Wednesday, March 4, 2015

A Land Down Under

Let me take a fact, let us all take a reflect upon our bowels.

Are we through yet? Because when it comes to my esteem for bodily fluids, GI products are at the bottom of the list, and my discomfort rises the lower down we go. Like my feelings for Justin Bieber, I find nothing intriguing about the intestines or their output. And my distaste does not concern itself exclusively with current bowels, but also those of antiquity. I am aware of scientists that study coprolites, on fossilized dung, in order to discover the details of prehistoric flora and fauna; if it was there, so the logic goes, something must have eaten it. Despite my fascination with all things ancient (including, if some are to be believed, my tastes in comedy, music, and pop culture), I'm perfectly content thinking that half the dinosaurs ate plants and the other half ate them, and that the earliest mammals thrived on Ding Dongs and RC Cola. I really don't need to know.

(My dislike for the topic is so extreme that when I heard I was about to be beat out by a medical school classmate in the race to claim the first scientific publication from our group, my angst disappeared when I learned that he was writing on the mechanisms of diarrhea. Perfectly happy to be in second place...or is that Number Two?)

Bowel issues fall into one of two categories. The first, of course, is diarrhea. Diarrhea in the ER is like a hand grenade. It either goes off, wreaking havoc everywhere, or sits there benignly, flirting with you to remove the pin. So nobody has just a "loose" bowel movement. Patients describe them in terms of volume, and "scant" or "trickle" is not an option. Instead, the range of acceptable adjective goes from "torrent" to "biblical deluge." ("Explosive," which defines every episode of diarrhea, is so common as to mean nothing unless accompanied by a match-lit plume...which I've not seen done, but have seen the aftereffects of, and found that it's the kind of thing you sort of admire someone doing just to prove Darwin right.)

Most diarrhea has something to do with either disagreeable food (in a physiologic sense, not in terms of personality) or a viral illness. There are multiple other causes, of course, from bacterial dysentery to inflammatory diseases to problems with nutrient absorption. The one thing all causes of diarrhea have in common in the ER is that once declared, the patient will be fully unable to provide a stool sample for analysis. It doesn't matter that they've been in the bathroom every 15 minutes at home. In the ER, there will be no output. (This is the same principle that governs why children with fevers of 187 degrees and nearly dead at home have no fever, are eating Cheetos, and vigorously protesting your interruption of SpongeBob in the ED.)

(I should note that what we think of as "diarrhea" in this county means nothing in the undeveloped world. I've seen and cared for people with cholera, lying on mats under a tent, and let's just say that our concept of diarrhea is simply a First World construct.)

In the vast majority of cases, diarrhea is self-limited, and treatment consists pretty much of rest, lots of fluids, and the occasional antibiotic. But there's one kind of diarrheal illness which is really a problem. It's called c. diff colitis, and it can be truly debilitating for the patient. The illness is caused by a toxin secreted form a bacterium named Clostridium Difficile, and it usually follows antibiotic therapy.

How does an antibiotic lead to an infection? It turns out that our guts are home to a multiverse (accounting for string theory) of bacteria. They're mostly helpful to us, contributing to the process of digestion and generating methane, allowing us to play "Pull My Finger" and make personal contributions to global warming. When you take an antibiotic for any reason, it doesn't just kill off the bacteria causing your infection. It kills off any bacteria that is sensitive to the antibiotic, anywhere in the body, whether or not you actually want that particular strain to hang around. So in c.diff colitis, you've killed off all your good gut bugs and are left with only the bad bacteria to cause you problems.

(It is interesting to think that the methane in your flatus...a byproduct of all that beneficial bacterial, as a simple hydrocarbon, likely one of the building blocks of life. Distant worlds have been found to have layers of methane clouds circling their equators and vast oceans of liquid methane forming endless, restless seas. If you believe, as I think is reasonable, that all of us are made up of the elementary particles originating from the Big Bang ("starstuff"), then it's intriguing to think that your personal expulsions of gases replicates the early history of the universe. The odor you're detecting after that burrito? It's the aroma of creation.

So if the problem with this disease is that the good bacteria have been cleaned out, why not put them back in? And that gives rise to the newest proposed treatment for c. diff colitis, namely the fecal transplant.

(EDITORIAL NOTE: You would be proud of me. I just deleted three paragraphs of fecal transplant jokes, mostly because I realized that just the concept of the fecal transplant is funny enough that I can't really add to it in any significant way. Unless we start to talk about donors and recipients. Talk amongst yourselves and be prepared to discuss in class.)

Which brings me back to why I was thinking about bowels in the first place. The other day an older man comes in complaining of constipation. I've never had constipation bad enough to come to the ER. and I hope I never do. While it's an easy clinical problem to deal with, it's beyond me why people are not only not embarrassed, but eager to share their bowel trials with me. Frankly, I'd be kind of ashamed. In fact, I've told my colleagues that if I ever have constipation bad enough to make me call and ambulance and go to the ER, I want them to slap the shit out of me, which will correct my behaviors and resolve my problem.

There are some people who have genuine issues with constipation. These include folks with severe neuromuscular disorders such as Parkinson's Disease where the bowel simply don't move along, or cancer patients on strong narcotic medications which has decreased bowel activity as a side effect. These folks look truly miserable, and it's the one time I'll give someone an enema in the ED. We use Milk of Molasses for an enema, which works wonderfully but permanently takes away any taste you had for a certain type of Archway cookie. (It also begs the question of what exact part of the molasses you pull on to milk it.) Otherwise, if you're stopped up just because your idea of fiber is a Frito, you get a plastic jug containing a powder of Go-Lytely to drink at home. Go-Lytely, by the way, is the finest example of the pharmaceutical labeler's art, as it should be called go voluminously, go frequently, and go now.

(There's also a subset of patients who are convinced they're constipated but they're really not. Clinically, the easiest way to check to see if someone's really packed up is to take a plain x-ray of the abdomen. Impacted stool shows up as grainy, hazy material within the walls of the colon. In these patients, when you tell them the x-ray shows nothing, they will vehemently disagree with the your assessment. These patients pose a true quandary, because while you know they're full of shit, the evidence says otherwise.)

But this guy simply hadn't had a bowel movement in a few days, and was quite vocal about his needs. One of our nurses tried to placate him, letting him know this wasn't so bad. She told him how, when she and her husband were raising horses, they would take a newborn foal and gently give it an enema to prevent colic and get it to drink.

The patient looked at her and said "I'll whinney for you."

Do you recall in elementary school gym class, where you learned the difference between hopping, skipping, and galloping? I hadn't used that knowledge since third grade. But it came in handy now as whenever I would spy her dutifully charting with her head down over the desk, I would enlist a few mid-level providers in galloping a circle around her, making equine noises as we go.

Whoa, big fella.

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