A unique delivery...

Had an interesting patient the other night. Not what it first appeared, but in the end we fixed the problem...

Triage nurse comes wheeling back rather quickly to my room, which always gets my attention. I head in to see what's so exciting, and am told the patient is 2 weeks post surgical repair of an abdominal aortic aneurysm, and having "searing abdominal pain". Triage nurse is afraid something might be going on with the repair, so we get the patient into bed, and the triage nurse starts hooking up the monitors, and I start assessing the patient. Hard, distended abdomen; two well healing incisions on each side of the groin. I stat asking questions, and the answer starts becoming clearer...

Doctor told the patient when they were discharged to avoid "straining at stool". Patient has been eating "soft foods", but has not had a bowel movement SINCE THE SURGERY 11 DAYS AGO!!! (I thought that would be a requirement prior to discharge, but, what do I know) I feel for the patient. I can well imagine how scary it must be to think that if you strain too much, you might "pop" something... but, 11 days???

Doc comes in, does a full exam, and, while doing a rectal exam (which the patient did not enjoy) says, "I broke some of it up, but you have a large amount of stool in your rectum. We'll give you an enema to try and clear it up, and get things going".

I go ahead and start an IV and draw some basic labs just in case (still a chance something could rupture) and get a soap-suds enema ready. Patient is unable to "retain" the enema, and we turn towards my not most favorite job, "manual disimpaction". I get a little stool out, but it is incredibly hard, not to mention incredibly painful for the patient.

Next, we try a warm mineral oil enema. Patient retains a little, and after 10 minutes, sits on a bedside commode. Not much going on.

I let the doc know, and he says, "Heck, we might end up admitting them. I've got a call out to the vascualr surgeon that did the repair now". He orders mag citrate, which the patient drinks down faster than anyone I've ever seen, and procede to plan three, the "triple-H" enema... (High, hot, and a hell of a lot for those of you who haven't heard the phrase before).

The hard part was getting the enema tube beyond the impaction, but, after some effort, I was fairly certain I had it through the worst of it, and let a liter and a half slowly fill. After a few minutes, the patient sat on the bedside commode, and waited....

Some banter about "You may have some cramping from the mag citrate" and so on, all of the sudden the patient got a weird look on their face; a look I can't describe. I was actually getting concerned, and about to lay them back in bed when they began screaming. I was getting scared, and thought something might be disecting, when all of the sudden there was a loud "boom", and the patient stopped screaming.

"Oh, God that hurt!" says the patient, as I help them to the bed. In the bedside commode was the largest single piece of stool I have EVER seen. (I actually weighed it. Just over eight pounds!) Patient said, "Wow, that must be what childbirth feels like" and I agreed, since they had just delivered what, in essence, was the same size of a newborn....

We watched the patient for a few hours, and then sent them home with instructions to take stool softeners religiously, and not wait more than two days before seeking help.

So, in essence, I helped with a delivery!