Dad + Doctor

You might think that medical training would be a great asset to any parent.  Docs are trained in all kinds of cool things like Heimlich maneuvers and laceration suturing.

Heck, if the wife got pregnant again (Nope…don’t even ask) and went into early labor, I bet I could spread out a shower curtain on our living room floor and just take care of everything right there.  Noo problem.  Doctor DAD!

But when does all that stuff actually happen (and do doctors anywhere really suture up their kids by lamplight in the kitchen anymore)?

What does happen to the kids much of the time is some thing or another that COULD BE TERRIBLE.  Everybody, even the cat, knows the incident, or symptom, etc, might be the end of famSW101 as we know it.  What the untrained blissfully don’t know…is JUST HOW TERRIBLE it might be.

So, in essence, the only difference between a doctor-dad and every other non-medical dad, is a stupefying knowledge of all the evil possibilities that could be behind a kid’s latest symptoms.

Headache for a few hours, some fever, woke up disoriented?  What do you think, honey?

Um.  Well.  Probably meningitis.  Have you ever seen a child die of meningitis?  We’ll be lucky if she keeps her limbs.  Could be coupled with flesh-eating bacteria, too.  Hopefully at least some of her face doesn’t rot off.  We may not even recognize her…if she miraculously survives the ordeal.  It’s ok, though.  We’ll still love her.  Help her set up a profile on even though she’ll be totally deformed.  Some saint of a man will learn to love her, unconditionally, like we do.

OR, saaay, it could be an absence seizure.  Maybe the first of many.  Maybe she’ll slowly have progressively worsening seizures until some galactically-renouned neurosurgeon implantes a permanent zaptrode into her medulla oblongata and calms the seizures but unfortunatley makes her arms twitch at 0.5 second intervals, often causing her to smack her own face.

“Probably just a cold, dear.  Check her every once in awhile, and keep me posted,” like, every 8-10 minutes would be nice, at least until I get home from work so I can sit at the foot of her bed chewing my nails down to the carpel tunnels until the last moment before I’m due back at work tomorrow.

Since the day I simultaneously got fired and quit my job (aka graduated, but that’s such a boring designation), I have been much more “Daddy” than “Doctor”.  Of course, this mostly has been great.  Lots of “back-ee-ball” with one particular boy.  Trips downtown to fairs and toy stores.  Swimming pools, squirt guns, stories.  You know…Dad-kid stuff.  Some good catch-up after 3 years.

Today, I got to take everyone to gymnastics.  Excellentcool.  I’m always working at this day and hour when not subsisting on the dole.

All 4 kids have their own class.  Each is good at particular things and they ALL have a blast.  10 minutes into it today, however, I see from the Parent Stadium, my 7 year old crying and sitting on the mat.  The instructor picks her up and carries her over to the parent area.

No problem.  She’s one of the more melodramatic.  We’re good.  All good.  Everything’s good.  I’m fine.  I’m FINE!

I saunter up to my crying daughter – James Dean vibe gushing in all directions – and find that she somehow hurt her knee.  Not sure how.  Didn’t bang it…probably.  But it’s so bad, she can’t bend it, walk on it or use her foot.  Instructor gets me some ice and goes back to her class.

Really?  You can’t walk, or bend it at all?  Like, at all?

Turns out she can, in fact, bend her knee…but every time she does, she screams in pain.  The noise she makes should be built into father-specific alarm clocks.  Set that thing to belt out a child’s scream of pain…and you could show up to a tax-code seminar at 4:30 am with a slight twitch and the retention capacity of a SETI cloud-processing computer.

Daughter is crying both because of the pain, and because she doesn’t get to climb the rope – her favorite exercise (because she’s the only one in the family that can do it).  Daddy knows Daughter would never miss rope-climbing.  You could nail-gun her leotard to the balance beam, and that kid would wriggle out of it and happily climb the rope freak-naked if she needed to.  For her, gymnastics is the rope.

And she’s the one who notifies me that she won’t be climbing the rope today.


*Red Flags*

*Cow Bells*

*60’s ‘Nam Choppers overhead*

So the poor crying girl is immediately subjected to a bunch of physical exam tests that really should be reserved for the likes of LaDanian Tomlinson or Landon Donovan.

I try to get her to walk (she bawls).  I check her gait (more bawling).  Tippee-toes.  Squatting.  I look for knee effusions (more crying, sorry sweetie), patellar tracking, joint-line tenderness, patellar grind test (she loved this), Valgus/Varus stress tests, McMurray, Lachman, A/P drawer, pivot shift, Nobel’s, Ober’s, Wilson.

None of this, alas, helped with the tears.

Did she blow out her knee?  ACL maybe?  At 7?  She’ll need a walker by 35! Maybe the PCL.  You can usually walk on those and she’s moving around a bit.  Maybe bursitis, or one of the collaterals.  Compartment syndrome?  Nah.  What about a fracture?  Maybe.  Could be.  Jeez, she’s gonna need pins!  Oh!  Didn’t even think of gastrocnemius tear…poor kid! Or meniscal tear.  What about Plica syndrome…I don’t even remember what the heck that is, but maybe she’s got THAT!

I held her in my lap through the whole lesson.  Then I carried her out to the car afterward.  Once home, wife and I set her up with ice and Motrin (anti-inflammatories).

A few minutes after she settled into her at-home field clinic, she starts crying again.  OH NO!  It’s really starting to hurt.  Something terrible really did happen.  Oh, my beautiful child will never run again, maybe never walk.

“Where does it hurt, sweetheart?  What’s wrong?  Why are you crying?”

“I’m so BORED!”

“You’re bored.”  My eyes droop a bit.  I cross my arms.

“Can I puh-leeze get up now?  I had to sit all through gymnastics too.”

10 minutes later, the kid is throwing her brother’s basketball and chasing moths.  Her knee still hurts, to be sure.  But only a little.  She fully plans on climbing the rope next week.

Residency was tough, yes.

But this is why I’m losing my hair.

Reader Q: Take A Laxative Before A Rectal?

Bob Asks:

Hi doc! I have an appointment with a urologist in a few days for an enlarged prostate.

I know the doc will probably need to do a digital rectal exam. Should I take a laxative or something else similar to what you’d take before a colonoscopy in order to make sure the rectal cavity is empty?

This is rather embarrassing and I don’t want to make this any more unpleasant for myself or the doctor than it has to be.

Also, if you think I should use a laxative, which one should I use, and how long before the appointment should I use it?

The Ignominous Future of Every Human With A Prostate
The Ignominious Future of Every Human With A Prostate

Bob –

It’s good for me to get questions like this because I often forget how much anxiety a physical exam can cause.  I only recently learned that many women shave their legs, and often wax their pubic areas, in preparation for their pelvic exams.

One woman, just as I was about to insert the speculum, said something along the lines of, “See doc?  No hair!  Isn’t that nice?”

The truth is that performing physical exams – the scientific evaluation of the of the human body – is the job of every doctor.  By the time we’re fully-trained, we’ve done thousands of them.  This makes non-medical things like smell, hair, feces, dirt, grime, growths, etc, decidedly uninteresting.

There really is a disconnect between the medical and non-medical parts of a physical exam.  This is part of the bigger question about how a male Ob/Gyn, for example, can see breasts and vaginas all day and then go home and be sexually attracted to his wife.  To most Ob/Gyns in that situation, it’s a strange question.  They’re two totally different worlds.

Plus, after you’ve done so many physical exams, you’ve seen some pretty crazy things.  Most ER’s have a “butt box”, for example.  This is a place where all the things people have inserted – in a state of sexual arousal, or out of just plain curiosity – into their rectums.  I had a patient once who came in with a full-size can of deodorant in his rectum.  “Fell on it in the shower, dude.  Can you get it out?”

So, it takes a lot for a PE to be memorable for a doctor.

That said, yes, a laxative might reduce the fecal matter in your rectum prior to the exam.  Over-the-counter laxatives won’t clean you out like the stuff they give you before a colonoscopy, but honestly dude, you don’t need that.  I’d do the laxative – any over the counter brand is fine – about 6 hours before your appointment, and make sure you’re near a bathroom!

It Could Be Worse..
It Could Be Worse..

Remember that a rectal exam takes all of 8 seconds.  The doc then quickly pulls the glove off and tosses it in the trash can.  Even if covered in something icky, you barely see it and rarely smell it.  I’d just recommend a good shower prior to your appointment.

If you’re really worried about this issue, you could do an enema.  There are over the counter versions you can do yourself, or you can have them done by a pro…which probably would not be helpful in your case!  An enema the day before your appointment will remove most of any material in your rectum.  So, you might feel less anxious prior to the appointment.

But again…all we ask is a good shower.

The Rectal Is Dead…Long Live The Rectal

My R-1 presented a case this morning, describing a 58 year old woman with left lower abdominal pain. Tradition holds that, in these situations, you get the patient’s name, ask a few other inconsequential questions, and then immediately jam your finger into their rectum.

O.K., that’s hyperbole. But from the perspective of an intern, sometimes that’s exactly how it seems.

“We have a 58 year old lady with left lower quadrant pain wh-”

“Did you do a rectal?”

So, the rectal exam looms over the entire patient encounter, tapping impatiently on the back of your skull until you finally relent and just get it over with. Not to be crass (although I’m post-call and feeling a little punchy), but doing a rectal – especially the first few – is a little like I remember the first kisses of my high school girlfriends (all 2 of them). At some point, The Kiss becomes the elephant in the room. I know I’m about to drop her off at her house, and I know we’re at that point where I have to kiss her or walk away, and so I procrastinate and ask all kinds of stupid questions to delay the inevitable.

rectal.jpgBut unlike a kiss (which is more like a rectal exam than you might think…so don’t think about it), I have never wanted to do a rectal exam. As medical students and interns, however, the exam is not only expected…it’s DEMANDED. One sure way to get torn up by an attending is to skip the rectal exam. Here’s a few of the things you’re supposed to be able to learn from the simple “digital sweep”:

– if there’s feces in the “rectal vault” and whether it’s hard (suggesting constipation) or soft
-if there’s blood (have to smear your finger on a test-card after the rectal exam, which isn’t pretty looking or smelling.
-if there’s external hemorrhoids
-if there’s rectal sphincter tone (if not, worry about major neurological trauma or stroke)
-if there’s polyps
-theoretically you can identify a fissure which can be a major source of bleeding
-you can check the prostate on males and feel for nodules (has almost no statistical correlation to prostate cancer, but we do it anyway in this country)

So, that’s a lot of stuff you can figure out with a simple rectal exam. Today, my intern failed to do the exam. He failed to “remember” it the other day as well. The ire of our attending was impressive as a result, but still, I think my intern will “forget” to do the exam on his next patient as well. Here’s some reasons why:

-the exam is an outmoded test that isn’t necessary – only old-school docs still do it
-it often stinks
-it makes everyone uncomfortable – doc and patient
-I can’t think of many places I’d less like to be
-modern imaging and a good history give you just as much information
-it really, really stinks

sunfinger.jpgThere was a time when every patient who came to the ER got a rectal by a hapless med student or intern. It was like they just wandered around the unit with an extended finger, a box of gloves and some KY, looking into every exam room. These days, even many ER docs don’t do the exam. Same for the admitting internists. The truth is that many physical exam techniques are becoming extinct, much to the dismay of the Old Guard who believe that you can diagnose everything from a triple-A to a spinal abscess with a good stethoscope and a tongue depressor. Back in the day, the physical exam was just about all a doctor had to diagnose serious disease. These days, we have all kinds of nifty tools that, yes, cost bajillions of dollars but spare us the ignominy of coating our fingers with someone else’s feces. Frankly, to most of us, it’s worth it.