Wednesday, December 3, 2008

The Gynecology Room (Redux)

In the house of medicine, we often give obstetrician/gynecologists a hard time. After all, it is the only medical specialty soley based upon a totally normal human event. We give them colloquial names such as “vaginicologists” or “spreaders of old wives’ tails.” Regardless, we in the emergency department usually despise the gynecology room. But, they provide memorable patients.

While a resident I was moonlighting at a fairly rural emergency department. A young Mexican woman came in complaining of contractions. I assessed her and sent her to the OB floor. During the night, a small dusting of snow paralyzed the town (people in my area start buying milk and break anytime snow is in the forecast). At 6:00 AM, 1 hour before my shift was about to end, I was called to assess Maria on the OB ward. The on-call obstetrician could not (reportedly) make it to town because of 2 millimeters of snow that supposedly made local roads impassable. I was literally beat. I had not slept in 36 hours and was not excited about delivering a rug rat. But, being the professional I am, I scrubbed and gowned up. Maria was a 19-year old Gravida 2, Para 1 (second pregnancy). I checked her and she was 10 cm dilated, 100% effaced and the head was at a +2 station. We were going to rock and roll. I sat on the stool and, in Spanish, talked her through the second stage of pregnancy. I readily delivered the baby girl, clamped and cut the cord and handed the baby off to the nurse. I took the curved Kelly clamps and wrapped the maternal segment of the umbilical cord several times around the clamps and waited for the placenta to separate. While I waited, I was so tired I dosed off while seated at Maria’s perineum. Suddenly, I was awakened by the sound of the placenta hitting the hard tile floor taking my clamps with it. This was a sound unlike any I had heard in my life. It scared the shit out of me. Suddenly, Maria started crying, “Mi hija. Mi hija. (My daughter. My daughter)." I realized that the mother thought I dropped her newborn baby. I reacted, although exhausted, by grabbing the placenta and picking it up to show the mother that I dropped the placenta—not the baby. I forgot that most people have never seen a placenta (it looks something like the alien larvae from the movie “Alien”). She took a look at the placenta and started screaming and saying Catholic prayers. I thought, “What the hell is going on with her.” Then, it hit me. She thought the placenta was her baby and that it was some sort of demon or alien. She began to scream and cry. Finally, I got the nurse to bring the baby to her side. For the life of me, I could not remember the Spanish word for placenta (it turned out it was a cognate—same word in English—just pronounced with Spanish vowels). Finally, I explained the situation and I think she understood. She was happy to see her baby girl was OK although she kept looking me with a look that would thaw a snowball.

Another memorable vaginicology patient was a 30-year-old female in the tuna pit. She had a “discharge.” Finally, I went into the room. The patient was pleasant enough, yet a few sandwiches short of a picnic. The nurse and I explained the procedure. I stuck my gloved finger into the vagina and struck a firm object. “That’s weird,” I thought to myself. I got the speculum and carefully inserted it. There was something solid in the vagina and it smelled like a morgue somewhere on the equator. The nurse handed me a pair of ring forceps and I removed a clump of pus that appeared to have some shape. I realized that it was a contraceptive sponge (these were popular contraceptive devices in the 1990s, except they led to some horrible pelvic infections). Then, I pulled another one out, and then another, and finally a fourth one. I looked up at the patient and said, “I see you are using the contraceptive sponge.” She said, “Yes, my boyfriend won’t wear a rubber.” I said, “You know you’re supposed to take them out when you are through with your sexual encounter.” She looked at me totally perplexed and said, “I thought they dissolved.” What amazed me even more is that she somehow managed to have sex with 4 contraceptive sponges in place.

Finally, one of the most memorable patients in the gyn room was a patient named Monique. She was a very pleasant black female who presented with a vaginal discharge. No big deal. This was the third patient with the same complaint during the shift. Monique was a big woman—in excess of 200 pounds. The young nurse (the young nurses are low on the totem pole and draw the tuna pit). The nurse put Monique up in stirrups. I explained to her what I was doing. My technique is to carefully insert a gloved finger into the vagina and put pressure on the posterior vaginal wall. Then, I tell the patient I will be inserting the speculum. I then turn the speculum sideways and insert it and then rotate to the upright position, spread the speculum and look for the cervix. At this point Monique started to move around and moan. I thought I had pinched her with the speculum. I released the speculum and reopened it. I was not pinching the vaginal mucosa. Monique started to move around more and moan. Her moans got louder. I looked and saw her vaginal muscles start to contract rhythmically and she pushed the speculum out into my lap. Immediately Monique apologized, “I’m so sorry doctor.” I still didn’t have a clue as to what was going on—-but the nurse did and started to smile. I asked Monique, “What happened? Did I hurt you?” Monique couldn’t speak. The nurse said, “Can’t you tell she had an orgasm?” I said, “What? Are you kidding me?” I looked and Monique was still twitching. I was perplexed. This had never happened before (at least in a medical examination room). Monique was very embarrassed (and apparently quite sensitive). I didn’t know what to do. I just sat there. Then, I had the urge to offer her a cigarette. In fact, I wanted a cigarette and I never smoked a day in my life. I was obviously the source of much teasing for months thereafter.

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