Thursday, June 12, 2008

Tales from Saint Boonie's: Gross, and I mean GROSS, Anatomy


I apologize in advance for this post.

If you are faint-of-heart when it comes to disgusting stuff, please bail now. Do NOT keep reading.

But if you don't mind a glimpse into a few little nitty-gritty secrets of life "behind the scenes," or at least behind the drapery - the non-glamorous side of medicine that most people don't get to know or hear about - welcome back to St. Boonie's.

Why do I have to write about this? Because I almost threw up in the O.R. today - I mean a real, honest-to-goodness near-HURL event. And over something that wasn't even that bad. I am going soft at St. Boonie's.

Like the average health care worker, talking about physiological processes or anatomical features over the lunch table doesn't bother me much. I have to admit, though, that I've never been the truly steely, never-ever-grossed-out, could-eat-lunch-next-to-a-bowl-of-innards type. I do find some aspects of my job...a little unpleasant.

Blood I can do. Organs I can do. But certain other things, I absolutely cannot deal with without that insect-like tickle in my throat that portends some projectile stomach contents. Most sights fail to shock me. But sights coupled with certain sounds - the rupture of a pus-filled abscess, or the crack and crunch of a joint - or even worse, certain SMELLS - the cheesy stink of a pus-filled abscess, or any hint of the feculent or fecal - push me right up against my ghastly limit.

Without further ado, the Top Ten List for the month of June: Top Ten Grossest Things I Wish I Had Never Heard About, Seen, or Smelled in the O.R. and its Environs.

Runners-up:

-Feculent matter in an orogastric tube. Anesthesiologists often insert tubes into the esophagus to help empty the stomach of its contents. In one patient having urgent bowel surgery this action produced five liters - that's twenty cups - of pre-poop poopy stuff pouring out through the tube and into the suction canisters. I couldn't help letting a verbal "Eew! Eew!" slip out now and again as the stuff was coming out. The surgeon was amused, good-naturedly enjoying my lack of enjoyment a little too much...

-Mucus wads

-Gangrenous toes

-Desquamating skin.

These aren't super-pleasant but after several hundred exposures you kinda get used to them...

10. Vaginal delivery. There, I've said it. I know I'm supposed to LOVE childbirth. I respect the process. I love children. I think motherhood is sacred. Babies are totally precious. But vaginas...Let's just say I was not meant to go into ob/gyn. I consider myself a supporter of women, women's rights, and women's dignity, and I find the idea of bringing a new human being into the world from one's own body glorious, but the actual event is...kinda messy and yucky and stressful. Vaginas all stretched and torn and bloody from pushing a seven-pound human being out make me wish I hadn't gotten out of bed in the morning. I could do my very own little vagina monologue about it (and actually did once, much to the amusement of the labor and delivery nurses and docs, who obviously aren't bothered by them at all), but I'd be wincing the whole time. It's my deep, dark secret. I find birth amazing and wondrous but at the same time, truly at the same time, a little dreadful.

9. Foreign body trapped in rectum. According to one of St. Boonie's most senior surgeons, these show up a LOT in St. Boonie's emergency room. I've only had to provide anesthesia for surgical removal of one once since I started working there, and that was enough lost innocence for me. Call me sheltered...

8. Nasal polyps. I've never enjoyed observing surgery that occurs above the level of the shoulder. ENT surgery often gives me the heebie-jeebies. But a half-cup of polyp removed from one nostril and a third of a cup from the other nostril of a person suffering with these polyps for a decade because her primary care physician didn't think they were a big deal, despite the fact that they had totally distorted her nasal anatomy and she had to breathe through her mouth for years? That's just unreal.

7. The Bezoar. A couple of thankgsivings ago CNN and The New England Journal of Medicine made the "hairball case" news with the headline "Doctors untangle the strange case of the giant hairball." Please don't eat your own hair, or someone else's. Please. It's not pretty. It's...well...sh___...oh, never mind.

6. Belly button escargot. This is is what got to me today. When someone comes to the hospital for abdominal surgery, once the anesthesia's on board, the circulating nurse cleans the abdomen with a surgical prep solution. Part of this cleaning procedure involves inserting a long cotton swab into the navel to remove whatever detritus resides therein. Today the nurse removed a two-centimeter clump of curled-up I-don't-know-what from the patient's belly button, and I almost lost it. Here's a tip (no pun intended): before you have surgery, please, please, for the love of all that is good, do a little navel care when you shower...

5. Bug crawling toward the light...out of a patient's ear. When I was doing pediatrics my biggest dread was to shine the light of an otoscope into a kid's ear, look into the lens that magnifies everything in there so it looks gi-normous, and see a scary, multi-legged, wing-flapping BUG trying to beat its way out of there...or succeeding! With a tremendous sense of gratitude I can say that the worst unexpected thing I ever found in a child's ear canal was a small, pink, Barbie stiletto.

4. Chunks of body dander on the sheet after a patient moves to the operating table. A lot of disease processes cause poor integumentary health. The results can be very visible, with mini-clumps of total-body dandruff of different colors and textures dotting the bed linens when a patient is moved off them. It's not the patient's fault, of course, but I do get very queasy when I catch a glimpse...

3. Poor hygiene in a ~300-lb person (in anyone, really, but morbid obesity really makes it worse...). Sometimes, and it's not always the patient's fault, the intertriginous areas get very difficult to clean, and people unfortunately get a whiff of poop-stink that smells like it's been sitting in a tight space for a week...or greasy-hair smell...and again, you're left with that awful pre-vomit tickle at the back of the throat...the attempt to smile and talk despite the fact that you're trying to hold your breath...the distraction of wondering what all that black stuff under the person's fingernails is... or why the alcohol swab turns from white to dark BROWN when you prep an area of skin for an I.V....

2. Fecal impaction. This is the reason I abhor the use of the word "impact" as a verb. It reminds me of the time one of the ob/gyn docs had to take a gloved hand and scoop, I mean scoop, gobs of poop out of someone's bottom before he could begin an acetic acid procedure to assess the woman's cervix...

1. Pus. Even the word grosses me out. One of our surgeons once drained a cup of pus from a lanced rectal abscess. It came out in cheesy green and white globs while tendrils of odor wound their way through the room as if searching for people's nostrils and the backs of their throats. The worst pus specimen I've encountered, though, was an excised empyema, or lung abscess. It was the smell of death itself - a piece of carcass made of blackened infected tissue decomposing in that unfortunate patient's lung. I seriously think I turned green and almost passed out.


Sorry, everybody. Please forgive me. I had to get that off my chest. So to speak.

_____________________________________________________
Update, August 15, 2008: Please check out Dr. Bates' posts on maggot therapy. Eeeeeeeeeeeeeeeew! (Yet, strangely fascinating...)

15 comments:

rlbates said...

You are so right, T. All of those things are gross.

katy said...

How can you not love a good nasal polyp??

MS4 said...

I can only agree...
Even though I'm not easily grossed out, the day they had to operate on this lady who had a rectovagial fistula, I almost passed out. This poor patient, this is such an awful thing to have!

What I find the most disgusting in anesthesia (I'm on my 2nd anesthesia placement right now- I love it so much!) really is sucking out the stomach junk through an NG/OG tube. I just can't stand the sound of the succion, and the color of the stuff...eew. No one seems to understand me in the OR though.

I have a question for you. Can propofol be used by non-anesthesiologists/CRNAs in the US? For example, GIs for their colonoscopies or pediatric heme-onc for the LP/IT chemo tx?


Love your blog, btw!

T. said...

I believe propofol is still supposed to be used by practitioners trained in the provision of anesthesia and resuscitation, which includes anesthesiologists and CRNA's.

There has been much controversy in recent years over the use of propofol by non-anesthesiologists - ever since the American College of Gastroenterologists petitioned the FDA to remove the warning label on propofol that calls for adequately trained anesthesia personnel and immediate availability of, and facility with, resuscitation equipment and procedures.

As far as I know the ASA maintains the position that it is imperative that clinicians who use propofol be well trained in anesthesia and resuscitation.

C in Miami said...

T, all this is so GROSS, PATHETIC, BIZARRE... But so real!!!!!
If I had to vote I believe the regurgitated fecal content in a Bowel Obstruction is enough for me to make me gag and actually vomit outside the OR while the CRNA watch the patient and the orderly run around the hallway in amusement with tissues...hypothetically speaking btw...hahaha
You are right, we learn to see, live and "eat" among fluids, smells and visuals that would make any "normal" human being question mother nature...
;)
but...what a great field!!!

T. said...

Hey, C - good to hear from you.

In my case the only reason the regurgitated fecal stuff didn't make my actual Top 10 List, and was instead a mere "runner up," was that the stuff was sequestered in the tubing and went straight into the canister without my having to have direct contact with it. But watching it go there was bad enough!

The surgeon cracked up every time he heard another "Eeewww!" from behind the drape...

Julie Meyer said...

I thoroughly enjoyed this post! I just reread my last blog entry, however, and found I had used the offending word--it stopped me, broke my momentum completely! Unwanted visions came. Ahhh! Hopefully, this too will pass.

T. said...

Julie - sorry about that! Didn't realize I would make such an...er...impact... :)

Bardiac said...

There are untold advantages to being a humanist! But I do have an old book that smells just a tad old when I take it out for show and tell. (It actually smells good in that really old book sort of way.)

(On the other hand, when I was in the Peace Corps, I could pretty much diagnose giardia on the bus. You don't really want to think about that too much.)

T. said...

Don't I know it, Bardiac - I was a humanist myself. An English major. I think my missing the humanities is a big part of the reason this blog exists! Incidentally, I love the way (most) books / libraries smell...

But the image of a young Peace Corps volunteer catching a whiff of Giardia on a crowded bus almost made me gag...

I wonder if the pus-filled abscesses would make me wretch less if the smell factor weren't there? I don't know...it looks pretty scary too...Isn't it funny how visceral our reactions can be? And how different people have strong reactions to different things?

I think part of the cringing with "gross" stuff might come from the back-burner realization that ANY of us could be in the predicament of having a yucky problem - abscesses, discharge, bowel obstruction, skin or foot issues, getting caught in an accident while unkempt or un-showered, etc. Maybe not, though - maybe the gross stuff is gross enough without this type of philosophical mulling!

T. said...

BTW,

Katy - I'll take a colon or endometrial polyp over a nasal polyp any day!

MS4 - didn't get to thank you earlier for stopping by. Best of luck with the anesthesia placements - it's the best specialty in all of medicine! :)

Ramona - I bet you have your share of non-glamorous work too. All I can say is, your patients are lucky to have you!

katy (aka funny girl) said...

I had to come back and make a case for my friend Mr. Nasal Polyp. I mean, have you ever seen one that couldn't fit through the nose and had to be extracted through the mouth?? When that pearlescent oniony goodness comes peeping through...good gravy, now that's medicine!!

On the propofol subject, our policy stated that only physicians could push propofol. Period. (Of course, they're the only ones that can turn the dial on the sevo and I did that plenty of times, so you do the math.) :-)

T. said...

"Pearlescent oniony goodness" is just about as good a description of a nasal polyp as I've ever seen. Ugh! Katy, I'll never look at pearl onions the same way again, anemic though they may be by comparison!

Uh...thanks! :)

And no, I've never seen the extract-through-the-mouth technique; our ENT just brought it out in pieces...lots and lots of pieces...or should I say, globules...

OMG, I think I gotta go barf...Excuse me...

katy said...

LOL!!

thecatsmeow said...

Oh, my...how utterly disgusting! I am not very squeamish at all, but I can totally see why some of the things on that list would be nausea and/or vomit inducing. Actually, some of your descriptors made me very relieved that I was educated and experienced enough to request that I be put under conscious sedation for a surgery I had on a very nasty MRSA abscess that also got me a week and a half in hospital last year. I knew that there were any of several reasons I couldn't handle being completely aware with just a local, the likely stench being one of them. My olfactory sense is acute, and I didn't need that on top of my already large bundle of nerves to make me totally stressed. Besides that, I would have wanted to actually watch the procedure, which would not have been possible! Yes, I know that's warped, but I am a wannabe surgeon who wound up in HIM...

And now I think I just got some more inspiration for a new blog post!