Fecal Impaction in the community

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
P

prolene60

Full Member
10+ Year Member
Joined
Jul 27, 2012
Messages
35
Reaction score
32
What do you guys do in the community to treat patients with fecal impaction and no complications? ( No large bowel obstruction, perf, and no megacolon). In academics it's a bit different because med students and residents usually just disimpact people but as an attending in a community ED do you guys go in with a mask and gown and glove up and get in all of your elderly people's rectums and disimpact or do you just do soap suds, golytely etc... Do you admit them to the hospital? I'm just curious what the standard of care is.
Members don't see this ad.
 
prolene60 said:
What do you guys do in the community to treat patients with fecal impaction and no complications? ( No large bowel obstruction, perf, and no megacolon). In academics it's a bit different because med students and residents usually just disimpact people
Click to expand...

Where do you train? I have yet to even see a manual disimpaction, they've pretty much gone out of style at all the hospitals I've ever rotated through, everyone just seems to use gallons and gallons of laxatives these days. I'd be curious to see an institution where it was still considered the standard of care.
 
If it's mild to medium - I give trial of PO miralax + a mineral oil enema to be self-administered at home.

If it's severe I do fentanyl to chip it down or sedate w/ propofol and get 'er done.

Remove watch, gown, mask, double glove.
 
Members don't see this ad :)
I actually have absolutely wonderful nurses, and the last time a disimpaction was required, he volunteered to do it without my asking him.. In general, a true fecal impaction requires me to get down and dirty. In reality, most times laxatives and enemas will do the trick. In academics, there's no impetus to try the latter.
 
prolene60 said:
What do you guys do in the community to treat patients with fecal impaction and no complications? ( No large bowel obstruction, perf, and no megacolon). In academics it's a bit different because med students and residents usually just disimpact people but as an attending in a community ED do you guys go in with a mask and gown and glove up and get in all of your elderly people's rectums and disimpact or do you just do soap suds, golytely etc... Do you admit them to the hospital? I'm just curious what the standard of care is.
Click to expand...

As an academic attending I have performed four manual disimpactions. All of them were discharged.
 
Very few people actually require manual disimpaction, it's uncomfortable for all parties involved, can be dangerous in the elderly. In the community at my shop, the nurses will disimpact if ordered (though not like it). I only do it if patient's are literally in the process of birthing a stool baby.
 
I probably do one every-other-month, perhaps monthly.

I probably see an elderly patient with true cc: constipation (i.e. not an SBO...) a couple times a week!

I agree if its not so bad, like to give a couple enemas, a bottle of mag citrate to go and a couple weeks on miralax.

That said, I've done that and had them bounce back the next day still needing a manual dig. I've had a partner give a gallon of golytely with 3x enemas at home and still be back the next day needing disimpaciton.

Sure it isn't pleasant, but one of our jobs is the fix things that we can fix. This is one of them. Plus I've probably earned 1 million nursing good karma points by getting a bedside commode out of clean utility, grabbing a fleets enema, and disimpacting someone myself. Worth it for the karma...

Now if I could only find the procedure code that makes this pay as well as a central line...
 
Janders said:
Now if I could only find the procedure code that makes this pay as well as a central line...
Click to expand...

I glove up every now and then. If there's a rock in the rectum, it's not coming out with GoLytely. As for coding, there is nothing for digital disimpaction alone; it's bundled with the E/M. What you can bill for is 46600 (Anoscopy; diagnostic, with or without collection of specimen by brushing or washing) after the disimpaction. If things get really bad and you need anesthesia, then you can try 45915 (Removal of fecal impaction or foreign body under anesthesia)
 
I'll disimpact if i have to....it's not the end of the world. However, our nurses make a mean Milk and Molassas enema which works pretty damn good.
 
Members don't see this ad :)
EM4life said:
Very few people actually require manual disimpaction, it's uncomfortable for all parties involved, can be dangerous in the elderly. In the community at my shop, the nurses will disimpact if ordered (though not like it). I only do it if patient's are literally in the process of birthing a stool baby.
Click to expand...

How is it dangerous? I am curious and not disagreeing with you.

Also, do you guys really sedate for the disimpactions? Do you leave the pt supine and then just dig? Ive only had one bad enough to consider that but I got the sense that our nurses would complain, then I would have to have a talk with our chair. Not to mention that I may have gotten unlucky and the sedation couldve gone badly.
 
I was told this during residency, my guess is there is a small chance of colonic perforation in an old person who's been sitting on a rock hard poo for a long time, there is also the threat of producing a vagal reaction which can obviously be bad news bears for the baseline unhealthy. It has never happened to my pts but I'd rather not test it out.


BJJVP said:
How is it dangerous? I am curious and not disagreeing with you.

Also, do you guys really sedate for the disimpactions? Do you leave the pt supine and then just dig? Ive only had one bad enough to consider that but I got the sense that our nurses would complain, then I would have to have a talk with our chair. Not to mention that I may have gotten unlucky and the sedation couldve gone badly.
Click to expand...
 
I don't mind disimpacting. It pays more RVU than intubating or an LP.
 
Heh, we were stirring drinks with it at one party.


Gallows humor. Got to love it.
 
I'd be interested to see if the ACEP toy really works.

At my shop, we basically do a short-stay "admit" for enemas until clear. If you write the order "with manual disimpaction," it happens. The patient goes up to a floor room with a bathroom, gets cleaned out, comes back, gets rechecked, usually stating "wow doc, I feel a lot better," and we send them home.
 
This thread has reminded me why I like the EM forums here. You guys talk about manual disimpactions the same way others talk about pokemon cards.
 
dchristismi said:
I'd be interested to see if the ACEP toy really works.

At my shop, we basically do a short-stay "admit" for enemas until clear. If you write the order "with manual disimpaction," it happens. The patient goes up to a floor room with a bathroom, gets cleaned out, comes back, gets rechecked, usually stating "wow doc, I feel a lot better," and we send them home.
Click to expand...

Haha, that's insane. Do you guys do that for additional billing for the observation/admit status or just plain pt satisfaction? The constipated pt PG scores must be fan[ny]tastic.
 
BADMD said:
Anyone who is at ACEP has the answer. This was in a bag on my hotel room door.

http://i.imgur.com/OCShxHS.jpg
Click to expand...

I think they REALLY missed the boat on the name with this one. Clearly the name "Rectal Rooter" would be much better. :naughty:

On a side note... had 2 disimpactions in last 2 shifts. Granted, I'm an MS-IV at an academic shop right now but I can tell you that these two would have been hard pressed (haha) to pass these things with any amount of laxative. Enema, maybe, but my attending both times (2 different people) said they only do enemas as a last resort cuz of the aromatic impact on the department and said disimpaction is the go to Tx. Both attendings also said "You don't have to do this... I wouldn't want you to and I don't think it's right to ask you to do it just cuz you're a student" so it wasn't an issue of doing it "just cuz you have students". Needless to say, as an MS-IV I gladly :rolleyes: said "No way, I'm doing this" but still...
As an aside, I learned a new medical term on the first one yesterday from the attending... she said "We call that one big ol ball o ****!!". True technical term too... looked it up and everything. :thumbup: On second thought, maybe "thumbs up" is a bad idea here... maybe just a single finger... non middle prefered.
 
Love the SMOG enema (Soap suds, Mineral Oil, Glycerin)...it rarely fails.
 
medic25 said:
I left mine in the hotel room; really didn't want to picture myself explaining what it was to a TSA agent at the airport...
Click to expand...

If they knew it existed, it might become a new tool for the TSA...
 
tkim said:
Really? At least twice a month I double-glove and go to town.
Click to expand...

If anybody on this thread that is currently doing manual disimpactions and is interested in trying out the DisImpactor product referenced earlier feel free to contact me. My email is [email protected]
 
You must log in or register to reply here.
Next unread thread

Similar threads

T
How to prepare for community job out of residency
Replies
21
Views
2K
RoyBasch
R
Groove
Anybody that's been out in the community for awhile miss working with residents?
Replies
17
Views
2K
carbonizedeyesockets
carbonizedeyesockets
W
Impact of CMG's on Practice and Care
Replies
2
Views
1K
NurWollen
NurWollen
Sunna12
Community vs. University
Replies
28
Views
5K
Groove
Groove
B
out of the ashes... academic vs county vs community?
Replies
26
Views
8K
gamerEMdoc
gamerEMdoc
Top