Reflection on a Monday Morning: Roll With It.

*written with permission of my brave and smart patient, Mr. M. - thanks.

Sometimes you just have to roll with it.

"Every time I move my bowels, I see a whole bunch of blood. Like everywhere."

"That must be pretty alarming."

"Yeah, it is, doc. The whole bowl turns red. . .and then later on, I'll just be sitting there minding my business and next thing I know, the whole backside of my pants is soiled with blood."

"Wow."

"Yeah, doc. It's bad. I saw somebody one time in the clinic and they set me up for a colonoscopy, but I never went."

"Why not?"

"Honestly? They scheduled me for a whole bunch of stuff that day. . . . .the eye doctor, the colonoscopy, nutrition. . . .so I mixed up the eye doctor appointment with the colonoscopy."

"Oh man."

Laughing. . ."Yeah. . . .you know how mad I was when I drank that whole gallon of Go-Lytely for a eye doctor? I was mad has hell!"

"Oh no! You drank the bowel prep? Before the eye appointment?"

"Every drop, doc!" He chuckled softly and then suddenly looked serious. "Yeah, every drop."

"Hmmm. Are you ever constipated?"

"Whatchoo talkin' bout, doc?" he teased while raising one eyebrow. I smiled back, familiar with this slang equivalent to definitely. He shook his head and went on, "That's an understatement, doc! I stay constipated. . .but every blue moon, it'll let up."

"I see. . . .well, you know that straining puts you at risk for hemorrhoids. That could definitely make you bleed."

"And fill the whole bowl up with blood?"

"Sure can."

"Wow," he said while looking away. He drew in a breath, "but you know what, doctor? Something in me makes me feel like it ain't just hemorrhoids."

Therein lies the problem. To me, for the most part, it did sound like hemorrhoids. Regular old hemorrhoids. But here he was. Sitting in the Grady emergency department telling me, literally, that he didn't agree with that assessment.

"Sir, when was the last time you saw a doctor? Like when was that clinic visit you missed?"

"It was 'bout six, seven months ago. I lost my job close to that time, and you know, I stay in the shelter now, so it's kinda hard to get around."

Damn. My fleeting thoughts about how to get him evaluated as an outpatient began to flutter away. . . . I looked at him carefully. Well-developed, well-nourished. Neat, clean clothing and a pair of running shoes. Hair, neatly groomed in a military style buzz with a hairline that, even in his sixth decade, was not being threatened by male pattern baldness. Rich brown skin and a meticulously groomed goatee framing smiling teeth that appeared to be brushed regularly. Clipped nails, a working watch. This guy his homeless? Damn.

"You became homeless after you lost your job?"

"Sort of. It's kind of messed up, doc. I'm a college graduate and I had a great job. I, unfortunately, got mixed up in drugs at one point. . . .crack. . . .but I got in rehab and was clean for like ten years. Was doing well, had me a good job again and everything. Then this economy went crazy and I got laid off. Man, I was so depressed, doc. Lost all my benefits, my house. . . .I got weak, man. I relapsed. They let me back onto my job, and don't you know I messed it up?" He looked down and sighed.

I quickly looked down at my billing card to see if anyone had mentioned substance abuse. I wasn't aware of that piece of history. "Wait--you are using crack. . .like currently?"

"Ain't gon' even lie, doc. I used a couple days ago."

I could feel my blood beginning to boil. Not because I was mad at my patient. I was mad at crack. I hate crack. Just hate it. It's like this horrible, ruthless bully that enters entire communities like gangbusters. . . .wielding a big gun and a machete and taking down everyone and everything and everydream in its path. I. Hate. Crack.

Next thing I know I was caught in a daydream of myself as a Power Puff Girl. . .flying through the air fighting off crack, one rock at a time. Knocking out dealers with a speedy forearm to the head and whisking every addict off to some safe crack-free shelter.

"Miss Mannings?"

I snapped out of it and looked back into his brown eyes. "Yes, sir."

"In my heart, I feel like this is more than hemorrhoids. I really do."

His hemoglobin was borderline low, but not scary low. Most people with bad causes of rectal bleeding have low blood counts. . .and they don't usually look this healthy. But how can you ignore what a patient who rarely sees doctors is telling you? I thought about the whole picture: unstable housing, crack cocaine use, and of course the history. I reviewed all that he said in my head. . .the bleeding with bowel movements and the feeling that this was something more. The only things that made me take pause were this strange report of soiling his pants with blood after a bowel movement, the fact that he had missed a prior colonoscopy, and the knowledge of him being homeless.

Near normal-ish blood count. Normal blood pressure. Clearly educated. Robust health overall. Previously lost to follow up. Enough bleeding to bring him to the busiest ER in Georgia. Hmmm. Should this guy really be admitted to the hospital or not?

This is one of the most common conundrums we face at hospitals like Grady. If every duck was in a row, you could probably feel okay about setting up everything as an outpatient. Make an appointment for an outpatient colonoscopy first thing next week, right? But what about when a patient has no phone number, has no resources, and already missed one colonoscopy? And what about when 90% of the story sounds like something non-lifethreatening, like hemorrhoids in a dude who's been constipated for, like, ever?

Oh, and what about the crack cocaine part? Do you shrug your shoulders and say, "What difference does it make? Even if this guy has a mass in his colon, it's not like he can be counted on to follow through with the demanding course of colon cancer treatment with a drug problem, right?" I mean, that is a real possibility. Not even far-fetched in the least.

So you make a decision. And you hope it's the right one.

We decided to admit this patient for his colonoscopy that day. He hadn't eaten breakfast, so the gastroenterologists were able to perform the procedure later that afternoon. (He was a champ and drank the whole gallon of GoLytely by 11 a.m.)

I completed his discharge papers the following day:

Assessment:

1. Rectal bleeding, secondary to Primary Adenocarcinoma of the Colon
2. Mild anemia, likely secondary to #1
3. Crack cocaine use.

Plan:

1. Adenocarcimona of the Colon limited to bowel only. Seen by colorectal surgeons
and oncology service for resection and neoadjuvant chemotherapy. Follow up
in Cancer Center this week. Appointments scheduled.
2. No indication for transfusion at this time. Initiate iron therapy.
3. Given resources for substance abuse treatment, counseled on cessation.
4. Pray. (Okay, I didn't put that in my note, but I thought it.)



What I learned from this situation:

• When patients say that something "just isn't right", listen.
• When one part of the history is odd, like soiling your pants with blood, listen.
  
• Look at the whole picture.
• Listen.
  
• Recognize when you're in a position to advocate for a patient with just the stroke of an ink pen.
• I still hate crack cocaine.
• Even though I hate crack cocaine, even those who use it deserve the benefit of the doubt.
• And most important, even when you patient uses crack cocaine, is homeless, missed their last appointment, and even when what this same patient thinks isn't exactly what you think--regardless of all of this--sometimes you just have to roll with it. Because many times the patient is, more often than not, right.
  

What would you have been thinking in this situation? What would you have done?