Night Shift
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Everyone has them. Some won’t admit it, but everyone has a situation or procedure that, even though they’ve done it a thousand times, they avoid as often as they can. You’re supposed to feel comfortable performing these procedures, but you feel just the opposite. For me, and I’m embarrassed to say this, it’s rectal exams.

They say that if you are bitten by a dog as a child, you will be afraid of dogs all of your life. Well, I guess my phobia began in med school (and no, I didn’t have any trouble potty training).

When I went through school we didn’t have “professional patients” like some schools have today. Furthermore, our instructors thought we needed to ‘experience’ some of the finer aspects of the physical exam before we inflicted our ignorance on our patients. So we drew blood from each other, started IVs, and passed NG tubes. Drawing blood wasn’t too bad. I hit my partner’s vein on the first try. And he returned the favor. IV’s caused a little more anxiety. My lab partner was a big guy with huge hands. He’d been a Kansas state wrestling champion. As it turned out, he was quite skillful and started mine without difficulty. But when it was my turn, his big juicy veins seemed to dodge and roll despite my repeated jabbing. I can still recall how his face turned beet red and all his muscles popped out as I inched through his tough skin, probing for a vein. Thank goodness we passed our own nasogastric tubes because I could tell he was bent on revenge. We each jammed the tubes up our noses, retching in the waste cans every time the tube hit the backs of our throats. One of the prissiest girls in the class went to the toilet, ostensibly to pass her tube in private. She told everyone that she didn’t want to be seen heaving in the lab, but we all suspected she went in there to cut the tube and hang the segments from her nose.

Just when I thought we were done with torturing each other, the instructor made an announcement. The following week we were to meet in the clinics. We were going to perform rectal exams on one another. I couldn’t help but notice the smirk come across my lab partner’s face as he popped the knuckles on his huge hands. My blood ran cold.

“What’s it like getting a rectal exam,” I asked Marty, a classmate of mine in the year ahead.
“I felt like his finger was going to touch my tonsil,” he said, squinting his eyes like he was telling a ghost story to some Cub Scouts. “When he took his finger out I shot shit all over the wall. It was horrible.” My jaw went slack and my mouth dried up. The pale blank look on my face let him know that I swallowing the bait, hook, line, and sinker.

Then he told me about a guy who took an exam glove and filled it with water. After tying off the wrist and shaping it in the form of a fist with the index extended, he froze it hard as a rock. With his lab partner on the table in position, the examiner sneaked the frozen hand out of the table, lubed up the finger and…

“What happened?” I gasped feeling a chill run through my body.

“The guy leaped off the table and ran out of the room with his pants still down around his ankles. The rest of the class was in the waiting room.”

“What happened then,” I rasped.

“I think he either left school, killed himself, or went into psychiatry. I’m not sure.”

That was enough for me. I was sick the day the instructor taught the practical on rectal exams. I think I had leukemia or a broken leg or something else terrible. All I know is that I wasn’t within a mile of the clinic.

When we actually started clinical rotations, one of my first experiences was with a gastroenterologist. I know I’m dating myself, but we didn’t have flexible sigmoidoscopes then. The rigid scope, lovingly referred to as the “silver stallion,” had a little glass door that the examiner looked through. The insufflator port on the side allowed the examiner to pump air into the colon in order to see it better. But if he ever opened the door to do a biopsy, he would quickly dodge any material that might come out with the whoosh of air. The hapless medical student looking over his shoulder was like an umpire set up behind a catcher, only this catcher dodged foul tips instead of catching them. I barely saw more than the back of the doctor’s head the whole month. Consequently, I was totally unprepared to examine that part of the human anatomy once it became my turn to be the real doctor.

One of my first rotations was the ER. And as luck would have it, one of my first patients to require a rectal exam was a rather attractive woman in her thirties. “Have you ever had a rectal exam,” I asked, hoping she would refuse.

“Of course,” she said, “every time I get a pelvic.”

“Have they ever tested you for passing blood,” I said, praying that someone else had done it for me.
“I don’t know,” she said. I was trapped. I thought about lying about the result, but I knew I’d get caught by my professor. Finally, I placed her on her side, like the book illustrated. But when I went to actually perform the examination, something went terribly wrong. I must have turned my head, or closed my eyes, or something. I felt no hemorrhoids, or stool, or . . . Oh no, that’s the cervix, you idiot! How could you miss the rectum?

 “Is that a new way to do a rectal exam?” she asked trustingly over her shoulder.
“Uh, uh, yes,” I said. “If there’s any hemorrhoids I don’t want to start them bleeding.” I was shocked at how quickly this whopper of a lie jumped out of my red sweating face. I left the room as quickly as I could, telling the unit clerk to schedule the patient for sigmoidoscopy next month, when I would be on cardiology.

Eventually I got to where I could do the exam, but I’ve never felt comfortable doing it. Recently I had a young male come to the ED complaining of rectal bleeding. Being the good doc that I am, I reluctantly told him that I had to do a rectal exam on him.
“You have to do what??” he almost shouted.

“I have to put my gloved finger in your bottom to see what the problem is,” I sighed. We looked at each other like condemned men.

I finally coached him into the knee chest position on the exam table, but when I attempted to perform the exam, the rectal sphincter just would not relax. The harder I pushed, the tighter he became, and the further up the exam table he crawled. I felt like I was pushing a car with my fingertip. With his head smashed against the wall, I finally got the tip of my finger through the orifice. But it was a worthless exam. He virtually leaped off the table muttering to himself, “I…I could never be a….”
Yeah, and I’d make a lousy proctologist, I thought.

Not too long ago, I had my 50th birthday. Adding insult to injury, my wife, who is younger, taunted me, saying, “You know what this means, don’t you? After fifty you need regular checks of your prostate and colon. Do you want me to make the appointment?”
“Don’t worry honey, I’ll make the call.” First I had to check to make sure my old lab partner was practicing in another state.

Mark Plaster, MD, is the editor-in-chief of Emergency Physicians Monthly and a
practicing emergency physician in Baltimore, Maryland. 

 

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