DRE - Part 2

Part of checking in on a patient every morning, is reading the nurse's report to get the vital signs, and also to see if the nurse has left any notes.  One day the nurse had noted that she had seen some blood in Mr. Sanchez's diaper.  I was a month away from finishing all of my non-psychiatric rotations.  Somehow I had hoped that I'd make it through this month without having to do any DREs.  Naturally, when I saw the note, I thought "oh no, here we go again."

I decided to check with my senior resident first before I ran and stuck my finger up some one's bottom.  He reassured me that some sort of a test was done on the patient's rectum a couple of days before, and it must just be some irritation from that.  I was relieved; until I saw the note again the next day; and then again the day after that.  Reluctantly my senior consented  to my doing a rectal exam on the patient.  In the hospital, if there isn't an obvious problem, you don't want to go looking for one, so I understood his reluctance.

I was worried; how was I going to talk the grumpiest patient in the whole hospital to consent to a rectal exam?  In all honesty, I was hoping he'd refuse it anyway.  It turned out that he was quite compliant with me, probably because I had been nice to him, and he had eased up with me.  I found myself repeatedly telling him that he doesn't have to consent to it if he doesn't want to, but he told me to go ahead.

There are moments in one's life that always stay vivid in one's memory.  I remember with distinction how I was looking up at the rail on the curtains as I was closing them to give Mr. Sanchez some privacy, and at the same time bitterly thinking to myself "how may fucking asses do I have to stick my finger in before I can be a psychiatrist!"  I took my anger out on the curtains, and by the time I turned back to my patient, I was the same compassionate doctor I had been before.

I told him to get on his side.  I looked at the poor man's bottom that was now all sagging skin, showing evidence of some long gone muscle mass and fat.  I approached the skin gently and began moving the two sides apart.  To my utter horror, the second I put the slightest pressure on his bottom, a large amount of blood squirted out of his rectum!

By this time in my training, I knew enough about bed-side manners to know that it's never good for a patient if the doctor, in the middle of the physical exam jumps three feet back screaming "OH MY GOD THIS CAN'T BE GOOD!"  Unfortunately, I was already half way through the air in my three foot jump before I remembered this fact, but just in time to stifle out the scream.

My brain immediately kicked into overdrive.  This kind of bleeding, over at least three days, couldn't be compatible with  life, or at best the patient should have been comatose; yet miraculously I had just spoken to the patient.  I stole a look at him to make sure, and yes, he was very much still alive.  Furthermore, he was alert enough to converse with me and give consent for the exam.  I came to the absurd conclusion that I must have seen it wrong, since I could not explain the situation in any other way.

I decided to check him again, hoping with all my might that I had made a terrible mistake.  Maybe I was just tired and was hallucinating.  I approached him as one would approach a dead lion, fearing at any moment for the lion to spring up and attack.  This time I was even more gentle, but alas, the moment I put any pressure on his bottom, more blood shot out.  No way I was doing a DRE on this guy!  I couldn't even get near the rectum, and the little strip I had with me that verifies presence of blood in fecal matter now looked downright ridiculous.

I found my senior resident and told him.  By the look of horror on my face, he could tell it was serious and he told me to page the Gastrointestinal (GI) team right away.  I paged them, but the disadvantage of talking to a guy on the phone was that he was not getting the gravity of the situation.  He told me someone was using his scope (an instrument to look into the rectum), and he'll be up as soon as the scope is ready for use.  I told him there was no way he could scope the patient, I pleaded with him to just go and take a look, but he refused to go without his scope.

Approximately two hours later I ran into the GI guy in the hallway, he had just come out of examining my patient, and frankly, he looked a bit pale.  He told me he could not scope the patient.  This was a great "I told you so" moment for me, but given the fact that I hadn't even believed my own eyes at the first sight, I let it go, and instead just gave him a blank stare which clearly asked "now what?"

After that, it seemed like every single department in  the hospital was consulted on Mr. Sanchez.  Turned out he had a rare reaction to one of the medications we had given him, and he was bleeding out of his guts.  He was too sick for any kind of surgery, so the only thing we could do for him was to put him on "bowel rest," meaning no food or water by mouth, and hope he'd get better on his own.  Poor Mr. Sanchez, he'd lost everything, and now he'd lost the simple privilege to eat and drink.

The days went by and miraculously his body healed itself.  His bleeding stopped.  He looked more and more healthy every day.  At some point, we began trials of feeding him and he tolerated well.  Every day I would visit him in the same sing-song, teasing, joking way, and now he was smiling at me openly.  In a couple of weeks, he went from being one step away from the grave, to being healthy enough for us to discharge him to a skilled nursing facility (SNF).

One day about a week after he was gone, I ran into one of the surgery interns that was involved in his care.  She asked me what had happened to Mr. Sanchez, and I told her with pride about his recovery and the discharge.  She responded with

"I knew it! He was too old and too sick to die."

I had gone to medical school with this intern and had always envied the elegance with which she could express herself.  The irony of her statement was understandable.  We had lost so many young and vibrant patients who came in for something as simple as a stomach ache and left in a coffin, that her statement made perfect sense.

I spent that morning contemplating what she had said, and simultaneously basking in the glory of medicine for our ability to have saved such a sick patient.  The glory didn't last long.  On the very same day, while we were doing our table rounds, which is when the entire group meets with the attending physician and we review every patient with the attending before actually going out as a group and seeing everyone, a nurse walked in.  The nurse asked my attending when he was going to sign Mr. Sanchez's death certificate.

I was so distraught I screamed.  My attending explained to me that Mr. Sanchez  had died of unknown reasons on his third day at the SNF.  The doctor at the SNF was refusing to sign his death certificate, and that was why they were asking my attending to do it.  I was furious.  I was also certain that he would refuse to sign the death certificate.  My attending gently explained to me that Mr. Sanchez had no one in his life.  Not a single person had come to the hospital to visit him, none had come to claim his body, and now no one was going to sign his death certificate.  My attending told me signing that paper was the least he could do for the human being who was once our patient.  To this day, I have the utmost respect for that attending.

What had made Mr. Sanchez hold on to dear life through all those days, only to give up on it at the SNF will be a mystery to me.  I took his loss personally and it was some time before I was able to accept it.  Ironically, the one DRE that stands out most in my memory, is the one that I actually never performed!

DRE - Part 1

Digital Rectal Exam; a fancy name for the act of sticking your index finger - preferably gloved - as far up a patient's rectum as it goes and feeling your way around in there.  It serves three purposes.  First, in men, it allows you to check the prostate and make sure it feels all nice and smooth, indicating it's healthy.  Second, it allows you to check for any polyps or masses that may be lurking there.  Last, but not least, it is a way of checking to see if there is blood in the stool.  Once you take your "digit" out, it is covered with fecal material that you spread on a strip which changes color in the presence of blood; obviously, you're hoping for no color change as you do this. 

Quite useful it is, the DRE.  I despised doing it.  I've always been about establishing rapport with a patient and helping them feel comfortable, so they would feel at ease while talking to me.  Somehow the rapport changes once you've stuck your finger up someone's ass.  The DRE is, however, a right of passage for everyone who is on the journey to call themselves a doctor.  We had a classmate named Taylor McArthy whose team somehow convinced him to do two DRE exams on the same patient within a matter of hours on the same day.  I don't think that was fair to the patient, but for the rest of med school, Taylor was known to us all as Taylor Double Rectal McArthy.

Obviously, this is an exam that we performed quite often and I have lost count of all the rectums that my fingers have met, but there is one that stands out above all else, and remains etched in my memory.  This was the case of Mr. Sanchez.

Mr. Sanchez was what we refer to in our professional language as "a train wreck."  He was in his early 60's but looked more like he was in his late 90's.  He was skin and bones, and there was something wrong with every organ in his body, except for his gastro-intestinal system.  He had been a long time heroin user, and the fact that he wasn't getting any heroin in the hospital made him quite nasty and grumpy. 

During residency we switched or 'rotated' departments every month.  In each rotation, we would be assigned to a group with one senior resident (2nd year or above), two or three interns (1st year residents), and two or three medical students.  The patients which belonged to the group prior to us would all be transferred under our care.

I inherited Mr. Sanchez when I started one of my internal medicine rotations during my internship year.  I was warned that he was going to be a tough case.  Usually we covered patients with medical students, who helped out, but this one was too complicated to assign to a medical student, so I had him all to myself.

I'm a big believer in involving the family in the patient's care.  It was not easy for me to find any of his family members.  He had some contacts listed, and I called them all; sisters, brothers, cousins, aunts and uncles.  None of then wanted anything to have to do with him.  His long history of drug abuse had alienated him from his entire family.  They explained to me that they were at the end of their ropes, and at this point were hoping he would die so his suffering would end.  I didn't judge the family.  I can only imagine how hard it must be to deal with a loved one's addiction.

I did feel sorry for Mr. Sanchez.  He didn't have a friend in the world, and the nurses and all the other doctors hated him because he was so grumpy and yelled at everyone (when he could muster up the energy).  I made it a point to be nice to him.  Every morning when I visited him I was super cheerful and joked around with him. He would try to be his grumpy self with me, but a couple of times I got a smile out of him.  When I did, I would call him out on it and tell him he's not as mean as he tries to make himself out to be.  He would yell and tell me to get out of his room, and I would skip out laughing and telling him I saw him smile.  In a few days he opened up more to me.  Now I'm not saying I performed any miracles, it's just that he didn't yell at me, actually complied with my physical exam every morning, and answered my questions, his smiles became more frequent too.