Two daughters bring their severely demented mother into the clinic. The mother is no longer able to speak, but over the last few days she has groaned more during diaper changes. Her nursing home is worried she might have a bladder or vaginal infection. To check her urine, we undress her and catheterize her. To check her vagina, we take a swab using a speculum. We spin the urine and look for sediment under the microscope. Nothing. We look at the vaginal smear under the microscope, using both a saline prep and potassium hydroxide. Nothing. We treat her for bacterial vaginosis, because it’s a condition that’s easy to miss.
A week later, the daughters bring their mother back. Once again we are thorough. Once again we are stumped. Once again we trust the daughters that the groans are worse. We take a careful history. We think of all the possible bad things. The worst things. But this nursing home is a good place. The caregivers there are experienced, well-liked, kind-hearted and trustworthy. This time we treat her for a possible yeast infection.
A week later, the daughters bring their mother back yet again. Same drill. Same result. Maybe some topical estrogen? The clinic nurses have her dressed again and ready for the ambulance ride back to the nursing home, when suddenly it’s clear her diaper has been soiled. I’m walking by and lend a hand. We slide the old diaper off, cleanse her in front, roll her over to clean her from behind–and spot what’s left of shingles sneaking into her gluteal crease and plunging deep into her nether regions.
“That’s the S3 dermatome,” I tell the resident–the skin area supplied by one of the spine’s sacral nerves. “Add that to your differential,” I tell the resident–a reminder to look everywhere in considering the diagnostic possibilities. “Don’t miss a chance to help clean a naked patient,” I tell anyone who will listen.
Daniel Becker
Charlottesville, Virginia
4 thoughts on “How to Change a Diaper”
Your essay resonated with me. I cared for both of my parents before their deaths. My dad suffered during diaper change, but no one gave him an appropriate exam. Oh, the golden years are often deeply tarnished. It takes a village of caring people to make this time easier for our elderly loved ones.
My mother was in a skilled nursing facility. I could sense something was very wrong. She was in pain. I told the doctor that I thought she had a urinary tract infection. He didn’t listen. He didn’t follow through and she developed sepsis. She almost died.
I’m sorry she didn’t have a physician like Daniel Becker.
Being thorough and persistent can be a difficult task to accomplish with a variety of patients, but it is so satisfying professionally when it is the means to solving a challenging diagnostic case. The last sentence of your story contains words to live by, Dr. Becker…
This is a great account of how we can help patients. The last line needs to be engraved in the consciousness of every physician, every APRN, RN, LPN and CNA—though for most CNAs it is already a fundament of every hour’s practice.