Sugar Walls, week 1

Kudos to anyone who recognizes that title from Sheena Easton (love her).

Yup, you guessed it. I'm on ob/gyn for two weeks right now. Nights only -- that part sucks.

I realized upon re-reading this blog that it sounds like book chapters. I intended a stream of consciousness, so I'll try to keep it as such.

I was really afraid to start. Most med students can tell you that 95% of them will look in horror at the prospect of starting their ob/gyn rotations (I was). The residents in ob/gyn have a reputation for being hardheaded complete bitches. Yes, that's sexist.

I think, however, that's unfounded. I love my current team -- my chief resident is a rockin' supersmart woman (who often lets me go home early); there's a fabulous intern on the team with great hair; and there's this awesome power-lesbian with huge arms that I wish I had. She's a fantastic teacher and is really showing me how to do gyn exams and ultrasounds very well. If anyone knows snatch, she does.

There's also this cute, mousy Asian med student on who is so eager. Ah, I remember those days, when I had a passion for this before residency beat it out of me in a meager six months. She did what I did on my first day on ob/gyn as a student -- after she delivered her first baby (a truly wonderful experience -- ONCE), she forgot to clamp the umbilical cord and cut it first.

Blood everywhere. Squirting like a stuck pig. This little slippery umbilical cord is flipping about like a firehose with no fireman attached to it. By the time we got the cord clamped, the room looked like it was right out of a murder scene. Poor med student, she was soaked in blood and amniotic fluid (always wear a faceshield!).

I carry the gyn consult pager all night long, and I'm supposed to see every gyn patient on the floor. Kudos to you women -- I don't know how you put up with that organ. Every time I look at it, it's a bloody (literally) mess and it seems so painful. (Granted, I see the sick ones, that's what they're doing in the hospital.)

I just saw two consults. The first one was a heavyset Hispanic woman in her late 30s who was not pregnant and came to the ER with fairly heavy vaginal bleeding two weeks before she was supposed to get her period. Nice lady, a little worried, but her hematocrit was stable as was her vital signs, so I didn't get too worked up over this one. Her transvaginal ultrasound was neat -- it showed a ruptured hemorrhagic ovarian cyst (another thing we men don't have to put up with). And I know this sounds terrible, but all I could think was how HAIRY she was "down there." I mean, I sat in front of her and could not see any labial skin. Just hair. I've never seen anything like it. Regardless, she was fine.

The next one was completely, wholly bizarre. This really highlighted to me the level of denial some people can be in in relation to their illness.

Apparently there was a woman who came to the ER for an asthma exacerbation. She had a recent cold and was feeling worsening shortness of breath. Something triggered her asthma, so she was huffing and puffing and trying to get air. The ER did the appropriate thing and gave her some steroids and an inhaled nebulizer treatment. She had felt much better.

So how is this a gynecology story?

I got a page from the ER about her. (In case you're not following: I'm an ER resident, so I spend most of my time in the ER. However, some months I rotate on other services to learn from subspecialists in that area so I'll know what to do with these patients when they come to the ER. Currently I'm rotating in ob/gyn so I get calls from the ER requesting me to consult on patients there for gynecologic complaints.)

So the ER called and told me her pulmonary story.

"Okay," I said, "what's the gyn issue?"

My ER compatriot on the line said, "we were discharging her and she made a mention of how she had a little 'extra bleeding down there.'"

"How much is 'extra'?" I asked.

"Well, I did a pelvic exam on her. You have to see this."

"See what?"

"Just come down."

So I headed downstairs to the ER gyne room. I introduced myself to the patient, told her that I would be evaluating her gynecologic complaint. She proceeded to tell me how she had some extra vaginal bleeding apart from her normal period.

"Mmmhmm. About how much extra would you say?" I asked.

"Hard to say. I just sit on the toilet and bleed," she replied.

"How often?"

"Everyday."

"For how long?"

"Oh, a few years now."

A few years? Odd. So I told her I would do a pelvic exam now, and I instructed her to lay back and put her feet in the stirrups and push her knees out towards her side.

I sat in front of her, pulled back the sheet, and I was left momentarily speechless: there in front me, was a huge mass coming out from her vagina. It was about the size of a large man's fist, and it looked like -- honest to God -- a pinecone, with triangles overlapping one another in a spiral fashion. And it was porous and glistening with mucous and slowly dripping with blood.

This was a giant vaginal tumor, and it was hanging out of her introitus, attached to the inside of her vagina by a thick biologic stalk. I hope you're not eating while reading this.

"Ma'am," I said with a forced expression of calmness that belied my suprise and disbelief. "How long has this been here?"

Her eyes became downcast, as though she was just busted for a crime.

Sigh. "About three years," she replied.

"Three years?" I echoed. "Have you seen anyone about this?"

"Nope."

"Why not?"

"I don't want to know what it is. I figured it would go away."

Three years later, it hadn't. Apparently it had only gotten bigger.

How's that for denial? This woman had a giant, fungating cancer spilling out of her vagina, and I could see the chaff marks on her inner thighs where this lecherous thing was rubbing against them as she walked.

We had a pretty long talk about this. I did what I thought was appropriate -- I didn't tell her right then and there that it was a giant tumor. I told her that there were several possibilities of what it could be (which is true), but honestly, there's not a lot on the differential diagnosis of a fungating mass extruding from the vagina that was growing over the last three years. She just didn't want to know she had cancer. I told her that she needed to be admitted and worked up appropriately, that we needed a sample to send off to pathology to get a handle on what this was.

Despite her denial, however, it seemed like she was almost relieved to hear someone tell her the truth: that it might in fact be cancer and she might (okay, probably) need surgery, chemo, radiation or all the above.

I thought about taking a picture of it for submission to a journal, but thought better about it for now. I get the feeling she doesn't want to be a medical curiosity on display.

Anyways, it's 2am. That means it's time to get some coffee.