Wednesday, February 01, 2006

But what about a finger in every hole?

As a medical student I've done my share of rectal exams. Esp during my surgery rotation when call nights were spent in the trauma bay doing the job of medical students everywhere -- rectal exams and placing Foley catheters. But apparently a new study shows they may not be that helpful in providing additional information about injury. And only partly because med students don't know what we're doing. From Cut to Cure.
DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.
And it's not my fault that I don't know what a high-riding prostate feels like, so quit yelling at me!
One factor that may contribute to the propensity of DRE to yield less than useful or accurate information is that it is generally relegated to the least experienced member of the trauma team (at least in academic centers), which is often a medical student. This may stem from the perceived menial nature of the task or a genuine effort to provide a complete educational experience. The issue of poor interrater reliability in determining normal and abnormal DRE has been raised. Further, other investigators have found difficulty even among experienced examiners in determining normal and abnormal rectal tone as confirmed by manometry.
This all reminds my of one particular night in the trauma bay. A man came in s/p motorcycle crash with multiple fractures. He was relatively stable and was getting a bunch of Xrays done before his trip to CT. I of course assumed my position, with KY and Foley kit at the ready. But something wasn't right... I got my resident's attention and pointed out the pt's scrotum, which looked pretty red and swollen. "Just do the rectal and get the Foley in," was his response. So I did the rectal... "Well?"
"Uh... normal I guess... but..."
"Get the Foley in."
So I did... and what came out was red. Not kinda dark like urine often is after a trauma, but RED. So then another resident looks over. "Shit! Was his rectal normal?"


Post a Comment

<< Home