Brown Cow Enema: Is This The Best Laxative Ever?

When you turn 90, it seems like having the best laxative is the most  important thing in your life.  No matter what's going on, what you're doing, where you're going, if you can't get that turd out, life ends as you know it. When your bowels don't work, nothing else matters. But the best laxative in the world could help change that.   As a physician, if you let your guard down, you could get trapped in a room for hours with a sweet old lady talking about how her friends and enemas.

I occasionally really old people with severe abdominal pain, negative lab and negative work up. It becomes known in  retrospect, as the $5000 stool.  I've even had the unfortunate death by constipation experience. While chugging a large volume of hyperosmolar laxative, my poor patient aspirated, coded and died. Can constipation kill?  In this case, we had death by constipation.  It was my first, and hopefully last death by constipation experience.

Constipation can be a difficult problem but nothing the best laxative can't fix.  Everyone gets it.  We have our standard medications in the hospital. I found this great overview on the best laxative treatment options for constipation for the general public and physicians as well.  
  • You can increase your bulk with fruits and veggies, wheat, Metamucil, but this can cause lots of gas.
  • Lubricant laxatives contain mineral oil that keeps the stool moist.
  • Stool softeners like docusate/Colace increase the water in the stool
  • Hyperosmolar laxatives retain water in the colon and soften the stool, things like MiraLax or lactulose. However, they can also increase bloating and flatus.
  • Saline laxatives, like mag citrate or sodium phosphate or Epsom salt pull water into the colon.
  • Stimulant laxatives stimulate the muscles to propel and increase water in the colon as well. Things like castor oil and senna, dulcolax and ex-lax. They can cause severe cramping.
  • An assortment of other less common medications and methods.
And then there is the enema. The order feared by all living nurses at one time or another. The old stories about nurses calling residents at 3 am only to get orders for enema, repeat times two if no results are probably true. I personally never had that bone to grind, but I'm sure a patient or two got the receiving end of a disgruntled doctor at some point in their lives.

So here she is. My sweet 93 year old with severe abdominal pain and a normal CT. She also has chronic constipation by her own account. What has she done for here self in the last 24 hours?  She has taken 4 teaspoons of milk of mag, two suppositories and given herself a Fleet enema. I'm not kidding. That takes talent. Especially at 93, I have to ask myself how hard it would be to assume the position. Most 93 year old joints simply don't bend like they did when they were 83. The main complaint after this escapade was "I had really bad diarrhea this morning". To which I replied, "What did you expect would happen?" To which she replied, "I just can't get my stool formed."  Ah, the life of the internist. 

It's about this time that a hospital team member reminded me of a  rather peculiar enema protocol.   I have heard hospital lore about how great this works. In fact I have heard some doctors swear by it. But the nurses tell me they are a pain to make and are a huge mess for the patient and a huge mess for the nurse, especially if the poor ol' lady can't hold it in. It's sticky. It gets on everything, and it's really hard to clean up. But, from what I've been told, it simply works wonders.  It's the best laxative ever.

As the materials are brought in from the kitchen,  a small amount of molasses is diverted for that perfect cup of coffee while the rest is converted into a milk and molasses enema.  Also known as the brown cow enema?  Also known as the best laxative ever.
  1. 16 oz.of warm molasses and 16 oz. of warm milk. 103°Fahrenheit
  2. Mix the milk and molasses together in a saucepan on the stove then add it to the enema bag
  3. Next, add water if desired to the bag adjusting the temperature to 103° Fahrenheit.
  4. Fill enema bag with solution, mixing with warm filtered water to achieve 2 qts.
  5. Hang enema bag about 18 in. to 3 ft. above rectum. (towel racks work well)
  6. Knee-chest position with chest against floor and rectum higher than head this is a best position to receive an enema
  7. Insert nozzle tip into rectum, using lubricant (Surgilube, KYjelly, Vaseline, Super Salve ) as needed.
  8. Inject solution into rectum slowly, and take as much as possible until it becomes very uncomfortable to take any more solution
  9. Massage abdomen in counter-clockwise direction this will help move the solution higher into the bowels.
  10. When bag is empty or no more fluid can be taken, remove tip
  11. Lie on each side for 5 to 10 minutes, while massaging abdomen. Now you can move to the toilet and release the enema
It it lunch time yet?

Go here if you want to know what a physic is and what it has to do with the brown cow enema.

"I was taught early on in my career to always respect your enemas."

Always respect your enemas nurse ecard humor photo

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession.  This ecard is part of complete collection of Happy Hospitalist crude medical humor available on Pinterest.  Read at your own risk.   It is also not medical advice.  Contact your doctor for questions about your  constipation.  Although, to be honest, they'll probably not call you back...

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5 Outbursts:

  1. The dividing line between being Old and Young is sharply demarcated by the Constipation Drug Deal-Breaker (CDD): Proposed drug possible SE equals diarrhea, Old= weathered determinism. Proposed drug SE equals constipation, Old= no dice, usually emoted with a drawled, "Nooooooo..."

    By the way, in both cases, the young shrug at you in their coolest "whatever" way and then promptly discount you and your advice, once safely out of the office, and wandering back in NonCompliance Land.

  2. Ahh, the infamous MOM enema...worked well on the onc rotation but used as a weapon of last resort.

  3. My personal favorite belongs to an older home health patient with chronic constipation. She will mix 4 teaspoons of milk of magnesia into 8 ounces of warmed prune juice into which a 5mg tablet of Valium has been dissolved and drink it before bedtime. I call it the Happy Brown Cow. Her theory was that the MOM and prune juice would cover the constipation and the Valium would allow her to get a good night's sleep . It actually works!

  4. Yeah--pretty funny. I sat in an ER 13 hrs with my sister, who was impacted from painkillers prescribed by some other hotshot medico, and everyone put off helping her while she moaned in pain. Good job, guys! I also had an ileus once and some other fabulous diagnostician sent me home to drink the pre-colonosopy laxative. I threw up all night and went back to the ER at 6:30 am. They did another x-ray. Nope--just need an enema. I said, "No, I don't." They said do you think something is obstructed? Yes! They left, came back. "Sorry, we were looking at yesterday's x-ray. You have an ileus." They admitted me on an NG tube for 4 days. That was fun, as all you know. I was informed before they basically drowned me putting that thing in that this was the procedure all nurses feared most happening to them. Well, it didn't happen to them! Bowel probs may gross you out, bud, but they are your job!

  5. Is this "Brown Cow Enema only for OLD people!? What if one is constipated and only 23? Is s/he "too young" to self administer a Brown Cow enema? I am only 23 male and rarely constipated. However, should a situation of the like arise, is it safe for a younger person such as myself to self administer this sort of thing? Thanks!


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