A lesson I learned from one of my attendings: the ED is a no disempaction / no enema zone. If word gets out on the street that you do this, every clinic within a hundred miles will add this to the indications they automatically turf patients to your door.
All such patients get dulcolax, miralax, and instructions to follow up in clinic within 24 hours.
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This is the problem with academic attendings. They have no idea who butters their bread. The question you should have is this:
Why is it a bad thing if people send you more rectal disimpactions?
These people are generally on Medicare, but if not, probably insured since if they're young it is probably chronic narcotics that got them that way. That means you get paid to do this. (The code is 45915).
Now, ask yourself, "Self, how much do you need to be paid to dig crap out of someone's butt for two minutes before making your nurse give them an enema and send them to the toilet?"
We've all got a number. Is it $10? $200? $2000? $2 Million? I bet we'd all do it for $2 Million, no? Now, go check with your coders and see how much 45915 pays. Is it more or less than your number? If more, then what's the big deal. If less, then it's easy enough to write for miralax. Do you know what 45915 pays in your shop? Why not find out?
Too many salaried docs/residents/academic attendings just don't "get it." It's a business folks. People want you to take care of their problems. They or their insurance company will pay you to do so. Why would you not want the business? That's like a fast food restaurant where every 10th person wants a salad. Do they just keep saying, "We don't do salads here, this is McDonalds." Nope. They add salads to the menu.
Aside from that, this is a person who hasn't crapped in a week, has a stomach ache, and has a softball in their rectum and feels they have an emergency. How would you like it if the doctor said, "Sorry, I don't/can't do that. You can go see a family doctor. They've had special training in this. Here's a list of doctors who might do it. You can probably get in by Thursday or so." Really? That's what you want someone to tell your grandma? Suck it up and help someone. I do these on anyone who needs it, and it probably adds up to a grand total of 2 a year. I'd rather do these all day than deal with a drug seeker, a drunk, or another undiagnosable 25 year old pelvic pain.
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