Case 43: The Assman

Viewer and Reader Discretion is advised.

It’s the warmest day in weeks and things seem almost back to normal in the ER. People are outside, turning ankles, fracturing wrists, and hopefully, still social distancing. My stomach growls as I dream about the savoury goat curry my mother left on the doorstep this morning. It was piping hot, beads of sweat gathering on the glass Corningware lid as I cradled it with a tea-towel and brought it inside. I’m starving, but with this mask and face shield, breaking for a snack or even a quick drink is cumbersome and impractical.

Just looking at the way my patient Ian* is standing makes my butt hurt. Bent forward with his feet wide, the sixty-year old shuffles into the room when I call his name. I don’t bother offering him a seat as I introduce myself and listen to his story.

His problem began just after lunch. Answering nature’s call, he grabbed a magazine, and eased himself onto the toilet. As usual, it took a half-minute to get his stream going, but he emptied his bladder completely and easily. Then, he started to push. As the metaphorical turtle poked out its head, Ian felt a sudden, sharp pain. He let out a yell and broke into a sweat, then took quick shallow breaths as if he was in labor. Slowly, as he relaxed, the pain settled. After several minutes, he summoned the courage to try again. But as he pushed, gently and slowly, it felt as if he was trying to expel the turtle, shell and all, rather than a harmless, lifeless turd. Figuring he’d have better luck later, he flushed, aborted his mission, and carried on with his day.

Before dinner, he tried again. Still sore from his previous battle, he gave a gentle push. This time, the pain was immediate and severe as if the hand of Wolverine had come through the pipes and probed his prostate. He jumped and clenched his cheeks, but that only made it worse. Panting, he edged apart his feet until the pain eased. He felt a drop crawl down his inner thigh and when he wiped, the toilet paper was bright red. He stood still for several minutes until the bleeding stopped and then waddled toward the shower.

Under the warm, soothing water, life was once again bearable. “I tried to feel where the bleeding was coming from and I felt something hard.”

“Like stool?”

He shakes his head quickly. “I don’t know. It was just really hard. It didn’t feel like it belonged there.”

“Okay,” I say. “I’ll be back.” A good story is the first step to the right diagnosis, and as I leave to get gloves and lubricant, I consider the differential. At the top of my list is a thrombosed hemorrhoid. If one pushes too hard or too long, veins can become engorged down below. These veins are hemorrhoids. Occasionally a vein swells and as the anal sphincter contracts and closes, the vein can be pinched and left outside the orifice. The blood in the vein clots and the result is a firm, painful, pea-sized thrombosed hemorrhoid. Treatment is simple: a small incision and extraction of the blackish-purple clot gives instant relief.

Fecal impaction is next on my list. Emergency Medicine is like roulette. You never know what’s coming next. Picking up the chart of a patient with a fecal impaction is like having the little white ball spin right off the wheel and hit you in the eye, and then having someone steal your chips as you hit the ground. The procedure is unpleasant for both patient and clinician. Sometimes, the mass of stool that gathers in the rectum is simply too large to pass. Treatment involves using a double-gloved, well lubricated finger to hook out small clumps until relief is achieved. It isn’t easy. Trying to extract poop with a single digit is like lifting sushi with a single chopstick. To the patient, however, it’s worth the effort, and like flushing earwax from the auditory canal, the procedure is satisfying for both patient and clinician.

There are, of course, many other possibilities. As I return to Ian, I think of The Assman**, a fictional TV show proctologist tasked with extracting sharp, dry pasta from an elderly man’s rectum. “If I wasn’t there, I wouldn’t believe it,” the show’s protagonist says. On so many days, the ER is like this. If I wasn’t there, I wouldn’t believe it.

Ian lies on his side, slips down his sweatpants and assumes the fetal position. I retract his cheeks and have a look. I see a small bleb that looks like hemorrhoid. It’s possible that this was once a thrombosed hemorrhoid, and that it’s popped, releasing the clot sometime between Ian’s shower and his ER visit. I tap it with my finger and ask if it’s painful. “No,” he says. “That’s not it. It’s a little higher.” The only thing higher is a puckered hole in which I’m going to have to stick my finger. I rip open the small pack of lubricant and slide my finger through the contracted muscle.

We both say it simultaneously: “Whoa!”

My finger retreats as Ian thrusts his pelvis forward. “That was it,” he says.

I step back and arrange the wording of my next question before I speak. “Whatever it is,” I say, “it’s as sharp as a needle.”

“I think,” Ian says, “I know what it is.”

“It actually feels like you have a splinter in your butt.”

“Well,” he says, “I ordered Chinese food last night and by the time it came to my door I was starving. As I stuffed my face, I felt a bone go down. By the time I realized what had happened, it was too late.

“That might be it,” I say. I leave the room, change gloves and grab a suture tray. I need something with which I can grasp the object and I don’t want it to pierce my skin. Moments later, his cheeks are retracted as my finger edges forward once again. The sharp edge pokes me and I pry open the sphincter until I see it. I open the jaws of the needle driver, advance it carefully, then lock the foreign body in my grasp. Ian yells out as I wiggle the bone free and pull it out. It’s triangular and its points are as sharp as those on a Ninja star.


Video altered to obscure detail

Bone fragment extracted from Ian’s anal canal

Hours later, I’m at home, eating my mother’s delicious curry. I chew slowly and thoroughly before swallowing and send my parents a text of thanks. It was my mother who encouraged me to go into medicine, telling me I’d be able to help people with strokes and heart attacks. What she didn’t tell me, however, is that I would be The Assman, just like my ER colleagues around the world are Assmen and Asswomen. When these ‘one in a million’ episodes occur, people requiring help don’t usually attend an office or clinic to see professionals like the fictitious Howard Cooperman**. They come to the ER where my colleagues and I are eager and willing to help them out.

*not his real name (thank you “Ian,” for allowing me to tell your one in a million story)

** Seinfeld, The Fusilli Jerry, Season 6, Episode 20

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  1. As a lawyer I thought some of my days in court were really “shitty”…, but not quite so much…thanks to ER docs out there

  2. I hope you’re doing ok! I keep checking for updates but haven’t seen any in a while.
    – Fellow Toronto healthcare worker

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