ER: All About Poop

I've discovered something about the fast-paced and adrenaline-pumped world of emergency medicine: it's all about bowel movements (or BM's, for short). Everything that we do, everything that we talk about, and everything that we think about can ultimately be traced back to shit, by however tortuous a path.

I get up early in the morning to make it into the ER by 7 AM, when my shift begins. Dr. V, who has just started his shift as well, is taking sign-out from his overnight colleague. After this process is completed, I join him as we tour the ER to assess our patients. As we pass by each patient, we talk about disposition: "This one can go home; that one needs another hour to sober up; this one is getting admitted to internal medicine..."

Lesson #1: When it gets full, we must "flush the toilet."

Each morning, the toilet, full of last night's drunks, admissions that have yet to be moved to the hospital floors, and bullshit complainers, must be flushed to clear beds for the day's incoming patients.

Yes, folks, we have just encountered a metaphor in which the "toilet" represents the ER, and the patients are, well...

So, yeah...

You're probably thinking that that is incredibly crass and unprofessional. And kind of funny. I would agree, on all counts. But think also about the burden of patient care that falls upon the ER, the basic complaints that waste valuable resources for lack of insurance and primary care, and the systemic inefficiencies that result in a lack of hospital beds for admitted patients. The root of the problem is much deeper than meets the eye. All we see is the shit in the toilet.

I go to see a patient, whose location is listed on the board as "UTP." UTP? I think, I've never heard of such a bed in the ER. I figure out, with help from a clever nurse, that UTP stands for Under The Picture. That is, the ER is so crowded that patients are stacked up in the hallways, and mine is in a secret location with the description "under the picture." I look around for the "picture," but my intellect is severely challenged on this one. After some sleuthing, I find out that the "picture" is actually a bulletin board, and I hone in on my target: Mr. S, a homeless man who had a seizure.

Mr. S, when asked where he lives, answers "in the streets." It is no wonder, then, that Mr. S has decided to take only one of his Dilantin daily instead of the three prescribed-- to make it last longer. It is no wonder, then, that Mr. S had a seizure this morning. Mr. S is used to this sort of thing, insists that he's fine, and asks to have his workup expedited so that he can get out of here.

What's so urgent?" I ask.

"I've got stuff to do!" he answers.

"What do you do during the day?" I ask.

"During the day? I rest," he replies.

Wow.

I can't say I'm surprised at his urgency to leave, though. It's hard to rest in an ER, with all the beeping and whirring and shouting--

Stop!!! Stop!!! Number one commandment!! Can you hear me? Number one commandment!! NUMBER ONE COMMANDMENT!!"

"Yes, yes, I know, Thou shalt not kill, right? Listen, we're just trying to help you."

"NUMBER ONE COMMANDMENT!! NO!! OWWWW STOP THAT!!! What are you doing to me!?! NUMBER ONE COMMANDMENT!! NUMBER ONE!!!"

-- courtesy of Hallway Dementia Patient and Doctor Attempting to Start IV

and overhead paging--

MISTER DAWSON, PLEASE RETURN TO YOUR BED. MISTER DAWSON, RETURN TO YOUR BED."

-- courtesy of Overhead Loudspeaker and Mister Dawson, Attempting to Flee ER

But at least Mr. S doesn't need a rectal exam.

Lesson #2: Everybody needs a rectal exam.

I've done it on men, I've done it on women, and I've even done it in public.

Unfortunately, a rectal exam is often the best way to get some very important information about a patient's ailment. Any patient with abdominal pain, for instance, should ideally get a rectal exam: it rules out occult gastrointestinal bleeding (a very important sign to detect, if it is present), can detect prostatic problems, and is just really fun for medical students. I smear the stool on a Hemoccult card (a special card that detects blood in the stool), and I instantly have a comedic prop:

Hey, Steve, do you want some POOP?"

"Depends... is it cooked?"

"It's marinated in juice.*"

* juice: developer used to detect blood on hemoccult cards

There are some situations in which performing a rectal exam weighs heavily on my conscience for the embarassment that it yields to the patient. One woman with severe abdominal pain got her rectal in the hallway, because there were no cubicles left (see Lesson #1, above). We did the best we could to curtain off the area with portable dividers, but I still felt the flush coming to my cheeks, a sympathetic embarassment of my own. It turned out that her abdominal pain was really opiate withdrawal, though, so a couple of painkillers later, she was sleeping like a baby and all was forgiven (or at least forgotten).

I guess I also feel weird about rectals because I understand that once I've put a finger up my patient's rectum (or threatened to do so), the nature of the doctor-patient relationship totally changes.

Mr. B, I'm really sorry, but I am going to need to perform a rectal exam. I know that it will be uncomfortable, but it is a really important diagnostic step, and necessary for your treatment."

"Oh... I'm just so embarrassed!"

"Mr. B, don't worry; it's going to be okay. It's really very quick, it's a common procedure we do, and there's nothing to be embarassed about."

"No, it's not okay! You're too pretty! Why did you have to be so pretty??!"

Does that count as a compliment obtained under torture? Whatever. I'll take what I can get.

Don't worry, Mr. B; I may look pretty on the outside, but inside I'm all mean and hardened."

Mr. B laughs heartily, the first laugh he's had since beginning his sleepless sojourn in the ER.

"Hahaha!! Okay. Do what you have to do."

In the end, the biggest lesson I have learned is to approach each day with patience, and each patient with humility, gentleness, and humor. Often, laughter is still the best medicine, and it is, by extension, good to approach every challenge with good spirits and tongue in cheek.

NO... not that cheek.