Context: The below narration is from when I was working as a Chief Nursing Officer in a medical teaching hospital.
During a routine morning round in a male surgical ward one day, I heard a person moaning loudly as if he was undergoing an extremely painful procedure. His voice made it obvious that he was in unbearable pain. He kept shouting “Amma… Amma.. Please either do something for me or kill me”, to which a female voice responded in an attempt to console him. I later learnt that this lady was his wife. Concerned with his moaning, I asked the night duty staff nurse, about what had happened to him and why he was crying / moaning. She told me that he was admitted the previous day for CA penis surgery.
As we approached him, he began communicating with us and pleaded us to reduce his pain. He shared that he was unable to pass stools due to severe abdominal pain which was now worse than the pain due to his cancer. He was frustrated that despite informing his family and the doctor of his pain, no one had done anything to relieve him from this severe pain. He also expressed irritation that his wife keeps saying “Eat, eat” as though she was not concerned about his pain at all. His wife immediately told us “Food is important for survival no ma’am.. Please tell him to eat.. Only if he eats can he can pass motion no?”. We quickly realised that she was in fact expressing her concern and love, but not in the way he was able to understand or wanted.
I quickly enquired with the staff nurse if the treating doctor was notified regarding his constipation, to which she said she wasn’t sure. I then checked his case sheet and realised that nothing was mentioned about his bowel pattern. I requested the staff nurse to immediately inform the treating doctor about this condition. We were told to administer tramadol to manage his pain and that the doctor would come by shortly to provide him with the necessary treatment. Once the injection was administered, I explained to the patient and the family, that his pain will be reduced and that the doctor would be meeting him soon. I instructed the staff nurse to keep me updated and continued on my rounds.
When I went to check on this patient after I completed my rounds, I noticed that the doctors were talking to him. I joined them and soon realised that no one was addressing his constipation issue. I jumped in and informed the consultant that the patient had not passed stools for the past two weeks. The consultant asked the resident to take a look and proceeded towards the operating theatre. I looked at the resident and asked him, “How can we manage the patient’s constipation, Doctor?”. He replied, “For now, let’s do an enema”. He wrote the orders for the same and left, following which the staff nurse administered the enema. Unfortunately for the patient, he was unable to pass stools even after this. I felt terrible as not only was the procedure ineffective, the patient was also troubled and disturbed.
Post lunch, I went to check in on this patient again and noticed that the consultant was sitting in the nurses’ station and documenting other patients’ case sheets. I informed him that the patient’s constipation issue was not resolved even after giving him an enema, and that he had a pain score of 10/10. I went on to add that may be the patient’s chronic constipation led to a faecal infraction and enquired if we can do a Per rectal examination. He said that he will instruct his resident to look into it left the ward. As we waited for the resident to come in, we kept the gloves and the Vaseline Proctoscope ready and even put a screen around the patient. The patient and I were now eagerly waiting for the situation to be managed. Just as the resident entered, his phone rang and as he was called back urgently. Before he left, I asked him if my nurse and I could do a digital evacuation. He gave me the go ahead and said that he would return. Honestly, I was waiting for this chance. I immediately pulled up the screen and explained the procedure to the patient and asked him if it was ok for me to perform the procedure. He responded by saying “Apathukku paavam illamma (In an emergency, anybody can perform anything). Please just solve the problem and help me.. That is enough for me.”
I put on my gloves and applied an adequate amount of Vaseline. As I begin the process, I could not believe how hard his stools were. They were like little black stones. As I kept removing them, more and more small, hard, round, stone-like stools were coming out. Finally, we cleaned the bulk of soft stool after which a foul-smelling, watery stool soaked the entire bed sheet even after we had used a more than adequate amount of mackintosh covers. Once the procedure was completed his abdomen become soft. We took him to the bathroom, gave him a thorough bath, and changed the sheets before asking him to get back into bed.
That was when unexpectedly the over 75-year old patient who was like my grandfather suddenly bent down to touch my feet and bless me, “Unpillakuttigal nallairukanumaa” (Your children should be healthy and happy). At this moment, everyone’s eyes (his, his wife, the nurses in the room and also mine) were filled with tears as we all got overwhelmed with the situation.
We realised how our small intervention had brought him so much of pain relief, comfort and happiness. My team also felt content as were able to solve his concerns.
When I went in the next morning, I noticed that this patient was sitting up in bed and was enjoying a cup of tea. His wife and he welcomed me with happiness and gratitude.
The simple and small act made the patient happy and comfortable after his two weeks of struggle with constipation.
About the Author:
Dr A Latha is a Faculty at the College of Nursing, AIIMS, Jodhpur, with over 26 years of Nursing experience.