Sunday, November 15, 2009

Inner Rumblings

I have come to the conclusion that America is the most bowel-focused nation in the world. Scholars of health beliefs, those who put together models for the purpose of enlightening the masses and acquiring tenure…I think I got that backwards…may be able to prove that this is not true. Perhaps they have done surveys of non-Western cultures, cultures in which bowels are simply part of Tao, that they ebb and flow as a river. Perhaps they are considered a sign of karma, a symbol of regeneration as everything that goes in comes back out once again. Perhaps they are mere entrails, things to be tolerated as part of this worldly purgatory we know as earth. Perhaps I hold this mistaken belief because, by accident of fate, Northeast Florida and East Central Kansas are uniquely bowel-conscious, and that these regions are joined in some mystical fashion by the good offices of St. Bonaventura (the patron saint of intestinal disorders). Perhaps there’s grant funding out there for me to find out.

I have come to this conclusion because I have recently fallen victim to the same obsession. This is a direct result of the ED “swing shift.” One of these shifts goes from 5 PM to 1 AM. While that’s no problem for night owls like me (everyone who knows me understands that I’m essentially non-functional before the day hits double digits), it does mean that by the time you get home, eat, wind down, and try to go to bed it’s often pushing three o’clock. It doesn’t help that I do everything the sleep hygiene articles say not to do, including using the bedroom as a platform for television viewing. It’s in the effort to lull myself to sleep that I’ve discovered the late-night world of the colonic infomercial.

The best of the bunch, and the one that really captured my attention, featured a “scientist” being interviewed by “serious, skeptical journalists” before a “live studio audience” drawn to the show by their “interest in health” to hear “what doctors don’t want you to know.” (In fairness, the audience did appear to be alive, as evidenced by the applause they dispensed at regular intervals when the camera cut away to them after a particularly profound pontification.) The highlight of the show was where he showed a picture of what was claimed to have emerged from his colon after use of his cleansing elixir. It was a mass shaped in roughly a semicircle, a dark black serpentine creation that appeared frightened to see the light of day. And that night, and for nights thereafter, I mused upon this picture. I was fascinated by the question of how he got it to come out in one piece like that, and I was absorbed in wondering how and why he would chose to fish it out of its watery grave. (There actually is a third question involved…if it did not come out in one piece, how did it get its shape…but we’re really not going there at all).

(Interestingly, my late-night viewing habits have also resulted in a fixation with the work of Edward R. Murrow after happily watching “Good Night and Good Luck” on the movie channel for what has to be the fourteenth time. I wonder how he would have covered the issue of colonic hygiene on the renowned “See It Now”:

“We don’t eat fiber, our fruit intake is low, and our sense of fullness is exceeded only by our sense of seeming self-satisfaction. How that can happen in a land where nutrition is plenty, ripe for the taking? Murrow and Friendly can see no answer but in our own internal Harvest of Shame. And as we consider our nation’s colonic health, we find it true that, as Cassius said, “The fault, dear Brutus, is not in the stars, but in ourselves.”)

I try very hard not to hold myself on a higher plane than my patients. (Well, okay, sometimes I do, especially when the ED patient‘s chief complaint is “Been sick, honey, been sick since the Korean War.” First patient I ever saw in my residency. True story.) But for me, bowel movements are simply one of the less tasteful functions of life, and to consider them an object of inspection and contemplation is just another sign that somebody needs to get a life. As one of my nursing colleagues put it, “Bowel movements are a necessary evil, not an object of fascination.”

I can still vividly recall the dialogue with one the first patients I saw with a bowel complaint while working at the University Of Florida:

Q: “Any problems with your bowels?”

A: “Doctor, I had a BM this morning. It was loose, not like my usual ones that are big. There were just some little pieces that looked like a rabbit. It was floating, so I poked it with a stick and it came back up. I called the ambulance. Does that mean anything? I knew you’d want to see it, so I brought it in with me. It’s in the baggie in my purse. Do you want to see it? ”

In the interest of science, there is an answer to the question (two answers, actually). The first is that stools float when there is a lot of undigested fat in them. The second is that I have no desire to touch, let alone look in your purse, and that I will trust your description of the malodorous event without feeling any need whatsoever to conduct any further investigation.

So what happens when the person with irregularity (polite term) comes into the ED? Most of the time we take an x-ray to demonstrate that there is in fact stool in the colon, and that there are no signs of bowel obstruction. (Every scenario has an ED nightmare we try to avoid, and writing off an obstruction as constipation is the risk element here.) Back when x-rays were printed out on acetate films, you could hand-carry the snapshot up to the patient, hold the film up the light, and show them the pebbly cylinders that go up, around, and down in a reasonable imitation of a tuba. Now that everything is digital and the films can’t be lifted from the computer screen, patients just have to trust you when you tell them that they’re really full of…it. (Which reminds me of several jokes that I can’t tell you.)

Then there’s therapy. The United States is an action-oriented society, and when we want our bowels to move we want them to move yesterday. Traditional stool softeners, such as fiber, fruits, and increasing physical activity, do not fit our lifestyle. So we want powerful agents, and lots of them; agents that let us know they’re working not just through the production of the desired product, but through the suffering that lets us know we’re cleansing both the bowel and the soul.

So my prescription for those who want action, and lots of it, is a preparation called Go-Lytely. It comes in a gallon jug, which more than satisfies the American desire to supersize everything in sight. (Including the output.) This solution acts by drawing more fluid into the bowels through the process of osmosis. As fluid enters the colon it not only helps to soften the stools, but the resulting distension of the bowel lumen stimulates peristalsis to help expel the intestinal contents. (Got that? There's going to be a quiz.)

Personally, I think the brand name Go-Lytely represents one of the most creative marketing ploys ever unveiled on the face of this earth. Go-Lytely does no such thing. The person who takes it goes heavily, goes forcefully, and goes quickly in an eruptive fashion reminiscent of Mt. St. Helens (or, if you prefer a classical analogy, like Vesuvius). From what I’m told, it’s a miserable few hours. On the other hand, after the potion has done it’s duty, I understand there’s a sense of completion, a lightness of being, and state of happy exhaustion like that which overtakes one who’s done a good day’s work.

I may need to try this someday, especially as I push closer to fifty and the inevitable colonoscopy begins to rear (no pun intended) it’s head. But I’m honestly still working up to it, partially because I dislike pain, partially because I’m not sure I’ve got enough reading material to peruse while the vile agent does it’s work, and partially because I fear I’ll end up like the last excreting Kansan who made national news (“Kansas Police: Woman Pried From Boyfriend's Toilet After Sitting on It for 2 Years,” Associated Press, March 12, 2008.)

You know, I think I’ll keep a stick handy as well.

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