The patient had been constipated for five days and, after being worked up, was due to receive an enema. I hadn’t seen him myself, but I’d read his summary in the clerking book so when the doctor asked me to go and check on whether he’d had a bowel movement or not, I didn’t think it was too unreasonable a request.
Until I entered the room.
I hadn’t stepped into it for more than two steps before smiling awkwardly at the prone patient and backing out faster than the speed of light.
The smell, my less-than-eloquent brain screamed. THE SMELL.
“I think he’s been,” I said quickly to the doctor. He stopped me as I passed him.
“You think? Did you ask him if he had?” he asked.
“It certainly smelled like he had,” I shuddered, thinking of the overwhelming waft of evil-smelling warm air that had assaulted my senses. “I didn’t think to ask.”
I knew this was the wrong answer as soon as the words left my lips. One of the cardinal rules of Emergency Medicine is never to assume anything. And it was very quiet in Casualties, so I really had no excuse.
“I’ll go and ask him,” I mumbled before the doctor could tease me for being squeamish.
My second exposure wasn’t any easier.
“Hello, Sir,” I said, introducing myself. “I understand you’ve been constipated for a while now. Can you tell me about it?”
“Well, since my surgery last Monday, I haven’t been able to go to the toilet at all.”
Surgery, I thought. Ileus?
Again, making completely baseless assumptions.
“Oh,” I said, “and this surgery was for…”
“Okay,” I said, paging through his admission book to find the doctor’s notes. “So after you woke up–”
“I was never put to sleep.”
“They said it wouldn’t be necessary and they just used local anesthetic.”
“Wait. You had surgery under local anaesthetic?”
“Yes. For my abscess.”
I finally asked the question I should have asked initially. “And where exactly was this abscess?”
“My ass.” Only then did I realize that the patient was still prone, and had been prone throughout our short interview. He pulled down his pants and I felt the room tilt slightly as the shock of what I was seeing registered. Right there, smack bam in his perinatal area, was a massive gaping hole of mixed pink and grayish red tissue. And pus. Lots of very smelly, very sticky pus. “They cut it open for me.”
Yes. You know why they say you should never assume? Because you make an ass of yourself and others. And I had just literally made an ass of myself. The patient hadn’t had a bowl movement. He had an infected perinatal abscess.
“Sir,” I managed to say, when my brain reconnected to my mouth, “do you know your HIV status?”
Look, it’s South Africa. A perinatal abscess in a young, fit-looking man basically equals some immune compromised status. But no more assumptions were going to cross my lips unsubstantiated.
“No. And I don’t want to. I’m not ready. My last doctor tried to convince me, the doctor here just tired to convince me. I already said I don’t want the test.”
I admit, I gaped at the patient in a completely non-neutral, unprofessional manner.
“Sir, did they explain why they think you should test. I could go through all the benefits of knowing your status with you right now–”
“I have already heard it all. I’m not ready. Just help me with this constipation and this pain and I’ll be on my way.”
“Sir, you’re probably constipated because of the abscess. Don’t you want to know why you have it and what options you have available to you?”
“Okay, can I examine you quickly–”
“The other doctor already did. Just give me my enema, please, girlie? I don’t want to be bothered any more.”
After about a minute more of trying to convince the patient to at least let me examine him (he wouldn’t) I left the room and headed to the doctor who was smirking smugly from behind the receptionist’s counter.
“How are you feeling?”
“Frustrated! He won’t let us do what we’re here to do.”
“It’s his decision,” he reminded me.
“Well that’s just a dumb decision. I can’t imagine how many times he’s refused testing. If he would just let us council him, he might feel more ready.”
“He’s been counseled plenty of times. But he’s also been judged a lot. Try to understand his reluctance to give that judgement validity.”
The patient never did agree to testing, and was referred back to his primary physician after the enema did what it was meant to, with a prescription and a handshake from the doctor.
I politely wished him well as he left, but I felt I was less convincing than the doctor was. I just couldn’t reconcile the idea of coming to the emergency room for help and then ultimately refusing that help. This is why I could never last in primary care. Facing patients every day who don’t comply with their medications, don’t pitch for follow ups, don’t adhere to their lifestyle guidelines, just generally don’t care as much about their health as you feel you do despite you doing your utmost to educate and counsel them. They’d see right through me in a second. They’d know every time they came back with the same problem that I’m just thinking How is this difficult? How is accepting help when you are sick difficult?
I just don’t have the patience for it.