I usually work two or three shifts a month at a small, rural hospital about two hours from where I live. Why? Mainly, the small hospital is less than ten miles from my childhood home, where my widowed father still resides, and thus provides me an opportunity to catch up with Dad as well as four of my siblings and their families, all who live within five miles of Dad.

I also thoroughly enjoy the different ER setting that working in a small hospital provides when compared to the trauma center I have been a part of for fourteen years. People are more appreciative, it seems, and less demanding. People are respectful. There seems to be a more heartfelt connection between the small town folks and the ER staff versus the big city dwellers who demand everything on their terms with our trauma center staff. I have yet to be asked for a turkey sandwich, a warm blanket, an extra pillow, or internet access at the smaller facility.

It is, simply put, refreshing.

Still, I have a hard time drawing the line between how emergency medicine should be practiced in a small town versus a big city. Should there be a difference, even? I’m not sure if there should be. I like to think I extend myself and my staff quite well to each and every patient, whether I’m in Smalltown, USA, or the big city.

During my last round of ER shifts near Dad’s, an energetic, spritely 80 y.o. woman came in complaining of constipation. By her tightly wound perm, I should have seen that she would be a hard patient to please. She typically had a bowel movement everyday. Unfortunately, the day before she came to see me, she had not had her typical movement. The next day, upset about skipping a day of evacuation, she came to our ER demanding to get an enema.

“Maam,” I asked, after introductions, “do you have any abdominal pain?” “No,” she answered. I continued. “Do you have any fever? Do you have any urinary complaints? Do you have any vaginal complaints? Do you have any nausea or vomiting?” To each question, she answered a resounding “no.”

“Maam,” I said, quite honestly, when I had finished a perfectly normal physical exam, “I am trying to figure out why you came to the ER if you otherwise feel alright. Did you call your family doctor about your constipation?”

“Why would I do that?” she asked, “they don’t do enemas in the office. And I need an enema.”

“Well, maam,” I confessed, “I don’t require our nurses to give enemas to people unless they medically need one. Without a fever, abdominal pain, or any other changes to your health, I don’t even feel you need an enema for just skipping one day of your regular movements.”

“You mean you aren’t going to order me an enema?” she asked, incredulous. “Have you had an enema here before, maam?” I asked, curious as to why she was so focused on getting an enema. “No, I haven’t,” she said, “but I know lots of people who come here to get one when they need one.”

While the patient went to the bathroom to “try to go again,” I left her room to question the nursing staff about their enema practices. “Oh no, we don’t do enemas unless we really have to,” the nurses said, almost in unison. What other answer was I expecting? Of course, nobody in their right mind was going to volunteer to give an enema to a healthy, non-distressed patient.

The woman returned from the bathroom. “No luck,” she said, smiling as if to say “so there,” as she comfortably walked back to her room and easily jumped up into her cot. “Well,” I said, “I think we have a plan for you, maam.” I then explained how I approach constipation in the otherwise healthy patient. I explained that she needed to make sure she ate enough fiber in her diet and drank enough liquids. She needed to be physically active which, judging from her energy, wouldn’t be a problem. We talked about her taking something to “keep her regular,” from FiberCon to Metamucil to MiraLAX, as she needed.

Finally, I talked to her about the meat of her problem. “Maam,” I said, “although I don’t suggest it right now, if you feel you are constipated and want to aggressively treat it, then use a Fleet’s enema. If you don’t have relief in one hour, repeat it. And if that doesn’t flush you out within four hours, drink a half bottle of magnesium citrate.” I went over this twice, actually, as she nodded her head.

When I was done, she got quite snippy with me. “You mean I won’t be getting an enema here in the ER today?” “No, maam,” I said, “I’m sorry if you are disappointed with that, but I wouldn’t make my staff give you an enema I’m not sure you even need.”

“I’m not giving myself an enema,” she yelled now, “I never did and I never will!”

I assured her that the instructions that come with Fleet’s enemas are very good, including pictures of how to go about things. As a side note, if you want a good laugh sometime, spend the dollar on an enema to see the cartoon drawings in the instructional pamphlet.

Well, she wasn’t buying what I was selling. “You mean my husband and nephew have been waiting in the waiting room for nothing? I came here for an enema and I am not happy I’m not getting one.”

She then requested if home-nursing would come by her house to give her an enema. Having an important connection with the home-nursing team (my sister Chrissie is a nurse who heads that department), I called Chrissie to get her input. After reviewing the patient’s complaints and exam, she mirrored my thoughts. “Does she even need an enema, Jim?” No, I assured her, she doesn’t. “Then just have her follow up with her family doctor in a day or two and if she is not successful by that time, we can send someone out to help her. It would be hard to justify sending home nursing in at this time.” I love my sister Chrissie, no bones or bullshit with her approach. Just like mine.

I went back in to the patient and explained my conversation with Chrissie to her. The patient was not happy. But she was healthy. Healthy and a little constipated.

After she left, threatening to go to a neighboring rural hospital an hour away where “I’ll bet they’ll give me an enema,” the nurses gave me a round of applause. I felt kind of bad, actually, for having this patient leave disgruntled, without her enema.

“Thank you for separating an emergency enema from a non-emergency enema,” said the charge nurse. I nodded my head to her as she continued. “You are the first doctor who ever said ‘no’ to that demand.”

This whole incident got me to thinking. At the big trauma center, I would never have considered giving this patient an enema, no matter how much she thought she needed one. We are just too busy to not utilize our time more efficiently. In the small town, however, people seem to expect that extra “oomph” of kindness. But a line has to be drawn at some point. Incidental constipation without symptoms does not, in my book, demand an enema “just because” the patient is obsessing over her bowel movement patterns. Or because they happened to sign into an ER to be seen.

Something tells me this kind lady will not be baking me an apple pie as a thank-you. Which sucks, since I love apple pie. But at least, whether it’s in a big city or a small town, I feel I treated the patient correctly.

“StorytellERdoc” is an emergency physician who blogs at his self-titled site, StorytellERdoc.

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