MacGyver Hacks: Enemas and Bugs
Whit Fisher and Anand Swaminathan
- The enhanced enema
- The problem:
- Sodium phosphate enemas are hyperosmotic agents. They work by drawing fluid into the bowel to soften stool, making it easier to move. To be effective, the enema has to be retained in the colon for a period of time.
- Retention of the enema can be challenging, particularly in those with dementia or psychiatric disease and in those with learning disabilities. These patients are also likely to become constipated.
- The hack:
- Place a Foley catheter into the rectum and slowly inflate the balloon.
- Using a Toomey syringe, administer the enema liquid through the Foley lumen.
- Tilt the head of the bed down about 15-30°.
- Leave the Foley and balloon in place for 15-20 minutes (enema retention time).
- Deflate the balloon and remove the Foley (and make sure to get out of the way!).
- Insect removal from external auditory canal
- Step 1: Kill the insect
- Don’t try to do this with water (drowning an insect doesn’t work).
- Options include lidocaine and mineral oil. Lidocaine may be the superior option because it also anesthetizes the ear.
- Step 2: Insect removal
- Can use a Fraser suction catheter or small forceps to remove.
- Flush with normal saline or water to remove all pieces.
- Typically, prophylactic antibiotics are not necessary unless you can see a significant injury to the canal.
CorePendium: Ear Foreign Bodies
Kenneth D. - November 9, 2022 8:13 PM
I recently had a patient that completely freaked uncontrollably. I gave pain dose of ketamine and now the nurse won't disimpact without it!
Whit F. - November 13, 2022 7:53 AM
Yes! It's one of those procedures that's minimally unpleasant for some, but mentally catastrophic for others (including us sometimes!).
Matt H. - December 3, 2022 12:32 PM
Thanks for the great tips!
1. How far in do you insert the foley?
2. How much water do you put in the balloon when you inflate it?
Whit F. - December 4, 2022 6:27 AM
HI Matt -
I normally put the foley just past the outer anal sphincter, so any squeezing tends to push the balloon into the rectum instead of pushing it out. Definitely not farther than a finger's length (maybe 8 cm?). For the inflation, I usually use the max volume suggested on the balloon (10-15ml of saline). I might go on the higher side of the volume if I'm using an unusually small foley. I'm not sure if there's much risk to a little overinflation, since any ruptured balloon fragments would just be pooped out, but I try to avoid going too crazy.
Remember to leave it in there at least 10 minutes for "best" results. Hope this helps!
J. B. L. - December 5, 2022 4:13 AM
A rectal tube has more holes, is more rigid so it can get past the obstruction and you can clamp it after inserting it and filling with fleet's - Wouldn't this be an acceptable approach?
Whit F. - December 5, 2022 1:00 PM
Definitely. In fact, I even used an endotracheal tube (7.0) once because I did have to gently push aside some obstructing stool. It worked really well. Where I work, rectal tubes are a little tougher to come by and the nurses tend to recoil at the name, so I try to focus on the most readily available and familiar supplies...because convenience and staff buy-in is really important. But any port in a storm can work!
Preston W. - December 31, 2022 2:50 PM
I have found that the absolute best way to remove bugs (and foreign bodies) for the ears is to obtain a myringotomy tray from the operating room. 1) kill bug with lidocaine 2) using the ear speculums provided (metal works best the light is enhanced) use the alligator thru the speculum to remove the bug whole. The ear speculum prevents injury to the external canal. Typically the insect is right at the opening of the speculum easy to grab and pull.
Josh N. - January 17, 2023 3:12 PM
Anyone have information on if it's safe to give enemas in pregnant patients coming in with constipation for which they have tried most everything at home, such as MiraLAX and even lactulose?
I thought I was the only one with the question, but can't find much in the literature about if it's safe or not, and after asking many of my colleagues, they all have the same question and hesitation to give it, but at the same time I feel bad, not doing whatever I can for a pregnant woman if it is indeed safe.
Whit F. - January 25, 2023 11:44 AM
Gosh, from a quick tour of the web I couldn't find a whole lot either. It seems like the concern is that an enema might "trigger uterine contractions," but not sure if there's any high-quality evidence that enemas (or a particular type of enema) is more likely to cause this than an oral regimen or suppository. I did find some papers on giving enemas in patients *already in labor* to reduce fecal soiling of the perineum, but that's not really what you're asking about.
Josh N. - January 29, 2023 8:54 AM
Thanks for looking into it! Given there’s not much out there and that I’m sure this is a very common Chief Concern that presents to our EDs, any chance we could ask for an EMRap piece on it?