*Please note, the names and details of patients/staff/friends/family have been changed to ensure anonymity. I have attempted to stay true to the nature of the stories in as much as their identities can be concealed.
Since the last one was kind of a downer, I am going to relay a (semi) uplifting story next.
There are a surprising number of people who come in with 'vaginal pain' as their chief complaint. Aside from being quite vague, it's almost always an indicator that the case will be a doozy. People don't just come in to the ED with vagina questions--they come in because something went wrong. Down there--as they say.
I actually like these cases. I am not a huge fan of doing pelvics (probably because I am also not a big fan of getting pelvics!), but I love women's health and I am always eager to improve my skills. I want to learn how to make an annual exam as painless as possible--and that requires practice. Sorry ladies of Southeast MI, I do appreciate you letting us learn how to be doctors.
This particular woman came in with 'eye pain,' though. When I went to see her, she was sitting perfectly comfortably on a bed, playing with her cell phone. The nurse had already alerted me that this young lady was also worried about some kind of STI. I understand--you're embarrassed, but you might as well get it out of the way by being up front in triage. In any case, I went to see her in an area where we had absolutely no privacy. I alerted nursing that we would be needing one of the individual rooms to perform a pelvic exam.
"So, eye pain?" I asked, with some intonnation that I knew about her other issue.
"Uh, yeah." She looked me up and down. I was probably only about eight or nine years older than her. I was also not looking particularly good. I don't do the best job of getting dressed when the uniform is scrubs; it's like the comfort of wearing such slouchy clothing spills over into my hair and my face and I just look terrible for months.
I introduced myself as the med student that would be taking her history and performing her exam. I told her that an attending or resident would be supervising the pelvic and that if she had any questions, there would be someone to answer them. I also let her know that we'd be moving to another room for more privacy.
Once we were alone in the other room, I was surprised to hear how cheerily she reported that she wanted to get tested for STDs [sic]. I asked her if she had any particular concerns and she explained that she had recently suffered her first bout with genital Herpes and she wanted to get tested for "all the other ones." I asked if she was worried that she might have something else and she shrugged, muttering that she was not all that concerned.
"Do you use protection during sex?" I asked.
"No," she said. Her response came quickly, was straight-faced, and unapologetic. I am not saying I expect an apology on behalf of all health care providers, but I mean, wow. This is one bold young woman, I thought.
"May I ask why you don't?"
"I don't know. I never have. And I have never gotten pregnant. I don't think I can get pregnant. But now I got these warts and I'm all like, damn. Maybe I should get tested."
There were so many things that I wanted to address in what she said. I chose to ask another question first.
"Do you use any kind of birth control?"
"No, and I ain't never been pregnant."
She confirmed my worst suspicion. By her history, this young woman had been sexually active for about five years. She has had numerous partners and has never used condoms. The possibilities that ran through my head were chilling. Is this really the first time she's been tested? EVER?! What if she has some advanced cervical change?! Does she truly believe she can't get pregnant? Why did her primary care doc not address these issues? All the while I am trying not to let my face convey my fears.
"I know you have probably been told this," I said, "but you're taking some pretty big risks by not using protection. I am concerned about a number of things. First, you can get pregnant. Unless you were born without a uterus and ovaries, you can definitely get pregnant--there's a first time for everything. If you don't feel like now is the right time to have a baby, you should really think about some kind of long-term contraceptive. Second, having unprotected sex--the kind without a condom--is putting your health at risk. HIV rates are growing for young women in Detroit, and herpes, Chlamydia, and gonorrhea aren't going anywhere. Has anyone talked to you about the Gardasil shot?"
"No, what's that?"
"It's a vaccine, kind of like the ones you get when you are a kid, that protects against the four most common strains of HPV--two that cause warts, and two that can lead to cervical cancer. It's like my favorite vaccine ever!"
She laughed and looked pensive. We performed the exam, which was pretty painful for her due to her herpes induced neuropathic pain. Though the outbreak was waning, it was still quite evident. In addition, she had some yellow discharge that looked more pathologic than physiologic. We ran all the necessary tests, the attending put in his two cents, and he left the room.
I was about to leave to, but as I reached the door she said: "What do it mean?"
"What does what mean?" I asked.
"Herpes. Like what do that mean. Is it gone now?"
Her doctor hadn't bothered explaining anything about her disease to her. He just gave her the acyclovir and sent her on her way. We talked for a long time. She had so many questions--it was as if she had been waiting for someone to talk to her about her body. We talked about a bunch of STIs, her risks, the rise of HIV in Detroit, how these diseases are transmitted and why women are more vulnerable. I asked her if she had ever asked a man to use a condom, and she admitted that she had not. When she was younger she just wanted someone to show her affection, and sex ended up being a way to fill that space in her heart. Unfortunately, these encounters had only lead to unhealthy relationships with most of the men she'd been with.
Eventually, a nurse knocked and gave me a look that said, "what is taking so long?" I had kind of forgotten that we were in the ER. I had reverted to my primary care persona, taking too much time.
It was a really revitalizing conversation though. In light of having matched it made me so happy that I would have the chance to be a family doc.
Oh yeah, I matched! Not only did I match, I matched into my first choice, a Family Medicine/Psychiatry residency in Pennsylvania. It's a dream. I will be able to ride that line I love so much. Jess is relieved that we are going to her city of choice--she loved it when we visited during interview season. I am still having to remind myself that it's actually happening! We're going to look for houses in a few weeks. WHOA!