4 in the stink/shift?

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Shadowed an em doc yesterday. 4 rectals in 12 hours. He said that was about avg. Not sure I can do that every day.

Who should I shadow next to restore my motivation? Derm?

Could be worse. You could be a surgical intern. There are only two reasons to NOT do a rectal exam then...

1. No finger.
2. No rectum.

On a more serious note: ALL subspecialties have undesirable aspects. I find "rounding" and "being on-call" to be much more undesirable than the occasional finger in the bungholio.

Was he not wearing a glove or something?

Originally Posted by Organically

Who should I shadow next to restore my motivation?

Get over it?

Originally Posted by RustedFox

Could be worse. You could be a surgical intern. There are only two reasons to NOT do a rectal exam then...

1. No finger.
2. No rectum.

I learned like this:

Only two reasons to skip a digital rectal exam:

1. No rectum
2. No digit

Kind of flows better

Single most overdone physical exam in medicine.

Completely worthless.

Saw an article once that completely changed my mind on this, essentially it said never, ever, to do a DRE. Pts can poop in cup or use a swab for occult blood.

I have to admit that the manual removal of impacted fecal matter still does need to be done.

Originally Posted by Organically

Shadowed an em doc yesterday. 4 rectals in 12 hours. He said that was about avg. Not sure I can do that every day.

Who should I shadow next to restore my motivation? Derm?

Dude, nothing is more disgusting than a serious skin rash except maybe childbirth, and some skin infections smell bad enough to bring tears to your eyes.

Seriously, though, almost all of medicine is gross. If you go into any clinical specialty where you deal with patients (not just EM), you are going to have to see and smell parts of the body you'd probably rather not. If that bothers you, medicine might not be the best career choice.

Originally Posted by danzman

Single most overdone physical exam in medicine.

Completely worthless.

Saw an article once that completely changed my mind on this, essentially it said never, ever, to do a DRE. Pts can poop in cup or use a swab for occult blood.

I have to admit that the manual removal of impacted fecal matter still does need to be done.

Untrue and uninformed--I don't like doing them either but there are clear medical indications for the exam

Originally Posted by Tiger26

Untrue and uninformed--I don't like doing them either but there are clear medical indications for the exam

Sure there are. But on everyone with an anus? I think not. My point is it's probably done more than it needs to be. And i would rather do a dre anyday rather than a pelvic. Any evidence to support the widespread use of them and I will gladly retract my statement.

Originally Posted by danzman

Completely worthless.

Originally Posted by danzman

Sure there are. But on everyone with an anus? I think not. My point is it's probably done more than it needs to be. And i would rather do a dre anyday rather than a pelvic. Any evidence to support the widespread use of them and I will gladly retract my statement.

Hyperbole. Not your friend.

Originally Posted by danzman

Single most overdone physical exam in medicine.

Completely worthless.

Saw an article once that completely changed my mind on this, essentially it said never, ever, to do a DRE. Pts can poop in cup or use a swab for occult blood.

I have to admit that the manual removal of impacted fecal matter still does need to be done.

So, we should just keep them in the ER until they have their daily BM? I think administration would be a little upset about the length of stay if we did that.

Originally Posted by SoCuteMD

So, we should just keep them in the ER until they have their daily BM? I think administration would be a little upset about the length of stay if we did that.

Amen. It takes long enough just to get a urine.

Originally Posted by danzman

Any evidence to support the widespread use of them and I will gladly retract my statement.

EBM for DREs, now that is an interesting journal club!

And the idea of using a swab? I'd rather have a lubed, gloved finger used instead of some swab that could break off inside and puncture the rectum.

Originally Posted by alreadylernd

EBM for DREs, now that is an interesting journal club!

And the idea of using a swab? I'd rather have a lubed, gloved finger used instead of some swab that could break off inside and puncture the rectum.

I almost never do them. There is very little that is going to change by exam. If someone has a complaint of rectal pain, I'll take a look externally and see if there is a fissure or hemorrhoid. If they are stable and not bleeding profusely, then can follow up with a GI doctor.

Originally Posted by SoCuteMD

So, we should just keep them in the ER until they have their daily BM? I think administration would be a little upset about the length of stay if we did that.

Ha, whats the average length of stay now? 12hrs...

An attending showed me how to use a long cotton tipped swab to get a sample for occult blood. DRE without the digit. Pts seem to like it more than my sausage fingers. Also, at many places they just use the little green rubber stick things (not sure what they are called but around here a lot of PCPs send pts home with them to get a sample.)

Look Im open to learning something new here, but im racking my brain and can't think of a single good reason to do one in the ED or in really any setting. If you think there is a mass, they are gonna get scoped and scanned anyway. The evidence about prostate exams leads me to think they are worthless.

Unless you are breaking up stuck poop, I don't see how they accomplish anything.

Originally Posted by danzman

Ha, whats the average length of stay now? 12hrs...

An attending showed me how to use a long cotton tipped swab to get a sample for occult blood. DRE without the digit. Pts seem to like it more than my sausage fingers. Also, at many places they just use the little green rubber stick things (not sure what they are called but around here a lot of PCPs send pts home with them to get a sample.)

Look Im open to learning something new here, but im racking my brain and can't think of a single good reason to do one in the ED or in really any setting. If you think there is a mass, they are gonna get scoped and scanned anyway. The evidence about prostate exams leads me to think they are worthless.

Unless you are breaking up stuck poop, I don't see how they accomplish anything.

I don't know where you are, but our length of stay isn't nearly that bad.

I have little tiny fingers, so patients don't seem to mind. I'd be worried about causing mucosal trauma with a qtip. Sounds like more work than just getting the rectal exam over with. I've never seen any green rubber stick thingies either. I'd happily skip most DREs if I could get the patient to give me a stool sample. You can also check a rectal temp on the patient and get a sample that way.

The only TRUE indication for a DRE in an ER patient in suspected spinal cord inury. to check for rectal tone.

Agree. Very little real utility. I do it when indicated but no nearly as often as others. For example, there is a practice at our place of doing DRE on every patient prior to starting anticoagulation. Insanity. We also still do them on our trauma patients where there is much evidence that they add nothing to the evaluation (and were made optional in the new ATLS for that reason).

I feel the same way about pelvics. The only thing I really care about most of the time is the bimanual, the speculum exam adds little to the "STD check" that is our most common indication.

The physical exam itself is dying a slow death. Most maneuvers taught in medical school have little utility. I highly reccomend JAMA's "The Rational Clinical Examination" series.

Originally Posted by logos

Agree. Very little real utility. I do it when indicated but no nearly as often as others. For example, there is a practice at our place of doing DRE on every patient prior to starting anticoagulation. Insanity. We also still do them on our trauma patients where there is much evidence that they add nothing to the evaluation (and were made optional in the new ATLS for that reason).

A hemmoccult has never changed my management. If they are elderly with "dark stool" epigastric pain, or anemia they need admission and scope, regardless of what a hemmocucult would show. We have some absolutely insane docs who insist on doing them on STEMI patients before starting Heparin or Plavix. Insanity I say!

I feel the same way about pelvics. The only thing I really care about most of the time is the bimanual, the speculum exam adds little to the "STD check" that is our most common indication.

Agreed with this two. There is no utility on most of the pregnant "spotters" or stable vag bleeder. I'll only do it now for people complaining of serious bleeding, or severe low abdominal pain with no etiology based on the other tests.

The physical exam itself is dying a slow death. Most maneuvers taught in medical school have little utility. I highly reccomend JAMA's "The Rational Clinical Examination" series.

You mean you don't use Psoas and Obturator signs daily in your clinical practice for belly pain?

I have not done a single pelvic or rectal examination in the last six months.

There are pros and cons to being an academic attending, and I count that as a pro.

Setting aside the debate over whether or not you believe in the utility of the rectal - 4 in 12 hours as an "average" seems high. Any thoughts on this? Am I odd in thinking that sounds like a lot?

Originally Posted by ToxicChic

Setting aside the debate over whether or not you believe in the utility of the rectal - 4 in 12 hours as an "average" seems high. Any thoughts on this? Am I odd in thinking that sounds like a lot?

I was thinking the same thing. As a resident I did maybe 3-4 per shift, but as an attending I do maybe 3-4 per month.

Look Im open to learning something new here, but im racking my brain and can't think of a single good reason to do one in the ED or in really any setting. If you think there is a mass, they are gonna get scoped and scanned anyway. The evidence about prostate exams leads me to think they are worthless.

Now, I agree with the general sentiment that it is an over done exam, and that the old "only two reasons not to do a rectal" line is mostly good for getting the lazy/scared MS3 to do the exam...

BUT

I still think they are useful! Even as a grown up attending, i still do my own rectal exams!

(1) Random old gomer with new/severe anemia: normal stool versus melena is a useful finding!
Yes, yes, I know you are going to admit them anyway, and one day they will have a BM that a nurse could check for you.... but finding that sticky, smelly unexpected melena is a true diagnostic joy which the skittish, squeamish, weak-willed among us will never taste!
(2) Prostatitis: It is real. Hard to diagnosis it otherwise. Man up and poke that prostate!
(3) Peri-anal, peri-rectal, peri-peri abscesses: useful to do a rectal. Or just chicken out and call the surgeon. Your choice. (*bock bock bock* *flaps wings*)
(4) Neuro examination: I would argue it is rare to have low tone be the ONLY finding, but when there are other findings of potential cord injury or cauda equina it is useful. I certainly don't do a rectal on every back pain patient. But maybe I should. No oxycodone without a rectal. We could put signs up!

Now, does every body with a couple blood streaks in their BM HAVE TO HAVE a rectal? Of course not. But I wouldn't fault you for doing one. Same thing for someone with pain during defecation.

Originally Posted by GeneralVeers

You mean you don't use Psoas and Obturator signs daily in your clinical practice for belly pain?

At my institution, the only time I've gotten an appy to the OR without any imaging was to have:

migratory pain, RLQ ttp with rebound, fever by rectal temp, +Rovsig sign, +Psoas sign, +Obturator sign...

Surg still wanted to wait for the WBC. All I can say is thank ****ing god it was 12.1, just good enough for them.

That was the only time I ever checked an obturator or psoas sign since I was a med student.

Originally Posted by Janders

Now, I agree with the general sentiment that it is an over done exam, and that the old "only two reasons not to do a rectal" line is mostly good for getting the lazy/scared MS3 to do the exam...

BUT

I still think they are useful! Even as a grown up attending, i still do my own rectal exams!

(1) Random old gomer with new/severe anemia: normal stool versus melena is a useful finding!
Yes, yes, I know you are going to admit them anyway, and one day they will have a BM that a nurse could check for you.... but finding that sticky, smelly unexpected melena is a true diagnostic joy which the skittish, squeamish, weak-willed among us will never taste!
(2) Prostatitis: It is real. Hard to diagnosis it otherwise. Man up and poke that prostate!
(3) Peri-anal, peri-rectal, peri-peri abscesses: useful to do a rectal. Or just chicken out and call the surgeon. Your choice. (*bock bock bock* *flaps wings*)
(4) Neuro examination: I would argue it is rare to have low tone be the ONLY finding, but when there are other findings of potential cord injury or cauda equina it is useful. I certainly don't do a rectal on every back pain patient. But maybe I should. No oxycodone without a rectal. We could put signs up!

Now, does every body with a couple blood streaks in their BM HAVE TO HAVE a rectal? Of course not. But I wouldn't fault you for doing one. Same thing for someone with pain during defecation.

Agree with the above.

Some might argue that there's no need to do a neuro exam on patients with stroke symptoms, because they're going to get an MRI down the road anyway. There's actually some merit to that argument, but it's not how I want to practice/learn/teach medicine.

It might be useful as a conditioning mechanism. Going to the ED every other week might become a whole lot less desirable if they know what's in store for them.

.

Originally Posted by SoCuteMD

I often wonder how many rectal exams attendings would want if they did them themselves!

Here's how I see it - if the resident has considered the differential diagnosis that the rectal/pelvic/tonopen/whatever will help to rule in or out, and he or she has confidently excluded it based on other evidence, then I am fine with not doing it. I get bent out of shape when a resident or medical student doesn't do an exam, and then when I ask about GI bleed/PID/glaucoma they respond with a blank stare.

So no, not every trauma patient needs a rectal and not every female of child bearing age needs a pelvic. If it wasn't done because your H&P demonstrates that it's clearly not needed - kudos to you. However, if the exam wasn't done because it's gross, or because the diagnosis wasn't considered - then we have a problem.

So yes, attendings may do fewer rectals on their patients than residents. I hope that's because the attendings are better at developing and refining differentials...but I'm not naive enough to think this is always the case.

Speaking of pelvic exams... I haven't done a bimanual exam in *insert time here* because the vast majority of patients that I see are just --- too effing fat --- for me to be able to palpate anything.

http://knowyourmeme.com/memes/the-ma...europe-and-usa

On a related note, I was walking in to the department the other day thru the parking lot, and was passed by a patient (who was obviously headed to the ED) on his motorized wheelchair. He had a fresh cigarette in his mouth and taking a big drag on his way up to the front doors/triage area.



GenVeers, docB... meet your newest buddy... RustedFox.

Never let anyone tell you that EM isn't glamorous. I do rectals on most GI bleeds that aren't complaining of bright red blood because if they don't have melena and their labs look reasonable then I usually dc with GI f/u. If they do have melena then I usually send a guiaic because I have a couple of GI consultants that are convinced that every patient with black stool just chugged a bottle of Pepto and isn't really bleeding.

Originally Posted by GeneralVeers

You mean you don't use Psoas and Obturator signs daily in your clinical practice for belly pain?

I perform them after eliciting the fluid wave and percussing the liver.

Aside from what Janders mentioned, I think you should stick a finger in baby butts looking for NEC, late intussusception, malrotation, etc. You might be able to wait for a hemoccult from other source, but I'd rather not.
And also: Rectal foreign body.

I'm also afraid of looking silly on the phone if I call to admit an anemic patient and haven't ruled out that source. It's something that you're not likely to run into trouble for doing (Only case I can think of is neutropenic fever) but has the potential to burn you if you are unlucky. Basically, I kind of believe the classic EM mantra of CYA by doing things that others might forget or otherwise be to lazy to do later on.

Another reason to do rectal: pt is blind and has anemia, dizziness, hypotensive without obvious cause, pale, etc