The rear end of things

I remember a day during my surgery rotation in which i had the pleasure of meeting a pleasant Oom who required our help.

I met him in casualty after being summoned by the casualty officer to assess and possibly discuss for admission with my medical officer who happened to be the don.

I was pleased to meet an aged gentleman to whom i apologised for the time i kept him waiting. He shuffled in his seat and assured me he didn’t mind. He then thanked me for my service to him before I could even offer my help. A rare occurrence indeed.

I probed for the problem and his reason for the visit. He obviously had no open wounds, was cheerful and his abdomen was fit as a fiddle, he was in what i thought to be good health. He avoided my question and veered off topic again. He spoke about his great grandfather who knew a doctor moosa in town who helped him amputate his leg due to diabetic complications.

As happy as i was to be seeing a clinically stable patient I began explaining how I had 30 patients in the wards in which I had to go do ward work for. He was silenced. He then went on to explain how overworked i must feel and how his grandkids aspire to be doctors. I suspected I may have encountered a patient i like to call a “talker”.

The profile usually fits an older generation who find a lot of time on their hands after retirement and no one to use it on. They usually live alone so they see a visit to the hospital as an outting to come and have some free human interaction . personally i didn’t mind. It was a break from the people who were too sick to talk and the people too frustrated to talk. However today I was on call. I needed to clean the wards before 4pm so I’d only be dealing with emergencies after hours and oom wasnt helping me. At this pace I’d be here for a very long while.

I blurted put “Oom whats the problem? Where is the issue?”

He turned a light shade of pink. I asked again assuring him im here to help.

He then paused and said “my rear end has been giving me troubles. I experience a sharp throbbing pain day in and night out. I cannot sleep. I can barely sit. Arthrtis has killed my bones and yet im forced to walk here because I cannot sit down”

The agony in his voice alarmed me. “Shame oom let me take a look”

I tripled gloved like it was second nature. I knew better to never approach the rear end without proper gloving. Took me a few bad messy incidences to learn the important of triple gloving

He was obviously embarrassed. Who wouldnt be? A young female approaching the rear was not exactly soothing for him. I tried to engage in small talk but I could see oom was really stricken with pain. His ears began flashing red , a phenomena I always admired in lighter skin people. The capillary beds dilated allowing millions of red blood cells to reach the surface and glow a firey red. The human body never ceases to amaze me.

He flopped over and buried his head in shame in the bed. I exposed the buttcheek and thats when everything made sense to me. I saw the most rounded anal abcess ive ever seen. Hot tender with Red edges and the contrasting yellow balled centre filled with staphylycoccus Pus. Shining and smooth. I could see the abcess pulsate with every breath oom took.

I was suprised oom managed to approximate his legs as the pressure onto the abcess would cause excruciating amounts of pain. I sympathized and felt obliged to reassure oom we would help him. I was commending him on his ability to put off coming to the hospital for a week and suffering with his problem for so long. He admitted It was horrific

I informed the don and explained to him that it would definitely need a debridement in theatre. After all the pus i saw was only a tip of the ice berg. The pus had tracked and seeped deep into the tissue causing an inflammatory reaction around the entire region.

The don was quick to come to assess especially if it meant possible drug and cut. Surgery was after all what the don loved to do. He took 1 look and glanced at oom. We need to drain this out in theatre. “Moosa counsel him on a diverting colostomy while I go negotiate with the anaethetist to push him after the current Caesar”. There was nothing more i hated than a diverting Colo just because it was the most unnatural thing under the sun. But in this case I knew it may be needed. A diverting Colo meant the bowel content would be diverted from the rectum and anus, through a stoma or opening in the abdomen allowing the content to seep into a bag. I found it so strange to know a patient could see the bowel content in a bag. Thats just, for lack of a better word, Gross.

The anaethetist happened to be one of my favourites. He was of Polish nationality and performed general anaesthesia like second nature. Drugs Always neatly drawn. Ringers always at hand. Everything seemed effortless. Always calm, never overreacting. In fact, i have only ever seen him wear theatre scrubs. I suspected he preferred it that way.

Pretty soon we were in theatre and the tube was in and oom fast asleep. We scrubbed and got to work. The Don showed me exactly what lay under the iceberg. An ocean of Frank pus. The pus had tracked so deep we were digging tissue out with pockets of pus. It created an entire network of pockets even defying gravity and going up, invading his left butt cheek. After the don was satisfied we packed and dressed the crater of a wound and the disappointing diverting Colo was done.

The don told me something I had never stopped to think about but now makes heaps of sense. He explained to me that even though the surgery required us to be on the messy side of things , the patient had entrusted us with his life and problems at the most vulnerable time. He allowed us to be a apart of ridding him of such pain and discomfort which could have pushed him into a septic shock in an instant. We restored his dignity in some way.

The rear end is indeed a sensitive area and so much can go wrong down there. From then on, I refused to shy away from the rear problems and welcomed the opportunity.