Friday, January 18, 2008

Sir, I need to place a finger in your anus

A lot of hoopla regarding the construction worker from Brooklyn who is suing the trauma unit who performed an "unauthorized" rectal exam during his initial evaluation. I hate to be a "doctor apologist" but when you find yourself being rolled into a Trauma Bay, your "inalienable rights of man" are temporarily suspended. I'm sorry, but that's just the way it is. The approach to trauma resuscitation is completely protocol driven. Everyone gets essentially the same work-up every time, all the time, in every level I trauma unit across America. The reason is, evidence suggests outcomes and 30 day survival numbers to be superior in centers that employ an algorithmic, protocol based approach. First you do ABC's. Then mental status exam/glasgow coma score, then a brief history, and finally a complete head to toe, back and front physical exam. So many of these patients roll in with severe head injuries or compromised by drugs/alcohol on board that you can't trust anything they say, initially. You can't afford to. Removing a c-collar too early, or skipping a rectal exam can be disastrous. The Brooklyn guy supposedly fell and sustained a head injury at the construction site. What if they found blood at the anal verge? Is it just hemorrhoids? Or maybe a shard of lumber that lacerated his rectum as he fell back unconscious? You don't know, but your interest is piqued and further work-up is warranted.

The problem in this area is one of proper triage. If I walk into my PCP's office and decline a rectal exam, it would certainly be assault if I were held down and forcibly rectalized. Trauma is a different animal. It's like when you were a little kid and had to be cajoled and bossed around by your parents. You didn't have a choice in brushing your teeth because it was "good for you." Same thing in trauma. The cost of missed traumatic injury far outweighs the momentary loss of dignity of having somebody put a finger in your anus for 1.5 seconds. Obviously this guy probably didn't need to be sent to trauma bay; he sounded completely alert and oriented and without obvious physical injury. But that's where he ended up. And we're much safer, in the long run, knowing that the guy got his inevitable rectal exam.

13 comments:

Doc's Girl said...

I shook my head at that news story, too, when I read it. Just plain silly. Ironic when they would have sued for malpractice had something in that area been missed when he came in...

From my experience in working in the ER for 2 years, I will say one thing: I totally upgraded my underwear drawer shortly after my employment and even now as I am not working there anymore. :)

...and, no, this started before when I was still single. :)

cutonthedottedline said...

Exactly. They would have been suing just the same if something was missed. Almost everyone who comes through the trauma bay objects to all or part of the proceedings. The trauma team has no way of knowing, without going through the whole protocol, who has a serious injury and altered mental status leading to combativeness, and who is just fine and doesn't need to be there.

I've had a few rare patients say thank you even while we're in the middle of the whirlwind. Everyone loves them.

ruby said...

If a young female patient entered the OR with some kind of trauma (maybe rape) where protocol included a pelvic/rectal exam, which even after trying to reason with her, she adamently refused, even if performed by female doctors. Would you be within your rights to forcefully exam her by holding her down or giving her a knock out shot.

Sorry, I couldn't resist playing devil's advocate, but I am curious.

Buckeye Surgeon said...

Absolutely. Think about a scenario where a woman is raped transanally, perhaps with a foreign body (broomstick, billyclub). Rectal injuries are the primary concern. The area needs to be carefully washed off and inspected. Any blood on exam would mandate proctoscopy, OR diversion, etc....

Of course, this assumes the patient is brought through the TRAUMA bay...... Tough to make the same argument for someone who simply shows up in the ER, ambulatory, saying she was raped.

Bongi said...

that stupid patient should be shot! bad genes could be used as the reason. bad for evolution to allow such stipidity to procreate.

what does he think, doctors love doing rectal examinations. we wake up in the morning and think 'another glorious day of sticking my finger into someone's anus!'
on the contrary he should be sued for making it necessary for a doctor to have to examine him fully. selfish bastard!!

Bongi said...

i must disagree with buckeye on one point, though. in our country if a patient expresses that you may not do an investigation and if they are of sound mind, you may not do the examination. full stop.

a clever doctor would get the patient to sign something stating this and leave it at that. i might consider telling him to get another surgeon if he refuses to allow me to fully evaluate him. but to examine him or her against his/her will is not permitted here.

Buckeye Surgeon said...

I agree consent is mandatory in the usual ambulatory or ER setting. But in trauma everything has to happen in five minutes. Speed and efficiency are what lead to early identification of traumatic injuries and better outcomes. Moreover, the phrase "of sound mind" is not applicable in the trauma bay; underlying alcohol/drug intoxication and closed head injuries cloud the practioners' ability to evaluate patient judgment capabilities.

Anonymous said...

What I think is whiny ass men need to grow up. Goodness, women have this exam all the time when they are pregnant and often when we go for our pap tests. We don't like it anymore than any men would like it, but that's the breaks.

Bongi said...

buckeye, agreed. of sound mind is the crux.

Anonymous said...

Hey Buckeye,

Do you have any difficulty getting those pesky swastikas clean and bright when you get your uniforms laundered. Wow, you must have gotten an A++ in Arrogance 101 in med school. You are exhibit A for the growing totalitarianism represented by the medical profession.

Buckeye Surgeon said...

Anon-
Surely there are better things to do with your time than to clutter this blog with hate and vitriol....

Anonymous said...

You got me, I hate the medical profession in general and I probably would not be fond of you. My message was a polemic not an argument, but you gave me all the evidence I needed to express my distaste for your attitude and what I think is the conventional attitude of your peers. He was like a child being told to brush his teeth, the momentary embarrassment of having someone put a finger up your ass (against your will), give me a break. That Sir, Doctor is rape.

joe said...

i agree that the full trauma workup is the best treatment for a trauma patient, and should be performed, even over patient's objections. if i were the injured party i would want whatever procedures were deemed necessary. however i would be very scared and anxious about what was going to happen to me, and would probably vehemently object to some procedures. for this reason i would prefer to be sedated, thereby enabling me to access the recommended treatment. i do not want to sue anybody, and i want what is recommended, i simply would refuse out of fright and anxiety. my being held down to force compliance would be a risky move as i am very severely claustrophobic and cannot tolerate this. i would do whatever is necessary to avoid this and would not care who might be injured. is this what i want, definitely not! but it is what would happen if anyone attempted to hold me down. once again, i wish to state my full approval of performing any and all procedures deemed necessary by medical staff, but feel that my situation is a special case in need of compromise, and possible deviation from standard protocol. i sincerely hope that anyone, especially buckeye doctor, will communicate your feelings and advice. thank you. joe