Chapter 15: Back in the Saddle Again

April 16, 1990, Bright Monday, McKinley, Ohio

"Let's go see your patient."

"I think I should present here," Mary said.

"Go on."

"Stacey Hamilton, sixteen; reports discomfort on urination; irregular menstrual periods after being regular; temp 39.6°C; BP 118/62; pulse 74; PO₂ 99% on room air. Reluctantly admitted having unprotected sex on several occasions since her fourteenth birthday. Last gynecological exam was in October."

"Your proposed diagnosis?"

"PID resulting from an untreated STD."

"Differential?" I inquired.

"Ruptured ovarian cyst, appendicitis, ectopic pregnancy, or endometriosis would be the most likely alternatives."

"Your proposed diagnostic plan?"

"Full-spectrum STD test series; pregnancy test; pelvic exam to test for cervical motion pain; blood test for ESR and C-reactive protein; ultrasound to check for edema and rule out the differentials."

"What do you think, Ghost?" I asked.

"I think you have the best med student in her class, and you stole her from me; that's what I think! I'd let her proceed with supervision."

"Mary, what is your proposed treatment plan if your diagnosis is confirmed?"

"Immediate antibiotics for a potential STD, which is also standard for suspected PID. Gynecological consult or referral to personal physician."

"Which would you do and why?"

"Consult; PID can require intensive in-hospital treatment and may need laparoscopy to confirm."

"Good. What did you miss?"

Mary thought for a second, "Social worker; first sexual encounter at fourteen, followed by an admission of multiple instances of unprotected sex. Of course, we have to report any STDs to the County Health Department, too."

"Are you comfortable completing your proposed diagnostic plan?"

"Except for the pelvic exam; I've observed, but I've never done one."

"Mike, on the other hand, has delivered babies!" Ghost declared.

"Something I hope to avoid for the rest of my career!" I replied. "Did she come in alone?"

"Yes. She has her driver's license."

"Then carry out your diagnostic plan, Miss Anderson."

"Yes, Doctor!"

I followed her out of the lounge to Exam 2, where she introduced me, then spoke to the patient.

"Stacey," Mary said, "we're going to perform several tests, which include drawing blood and taking swabs from your mouth, your vagina, and your anus, as well as performing an ultrasound and a pelvic exam. You have a right to have a female doctor supervise me if you prefer."

"You're going to do the exams?"

"Yes, I'm a trainee until May, as I explained, so Doctor Mike will directly observe because he's my teacher."

"It's OK," Stacey said. "Are you going to tell my parents? I wanted to go to the Free Clinic, but it's closed."

"So long as you don't need to be admitted to the hospital, no," I said. "Once you turned fifteen, you gained medical autonomy over reproductive health. Mary, proceed."

"Stacey, you'll need to change into a gown," Mary said. "Everything comes off, though you can leave your bra on. Doctor Mike and I will step out. If you need help, push the purple call button on the wall, and a nurse will come to help you."

Mary gave Stacey a gown, and we stepped out into the corridor.

"Where are the gynecological trays?" Mary asked.

"Ask Ellie, and she'll have one of the nurses retrieve it from the supply room and assist you."

"It really sucks that the Free Clinic closed!" Mary declared.

"If the young woman has no need for admission, it's going to cost her or her family or her insurance several thousand dollars versus it possibly being free at the clinic."

"Uhm, if she has to pay, what happens? I mean, it's not like a sixteen-year-old will have a few thousand bucks!"

Lara had that kind of money at sixteen, but she was an anomaly.

"That's all left to Social Services and the County Health Department. The hospital is unlikely to send her a bill if she states she doesn't want her parents to know, but they might try to collect from her parents' insurance company, which would potentially have the effect of them finding out. But again, that's not on you or me, and the social worker will manage it."

Mary went to speak to Ellie, who asked Amy to get the gynecological tray and assist Mary. We waited another two minutes, then Mary knocked on the door to Exam 2. We waited five seconds, then the three of us entered to find Stacey sitting on the exam table dressed only in an exam gown.

"Stacey, this is Nurse Amy, who's going to assist me," Mary said. "First, Nurse Amy will draw blood, then I'll perform the swab tests and the pelvic exam."

"OK," Stacey agreed.

Amy drew the necessary tubes of blood for the STI, ESR, CRP, and pregnancy tests, then Mary swabbed Stacey's mouth. Once that was completed, she and Amy got Stacey into position with stirrups. Mary swabbed Stacey's vagina and anus, then looked to me. I guided Mary through the pelvic exam and, once that was completed, through an ultrasound.

"We're going to step out for a moment," Mary said. "We'll be right back. Amy will stay with you."

"OK," Stacey agreed.

Mary and I went out to the corridor.

"OB/GYN consult," Mary said. "She has all the signs. Do we do that first? Or call the social worker?"

"We can let OB/GYN handle that. Call for your consult, and we'll discuss it with the OB/GYN Resident before speaking with Stacey. What's your diagnosis?"

"I'd say she has PID attendant to a chlamydia infection. There's an off chance she's pregnant, but there was no indication of an implanted embryo in the uterus or Fallopian tubes. Recommend ceftriaxone IM and oral azithromycin."

"Agreed. Give the antibiotics, then call for your consult. Did you ask about alcohol or drug use?"

"She denied both, and I saw no signs of IV drug use nor any physical signs of alcohol or drug abuse. Also, no signs of any physical abuse."

"OK. Let's go back in."

We went into Exam 2.

"Amy, ceftriaxone IM, and oral azithromycin," Mary said.

She wrote those on the chart, and I signed it, then Amy went to get the antibiotics, taking the blood with her so it could be taken to the lab.

"Stacey, we're going to give you two separate antibiotics," Mary said. "The test results can take some time, and it's much safer to administer the antibiotics now rather than wait. We're also going to call a gynecologist to speak to you because we believe you have PID — Pelvic Inflammatory Disease. That can result from sexually transmitted diseases or from sex without condoms."

"How bad is that?" Stacey asked.

"Usually, it's treated with antibiotics, and you would follow up with your gynecologist. We just want to confirm with a gynecologist before we release you."

"OK."

Amy returned two minutes later and administered the antibiotics, then Mary called for a consult. We stepped out of the room, and about ten minutes later, Marilyn Cartwright from OB/GYN walked up to us. I nodded to Mary, who presented.

"Already seeing the effects of closing the only clinic in the country to provide reproductive services, I see," Marilyn observed. "Let me examine her and ensure we aren't missing something."

"OK. If you don't take her, we're going to call a social worker."

"Make your call," Marilyn said. "I can't imagine you missed anything, Mike. You've delivered one hundred percent of the babies in the ED in the past three years!"

I laughed, "One out of one is, indeed, a hundred percent!"

"All kidding aside, antibiotics are the standard, barring complications. Let me examine her."

The three of us went back into the room, Mary introduced Marilyn, and Marilyn conducted an exam. Once that was completed, Mary let Stacey know she could dress, and we stepped out.

"I agree with your preliminary diagnosis of PID attendant to a chlamydia infection."

"Thanks, Marilyn," I said. "Mary, use the phone at the nurses' station to call for the social worker."

"What do we say to Stacey?"

"That with a suspected STD, it's required. If she balks, simply say the social worker will contact her, and we let her leave because we don't have a medical reason to keep her."

"OK."

She made the call, and because Amelia Clinton, a new social worker assigned to the hospital, was immediately available, we waited for her to join us. She arrived two minutes later, and Mary presented the case to her, after which the three of us went into the room.

"Doctor Mike will sign your discharge papers," Mary said. "You'll need to take the antibiotics for the next ten days, but your symptoms should begin to clear up by the end of the week. Please don't stop taking the antibiotics until you've finished the course. This is Ms. Clinton from Hayes County Family Services, who would like to speak with you. I'll come back with your discharge papers in a few minutes."

"Hi, Stacey," Amelia said.

Mary and I left and went to the nurses' station to fill out the paperwork.

"What's your private take on a fourteen-year-old having sex?"

"That depends," I replied. "At fifteen, I'd have been for it; as a dad, not so much!"

Mary laughed, "I think that's a fairly universal opinion amongst both teenage boys and fathers."

"Your dad?"

"Would have sent me to a convent if the Evangelical Free Church had convents!"

"Swedish, right?"

"Blonde? Check. Blue eyes? Check. E-Free Church? Check. Last name Anderson? Check. I have ancestors on both sides who emigrated from Sweden during the European Potato Famine. Somewhere along the line, they dropped the double S in Andersson, which is a dead giveaway for being a Swede."

Mary completed the discharge paperwork and notes, and I signed the chart and discharge sheet, and we returned to Exam 2 where Amelia and Stacey were talking. Mary presented the discharge instructions, then we left to allow Amelia to continue the conversation.

"Very good work, Miss Anderson. Write those procedures in your book for my signature."

"Thanks! I was wondering if, as your student, I should be 'Doctor Mary'?"