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!