not the worst injury he has seen during his residency and his career as an attending surgeon.
“The most serious damage I’ve ever seen was from a fluorescent light bulb,” he says. “It was a long one, like one of those up on the ceiling. They’re very fragile. So, naturally, it broke inside him and ripped his rectum, causing lots of bleeding and perforation.”
The surgical labour involved in fixing the patient was daunting. “We had to remove a segment of rectum,” he says, “and do a colostomy. He had multiple operations over the ensuing six to twelve months dealing with bits of glass and reversing the colostomy. It was a nightmare.”
That was bad enough, but there was more. Most inserted foreign objects pose a risk to the patient only. Not so with a fluorescent bulb. “It was very dangerous for the surgical team. Shards of very sharp glass were in his abdomen near blood vessels and near the ureters. It was a disaster. We had to clean up as much glass as we could.”
Burnstein told me his stories with admirable restraint. Still, the surgeon, who admonishes young doctors not to spread stories about Code Browns and especially not to laugh at them, feels far less inclined to do so for self-inflicted injuries of the rectum.
“I wouldn’t be as aggravated if OR time wasn’t so precious,” says Burnstein. “These people need help. I shouldn’t be grading who needs help, but when operating rooms are being tied up by the removal of a foreign object in the rectum, it’s a little annoying.”
Worse still, many of these patients are repeat customers. Burnstein refers these patients to psychiatrists, but that does little to prevent future episodes. “In my experience, psychiatrists are not terribly interested in that particular problem. I guess what I should be saying is less that the psychiatrists aren’t helpful than that these patients are very difficult to help.”
And when it’s time to pick up an instrument to help, like all doctors, Burnstein does not have the right to take a pass. For Burnstein, it’s just another day at the office.
4. Status Dramaticus
I’m an adrenaline junkie. Like most doctors and nurses who work in the ER, I thrive on the excitement of pulling patients back from the brink of death with seconds to spare. I long for patients who bring bona fide life-and-death drama to the place where I work.
Patients like a 41-year-old woman I’ll call Andrea, who arrived by ambulance one night. Two paramedics rushed her through the sliding doors past a startled triage nurse and headed straight for the resuscitation room. Andrea was in such a bad state the medics weren’t going to wait for the triage nurse to tell them which room to take her to. I saw a blur of stretcher and paramedics round a sharp corner as they hurried into the resuscitation bay and decided to follow.
“Forty-one-year-old G1P0 three days postpartum vag delivery with a PPH,” one of the paramedics shouted as she and her partner transferred Andrea to a gurney. “BP 70 by palpation with a pulse 120 and thready.”
Andrea had delivered her first-born child, a daughter, three days earlier. She was doing well following her discharge from hospital. The baby girl had latched onto Andrea’s breast and was feeding hungrily every three hours. It was during a feeding about an hour before she arrived in the ER that Andrea suddenly felt queasy and started to sweat. She noticed a warm and cozy feeling around her lower torso. For a moment, Andrea felt as though she were relaxing in a hot tub. Then she looked down—past the baby suckling at her left breast—and noticed that the bedsheets around her hips were sopping with fresh blood.
The blood loss had caused Andrea to go into severe shock. Her BP (blood pressure) of 70 was dangerously low. The pulse of 120 was nature’s way of trying to compensate for the low blood pressure by getting the heart to work faster. A thready or weak pulse meant that Andrea’s heart was losing the battle. I could see that Andrea was in severe shock; she was hemorrhaging to death from a postpartum bleed.
Unlike
the bleeding from a first-trimester miscarriage, postpartum hemorrhages (PPH) can be massive. They are the most common cause of maternal death in the developed world. I estimated that Andrea had lost more than a third of her blood volume. This is one of those situations in emergency medicine in which finding the cause—one or a combination of a fatally weak womb muscle, bits of placenta still inside the womb, or blood that does not clot properly—takes a back seat to the ABCs of resuscitation: airway, breathing and circulation.
“Let’s start 100 percent oxygen by non-rebreather,” I told the nurses. “Two large-bore IVs—one running normal saline and the other lactated ringers—both wide open. Type and cross for eight units of blood. Let’s start an oxytocin drip. Let’s give her four tablets of tranexamic acid. And call the OBGYN resident stat.”
Oxytocin would get the womb to contract. That might stop the bleeding. Tranexamic acid would help stop the bleeding by getting the blood to clot. “Type and cross” is an essential blood test before giving a transfusion. It determines the patient’s blood type and tests it against potential donor blood for compatibility. Without this step, the patient could die of a transfusion reaction. The trouble is, it takes at least forty-five minutes to do a proper type and cross. I reckoned that Andrea wouldn’t survive that long without a transfusion. Already in shock, her thin blood was no longer properly nourishing her heart, her brain and her other vital organs. Without quick action, Andrea would go into irreversible shock as her vital organs failed.
“Call the blood bank and tell them we need type-specific blood stat,” I told one of the nurses. In a dire emergency, we transfuse blood that has been typed and is appropriate for the patient yet hasn’t been cross-matched. Type-specific uncross-matched blood is usually available within five minutes of the request. While there is a risk of a transfusion reaction, the risk is worth the life-saving benefit. When type-specific blood is transfused, a cross-match is performed as the blood is being transfused; that way, the transfusion can be stopped immediately if a potential transfusion reaction is discovered.
The Secret Language of Doctors Page 6