Wednesday, June 13, 2012

Secrets and Shame, rated NC-17


 
A/N: I see a lot of obstetric and gynecological problems where I work. Therefore, some of my stories contain material that may not always be appropriate for young children. Nothing is intended to be offensive. I just try to narrate the story as I experienced it. This story is rated NC-17 for some sexual references.

 
Three o’clock in the morning, my phone rings.

Huh? What? My mind struggles to grasp reality as it emerges from the haziness of slumber. “My phone…Patient... Hospital… Admission…Must get up,” vague thought fragments float across my consciousness as the notes crescendo in volume.

I roll over, disturbing Milo, my cat, who is sleeping on the bed curled up peacefully next to my legs, oblivious to my hospital summons. She opens her eyes and blinks at me with an expression that says, “Why in the world are you getting up now!”

The phone registers “missed call”.  Further details show it’s from the nurse phone, aka. The hospital.
“Two, two, one two, two, five,” wait, I realize I’ve punched in the wrong number to call the nurse back. I try again, “two, two, one two, five, seven, seven, two.” Got it.

Noela, one of our new nurses, a sweet, recent nursing graduate with a soft voice and cheeks that give her a perpetual baby-face, answers. “Doctor, there’s a patient here who wants to see you.”

“Have you taken the history and done the physical exam?”

“Not yet, doctor. The patient wants to know if they can see you.”

“Yes, I will see them,” I reply with a touch of impatience, “You can start asking about the problem and examining the patient, I will come shortly.”

“Ok, doctor,” she agrees.

I doubt I’ll be getting back to bed this morning. I pull on some blue-green scrubs that are folded in my closet. I still feel cold so I add a sweatshirt over my top. I rub my hands and soak in the fuzzy softness of my old sweatshirt. Nothing is quite as comfortable as a well-worn sweatshirt!

In the hospital I recognize the guardian of the patient. She smiles at me. Debbie is a tall, slender woman with a professional look. Despite the wee hour of the morning, she is dressed in a smart, black and white A-line dress, belt around the waist to accent her figure and matching heels.

I return her smile and greet her with a familiar handshake. “How are the twins?” I politely inquire.

“They’re fine, doctor” she beams.

Noela is seated behind the massive, wooden nurses’ station. The counter top is so high that anyone sitting in a chair vanishes. Seated opposite Noela, in the wooden consult chair is a young lady, head bowed, hugging a large blanket. She lifts her head momentarily as I squeeze myself behind the counter and perch on the tiny exam table.

I observe her closely as Noela begins to tell me about her medical history. “25 year old female with vaginal bleeding since ten o’clock last night. No other complaints.”

My examining eyes scan our patient seated dejectedly in the chair. Although she is 25 years old she seems more like eighteen. She wears a sweater and skirt. Her thin fingers fiddle nervously with the edges of her sweater while her arms hug her blanket. She makes no attempt at eye contact. Large, drops of bright, red blood drip underneath her chair and form a small puddle at her feet. She shows no reaction to her plight.

“That’s it, Noela?”

“Yes, doctor.”

I turn to our patient; we’ll say her name is Mercy. “Mercy, do you have any cramping?”

“Yes,” she mumbles without looking up.

“Any fevers or other complaints?”

“No.”

“Are you pregnant?”

She shakes her head, no.

Her last period was two weeks ago. However, a recent period does not always mean someone isn’t pregnant. Bleeding during an early pregnancy can mimic a period.

“Do you have any breast pains or feel like you want to vomit?” I press.

“No.”

“Are you sure you’re not pregnant?”

She raises her head; her eyes flick briefly to her guardian hovering nearby,” Yes” [I am not pregnant].

“Ok. We’re going to go to the back and do an exam.” I wiggle out of the nurse station again, and lead nurse and patient to a small, private room where we have an exam table set up. I invite Debbie to have a seat outside in the hallway while she waits.

I gather light, speculum, gloves, and gauze. I expect that Mercy is having a miscarriage – bleeding, cramps – it’s the most common reason for bleeding outside of normal menstruation. In the privacy of the exam room I ask again, “Are you sure you’re not pregnant? What are you doing to prevent pregnancy?”

“Condom,” she softly replies.

Hmmm…I’m still not convinced but, for now, it’s all I have to go on. I can check a urine pregnancy test later.

I insert gloved fingers and palpate uterus and cervix. Mercy remains passive and stoic. The cervix is closed and the uterus feels small. Still – something is not quite right – I cannot say exactly what, but a warning signal starts buzzing in my mind. I insert the plastic speculum and attempt to shine the light in a direction that allows me to visualize the cervix. Blood obscures my view. I grab the gauzes and swab gently trying desperately to see where the bleeding is coming from. As I rotate the speculum and palpate with my fingers, I worry about causing too much pain. “Are you ok?” I inquire. “Am I hurting you too much?”

“No.” she replies. She doesn’t grimace or tense or show any reaction at all to an exam that is not exactly comfortable even under normal conditions.  Eventually, I find a large, jagged tear deep inside the vagina. It’s not visible from the outside.

“What happened?” I look at Mercy and wait for an answer. It’s a blunt question but I’ve not been told the truth so far. Maybe the specific wording on her chief complaint was a clue. “Vaginal bleeding since 10 pm.” Rather specific when I think about it in retrospect.

Without emotion, she flatly intones in a voice that is barely audible, “We had sex.”

A thousand questions float through my mind. Was it consensual sex? With whom did she have sex? Was she raped? Why did she wait five hours before coming to the hospital? For now, I stick to the basic problem at hand, that of stemming the brisk bleeding.

I think about suturing the wound to stop the bleeding. I set my long-handled needle holder, grasped in my right hand, down, in order to dab the blood away while holding the speculum in place with my left hand and maneuvering awkwardly to keep from blocking the beam of light. Picking up the suture again, I make a few, false, trial passes to estimate where to begin suturing. It becomes painfully obvious that I am not going to be doing any useful repair in this manner! The laceration is deep inside a small vagina. Essentially I have only one hand since my left is occupied with maintaining the speculum. Continued bleeding quickly obscures the view. Part of the art of medicine is to know one’s limitations. I realize that surgical repair in this fashion will be futile. I don’t have the proper equipment, anesthesia or experienced help to assist me.

I call out to Noela who is standing behind me. She would like to help, I know, but has no clue what to do. “Noela, get me some epinephrine and more gauze.” She scampers off to the medication drawers to find the materials and returns quickly with them.

“Here, doctor,” She hands them to me.

I break off the top and bottom of the epinephrine and pour it on the gauze. With gentle pressure, I insert the gauze deep into the vagina. I add a second. I pray the pressure will staunch the bleeding for tonight. There is nothing more I can do.

***********

I stop to see Mercy in the hospital on my way to clinic later that morning. (At a much more reasonable hour of eight o’clock!). She is lying in the hospital bed quietly. “How are you feeling today?” I inquire.

“Fine.” She replies vaguely.

Noela informs me that the bleeding has stopped. She hasn’t soaked through any sanitary napkins.

Before I get busy with outpatient activities, I pull out a couple medical references and refresh my memory on vaginal lacerations. To my dismay, I find that deep vaginal wounds, like Mercy’s, can have many complications – bladder injury, rectal fistula, internal hemorrhage, etc. Yikes! There’s some information about the kind of examinations one should do in her case. When I get a break in my schedule, I have Glory walk Mercy over from the hospital to the clinic. We check her bladder with a catheter and test her urine for blood. I reassess the rectum. Finally, I take the ultrasound and look for signs of bleeding inside the abdomen. I try to remove the packing but fresh bleeding resumes

I should be comforted by not finding any signs of complications on my various examinations, but I’m not. “Am I missing something?” Small nagging doubts niggle in the back of my brain. “She’s so pale now. Maybe there’s some bleeding that I didn’t see on ultrasound.”

Looking up more literature on vaginal lacerations is not encouraging. I read about case after case where the patient required general anesthesia and surgical repair in the operating room (theater).  I can’t endure my constant anxiety anymore. I need help.

I try to call one of the gynecologists who works in Buea at the large, government hospital. His phone number doesn’t go through. Next I call the local surgeon in Buea, Dr. Changa.

“Oh, hi doc!” he cheerfully answers his phone. “How are things at Seven Days?”

“Not bad.” I give the obligatory polite response before stating any problems.

“That’s good!”

“There’s a patient here with…and I give him the case presentation of Mercy. Would you come and examine her? I’m afraid she might need surgery.”

“Sure, doc!” Ever upbeat and energetic, “Want me to come now?”

“Yes, I think it would be best.”

Cameroon is not known for being prompt. When someone says they are “coming”, you should always ask where they are coming from! It may be that they are coming from Douala, which means it will be at least two hours before you see them. You can never really know when a person will arrive when they say, “I’m coming.”

To my great delight, Changa arrived in less than ten minutes! Amazing! I was thrilled.

Dr. Changa reminds me of a jolly St. Nicolas! He is short and round with rosy cheeks and a twinkle in his eye. A toothpick dangles from the corner of his mouth in a manner reminiscent of a pipe. He pats patients and nurses on the head in a friendly, fatherly gesture and calls people “my dear” as he passes them in the hallway. An infectious aura of energy follows him.

Upon his arrival, we enter the hospital and examine Mercy again, together. When the packing is removed, we see exactly where the tear is located. There is no fresh blood.

“You work where others play,” he turns to me with a smile. “She will be fine. She doesn’t need any surgery or stitches.” Before I can fully comprehend everything, he’s off. Dashing away to the next house with an energetic bounce in his gait.

I feel relief, an inner calm flood my heart. I cannot really express the gratitude I have toward Changa. One of the biggest trials I have in Buea is working alone. Yes, there are other doctors around to call or email. One cannot just describe a case over the phone and expect an answer without examining the patient together though; I think it’s a Cameroon thing.  It’s definitely not the same as having someone nearby to give you a second opinion or just confirm a suspicion.

 **********

On hospital day two, Mercy is impatient to leave. I remove the packing and make her wait half a day to ensure no fresh hemorrhage develops. None does.

I send her out with very strict instructions. She is still quite pale but all her vital signs are stable and she denies any dizziness or weakness.

I worry about her though. “Are you safe to go home?” I ask as I write up discharge instructions.

“Yes, doctor.” She answers.

I wonder. I can only take her at her word. With repeated warnings I send her on her way. She is told to follow up Monday. Today is Monday. She did not come. “Well, Lord, wherever she is, keep her safe,” I pray.