Alan had a banner week after his session with Sarah. He was less stressed out, sleeping well, and full of energy. He even starting doing 2 mile runs every other day. And of course, there was the more obvious turn for the better in terms of his bowel function. He was regular and his BM’s were no longer painful ordeals. Sarah kept tabs on him through the GITracker app she had installed on his phone. He had to send her daily reports and if he didn’t, she was on him. He found it quite embarrassing to have to share with her the character of his bowel movements — the caliber of his stools (he had to estimate down to the millimeter), the consistency and any pain or discomfort he had passing them.
Sarah would have him come to her room every Friday afternoon after his last class to talk. They would go through how he was feeling, and she would always have him lie down for a slow methodical abdominal exam. She‘d have him take his shirt off and lie down on her spare bed on his back. It was winter now, and so he was usually wearing jeans. She’d have him unbutton and unzip and push everything down to just above his pubic bone. She was still learning her physical exam skills with a preceptor in her studies, so she was totally by the book: always starting off by inspecting his bare abdomen. Alan thought this was odd and it made him a little fidgety. She would then auscultate and was thorough to the degree that she would listen to all four quadrants with both the diaphragm and bell of her stethoscope. And she always warmed it in her hands before putting it against his skin. She would then start palpating him. She would sip from a big mug of herbal tea as they discussed things just before the exam, so when she first laid hands on him, her hands felt delightfully warm — warmer in fact than would be physiologically normal. Alan came to enjoy this greatly. He had no other physical contact at school with another person and so having Sarah’s hands on him helped meet a deep need for him. He could feel his stress melt away was her hands moved over him. It no longer happened that she would have to tell him to relax as she examined him. He always was already. His abdomen was soft and her hands would sink deeply as she pressed more firmly. She would then percuss his liver and as she became increasingly skilled at it, she was able to produce ever more resonant sounds over the areas where there were gas filled loops of bowel. Alan likened the sound to muffled notes of a bongo drum.
Alan stayed pretty healthy for several weeks, but with the challenges of the limited food selections at the dining hall, he started to have some gradual return of his symptoms. He was less than 100% truthful with his data entry into the GITracker app, trying to keep things from Sarah and get himself back on track on his own. It was a testament to Sarah‘s rapidly improving physical exam skills that she was able to detect the deterioration right off. As she examined him, she started slowing down and focusing on his left lower quadrant and Alan could see the look on her face become more intense and focused. A feeling of dread overcame him as he started to realize she was likely discovering things were not quite as he would have her believe, “Alan, you‘re more distended and things feel a bit lumpy again down here again.” Are you sure your BM’s have been as you described this week?”
”UmHm” was his feeble unconvincing response.
Sarah was a little annoyed. She finished her exam and dropped back from her upright kneeling position to sit on her feet. She looked at him, but he tried to avoid making eye contact with her. She would have nothing of it, “Look at me Alan. What’s going on?”
”Nothing!” he responded, sounding like a child who had just been caught.
”Something sure is going on. I can feel it,” Sarah said as she stood up.
”I need to do a rectal exam on you. We can’t let this get out of hand again. Take off you jeans and undies all the way. I’ll be back in a few minutes.”
“Can I put my shirt back on?” Alan asked almost with a begging tone.
”No. Everything off,” was the terse reply with a hint of annoyance.
She walked out and closed the door behind her to let him get undressed.
Alan was upset and anxious. Sarah had not addressed him like these ever before. As he considered his predicament, it was more that he had disappointed her rather than what she would be doing to him next that upset him. He quietly undressed and then got back into bed and pulled the blanket up to his neck.
Sarah knocked on the door and then came back in. She had in her hands some items unfamiliar to Alan. He could see off-white exam gloves, a blue and white sqeeze tube of something, some small laminated cardboard squares and a small plastic bottle of liquid. Puzzled and uneasy not knowing what these were for, he asked about them.
”I need to check your stool for blood when I examine you. With things not going as expected, I don’t want to miss some other explanation for what’s going on.” Sarah explained. ”I‘m sorry I was a bit short with you, I‘m just disappointed that we have lost some ground. I’ll try not to have that tone with you. Roll over onto your side for me,“ she said as she pulled on the beige gloves.
Alan complied and was now facing away from her but still under the blanket. Sarah pulled down the blanket to below his knees and the chill of the room air came over Alan.
”OK, like before, bend and pull up your right leg, straighten you left leg and stick your bottom out.”
Alan hated this positioning, but he followed her instructions to a tee. Sarah pulled her desk lamp over and switched it on, and the chill of the air on Alan’s bare bottom was offset somewhat by the heat of the bright light as she pulled it even closer to him.
“First I am going to check outside.”
She separated his buttocks with her hands and she was pleased with what she saw, “At least the skin inflammation is gone. No redness. Your anus is brown and the skin around it white like it should be. You have a small mole on the back of your scrotum. We need to keep an eye on that.“ She let go of him and his buttocks sprang back together with youthful firmness.
Alan could hear her preparing things. First, a wet bubbling sound as she squeezed lubricant onto her index finger. ”Alan, I need to use a different lubricant this time. Vaseline would interfere with the test I am going to do on your stool. I‘m going to use a water based gel. Very slippery and comfortable, but it will feel noticeably colder at first.“
Sarah lifted his upper buttock, and began lightly applying her finger tip. Alan flinched slightly at the cold. As she very gently moved the pad of her finger over his anus, she gave him the familiar instructions, “OK, to relax your bottom, deep breath in and push out.” She could feel with her fingertip that the sequence had the desired effect and she glided her finger into his rectum. “Good! You’re nice and relaxed.”
Sarah moved her finger circumferentially around the interior of his rectum and as she often did, shared out loud with him her findings, “Well Alan, I‘m not finding what I thought. Not so full, but higher up, I can feel some hint of blockage.“ She pushed in as deeply as she could to try investigate this and Alan could feel the other closed fingers of her hand push firmly on his perineum pushing him almost onto his stomach. “Yes, that’s where the trouble is. High up in you rectum.” She continued to move her finger around thoroughly, but always gently and smoothly. It occurred to Alan that this she was really taking her time, but instead of the sense of near intolerability, he remained calm and he was able think clearly about what was happening instead of the frantic near panic —“Take it out! Take it out!” —that he felt the first couple of times. In fact, when he was able to let go of his deep embarrassment for a few seconds, he found some comfort in this contact with Sarah too — her upper hand firmly on his buttock, her nearness right behind him that he could sense from the sound of her breathing and hints of the smell of her hair. And of course her finger inside him so intimately that it seemed to approach the core of his being.
When she withdrew her finger and Alan could feel the excess cool lubricant dribble onto his lower buttock.
”You can sit up now Alan.”
He rolled onto his back then swiveled and rose up to a sitting position, covering his lap with the blanket. As much as he was getting a bit more accustomed to this, he could still feel some of the surging warmth in his cheeks and ears and hoped they were not too visibly flushed. He could see Sarah with the finger she had examined him pointed upward as if making an exaggerated rhetorical gesture. It was shiny with lubricant and clearly soiled with his stool which was very apparent on the pale whitish surface. His profound embarrassment increased further as she opened a cardboard envelope with her other hand and proceed to smear her examining finger back and forth across this. She pulled off the glove on her examining hand and took the small plastic vial from the desk with her bare hand and expressed a few drops of clear liquid onto the back of the card. She then watched for a minute, getting up to her feet as she did. She took off her other glove and threw it and the card into the trash. When she turned back to Alan, the more serious look on her face concerned him. “Get dressed Alan. I’ll be back in to talk with you in a minute.”
”Can I clean myself off?”
”Here, use these.” Sarah handed him to plastic box of baby wipes and walked out.
Alan was a little frightened as he cleaned up and got dressed. He was pacing around the small room when Sarah knocked and came back in.
“Sit down so we can talk.”
Alan sat at the edge of the bed and looked up at Sarah. She could see the fear in his wide-eyed expression and also hear it in the quiver of his voice as he spoke, “Sarah, what is it? What’s wrong with me?”
Sarah sat on the floor in from of him and put her hand on his knee. “There’s blood in your stool Alan. It could be from a lot of things. Most likely not something serious, but it needs to be investigated further.“
”How? What do I have to do?” Alan was still shaken despite the bit of reassurance Sarah offered.
”We need to get help. This is beyond the reach of dorm room medicine.” No pun intended, she thought to herself