Patient w/Ileostomy 3 months- Atypical Isssues

[JCatGuy]

I have a patient who was just admitted into ltc. He was given an ileostomy for severe colonic inertia, and he was left w/his rectum and colon, as all waste is now diverted from small intenstine to ileostomy. It's been three months since surgery. He reports to severe suffering of cramps, and the only way he gains some relief is by taking a used 4.5 oz enema bottle, sterilizing it, adding warm water and giving it to himself. At that point he sits on toilet he pushes out globules of round grey/beige round matter. He showed me during my last visit, about 15 of them, that he cliams he mostly pulled out w/his lubricated finger and the rest came out after inserting the warm tap water enema. Only then, does he claim tepmpary relief...only to have repeat this process as he describes as this, "torturous procedure", every third day.

I've seen the output and I have never saw anything quite like this before, as it does not appear to be normal discharge. I tried contacting his Surgeon, who does not return my calls...nor does surgeon return the patient's call.

The story was that Surgeon initially was going to do an open surgery, due to patient's history of severe impactions, in addition to xrays showing full colon...patient had claimed Surgeon told him that he was going to do open surgery because he was going to need to either squeeze the colon to get the impaction out, or use Gastrograffin, and or finally perform resection to clear the large colon. Surgeon instead performed laproscopic surgery, leaving those options unavailable. Patient was never told why the plan of action was changed.

After the successful surgery, he kept paitent in hospital for 5 weeks, not for healing of the surgery but in trying to clear his large intenstine by giving him repetitive enemas via the stoma (using Gastrgraffin or Peg 3350)...and only one time did any feces come out, as patient described. Patient was in severe pain, when he was released from hospital 5 weeks later, not from the surgery but from the same pain in he went in for.

I do not know what I can do for this patient as his pain is severe and he is not receiving the care from his surgeon that he requires. He reports to having no Gastroenterologist to see. The GI specialist that dx'd him w/global colonic inertia was an inpatient MD during an ER hosptialization, who does not accept patients insurance, as an outpatient (medicare/medicaid secondary insurance).

I am at a loss at what to advise to him. It appears to be a case of patient abandonment yet patient is so weakened he claims not to have the strength for any formal charges and is clearly becoming depressed from his suffering and sense of helplessness. I want to change this.

As far as his stoma and ability to change his bag, he does well. However, his lower abdomen is swelling up and he is breaking out in severe hives...which concerns me, re:auto-intoxication, as patient reports to never having hives prior to surgery...Hives began 1 month in the past.

Any advice would be most appreciated.

Thank you, Nurse JL

[XB9S, BSN, MSN, EdD, RN, APN]

If this surgeon will not return calls can the patients primary care provider not intervene and refer to another colorectal specialist. From what you describe I would say your patient needs the attention of a doctor to help sort out his problems

[JCatGuy]

I am pondering whether or not to tell patient about Patient Abandonment, but he's so sick...w/no family support...don't know if it would be too much of a strain on him to go through that kind of legal process. In the manwhile, I try to keep him comfortable and am keeping my eyes open for a surgeon who will accept him w/all his complexities, and poor insurance coverage.

Thank you, JC

[XB9S, BSN, MSN, EdD, RN, APN]

That's really awful, I wouldn't even know where to start,as I live in the UK where insurance coverage wouldn't be an issue he would have access to a general practitioner who could refer him on for a second opinion and the hospital he had been treated in would be able to refer him to another surgeon if needed, is there no other avenue he can take to get seen by a surgeon.

My heart goes out to this poor patient and to you for trying to do your best in such a difficult situation.

[XB9S, BSN, MSN, EdD, RN, APN]

I guess my only other suggestion would be to get this patient back in as an emergency, (not sure if this is feasible as I don't know US healthcare systems and what is covered and what isn't) If he continues to be in pain then he needs treatment