human behavior

On worries

Posted in Habits & Manners, Health & Medicine by humanb on April 30, 2010

A charming 91 year-old women presented to the Emergency Room the other day with two weeks of constipation and a grossly distended abdomen. After obtaining her medical history and performing a basic examination, the junior emergency doctor explained to her the necessity of a rectal examination to feel for masses or fecal impaction. He apologized for the need for the exam and offered her the option of having me, a female medical student, perform the exam. With almost cinematic emphasis, she looked at him, then looked at me, then replied:

I think she better do it.

So I did. I had done two before on male patients about a year ago and a few on the male teaching dummy before that. Still, the junior doctor had to move me to the right side of the bed because I had forgotten about best positioning, and had to fetch me some lubricant because I had forgotten about the need for it. I thought I remembered the basics of the exam itself though. It ain’t rocket science.

I inserted my gloved index finger as far as it would go, and with circular sweeps tried to feel for fecal impaction. The rectum was dilated and empty and I found it difficult to reach the walls, but I was confident that there was no obstructing mass in the area my finger could reach. Afterwards, the doctor insisted on examining my finger himself for any traces of blood.

After reviewing the woman’s abdominal X-ray we concluded that she had a small bowel obstruction and called the surgeon. Part of the conversation between the emergency doctor and surgeon went something like this:

Surgeon: Did you a do PR?

A ‘PR’ is a per rectal examination.

ER Doc: Yes, I did. Uh, that is, my medical student did the PR, but I was present.

Surgeon: You were present. Has the medical student even done one before?

ER Doc: Oh, yes! She’s done quite a few of them before! And I saw her insert her finger and examined the finger when she removed it.

Surgeon: Uh huh. Yeah well, you should do it again. A PR exam by a medical student is not a PR exam. I’ll be down soon.

To his credit, the ER doctor had faith in my exam skills and didn’t repeat it. But after I heard that conversation, doubt crept in.

When the surgeon finally came down he disagreed with our diagnosis of small bowel obstruction based on X-ray. It was large bowel, which means an obstructing mass was more likely. And he asked me not once, but twice (if not three times):

Surgeon: And the rectum was empty? You felt nothing in the rectum?

humanb: Yes, it was empty as far as my finger would reach.

Surgeon: Well your finger is probably longer than mine. Alright.

So the surgeon sent her for a CAT scan of the abdomen to get a better picture of the problem and had her admitted to the main hospital. Soon afterwards I left for the day, but I carried that patient with me…

In my mind’s eye I kept going over and over that rectal exam… on the long drive home… as I changed out of my work clothes… as I checked my email and stared at the evening news… as I prepared dinner… Did I go as far as I possibly could or was I too gentle at the expense of being effective? Did I sweep the walls for lesions? Could I have missed a mass?

I called my husband at work as he prepared to leave for home. “How was your day?” I asked. My husband, a corporate lawyer, told me something about a client in North America that had him concerned.

“How was your’s?” he asked. I told him about the rectal exam, of course. I was feeling very unsure about it by this stage. His reply:

Wow, your worries aren’t my worries.

Funny. But not true.

Our worries are the same. We all worry about a few discrete things in life: our health, our loved ones, money, and fu**ing up – be it at work, in relationships, or in social situations.  I suppose some of us also have existential worries. I do, anyway.

My husband worried about his responsibilities with respect to his client. The pensions of thousands of people were at stake. I worried about my responsibilities with respect to my patient. A woman’s life was at stake. Did he cover all the bases in the contract? Did he miss something? Did I sweep every surface? Did I miss something?

The problem with the Emergency Department is that you never know what happened to patients after they’re admitted to the main hospital. You move on to the next patient in ED. So the next day, though she was gone, I looked up the results of her CAT scan: she had a mass in her lower colon. It was too far up to have been felt, but the CAT scan report said there was feces and flatus in her rectum. Maybe that was too far up too. Maybe not.

I’ll never know.

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