Wrecked All Eggs Sam
My team was on Long Call on Sunday, and I picked up two patients to follow. 'JJ' is a 74-year old man who was admitted to the hospital for a foraminotomy (a procedure that is performed to enlarge the passageway where a spinal nerve root exits the spinal canal). The surgery went well, but during the post-op recovery, JJ's blood pressure and O2 saturation dropped, and he became delirious. He was transferred to an intensive care unit, where he received supportive care until his vital signs stabilized. At the time, it was suspected that JJ had developed a bilateral pneumonia secondary to aspiration, which is a risk in surgery requiring general anesthesia. He was subsequently transferred to our team for care.
Rahul and I visit JJ in the MICU (Medical Intensive Care Unit) to perform a history and physical exam. JJ is an incredibly nice man, and is patient with our questions and the physical. We say farewell, and go downstairs to our den to write our notes while JJ is transferred from the MICU to one of the medical wards. This looks like a straightforward case - a patient who developed pneumonia, and we'll just provide support during his recovery. He looked dehydrated during the physical exam, so we order an infusion of normal saline.
His lab values are generally unremarkable, although we note that his hematocrit is rather low. There are a number of things that could cause a drop in red blood cells, but primarily we worry about an internal bleed or anemia. X-rays of his chest and abdomen don't show any evidence of hematomas, so we worry about a gastrointestinal bleed. Well, there's a relatively quick way of testing for blood in one's stool: the fecal occult blood test.
Rahul asks whether I went to learn how to perform a rectal exam. I figure I have to learn it at some point, right?
Rahul: Okay, here's the rectal exam in four steps:
Rahul: Yeah. Why - don't you want to?
Mikey: No, I just thought it was funny that you had to mention that as one of the four steps.
Rahul: I have to - last week I saw John running down the hall looking for a smear card with the glove still on his hand, stool and all.
Mikey: Ah.
We go into JJ's room and inform him about the possible bleeding, and tell him that we have to perform the rectal exam. JJ takes it in stride - shouldn't be a surprise: JJ was a rifleman in both the Korean and Vietnam Wars, so he shouldn't be afraid of my index finger. Rahul throws me some gloves, and we set up for the procedure. Rahul notes that we're missing one thing - lubricant.
From Rahul's Words of Wisdom:
Okay, I'm gloved up and ready to go. I'm pretty sure I'm more nervous than JJ, but I also think that it'd be more cruel for me to hesitate. It's done in about 10 to 15 seconds - I got a pretty good swipe and felt the prostate, palpating no nodules. I quickly smear some stool on the test card and we send it off to the lab. We make sure that JJ is comfortable and tell him that we'll check in on him tomorrow.
And I remember to take off the glove. As if.
Tomorrow (maybe): The Agony and ...More Agony
Rahul and I visit JJ in the MICU (Medical Intensive Care Unit) to perform a history and physical exam. JJ is an incredibly nice man, and is patient with our questions and the physical. We say farewell, and go downstairs to our den to write our notes while JJ is transferred from the MICU to one of the medical wards. This looks like a straightforward case - a patient who developed pneumonia, and we'll just provide support during his recovery. He looked dehydrated during the physical exam, so we order an infusion of normal saline.
His lab values are generally unremarkable, although we note that his hematocrit is rather low. There are a number of things that could cause a drop in red blood cells, but primarily we worry about an internal bleed or anemia. X-rays of his chest and abdomen don't show any evidence of hematomas, so we worry about a gastrointestinal bleed. Well, there's a relatively quick way of testing for blood in one's stool: the fecal occult blood test.
Rahul asks whether I went to learn how to perform a rectal exam. I figure I have to learn it at some point, right?
Rahul: Okay, here's the rectal exam in four steps:
- Put a glove on.
- Insert your index finger into the rectum, swipe, palpate the prostate and take note of any nodules.
- Swipe the stool from your index finger onto the fecal smear card.
- Take off your glove.
Rahul: Yeah. Why - don't you want to?
Mikey: No, I just thought it was funny that you had to mention that as one of the four steps.
Rahul: I have to - last week I saw John running down the hall looking for a smear card with the glove still on his hand, stool and all.
Mikey: Ah.
We go into JJ's room and inform him about the possible bleeding, and tell him that we have to perform the rectal exam. JJ takes it in stride - shouldn't be a surprise: JJ was a rifleman in both the Korean and Vietnam Wars, so he shouldn't be afraid of my index finger. Rahul throws me some gloves, and we set up for the procedure. Rahul notes that we're missing one thing - lubricant.
From Rahul's Words of Wisdom:
Performing a rectal exam without lube is really really cruel to the patient.
Okay, I'm gloved up and ready to go. I'm pretty sure I'm more nervous than JJ, but I also think that it'd be more cruel for me to hesitate. It's done in about 10 to 15 seconds - I got a pretty good swipe and felt the prostate, palpating no nodules. I quickly smear some stool on the test card and we send it off to the lab. We make sure that JJ is comfortable and tell him that we'll check in on him tomorrow.
And I remember to take off the glove. As if.
Tomorrow (maybe): The Agony and ...More Agony
posted by Mikey at 11:05 PM
3 Comments:
See, now you're just teasing. Putting "Rahul's Words of Wisdom" and "Performing a rectal exam...." in bold/color makes it look like these are links...
Now your site will get all sorts of hits from people interested in:
performing rectal lube cruel
As if you didn't meet enough interesting people!
Between you and Kari I am starting to worry. Let's just all pretend that you didn't just blog about putting your finger in someone's butt (I do have a funny story about that though) and I won't think of Kari the next time I have cucumbers on my salad. *shudders* I hope she peels that sucker - wax sounds worse that dry latex glove.
I feel that I did my best to keep both the exam and the narrative of said exam as concise as possible.
Post a Comment
<< Home