Chapter 45: Oh, Stop!

September 6, 1989, McKinley, Ohio

"Good morning," I said to the pretty blonde receptionist at the McKinley Free Clinic just before 7:45am on Wednesday morning. "I'm Doctor Mike Loucks."

"I remember you," she said with a smile. "But you were a medical student when you were here two-and-a-half years ago. Doctor Turner is waiting for you in his office."

"Thanks, Tamara. I remember where it is."

"Great! If you need anything, just ask!"

"I will," I replied.

I walked through the door and turned right, then walked down the short hallway to Doctor Turner's office.

"Good morning, Mike," he said.

"Good morning, Doctor Turner."

"Gale, please," he said, extending his hand.

We shook.

"Do you have your prescription pad?" he asked.

"I do. Doctor Gibbs reminded me yesterday that your rules are different from the hospital's."

"No pain medication and no controlled substances; generally, you'll only write scripts for birth control pills or antibiotics. Trina will write any scripts for diaphragms because they need to be fitted. You're authorized to do any of the procedures we do here, though I know you won't participate in an elective abortion."

"Correct."

"But you don't have a problem with our counseling policy, right?"

"Sure I do, but I'll still follow it."

"You're an odd duck, Mike."

"You are not the first person to say something like that! What's the drill?"

"See patients, assist the nurse practitioners with procedures that require an MD, and generally be a doctor. That frees me to do the things about which you have reservations. Use the small office next door, Nurse Michelle is assigned to you, and Exam 1 is all yours. Misty, the nurse at the front desk, will assign patients. Any questions?"

"I think I recall the procedures, but if I forget, I'll ask Trina."

"She's looking forward to seeing you. Let me know if you need anything."

"Thanks, Gale."

"Can I ask..."

"Why am I wearing a shirt and tie rather than my clerical robes?"

"Yes."

"You know what happened two years ago, right?"

"Yes."

"I chose to remarry, and the Orthodox Church doesn't allow clergy to marry. My options were to ask for release or take a vow of chastity."

"Say no more. Thanks for answering."

I left his office and walked down the hall to the small break room where Trina was sitting.

"Doctor Loucks, I presume?" she said when I walked in.

"I introduce myself and go by Doctor Mike. Everyone except patients and med students simply calls me Mike. How are you?"

"Good! You?"

"Good."

"No clerical robes?"

I gave her the same explanation I'd given Doctor Turner and then recapped what had happened in the thirty months since I'd trained at the clinic. A short, thin redhead came into the break room, and Trina introduced her as Nurse Michelle.

"Trina," Misty announced, coming into the break room. "Your 8:00am is here. Doctor Mike, we have a walk-in."

"I'll bring the patient to Exam 1, Doctor," Michelle interjected.

She left, and five minutes later, to give her time to take the patient's vitals, I knocked and entered Exam 1.

"John Atkins, nineteen," Nurse Michelle said. "Vitals normal."

She handed me the intake form, and I quickly scanned it.

"Hi, John," I said. "I'm Doctor Mike. What brings you to see us today?"

"I have a strange bump on my Johnson."

"Michelle," I said, "specific vitals?"

"Pulse 73; BP 120/60; temp 98.4°F."

"John," I said. "I'd like to start with a basic exam, then I'll examine your genitals."

He agreed, so I washed my hands, put on gloves, and ran through a basic exam, calling out the results to Michelle to add to the chart. I found nothing remarkable in my exam and then asked John to drop his jeans and briefs after confirming he was OK with Michelle staying in the room. Once I'd completed the exam, I had him pull up his briefs and jeans.

I had spent my free moments at the hospital on Tuesday reviewing my OB/GYN flashcards, as well as those on virology and sexually transmitted diseases, and at home on Tuesday evening, I'd reviewed the plates of STD images to refresh my memory. This diagnosis was fairly easy.

"You have a genital wart," I said. "It's a relatively mild form of sexually transmitted disease caused by a virus, specifically Human Papilloma Virus, also called HPV. Something like half the population in your age group has it, and the vast majority of cases show no signs and have no symptoms.

"There is no vaccine or other treatment that will eliminate the virus, and in most cases, your body will simply clear the infection on its own. When symptoms do appear, such as genital warts, we generally use a drug called Podofilox, which is a topical cream. It will help clear the wart. I'll apply the first treatment and write you a prescription for it."

"My girlfriend gave me VD?!" he asked in surprise.

"Technically, yes, but HPV is in a different class from other so-called social diseases, such as syphilis, herpes, chlamydia, or gonorrhea. It's also possible you contracted it years ago, and there is evidence that it can be transmitted from mother to child when giving birth. It can also be transmitted via hands or objects. It might be transmissible by blood, but the jury is still out on that.

"The only action you can take at this point is regular use of condoms; otherwise, you'll simply pass the virus back and forth with your partner. Your girlfriend is likely infected, even if she has no symptoms, which she might never have. You need to encourage her to see her gynecologist and have regular Pap smears. If she doesn't have a gynecologist or can't afford to see one, she can make an appointment here."

"OK," he replied.

"Michelle, I need a tube of Podofilox, please, and an HPV pamphlet."

"Right away, Doctor!"

Fifteen minutes later, with the cream applied and instructions on how to use it, I handed John a prescription for another tube if the wart didn't clear with the first tube, the HPV pamphlet, and instructions to see his primary care physician for follow-up. Once he left, I asked Michelle to step back into the treatment room before our next patient.

"My preference is for vital signs to be expressly stated, please. Also, when we're not with a patient, just 'Mike' is fine. No need for the formal title."

"Sorry," she said.

"No need to apologize. Every physician has their own style."

"I'll go see what Misty has for us."

"I'll use my office to complete the chart and come back in about five minutes."

I removed my gloves, tossed them in the hazardous waste bin, and then went to the small office and completed the chart, putting it on the credenza behind me. One of Doctor Turner's duties was to review all the charts, and he'd take them home with him. That was one thing I appreciated about the ED — Attendings did all chart reviews, so I wouldn't have to worry about that for several years.

When five minutes had passed, I joined Michelle and a female patient in Exam 1.

"Katy Brooks, sixteen, seeking birth control pills," Michelle said. "Pulse 70, BP 110/60, temp 98.3°F."

"Hi, Katy," I said. "I'm Doctor Mike. Let's start with some basics. Are you sexually active?"

"I haven't, you know, gone all the way."

I looked over the intake form and saw she'd checked the box next to oral sex and had written in '2' next to number of partners.

"Let me ask a different way," I said with a smile. "Have you done things which your dad would consider 'sexually active'?"

"Uh, yeah," she replied, blushing slightly.

"And have you ever had a test for sexually transmitted diseases? What you might have heard called VD?"

"No."

"Do you see a gynecologist regularly?"

"Every year since I got my period when I was thirteen."

"And a regular physician?"

"I saw a pediatrician until I was twelve; now I just see my gynecologist."

"May I ask why you're here rather than speaking to him or her?"

"Her. She's my mom's gynecologist, and if I make an appointment, my mom could find out. I, uhm, don't want to wait until my next appointment in May."

"You could tell them not to inform your mom," I said. "And they're required by medical ethics to honor that request."

"I couldn't afford to pay for the exam," Katy countered. "I don't work."

"And that's why we're here. What I'd like to do is perform a basic exam, which means listening to your heart and lungs, checking your eyes, ears, nose, and throat, and checking for swollen lymph nodes. You won't need to undress; just untuck your blouse and unbutton the top two buttons."

She did that, and I checked her heart and lungs, then used the otoscope to check her ears, eyes, nose, mouth, and throat. That completed, I checked her distal pulses and then felt for enlarged lymph nodes in her neck.

"I don't find anything that would preclude a prescription for birth control pills," I said. "I would like to have the nurse draw blood for an STD test, given you've had multiple partners with whom you've engaged in oral sex."

"Uhm, neither of them has gone all the way."

"Fellatio or cunnilingus are pathways for the transmission of STDs," I replied gently.

"Er, what do those words mean?"

"Oral sex. Fellatio is what you do; cunnilingus is what he does. Either way, you exchange bodily fluid, which is how STDs are transmitted. I'm not implying you have one, and I can't force you to have the test, but it would be a good idea. It's completely anonymous and we'll give you a code number so you can call without identifying yourself, and nobody could get your name by calling the number."

"Uhm, sure."

"Michelle will draw a tube of blood, and I'll write your prescription. I'll also give you a three-month supply, and after that, if you can't afford them, you can continue to return here for another three-month supply at little or no cost. Also, you should inform your gynecologist or primary care physician that you're taking birth control pills, and you should begin having Pap smears each year."

"Wait! I have to tell the gynecologist?! I came here so I didn't have to."

"Ethically, she can't say anything to your parents. That said, the Free Clinic does provide gynecological services. You can make an appointment with the desk, and in your situation, there would be little or no cost. The challenge there would be not seeing your mom's gynecologist, which would raise questions. It's my opinion you should continue to see the gynecologist and make it clear you do not want her to share anything at all with your parents. If she did, she could lose her medical license."

"You're sure?"

"Positive. Michelle, you can draw the blood, please."

She did that, properly labeling the tubes.

"Do you have any questions?" I asked. "Either Nurse Michelle or I can answer pretty much anything you can ask."

"I had health class," Katy said.

I smiled, "I suspect that was similar to mine, and the amount of information conveyed was actually minimal. Let me ask you a question, which you can decline to answer if you choose. OK?"

"Yes."

"Do you expect your first time to hurt, and do you expect to bleed?"

"Obviously."

"Actually, not so obvious. Do you play any sports?"

"Softball and soccer. Why?"

"Then the odds of you having an intact hymen are very small. By age sixteen, it usually either atrophies or is ruptured by athletic activity."

"WAIT! I'm not a virgin?!"

"A misconception perpetrated by ignorant people," I said. "If you haven't had intercourse, you're a virgin. But in the end, that's nobody's business except yours. It's literally impossible to tell if a woman has had sex or not. Anyone who tells you differently has no idea what they're talking about. There are outliers, of course, but even in those cases, the barrier is thin and mostly open, as otherwise you couldn't have a menstrual period."

Katy laughed nervously, "I didn't even think about that!"

"Most people don't," I replied. "As for it being painful, in girls who are over fourteen, that is nearly always because of lack of foreplay, nerves, or some other thing that inhibits lubrication. In addition to the birth control pills, I'll give you a pamphlet which explains all of this in non-medical terms, as well as a tube of lubricant. You apply that to your partner's erection, and there should be no pain at all."

"You're sure?" Katy asked skeptically.

I looked to Michelle to confirm.

"He's telling the truth," Michelle said. "I was sixteen my first time; we took our time, and it was wonderful. There was no pain, and I didn't bleed. My friends who rushed or who did it in the back seat of a car had somewhat different experiences. Find someplace private where you won't be disturbed, take your time, engage in foreplay, and use the lubricant, and everything will be wonderful."

"The only other consideration," I said, "is that birth control pills don't prevent STDs. Rubbers are the only effective way to reduce your risk, though having only one regular partner can limit your risk, assuming he also only has you as his partner."

"If my boyfriend cheats on me, the last thing he'll need to worry about is VD!" Katy growled.

"A sentiment I've heard expressed by various girlfriends over the years," I chuckled. "That said, you wrote on the form you had two partners."

"Uhm, the first one was at a party where we played 'Truth or Dare' when I was fifteen. That was before I started going out with Don."

"OK. Let me get your pills, the pamphlet, and the lubrication, and you'll be all set."

"You need to take the pills religiously," Michelle said. "Every day at the same time, and if you miss one, you double the next day, but you have to use a condom until after your next period."

"Seriously? Why?"

Michelle looked to me to answer.

"The Pill works by regulating hormone levels, and even a period as short as twenty-four hours can result in enough variation to allow pregnancy. The other thing to remember, and this is in the brochure, is that antibiotics and some herbal supplements can reduce the effectiveness of birth control pills."

"This is WAY more complicated than what they explained in health class!"

I nodded, "Another common complaint. Any other questions?"

"No."

I left the room, got the pills, the lubricant, and the pamphlets, then returned to give them to Katy, along with the prescription and the form that would allow her to retrieve her test results. She thanked us, and Michelle walked her out. I returned to the small office to complete the chart, and Michelle came to the door.

"Someone just walked in, but they're filling out the intake form, so it'll be a few. You did a really good job with Katy."

"Thanks."

"I go home for lunch," she said with an inviting smile. "You're welcome to join me."

"I appreciate the offer, but if I did that, my wife would ensure nobody ever found my body!"

"Bummer, but I understand. The offer is there if you change your mind."

"Again, I appreciate it, but there is zero chance of that. And I'd appreciate it if we kept this professional and friendly, please."

"Sorry," she said. "I'll let you know when Misty lets me know the patient is ready to come in."

The rest of the day followed the pattern, and I saw a total of ten patients for a variety of sexual healthcare matters, with a break for lunch, which I ate alone in the break room. At 5:00pm, I handed the charts to Doctor Turner.

"How did things go?"

"No problems," I replied. "Michelle and I work well together, and Trina answered the one question I had."

"Great! Then we'll see you next Wednesday."

I left the clinic, headed to the hospital to retrieve Rachel from daycare, then headed home for dinner and Vespers at the Cathedral.

September 7, 1989, McKinley, Ohio

"How did things go yesterday?" Doctor Gibbs asked when she arrived in the ED at 6:00am.

"Other than a cute redheaded nurse propositioning me, just fine."

Doctor Gibbs laughed, "Nurses and doctors having affairs is so common that blatant requests to cheat are not out of the ordinary."

"Oh, I know. I declined and simply politely requested that we keep the relationship professional and friendly."

"Professional?" Doctor Gibbs smirked. "You're the last person I'd think needed to pay for it!"

"Oh, stop!" I chuckled. "I'd pay alright, and it's a price that's too high.

"On a different topic, I'm sure it won't come as a surprise that Krista complained that she's not receiving enough procedures and isn't being given an opportunity to succeed."

"To whom?"

"Doctor Mertens. There's a meeting with her, Doctor Northrup, and me at 3:00pm."

"What did Paul Lincoln have to say?" I asked.

"That he reviewed her procedure book, and he's assigning her tasks appropriate with her training while looking for opportunities to expand her skills."

"That's the right approach," I said. "I suspect the crux of the complaint is that I take a more expansive view of what students can and should do. You know why."

"You've latched on to that Osler quote like a dog with a tasty bone."

"He wasn't, and isn't, wrong. You know my take."

"'I want more procedures!'" Doctor Gibbs said, trying to mimic my voice.

"The refrain of every medical student, and with good reason."

Ellie came to the door to the office, "Sorry to interrupt. Paramedics are four minutes out with an MI."

"Give it to Mike," Doctor Gibbs said. "Go heal the sick!"

I left her office, gathered my students and Kellie, and the four of us went to the ambulance bay to meet the EMS squad. I knew how it was going to turn out as soon as I heard from the squad driver that a fireman was doing chest compressions — at best, a 5% chance of coming back. The four of us worked on the patient for fourteen minutes before I threw in the towel, as he'd been down ten minutes before he'd arrived in the ED. I called Doctor Gibbs to pronounce the patient, then had Heather bring his wife into the consultation room, where I presented the news and turned her over to the chaplain.