As a senior-year nursing student, I had the opportunity to participate in a work-study program for ten weeks at a local hospital in a medium-sized city in northern California. My assignment was in the Intensive Care Unit on the night shift from midnight to eight-thirty in the morning, three shifts per week. I worked intensively with six patients a week who had health problems in all body systems: neurological, cardiac, respiratory, circulatory, renal, and (my favorite) gastrointestinal.
It was common for patients in the ICU to be heavily sedated to keep them from pulling out their ventilator tubes and IV lines. One of the side effects of constant sedation is constipation and its evil relative, fecal impaction. On two occasions, I had the joy of performing a manual disimpaction: what nurses call breaking up a poop that blocks the rectum by hand. I donned sterile gloves (the thicker, sturdier kind), applied a liberal helping of lubricant, and went to work.
Getting two fingers into the anus is easy when the patient is knocked out -- they don't struggle or tense up on you. Smooth sailing on the way in. Both times, the offending mass of turd was within easy reach, only three or four inches deep. I didn't have to break out any special tools (which might perforate the rectum!) to obtain the poop either time. I used a circular, sweeping technique to break off pieces and get things moving again. Think of the tough-to-pass fecal mass as club-shaped -- narrow at the top, but wide and heavy at the bottom. I have big hands with thick, blunt-ended fingers, which are perfect for leveraging out a stubborn gigantic poop! I was able to remove a couple handfuls of turd each time just by digging deep and working it out. I was surprised by how effective the technique was!
Most patients need to be turned and repositioned in bed every two hours to prevent pressure ulcers and circulatory problems. Since I'm six-foot-three and about two-fifty, the smaller female staff nurses needed my help to move patients a lot when the lift team wasn't around. Rolling a patient over also means that you can get a good look at the patient's backside; we often found a little surprise when we did. I would gleefully declare, "Oh, look, there's a BM!" and we would clean up the shituation right away.
Gravely-ill patients can make some really bizarre crap. Much of the time, the poop was watery and loose since they were being fed liquid nutrition through IVs or nasogastric (nose to stomach) tubes with stuff that looks like baby formula. These folks can have yellow, green, gray, or even orange poop, depending on what medications they are also getting. GI bleeds can cause red or black poops, depending on where the bleed is between the stomach and butthole. Just about every color except blue! Nurses call these unanticipated turd episodes Code Brown -- as if to say that a little poop was a dangerous thing! Not really, in my humble opinion; just a minor inconvenience to clean up after.
Once during bath time, the nurse I was working with had me hold the patient up on his side so she could clean his back and buttocks. When she was cleaning out the anal cleft, the act of stimulating the area with a washcloth caused the patient to cut loose with about a quart of the loosest diarrhea I have seen since I ate a burrito off a roach coach in a bad neighborhood. The patient's gown, sheets, bedding, and mattress were defiled by green drizzlies! We had to put on biohazard infection control plastic gowns, facemasks, and double gloves for the clean up that took us both about twenty minutes.
Working in a hospital, you will learn a respect for the poop.
Another time, there was a patient who had been having loose diarrhea for a few hours. The doctor ordered that a rectal tube be put in place. The nurses suggested that I perform the installation of the Fecal Management System (sounds official) to gain experience with the equipment.
I enthusiastically stepped up to the task. The appliance looks like a long, flat tube two inches wide, with a half-gallon collection bag on the far end and a doughnut-shaped inflatable balloon on the near end that goes up the butt to keep it in place. These only work when the poop is almost completely liquid -- otherwise the tube would clog and the shituation deteriorates from there! The doughnut is deflated, lubed up, and driven in with a finger or two to guide it home.
As I was installing the device, I kept thinking about the song Slide It In, but thought it best if I didn't sing while I worked. As soon as I got it in and blew up the balloon, loose olive-green poop began working its way out toward the bag on the far end. The placement was a success. I felt proud of my achievement! Another poop-related skill I could check off my To-Do list.
I remember one patient, an elderly gentleman who had survived colon cancer years before and was in the hospital this time for respiratory problems associated with pneumonia. Many colon cancer patients have a permanent ostomy done and a section of the large intestine surgically removed. The anus is often sewn closed and no poop passes that way ever again. The intestine has an opening formed in it through the abdominal wall and the poop is collected into a bag that is hidden by a special belt under the shirt. This fellow was not sedated since he was not on a ventilator; he had a mask on that forced humidified air into his lungs.
I was in the process of changing his collection bag when he went into a paroxysm of coughing. Coughing (and vomiting, for that matter) has the effect of increasing intra-abdominal pressures by muscle action. Every hacking cough he did, a little turdlet appeared through the ostomy. I stood by with a stack of paper towels and caught the little poops as they entered the world, one by one. I counted twelve by the time he settled down. I kind of felt like a catcher at a baseball game; fortunately these were not fastballs! Each little crap was about the size of a mini-tootsie roll (and about the same color, too). I felt very lucky that he was not experiencing diarrhea; he might have spattered the ceiling!
This hospital had charting that was done on the computer instead of the old-fashioned paper-in-file-folder charting, like at other institutions. The computer charting allowed for much more detailed assessments of all the body's systems. I especially enjoyed documenting the gastrointestinal assessment portion, where all things poop-related were noted. How many times did someone poop in eight hours? How much poop was there each time? What was the consistency of these poops? What was the color of each poop? Were there any discernable imbedded materials in the poops? What was found in the poop (vegetable matter e.g. corn, peanuts, bean hulls; foreign objects e.g. marbles, gravel, gerbils; etc.)? How did the poop smell? Did the person have any discomfort, pain, dissatisfaction, or any other negative psychological reaction to the poop? Does the person have a medical history of problems with the poop? Does the person enjoy or feel ashamed about pooping? Are there any family concerns about the poop?
This kind of charting makes the nurse really think about the poop and all its fecal characteristics in detail. This can only serve to improve the practice of nursing by focusing our attentions on the all-important output of the patient. As I told my preceptor several times, "The poop is a very important indicator of overall health. We should take notice of the poop."
Also, patients should be encouraged to poop. There can be no shame in this natural function, and regular poops are part of healthy living. A constipated patient should be praised and congratulated for finally passing a turd after many days of trying. It would be an event worth notifying the physician and charge nurse about! "Mister Z finally had a very large, solid, brown BM this morning at 0530! It must have massed two kilos! Hooray for Mister Z! May he live long and poop often!"
This summer's experiences in the Intensive Care Unit were a great way for me to practice my skills and communications with the hospital physicians and nurses in my professional role development. Along the way, I also got to see human poop experience in new and fascinating ways. I look forward to a rewarding career in nursing after I graduate next year, especially when poop is involved...
