Fecal Disimpaction: Another Unpaid Mandate?
Among the worst possible chief complaints, particularly when falling on the first or last patients of a shift, is the dreaded fecal impaction.The actual wording takes various forms:
"I think I'm impacted again"
"No BM in one week; bloated"
"Bowels are locked up"
"Pressure in my rectum"
The typical patient is an oldster who was recently started on vicodin; they have the triple threat of the Play-Doh stools which are universally caused by this narcotic, decreased abdominal musculature limiting their ability to bear down, and decreased bowel motility that seems to come with aging. Plus they are probably on 5-10 other medications which contribute to constipation, and they aren't drinking enough liquids. Except for prune juice, which apparently doesn't do shit (so to speak).
Whatever the cause, they have a huge clay-like stool ball that fills their rectum and won't come out naturally. So we have to go in and pull it out. With our hand. Or more commonly, one scooped fingerling at a time, over and over and over again. This is done until they beg us to stop, they start bleeding from the trauma, or we just can't bear it anymore. There are no other endpoints.
As a bonus, they often have lots of liquidy stool that has backed up behind the massive pooball, which not only serves as a lubricant but an air freshener as well. So after several minutes of violating this fragile elderly patient in one of the most horribly unpleasant and embarrassing ways imaginable, causing us to at least wonder if the lingering shit-smell on our clothes is noticeable to our next several patients or our family when we get home, we ultimately have no procedure code with which to bill for this absolutely necessary but maximally unpleasant service (cue shadowfax to come tell us his super-secret $500 billing code for this....PLEASE!)
WTF is up with THAT? I vote we send all such patients to the CMS for the pencil-pushers to disimpact. Then perhaps they might begin to understand the value of this procedure. And to the impacted patients, a request:
Please don't come in at shift change.
Labels: medical, play-doh poop, WTF
posted by scalpel at 8:53 AM
37 Comments:
It would appear that 45905 and 45915 would apply, so long as you use some sedation. Why would I know that? Consider my age.
Well there goes my breakfast. Remind me never to get old, thanks. :)
Just get a gastrograffin enema. It gets them to poo on the radiologists!
Nice picture, by the way.
I like the sedation idea and billing for it. It should at least be worth 1000$ dollars. I mean what is a plumber going to cost to disimpact your house when shit is coming up through the sink?
Er.... You ought to think about coming over to the retail side and keep your manicurist happy.
Um, since when do docs disimpact people? Does your hospital have job openings?
And yes, a sympathetic doc will do 1 soap suds enema and if that doesn't work, the radiologic gastrograffin enema. Others will just do 1-2 soap suds/tap water enemas and scripts for 3-4 bottles of mag citrate.
If anyone sedates a patient for an enema, they must be the one to attempt to get them up to a commode during the procedure and cleaning them up when they can't.
Better blame the PCP or better yet the patient themselves.
You just can't beat a M.O.M., mag citrate, prune juice cocktail to help squeeze out the grumpies.
As a patient, I'd say that the gastrografin enema is probably more *immediately* unpleasant (painful!) than a manual disimpaction. But it gets the job done and you're not writhing in pain for hours while the poor nurse digs around your rectum.
Soap suds never worked for me. Neither does any of the OTC stuff alone -- although I've had some success with manually disimpacting myself & a Fleet enema together.
It's really weird. You never really think about how often you poo until you're all backed up and then it suddenly dawns on you that you haven't had a healthy bowel movement in six or eight weeks.
Jerry, a plumber is going to charge $162 to clear the clog, unless he has to go up on the roof (then it's about $100 more) or remove the toilet (about $200 more). If he works for Roto-Rooter that is.
I was just going to post that my husband's found out certain medications can clog sewer lines. Those are the lucky ones, and the next time he complains about it, I'm showing him this post.
At our hospital, the docs disimpact (only in the ER...if you work on the floor, it's the nurse that does it, but you do have to have an order- I've been told because it's an invasive procedure). And of course, no doc likes doing it, so they order a bunch of enemas for the nurses to do, which never seems to work, and then end up disimpacting anyway. (I'd probably do the same thing in the docs position though). Just make sure to lube up those gloves! (I've found that it works well to dump some mineral oil all over your gloves). Somewhat related- once, when I worked on the floor, I had a doc order a "milk of molasses" enema- WTF? The pharmacy actually sent me a little jar of molasses. I don't remember, but I don't think it worked. Who knew I had so much to say about poo? Love the picture, love your blog!
Meghan, ER nurse in SoCal
I am a general surgeon and I have had to disimpact a patient under general anesthesia in the operating room. He was 20-ish guy with some developmental delay. His impaction was so severe he was developing an acute abdomen and his cecum was about 16cm across.
Don't forget to double glove because it is a B when if the glove breaks.
Also, can't remember where I saw it, but there was a study did cultures on the fingers that were gloved before and after digital rectal exam, and guess what??? Pooh made it through!
I am totally baffled.
Why not send them home with a laxative, and tell them to eat 8 oz. of very finely chopped cucumber/celery salad or watery fruit (roughage), drink 8 oz. of water every hour for the next 8 hours, then go sit on the toliet with your knees up and your heels on the rim, and...
there it will go, nice and easy and OUT, and no trip to the ER ???
Preventative medicine. Such a good thought. So little used... sigh.
When you're 85 years old with a hip fracture and a cantaloupe-sized ball of putty that needs to come out through a golf ball sized opening, then you'll understand.
Our hospital has the aptly named "code brown" team, a team of home health nurses that go out to the patients' home and do the dirty deed (disimpaction). All I have to do is insert finger, pronounce the patient impacted, write the order, and the team is activated ... 24/7/365.
My parters and I try to see who can be "number one in the business of number two" and get the most referrals for the code brown team.
Annie, do you not know there are those who suffer from true constipation that certainly does go on for weeks on end? I had a radical pelvic surgery and as a result ended up with an atonic bladder and bowel both.
The bladder was easily fixed with learning self-caths but the bowel, now that was a different story. I spent weeks worrying that I would be one of those that would have to have done what scalpel is talking about. Also, it is further complicated because of the extent of surgery, your drs. dont want you using anything to harsh. It was a nightmare that went on for months.
People who have never experienced it can not possibly understand what this feels like and how very sick you are because of it. Your solution may work for you and those with imaginary constipation but it won't do much for those who really suffer from it.
I humby apologize for youth, health and ignorance.
I will remove my foot from my mouth now and go about my business, knowing I should have been more compassionate.
Annie,
No need to apologize. Time will take care of all three of those issues. Well, two for sure, heh, heh.
In his waning months, I disimpacted my own dad. Finally he got his money's worth out of staking me to med school.
Wow, and I thought the military was hard on your modesty!
Meghan,
I think what the doc really meant was milk _and_ molasses enema. Whole milk and molasses, warmed up slightly hotter than body temp. We used it in an ER I used to work at. Not sure why, but it was highly effective.
jerry said:
... "I mean what is a plumber going to cost to disimpact your house when shit is coming up through the sink?"
Just had that procedure done - unfortunately! - and it set me back $250.
i'm with nurse k on the point of -where on earth do docs disimpact people? where do i sign up?
If I, a plumber, had my way:
1st, I'd register as a "charity" 501(c)3, tax exempt. (Bob's Baptist Teaching Plumbing Service, or maybe St. Bob's of the Divine Mercy and Infinite Care Plumbing Service) I'd swear to the gov't that, in exchange for not paying taxes like everybody else and getting big ole' HUD contracts and exclusivity, I'd help anybody. Hire a nun to follow me about on while I do God's work - for a fee!
I would pull up in an excessive vehicle, maybe a Mercedes, to your home. I would whine about how I can't make it on 6 figures, and how I "help people" with my charity plumbing, while looking at my Rolex to make you you don't waste too much of my time.
Next I'd check to see if you have a sink that is manufactured by a plumbing company that has a sexy rep come by my office and gives me the nicest kick-backs for using their products. If you do, great, if not I'll insist that you use my brand of sink, even though they are the same. Got a quota you know!
Then I would ask if you have home owner's insurance; if you did I make sure that you have the "right" insurance, and double check to see if I am paid more for not fixing your sink, or just fixing part of the sink.
Now, at last, if your sink isn't that broken (most aren't) and it is a simple procedure, I'd charge $200.
If you didn't have home owner's insurance, well THOSE kind of people always want free stuff. I'd try to blow you off, I'd jerk you around, tell you the sink is fine, and charge you $2k to encourage you to just call me "when you really need me" (those kind of people, ya gotta be firm with the lower classes). I could have been treating somebody who could have afforded a new toilet b/c they had insurance! Of course, the toilet and the sink have nothing to do with each other, but factor in the kick back I get for toilets, the kick back I get for not fixing sinks, and I can buy my another vehicle, maybe a hummer this time! Hey, I'm keeping my oath to treat you - never said anything about treating you equal chump!
Eventually the sink will overflow, and you'll have to keep calling me.
At this point I can't ignore it, something is wrong and I'd charge you $2000 each visit b/c you don't have insurance. If you asked for payments, I'd refuse no matter what payment plan you offered - all or nothing!! Then I would sue you, add on attorney's fees, court costs, billing fees, etc., and force you into a payment plan. Now my attorney friend gets some loot too and is he grateful (fee splitting is illegal and I would NEVER do that - I get "gifts" for "holidays" and sometime "find" envelopes with cash by accident), and I can pay for that nun I hired! Of course nobody can get blood out of a turnip, so your payments would be the same or less than what you originally offered, according to court guidelines.
If I really did that I'd go to prison, multiple counts. Must be nice to be a doctor!
Signed,
A plumber with stomach problems who lost his insurance.
If my sink was clogged up, I'd unclog it myself instead of expecting a plumber to do it for free.
Or if I couldn't unclog it myself, I'd happily pay the plumber market value to do so.
I'm a physician and I write fiction. I recently wrote a story about my first disimpaction that seems appropriate here. Enjoy!:
http://www.beattoapulp.com/stor/2008/1228_gg_Disimpaction.cfm#sresp
GG
i am 23 and SUFFER from severe constipation. Beilieve me, the ER is the last place i would want to go if i wasnt able to do it myself, not only because it is humiliating, but most doctors and nurses either resent me for having to do thier job, or they think its all an exaggeration. I have tried everything, diet, exercise, enema's, other laxatives, and i have disimpacted my self a few times. You have no idea what its like to constantly worry about your colon exploding, and the fact that you might need very expensive surgery, while having no health insurance. I would give anything to have normal bowel movements; and this blog's harsh and incredibly offensive comments regarding the patients who need this kind of help validates my effort to do everything possible before having to resort to an unpleasant, and humiliating trip to the ER.
I'm 31, disabled and have been on pain medication for the last 3 years. I had a horrible impaction 2and a half years ago thanks to a really dumb pain Dr that didn't say a word to me about opioid constipation when he put me on lortab 10s.
I spent 9 horrid days in the hospital, first the ER throwing up and in some of the worst pain of my life. No pain meds for hours while I drank that nasty "juice flavored" stuff and had my cat scan. Then no food or drink for 4 days and a lot of walking with the help of dilaudid, on day 6 I was finally given the enema...with my dilaudid..BIG mistake. Dilaudid knocked me out..nurse left and I woke up to a mess. Everyone was thrilled but me!The good part was I learned that all the trouble I had with Lortab, Percocet, Vicodin (severe dizziness, nausea, fainting, bowel and stomach problems) plus the fact that they didn't help my pain at all were over. Dilaudid was my miracle. I was able to walk for the first time in years and with my pain managed I could do the simple things I missed..grocery shopping, cooking, going out to visit friends and family etc etc.
But it took a long time to get my bowels moving. I now have it down to a science. Stool softener every morning, very little red meat(and I LOVED steaks..now I can't even force myself to eat one) and a romaine salad 2-3 times a week with lots of yummy caeser dressing(very oily help lube the intestine), Fiber Sure and Mirilax in a big glass of juice 1-2 times a week and when all else fails fast for 18 hours and drink chicken broth (Hydrates the "poo ball" in the bowel and rectum).
Even with all that a few times a week when I'm able to have a BM I always have to use gloves and lube to manually help. Its easier to do it yourself with a lot less bleeding and pain. But its much better than ending up in the ER with a very dry painful impaction. Even my 87 year old Grandmother has used my method and is so relieved not to deal with the pain, suffering and embarrassment of a Nurse having to do the discompaction.
I hope this can help someone dealing with this very painful and private problem.
Nothing personal, but after many years of being a nurse, and dis-impaction and cleaning up "poo air fresheners" I have to laugh my ass off at this post...
You want to charge for removal of a large rectal obstruction of natural origin, hahahahaha.
I don't know how many doctors especially surgeons say "um, nurse he needs to use the toilet".. hehehehe. I love it.. Sorry.. Sounds like maybe you should back of on the narcs and poly pharmacy.. No shit right.... sorry... You know what mixes good with that freshener of human excrement is that orange spray, then you have: Citrus poop... Good luck with that charge...
My four year old has Hirschsprungs disease and impaction can lead to enterocolitis that could kill him. This doesn't just happen to old people, some children need it to save their lives.
my life was changed forever when, at the tender age of 9 I walked into my grandparents' bedroom and found my grandmother performing this procedure on my grandfather.
I'm sure it was therapeutic, not sexual, although for the next 40+ years I think I'd rather have walked in on them having sex.
from a ypung, happily married woman who suffers from multiple autoimmune diseases that have decreased my motility to the point where I am ONLY able to move bowels my daily disimpacting myself, I would like to say to all of you that until you walk in my shoes, shame on you all! It is a devasting reality that I am left with no choice but to do. Imagine how I feel, a young mother with my child knocking on the door to come in, wondering why it always takes mommy so long in the bathroom. Not to mention the severe bleeding that comes along with my daily practice is so awful, it gets all over everything, the blood, and takes me forever to clean myself and the toilet up. Think about that reality for a while, and to the wiseguys who made comments such as send these people home with a laxative or whatever, guess what, there are many others out there like myself who can not use any of that stuff, so have some compassion.l Shame on all of you, making fun of these poor people who are probably elderly and unable to do it themselves. I consider myself lucky that I can at least take care of my self in the privacy of my own bathroom. Really, shame on all of you, there really is nothing funny about it. Its very sad and depressing, so think about it from the other side for a while and hope someday none of you need it.
Wow...I agree with the previous poster. Except instead of saying 'Shame on you all' my comment is F*CK YOU ALL!!! since I also am left with no choice but to dis-impact myself. Maybe you guys should find a new career........
How can you be so uncompassionte and still be in the medical field? Im sure these patients are embarrassed and in pain. Your there to help them, try looking at it from another their perspective. Maybe it will humble those of you who need it.
there is NOTHING funny about having to be disimpacted! I used to fight with my freind about his help offering but refusal was no longer an option when given the choise between that a few times a month or a BAG(been there, HATED it and had it reversed). sigh. Knock it off and grow up all of you who think this is funny.
Because finding the humour within our job which is surrounded bu suffering, death and other unmention-able awful things is one of the ways health professionals cope. We have to face these things on a daily basis, we need some humour to help us emotionally and psychologically. Non health professions don't get it.
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