WhiteCoat

That’s Some Serious Constipation

By Birdstrike M.D.

 

“Help.  Help!  I need something for the pain!” I hear a woman wailing from Emergency Department room 4.

“What’s that all about?” I ask Veronica the nurse.  “I guess I need to see that one first, don’t I?”

“No.  She says she’s got constipation and no other problems.  You need to see room 7 first, which is a 70-year-old male with back pain, hypertension and a family history of abdominal aneurysm.  He might have an actual emergency,” answers Veronica.

“Definitely, and thanks for letting me know,” I say, as I walk in to see the possible abdominal aortic aneurysm (AAA) patient.  I glance at his vital signs.  They are totally normal.  I walk in the room and he’s sitting on the stretcher eating a triple cheeseburger, smiling and says, “What’s up doc?”

“What brings you in here today, Sir?” I ask.

“Oh, nothin’.  My back hurts.  I think I pulled a muscle,” he says.

“Have you ever been told you have an abdominal aneurysm?”  I ask.

Out of room 4 and into my ears, blast some more primordial screams, “Oh.  Oh!  Ooooooohhh!

“No, I’ve never had one, but my dad died of an aneurysm.  I’ve got high blood pressure, though.  You better go see that lady, doc,” he says.  “I’ll be fine.  You go check on her.”

“Let me feel your abdomen,” I say.  I can’t feel any pulsating mass.  I push a little deeper: still nothing.  I feel his radial, femoral and foot pulses: they are all normal.  I finish my exam and put in an order for a CT aortogram,  along with the rest of his workup.  “Sir, I need you to put the cheeseburger down, until we get this checked out, okay?  We need to keep your stomach as empty as possible until we know what’s going on, alright?”

“You got it, doc,” he answers.

I move on to room 4.  “Oh.  Oh!  Heeeeeelp!   I need a laxative.  Please, something for the pain,” screams an obese 42 year-old Caucasian woman.

“That should be no problem.  Just tell me a bit more about what’s going on, ma’am,” I ask as she paces the room, obviously very uncomfortable and anxious out of proportion to a case of constipation.

“It’s been about a week since I had a bowel movement.  I feel  r e a l l y  bloated,” she says.  “Whoa.  Whoa!  Whoa!”  she moans, then takes a few slow, deep breaths.  “It feels like I’ve got an 8 pound ROCK stuck down there binding me up.  Please!  Give me a laxative, an enema or something.  Stick your hand up there and take it out, I don’t care what you’ve go to do.  Just do something for the pain.  I’m begging you, please!”

“Where is your pain?” I ask her.

“Right here,” she says pointing to her lower mid abdomen.

“When was your last menstrual period?” I ask.

“Oh, geez.  Oh geez!” she says, as she stops pacing and lies down on the stretcher.  She lies on her side and gets into a fetal position.  “Just give me an enema.  I’ve been disimpacted before.  Just do it.  Do it!”

“Okay, I’ll have to do a rectal exam.  If there is an impaction, I’ll try to remove as much as possible and then we will give you an enema.  It will be very uncomfortable, but you’ll get tremendous relief.  Okay?”  Veronica hands me some gloves and some lubricant.  I lean over to do the rectal exam and she lets out her loudest scream yet.

“I think it’s coming out!  Arrrrrrrrrrrrrrrrrrgggggghhhh!” she screams.  I lean over again to do the rectal exam and out comes a very,

high-pitched,

“Wa”

“Wah”

Waaaaaaaaah!

Huh? Veronica and I quickly turn to each other; our eyes lock together, bulging in disbelief.  “A baby?! What the…?” both Veronica and I ask in unison.  “You didn’t tell us you’re pregnant!”  we both say, in stereo.  This woman is not constipated, she having a baby!  Not only is she having a baby, she having it in my 8-bed “almost” ER where I only work once per month, where I’m the only doctor on duty, and with no Obstetrician or  Labor and Delivery unit.

“What?  Pregnant?!  I’m not pregnant!” says our “constipated” patient.

Just then, I realize that it’s been years since I’ve delivered a baby.  The head is out and the baby already managed to take a breath and emit a loud wail between contractions.  Oh crap! I think to myself.  “Call 911 for transfer, get an OB kit, and hook up some oxygen tubing, while I deliver this baby.”  Please, let this be a quick, easy delivery where I just catch, I think to myself.

Aaeerrrrrrrgggh!” she screams as I hold the baby’s head and then deliver the shoulders.  With only a second or third push, out comes a screaming “8-pound-rock” of a baby boy.  We clamp and cut the cord, wrap the pink, screaming, wiggling baby in a blanket and hand mom the new unexpected addition to her family.  The complete lack of prenatal care didn’t seem to hold this kid back, I think to myself, as he’s as vigorous and healthy appearing as I’ve ever seen a newborn baby.

Our new mom holds her baby and begins to cry.  “I’m 42 years old.  They told me I could never get pregnant.  He’s my miracle baby.  I didn’t even know I was pregnant,” she says, still in disbelief, sobbing.

“Neither did we,” I say, breathing a momentary sigh of relief.  “Where’s the ambulance?  We need to get mom and baby to Labor and Delivery.”

Suddenly, I realize I have a possible AAA patient in Room 7.  Hopefully he’s still stable, I think to myself, not having expected to have to play Obstetrician while he was getting a CT scan for possible leaking AAA.  I glance into his room and he’s sitting up, chomping down not on his cheeseburger, but a super-sized order of fries and a 32 oz. Coke.  This guy isn’t sick, I think to myself.  I check his CT report and the rest of his tests.  Everything is completely normal.

“I have good news, Sir.  All of your tests are normal.  There is no evidence of aneurysm.  You probably did pull a muscle in your back.  I’m going to let you go home now,” I tell the 70-year-old man with “back pain”.

“Doc, I know it’s none of my business, but I was in the waiting room with that woman, and she was screaming and carrying on about being constipated,” he replies.  “I must say, I thought she was being a bit over dramatic, but I saw one person go in that room and two come out.  I got to give it to her, that’s some serious constipation!”

 

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This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is inspired by the real life experiences of the author or any other physician, all names, dates, ages, sexes, locations, diagnoses, events and all other factual information are routinely changed to the extent that they should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmonthly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.

14 Responses to “That’s Some Serious Constipation”

  1. Canuck says:

    Birdstrike, that’s in a nutshell what ails US healthcare. He tells you he’s strained a muscle, he’s smiling, he’s chomping on a burger, has normal vitals, has a normal exam : possible leaking AAA my backside…

    If every 70 year old with backpain and this pmh / fh / clinical context with no clinical judgement is getting an emergent ct scan in your er (as opposed to a more appropriate opd screening u/s via his family doc), you guys are in deep doo doo…

    • ThorMD says:

      Ahhhh, but if we miss a AAA, we get sued for 5 million dollars and nailed to the cross.

      It costs me nothing to get the CT. It costs me everything if I miss a AAA.

      I agree the American system is messed up – but we make decisions every day to protect ourselves from litigation.

      • Pain says:

        A normal exam doesnt mean he shouldnt get a ct- physical exam cant rule out AAA. Its about 50/50 at detecting them once it gets to 4cm

      • Canuck says:

        And I’m calling bullshit on that one, Pain…

        It’s not just the normal exam, it’s the “I glance at his vital signs. They are totally normal. I walk in the room and he’s sitting on the stretcher eating a triple cheeseburger, smiling and says, “What’s up doc?”

        The odds of this patient being in the throes of an AAA leak or dissection are ZERO, as in zilch nada squat zero.

        In fact, I’d FAIL you in an exam situation if you justified it as such, because his “emergent” CT is INAPPROPRIATE, period.

        That means that you CT *every* 70 yr old with (benign, if the CLINICAL CONTEXT IS TAKEN INTO ACCOUNT) back pain simply to CYA, which contributes to that green glow in the dark I see emanating from over the border to the south.

        Be careful of using the medico-legal climate too lightly as an excuse, in this context citing it as the reason simply indicates to me *the doc* is the problem, not the lawyers…

        For heavens sake have the balls to put medical decisions where they belong : with MDs, not lawyers.

        Doing an emergent CT on this guy was CRIMINAL, if there were any lawyer issues to be debated here, it would be exposing him to unnecessary radiation.

        This patient needed a bedside FAST as a screen for an AAA, or at best an OPD U/S via his Primary.

        He needed an emergent CT to rule out emergent dissection or leak, as much as I need a brain transplant.

        Jmho ;-)

  2. Denny Carr says:

    50 years ago when I was a high school ER orderly we had a young gal brought in by her Mom for acute abdominal pain. While the ER Doc (opthamology resident) was checking her out, she delivers a healthy term baby. Fortunately we had a good ER nurse to take over, because the eye doc about passed out. I went out to tell the new Grandma and she did pass out. I really regret not keeping a journal.

  3. Marilyn says:

    As Thor said, litigation.

    Canuck, that’s one of the MAJOR problems of the American health care system. We have hamstrung our doctors because they are “damned if they do and damned if they don’t”.

    You can’t blame them for doing whatever has the least loss potential.

  4. dj says:

    Had almost the exact same thing happen to us new year’s eve. End result? surprised staff, surprised new mom and surprised new dad *in shock i think……

  5. SeaSpray says:

    Wow – that’s some shift!

    I always wished I was working when a baby was born in the ER, although I know it’s an ER doc’s potential nightmare. I remember a young girl had a baby there and stated she didn’t know she was pregnant. I just cannot understand how any woman/girl can not know they are pregnant. ??? Movement of the baby, particularly as it grows. The inability to crunch your large …hard …stomach down in last couple of months, particularly getting out of deep chairs, etc. Tying shoes, even getting panties on with ease – basic stuff. Braxton hicks contractions. Increased frequency of urination, enlarge breasts (can I say the “B” word here:) and so on. But especially …HOW can any woman NOT KNOW they have a LIVING…GROWING BABY in their body?

    I’m glad you all made out alright. :)

    That would be one hideous case of constipation and how could she not tell the difference? Weird.

  6. Dharma says:

    Crazy story… excellent delivery (pun intended)!

  7. Beth says:

    Heh…one of my co-residents during peds residency was called from NICU to ER after a woman started screaming down the hallway “Help! My butt is cryin’!”

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