This happened many years ago but it has stuck in my mind ever since. It is a good example of how much you learn about the patients that you care for.

I was working the 3-11 shift on the Med-Surg floor and assignment schedule showed that I had several to prep that evening. One of the patients that I was to take care of was admitted for a tubule ligation. The procedure is performed to tie off the fallopian tubes and render the patient incapable of conception. Modern procedure uses laproscopic techniques needing only small punctures through the abdomen for instruments to be inserted. In those days the fallopian tubes were accessed through two fairly long incisions through the lower abdomen. This necessitated shaving the entire abdominal area and pubes as part of the prep, then administering a large cleansing enema.

The patient was the wife of a local minister and was well known in the community. They had a reputation of being an "ideal" couple. They frequently appeared together at church, school, and social functions. Although I didn’t attend their church, I knew who she was because they were so prominent in the community. I visited her room about midway through the shift to explain the prep procedure to her. Her husband was still in the room as visiting hours were not yet over. They both listened attentively as I outlined the procedure to her. I finished by asking him if he would depart promptly at the end of visiting hours so I would have adequate time to attend to his wife.

He assured me that he would, then added, “I think I’ll get going now so you can get started”, grabbed his coat, gave her a quick peck on the cheek and bolted out the door. I could see the hurt look in her eyes and felt a twinge of guilt knowing that I had provided him the excuse to desert her. I excused myself and told her I would be back in a few minutes.

The normal procedure was to do the shave before the enema so there would be no interruptions caused by the patient running to the bathroom multiple times getting rid of residual enema. I charged out a prep kit and returned to her room with it. She was upset and crying softly but quickly suppressed it when I entered the room. “I suppose you have some unpleasant things to do to me”, she queried.

“Their will be some of that but I’ll make it as easy as I possibly can for you, OK?” I replied. She nodded in agreement as I pulled the blankets back. She was wearing her own robe but had already removed her underclothes.

“We need to shave your whole tummy from your rib cage down to the tops or your legs, so just lay flat on your back with your legs together,” I instructed and she shifted her position to comply. The first thing evident to me was that this lady wasn’t very clean. She needed to bathe more often and she was generally unkempt. Her legs and underarms had not been shaved recently and she carried a noticeable odor. I added some warm water to the prep tray to activate the soap and applied the lather to her tummy and pubes and began to shave starting with her tummy then progressing toward the pubic area. She seemed to be completely relaxed and began to talk. She related that she saw very little of her husband because he was so busy with his ministerial work. She offered that he had to hurry off tonight to call on one of his congregation.

I continued shaving and then I noticed something imbedded in her navel. It was a dark mass of dirt, oil, and dead skin that had been accumulating for some time. I almost completely filled her navel. I decided that it should be removed due to its proximity to the incision sites. One of the accessories of the prep kit was a wash cloth so I wet it with the warm soapy water and folded it over her navel area to soften the mass.

I continued to shave and she continued to talk about herself and her life as a minister’s wife. It was not a happy story. She was left alone quite a bit as her husband’s attitude seemed to favor the problems and needs of his congregation over hers. He constantly reminded her was that his (their) life was one of sacrifice. Their time together was mostly when they attended some sort of community affair.

By this time I had carefully shaved her pubic area and the shave was finished. I used the wash cloth to dislodge the now softened mass in her navel and placed it in a waste container. I then used the wash cloth to wash her perineum and anal areas as though it was a part of the prep, then dried her with a towel. She seemed embarrassed and said that she had tried to remove it herself several times but stopped because she was afraid it might hurt. She had never thought of using moisture on it. Can I remove it myself if it should form again? Then it dawned on me that she was stalling.

I cut the conversation short by asking her if she had ever been given an enema. She frowned and told me that she had been our hospital last year for some tests and X-rays, and that they gave her enemas before each test.

“How did you get along with them ?” I asked?

“They hurt but I got along OK.”

“Did you use the bedpan or were you able to hold it well enough to walk to the lavatory and use the commode?” I lowered the bed as we talked.

“They made me use a bedpan most of the time, they hurt so much that I had accidents.”

So I opted to have her use a bedpan instead of the lavatory and excused myself to prepare her enema.

I returned to the service room and disposed of the prep kit and got out a new enema bucket and a bedpan. I connected the tubing and clamp, and then filled the bucket with warm water as full as I could and poured in a packet of enema soap. I draped the equipment with a towel and carried it back to the room. She was sitting up in the bed. I sat the equipment down on the bedside table. As I was making ready, she lay down and turned on to her left side and drew her knees up toward her chest!

“Is this OK ?” she asked.

“That’s just fine. I’ll be ready in just a second,” I replied, somewhat surprised.

“Is this going to hurt as bad as the last time? Those other enemas hurt and ached and gave me terrible cramps.”

“I’ll make it as comfortable as I can,” I promised. I was ready to begin. I folded the blankets and gown back exposing her buttocks. She began to cry again softly.

“OK, push for me like your trying to BM,” I asked. She responded and I inserted the tube into her anus.

“OH !” she exclaimed.

“Now take nice deep breaths for me and try to relax and just let it fill you up.” I instructed and opened the clamp.

She panted a few times then, “Oh, its starting to hurt again,” she whimpered.

I responded by inserting the tube further, past her rectum and up into the colon.

“Is that better ?” I asked hopefully.

She let out a sigh. “A little, it’s a little better now. But it still hurts so bad, I don’t know if I can stand this.”

I kept the flow going and the level in the bucket began a slow descent. She gasped and let out a few quiet moans and began to sob again so I closed the clamp.

“Why don’t you roll over and get on all fours for me? I think that would be more comfortable for you.” I had decided to try the knee-chest position hoping she might be able to take the enema easier that way. She turned over on her tummy and got up on all fours. ”Now put your head and shoulders down on the bed and keep your bottom up for me, OK?” She complied and I reopened the clamp. “How’s that?”, I asked after she had taken some more.

“That’s better, I can stand this. I just feel full but it doesn’t hurt like the other way,” she said breathlessly. Then she dropped a bomb.

“You know, I really don’t want this surgery, but my husband insists,” she confessed.

I was stunned. I closed the clamp and stopped the enema and leaned forward over the bed so she could see my face. “If you don’t want this surgery, no one can force you to do this against your will, not even your husband.” I counseled. “If you don’t want to go through with this, we’ll stop right now.”

She thought for a moment. “Noooo….., I said I would,” with an uncertain tone.

“You’re sure?” I wanted confirmation.

“Yes, I’d better go through with it,” she repeated.

“OK, then we need to finish your enema.”

She nodded and I reopened the clamp. The bucket emptied more easily than before and she took the whole volume without further complaint. She breathed in short pants until the bucket was empty but there was no more conversation. I removed the tube from her, unplugged it from the bucket and coiled it up inside.

“Can you hold it for me for a while?” She nodded. She was now curled up in fetal position with her arms across her tummy and her bottom still in the air.

I put the bucket in the cabinet of her bedside stand so it would be available for post surgery and picked up the area for a few minutes and disposed of the trash.

“OK, lets get you to emptied out.” I picked the bedpan up and sat it on the bed just behind her. I helped upright her so she was able to just sit back on the bedpan in a squatting position.

“Oh, I’m so full.” she exclaimed! “I’ve never been this full before.” She kept saying, “I’m so full.” over and over.

“Hold it for as long as you can and I’ll be back to see how you’re doing.” I left her to her privacy and moved on to another patient. In twenty minutes or so I sent an Aid to her room to remove the bedpan and take it to the dirty kitchen and put it in the cleaning machine and to clean her up.

Later in the shift I went back to her room to check up on her. She was sitting up in bed and smiled at me as I entered.

“I’m glad that’s over. Thank you so much for being so considerate and making it easier for me. That was a lot better than last time I was here.”

“You did very well and you’re an excellent patient.” I commended her.

I made some notes on her chart at the end of the shift concerning our conversation for him to again verify that she was having the surgery of her own volition, and went home. I looked the next day to see, if by chance, her surgery had been canceled. It wasn’t.