The morning had been a busy morning. This was the first time in my career that I had performed a joint physical. It had went well.

The husband and wife were nice people, very pleasant and friendly. The wife was a little shy and had become embarrassed but it had turned all right. They seemed satisfied with the services that my receptionist and I provided.

It was noon and I had offered to buy my receptionist lunch at the cafe. We went and ate and then returned to the office.

There wasn't much on the schedule for this afternoon. We both cleaned the exam room and put it back together. While doing this I made some small talk about this morning.

And asked what she thought about helping out as my nurse? My receptionist told me it was interesting, that yesterday was the first time she had witnessed anything like this before. I asked how she had learned what she knew about nursing? My receptionist told me she took some nursing classes when she started college, but never pursued it any further.I thought about this for a little while and then asked her if she might want to learn more? My receptionist told me possibly and asked me how? I told her that since she had a little education in nursing already she could start assisting me and help by doing some hands on training, and then if she thought she wanted to pursue it further after that, she could start taking some more classes.

My receptionist said she would try it for awhile and see. I told her ok good, I was glad to hear that. We finished cleaning and went back up front.

We continued talking and I asked her how she felt about seeing the stuff that happened to the patients this morning? My receptionist told me it kind of embarrassed her a little to see a man like that. I asked her do you mean seeing his penis? and the fact that he was aroused? and she said yes. And then my receptionist told me seeing him bent over like that was a little embarrassing also. I asked her if she meant seeing his anus? and she said yes seeing that part of him was a little embarrassing as well.

I told she would get used to it. We continued talking. I asked her about seeing the woman? she said that didn't embarrass her, but she felt kind of bad for her getting that stuff done to her. I asked my receptionist to explain herself, she just said you know the speculum, and the finger in her rectum. I told my receptionist it's not fun, but it's necessary. I said to her that she new better than I did about how the speculum felt. She told me it's not fun, it's kinda of painful, then she looked a little sheepishly, and told me she didn't really know about the finger in the rectum? I looked back at her and told her more than likely you will find out what it feels like in time.

By now it was time to close up the office and go home. We told each other good night and we would see each other about eight thirty in the morning.

The office was already open when I got there. I walked in and was greeted with a big good morning doctor. I returned the good morning. And announced it looked like somebody was in a good mood. My receptionist told she was in a good mood and it was a nice day. I asked what was the morning agenda like? she said there were three appointments for the morning. The first one at nine and the last one at eleven. I told her fine and headed to my office to get ready.

The first appointment arrived and everything was going according to schedule. I walked my last appointment out to the waiting room when he was done. He left and my receptionist told me the lady who was here the other day had called in. I must have had a confused look on my face, she said you know the one who was here with her husband. I remembered, and then asked what did she say? My receptionist told she called in because the laxative you prescribed for her isn't working. I asked what she said other than it was not working? She said she didn't feel good and thought maybe you could give her something else? I asked what time was she coming in? My receptionist told me she had told the woman she could come in anytime, That I wasn't busy, I said that was fine.

My receptionist asked me what I thought, I was going to do for her? I thought for a few minutes and told my receptionist. I really didn't know until I examined her. And that I would need a chaperone in the room during the exam. And today is as good a day as any for her to start furthering her education. Then I told her when the woman gets here and is checked in, to put her in the second exam room. And then go ahead weigh her, and get her vitals and I would be in.

About twenty five minutes later I heard the front door open and some conversation. Then I could hear my receptionist and the woman enter the exam room. I waited about ten minutes and then headed to the exam room, knocked and entered, reintroduced myself to the woman and asked her what was going on.

She looked at me and told me she didn't feel well. I told her I had heard the laxative I prescribed wasn't working. She said not very well, I asked if she had been able to move her bowels? She looked uncomfortable with this question, but she looked at me and told me not very much. I asked if any? She said a little but not much. She was wearing a t shirt and jeans I told her my nurse would give her a gown but she could leave her shirt on but would need to take her jeans and underwear off. She looked confused I told her she was just here, I would listen to her heart, but that would be enough, but I was going to have to give her rectal exam. She said In a disgruntled voice you just did that yesterday. I told her yes I know but, I told you then you were constipated and impacted, I went on and explained now I need to see how impacted you are. She said oh I didn't realize this, I just thought you would give me something else. I explained I need to know how bad it is ? to know what to give you. She said ok I guess so. I grabbed my stethoscope and listened to her heart, and then I listened to her lungs just to make sure she was breathing all right everything sounded good. I told her to get changed and my nurse and I would be back in a couple of minutes.

My nurse and I waited about five minutes and then I knocked on the door and we both entered the exam room. The woman was in the gown and sitting on the exam table waiting. I told her that her vitals were good and she didn't have a fever. I would need to examine her stomach, to see if I could figure out what was going on. I asked her to lay down and place her hands behind her head. She did as I asked and I began feeling her stomach pushing on it firmly but gently. Her stomach felt hard , a little swollen, I told her I had to ask her a couple of questions and she shouldn't be embarrassed by them. I told her, her stomach felt hard and a little swollen, I told her I needed to know if she has been able to pass gas? Her face turned a little pink and she said not very much, I asked if she were having gas pains and cramping ? She said yes pretty bad pains and cramping.

She asked me what I was going to do? I said what needs to happen is you need to move your bowels. I think that you are very constipated, and there's no way for your gas to escape and that is what is causing the pains and the cramping. I told her first I needed to give her a rectal exam to see if I could tell how severely she's constipated. Then I will know a little more and will have a better idea of what to do.

She was still laying on her back, I asked her to roll on to her left side and bring her right knee up towards her chest. She did as I asked, while I went and got a pair of gloves and a tube of lubricant. When I got back to the exam table my nurse had walked around so that she was standing in front of the patient, so that way my nurse could make eye contact with the patient and patient could speak with my nurse if she needed to.

I asked my patient how she was doing? As I pulled my gloves on, I then told the patient I was going to raise the gown and look, this exposed the patients backside. In this position her vagina was exposed, as well as her anus. Her anus looked healthy. I told the patient I was going to spread her cheeks and lubricate her anus with my finger I squirted some lubricating jelly on my finger then spread her cheeks exposing her anus, I asked if she were ready? She nodded her head yes I placed my finger against her anus and began pushing into her rectum, when I felt her sphincter, resist my finger I stopped and gave it a second to relax and open, then I pushed my finger fully into the patients rectum. As soon as the patient felt my finger entering her she tensed her leg muscles and tightened her buttocks, her anus began clenching my finger, as a couple of small grunts escaped her throat, she then reached her hand out to hold my nurses hand. My nurse soothingly held the patients hand comforting her. Once my finger was all the way in her rectum I could feel very hard dried stool. Her rectum was very impacted, with thick stool which had dried out, I took my finger and tried to feel how far up her rectum she was impacted. It was as far up as I could feel. I explained what I was feeling as I was examining her. I slowly pulled my finger from her rectum feeling her anus close around the tip of my finger. I looked at my finger to examine the stool I had collected but my finger was relatively clean. Once the patient felt my finger exit her anus she then asked me what I was going to do. I told her that she was severely impacted. And I thought she was going to need a enema to loosen her stool so she could pass it.

When I told my patient what I thought needed to be done, I saw the look of resistance on her face. She was not open to the idea of a enema. She told me no! she didn't want a enema there must be something else I could do? I told her it was my opinion that a enema was the best option for treating the problem. She told me she would not do that. There must be something else. By now she was becoming frustrated and upset about with the situation. In a calm voice I told her there were a couple of other options, but the enema was the best option, it would work the fastest and was the most reliable. There were suppositories but they take a while to work and there was no guarantee they would help. I could give her another laxative but it didn't work the first time, so it probably was not going to work now.

By this time the patient had become so upset she was almost in tears. I told her I could not make her do or take anything she did not want to. But if she doesn't do something she will end up sick. And possibly in the hospital having it treated by a manual disimpaction. She looked at me and asked me what that was. I looked her in the eyes and in a calm voice explained. That is when a doctor or nurse inserts two fingers into your rectum and manually breaks up your stool and removes it with there fingers. She looked at me in disbelief and then looked at my nurse who nodded her head yes, and then told the patient this is true. My patient didn't say anything for a few seconds, and then said that maybe we should try a suppository. I looked at her and told her we can try that, but if it doesn't work then will you let us give you the enema? It's for the best we need to fix this, before you get worse. She reluctantly nodded her head yes.

I told her ok this is what we will do then, we will try a suppository. I then explained the situation with my nurse trying to further her education and asked the patient if it would be ok if my nurse administered the suppository? That she was qualified to do so but I needed the patients approval first. She said that it would be fine if my nurse did it. As she was telling me this I saw her face becoming distorted with a painful grimace and her hands were grab her stomach. Then I heard a PFffftt and then I saw the patients face turning red with embarrassment. I asked her if she was having gas pains she nodded her head yes and then there was another PFFFFTT and the patient let out a small moan and said she was sorry both my nurse and myself told her it was ok not to apologize. I asked my patient if she was alright? She said she was ok . I told my nurse that I would go get the suppository and I would be back.

I left the exam room and walked down the hallway to the room where we kept the meds. I grabbed what we needed a four gram suppository and a small jar of Vaseline. I walked back to the exam room. I knocked and entered I laid the foil wrapped suppository on the counter and told my nurse to go ahead and if she needed help? to let me know.

I went and stood by counter out of the way and watched as my nurse went and got a pair of gloves. And then asked the patient to lay down and roll on to her left side and bring her right knee up to her chest. She then put her gloves on and raised the patients gown exposing her bottom. I watched as she took the jar of Vaseline popped the cover off and dipped the forefinger of her right hand in the Vaseline getting a glob on her finger. Then explained to the patient she was going to apply some petroleum jelly to her anus then fully insert her finger to lubricate the inside of her anus and her rectum. I watched as my nurse spread the patients cheeks and smeared some petroleum jelly on the outside of her anus then told the patient now you are going to feel some pressure and pushed her finger fully into the patients rectum. This made the patient squirm a little and curl her toes. Once she had her finger removed from the patients rectum my nurse took off the dirty glove, leaving the clean glove on, put on a new glove and then went and grabbed the suppository and opened the foil wrapper . Walked back to the exam table and behind the patient telling her now she was going to insert the suppository with her finger by pushing the suppository all the way in, and then leaving her finger buried up her rectum until she felt the suppository melt. My nurse was doing a good job so far. She placed the suppository against the patients anus then held it in place with the tip of her finger, then all she told the patient was now and pushed the suppository in followed by her finger until her finger was indeed buried up the patients rectum and her fist was lodged between the patients cheeks. The patient gasped and flinched when she felt the suppository and finger invading her rectum. Now that my nurse was just holding her finger in the patients rectum the patient was just laying still and breathing deep and heavy. My nurse asked the patient how she was doing and then looked at me and smiled. The patient answered my nurse by telling her she was doing good. My nurse glanced at the clock on the wall and was patiently waiting for the suppository to melt. While we waited my nurse explained to the patient that it could take fifteen minutes to maybe sixty minutes for the suppository to work. The patient nodded her head yes, and then layed there quietly waiting.