Poop Queen

I didn’t see it coming , but poop has become a frequent focus in my career…and life.  Gastroenterologists and parents who change poopy diapers probably think the same thing or scoff at my confession, but I’ve unwittingly assumed it as a soapbox matter because there’s a hole in our understanding.

It probably all started back in residency when I rounded with a particular group of young doctors in the hospital.  The physicians in their first and second year of residency created a hazing-type of award called the “Golden Finger”.  A chart drawn on the white board outlined every intern’s name next to a series of columns that denoted certain procedures they regularly performed on patients.  They marked every procedure they squeezed out, but only one column resulted in a trophy, the digital rectal exam (DRE).  Also used for prostate exams, the DRE can be used to manually disimpact the poop chute of a constipated patient.  I doubt it’s pleasant for either patient or doctor.

On the other end of the pooping spectrum is diarrhea, and it can be bad.  In hospitals especially, the spread of Clostridium difficile (C. dif) is as feared as the plague or an impending ice storm, although an ice storm would smell better.  As a resident I presented an educational session over lunch to hospital staff about C. dif.  Antibiotics and stomach acid suppressants can sometimes be just as harmful as they are helpful and lead to outbreaks of C. dif colitis.  The poop is watery and it is frequent.  Washing hands with soap and water and bleaching surfaces are the best preventative measures against its spread.  The best treatment?  Fecal transplants.  It’s a thing.

There’s a fluffier side, albeit just as informative.  A little show called Scrubs immortalized the importance of poop in a song.  It’s not just the fact that the bowel moves or not, but it’s the condition and contents of the poop that expose your darkest secrets.

Runners talk a lot about poop.  There are port-a-potties available on running routes for that very reason.  While urination may be the primary goal for some—some runners just let that go—poop can’t be freely and inconspicuously dropped.  One needs privacy and a pot, or at least a hole.  One time I ate fettuccine alfredo the night before a long run.  I thought carb-loading would be beneficial.  What I didn’t count on was the effect of the deliciously creamy fat in my meal.  After my 8 miles the next morning, I almost did not clear the 15-minute drive home to release my belly angst.

Now it seems that much of my job as a clinical pharmacist is to teach the importance, methods, and mechanisms of keeping things flowing.  Here are a words of wisdom I float to young doctors and those wishing to become more proficient in the cathartic arts:

• Drug-induced constipation is predictable, therefore, mostly preventable or at least manageable (i.e. if you prescribe a med that causes constipation, you should also prescribe a stool softener and/or laxative, lifestyle modifications/exercise, fiber, and water).
• Constipation is much easier and less expensive to prevent than it is to treat (i.e. once constipation is present, you’ve already lost the battle; time to bring out the big, unpleasant guns).
• If constipation has been going on for days, the best route to treat is from underneath (i.e. suppository or enema).
• If you consult a gastroenterologist for constipation, they will almost always choose the most expensive (albeit, sometimes the most effective) treatment (i.e. potential wasted resources).
• There are no real evidence-based guidelines for constipation. The patient population and causes of constipation are so heterogeneous (i.e. varied) that a one-size-fits-all approach (or saying one type of treatment is “ineffective”) does not work.
• Common sense and experience go a long way. Start with your least expensive agents first.  Match the cause of the constipation with the mechanism of action of the bowel regimen.  Maximize doses, routes, and frequencies.  Then, move up the cost ladder.  Then, consult gastroenterology.

Many days my recommendations for bowel regimens pass like this:

“Mr. A is on Norco® PRN [as needed], but he’s taking it 3-4 times a day and has nothing ordered for his bowels.  Can we add docusate scheduled once daily at least?  And maybe senna PRN?  If our attending [physician] prefers Miralax, that’s okay, too.  Just need something scheduled.”

“I was checking Ms. B’s recorded bowel movements, and she’s had none for 5 days.  We started her on diltiazem for her a. fib, and that is known to cause constipation.  She’s also been taking TUMs.  Can we add some scheduled docusate and a one-time bisacodyl suppository?”

Although these seem like rather immaterial propositions and for a seemingly an innocuous illness like constipation, you wouldn’t want to wait until the patient gets a small bowel obstruction and has to be decompressed with a nasogastric tube or until we have to give a $150 one-time injection in hopes to get things moving…or better yet, put in for a gastroenterology consult.

Recommending bowel regimens is akin to a mother reminding a child to flush the toilet after use.  It seems like a minor thing in the hospital, especially when a patient is there for severe pneumonia or a myocardial infarction, but it’s a necessary thing.  Bowels don’t shut off just because there are more life-threatening matters at hand.

I have acquiesced to the fact that this will just be part of my job.  I review medications and look for missing pieces, offending pieces, interacting pieces, and so on.  Who better than me to be on the lookout?  They (the young doctors) know it, too, and I have been crowned the Poop Queen.  I will preside over my kingdom from my throne, if I must.