Writer's Block

As I stare at my laptop and pray to St Francis de Sales (patron saint of writers) for inspiration, I realize that I have writer's block. The fact that I am not Catholic, highlights my dilemma. Hermes, Thoth, Kuan Yu or Ganesha are all deities that might heed the desperation of a blocked writer.Then I remember that I am an ER doctor who enjoys writing and my block was relieved.

A not uncommon presenting complaint in Emergency Medicine is constipation . Bowel complaints may be either the main problem, a symptom of a disease process or an issue revealed during the ROS (review of symptoms).

First it is necessary to define our terminology. Constipation is very patient sensitive. Missing part of the GI tract due to congenital or surgical reasons leads to "dumping syndrome". Normal number of bowel movements per day for these people may be 1-20. Many people have a single BMPD. Other perfectly healthy individuals may only have 2-3 BM's per week. Therefore the question I ask is "has there been a change in your bowel habits".

A brief aside is needed to deal with euphemisms. Bowel movement is a somewhat stilted term for a universal bodily function. Dumps, poops, cacas, number 2's, craps, and sh_ts are all acceptable ways of addressing the concept of fecal elimination. Similarly diarrhea may be referred to as the trots, runs, or squirts. My brother-in-law likes to say he is peeing out of his ass.

The extremes of age constitute most patients with a main complaint of constipation. The elderly have less vigorous contractions of the muscles of the large intestine. This problem is aggravated by many of the medications that the older patients may be taking. Medications for asthma, emphysema, COPD, Parkinson's disease, glaucoma, hypertension, insomnia, anemia, depression, psychosis, pain and nonprescription meds for colds and the flu may all lead to constipation. Decreased thirst and lack of access to water in the nursing home patient may also contribute to constipation.

Mothers frequently bring in their babies with a chief complaint of no stools in (_) number of days. A quick examination of the abdomen and possibly the taking of a rectal temperature may cure the problem. Changes in formula or powdered formula that is not diluted with the recommended amount of water may make the stools hard and difficult to pass. In the newborn, congenital problems with the coordination of the nervous and muscular components of the intestines must be considered.

Diseases of the spinal cord may present with constipation. Spinal stenosis, multiple sclerosis, arthritis of the vertebrae, infections near the cord and intervertebral disc disease may all cause constipation. A careful history and physical exam should help in diagnosing these serious conditions. Imaging studies, especially MRI of the spine will confirm the ER doc's suspicions.

The etymology of the word impaction comes from Latin impingere, to impinge. In the ER impaction may refer to third molars (wisdom teeth) growing into the second molar. A fracture of a bone is said to be impacted if the two ends of the fractured bones are jambed together, i.e. impinged. The use of the word impaction that makes even the most seasoned ER doc cringe is fecal impaction.

When a patient with constipation has a mass of dense stool that is too large and/or too hard to pass, he or she has a fecal impaction. Sometimes a thin liquid stool may ooze past the impaction and the patient has both symptoms of constipation and diarrhea.

My PA, Robin and I try to take turns "curing" the dreaded fecal impaction. One prepares for disimpaction by donning a barrier gown, and double gloves. My armament includes a mask with a dab of Tiger Balm applied to the inside. This gingery scented ointment counteracts the inevitable odor emanating from the patient. Sedation is beneficial as disimpacting is a painful procedure.

Ah, I feel relieved. Treat your digestive system well. Eat lots of fruits and vegetables. Exercise daily. Whole grains are the bowel's friends. Don't abuse laxatives.