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Tuesday, September 15th 2009

I Hate Poo

Life as a healthcare provider is privileged. You get to see a lot of humanity. The good, the sad, the humorous.

Probably two weeks into being a physician I had to push neostigmine on a patient. Neostigmine is a powerful cholinesterase inhibitor that among other things causes…significant bowel contraction. Which is why I was using it. My patient had come into the trauma ICU following, literally, a nose bleed. Early onset dementia had left the patient in a nursing home and following a fall at that nursing home no one had been able to stop his epistaxis. Down in the ER they had literally stuck foley catheters deep into his nostrils and inflated them to apply pressure and stop the bleeding.

Typically Doesn’t Go In The Nose

He had a lost a lot of blood and had a lot of comorbidities and was at high risk for rebleed and so he ended up in the ICU. Easily, supposedly the least sick patient in the trauma ICU.

He had significant deconditioning on presentation and likely had some generalized ileus. Being in the ICU and further bedridden didn’t make his condition better and his belly started to grow. A KUB sometime into his stay showed a pretty significant generalized ileus without evidence of obstruction. Enemas and other efforts didn’t do a lot to decompress him. So my resident sent me in to give the patient neostigmine.

Neuostigmine isn’t always a benign drug. ‘Side effects’ include bradycardia and, that persisting, arrest. So my resident had me go into the room to administer the neostigmine with a syringe of atropine should I require it. The rest of the team, in a telling move, stood outside peeking into the room; they feared the consequences of rapid bowel contraction.

I slowly push the neostigmine and I stand there, vigilant, grim waiting to have to urgently give the atropine if needed. I’m tense. I’m a two week old doctor and my resident has made this out to be a serious medication.

Suddently my patient starts with, “I have to go. I have to go. I have to go.”

“Okay, sir, we’re getting you a bed pan,” I say. It does nothing to temper my poor demented patient, “I have to go. I have to go. I have to go.”

The nurse runs out of the room to get a bed pan; an admitted oversight for everyone involved in this endeavor. “I have to go number two!”

“It’s okay, sir,” as we slide a bed pan into position. “You can go if you need to.”

I’m watching his heart rate on the monitor and then the patient starts throwing in a new phrase. At first I think he’s saying, “I hate you.” But as I strain to listen it’s clear, “I hate poo. I hate poo. I hate poo.”

I almost lose it. Sitting there with atropine in hand should this patient have a crisis and brady down, I have to turn around and walk to the corner trying to stop myself from laughing.

I refuse to call it unempathetic; there was something endearing and worth a non-condescending chuckle about what we were putting this man through to treat him and help him. It’s the humanity of practicing medicine.

“I hate poo. I hate poo. I hate poo.” Me too.