Kids these days...

There was a knock on the exam room door in the middle of one of my routine OB visits. I gave my patient a confused and frustrated look as I got up to answer the door.

“This never happens,” I said. Though it has already happened more than a handful of times. “Sorry.”

When I opened the door, one of the medical assistants was standing there apologizing but letting me know that a pediatrician from downstairs asked that I be interrupted in order to consult with her over the phone regarding a 16 yo pt she had “on the table.” I excused myself and headed toward the phone thinking, Why would a pediatrician be asking for me? Like, she wants me? Me, me? Or just a clinician? My MA didn’t know. She just handed me the phone.

“Hello?”

“Hi, thanks so much for taking my call.” The female voice on the other end said.

“Well, I was told you wanted me to be interrupted.”

“Yes, yes, thanks so much. I hate to bother you during your busy day but I have a pt here, like on the exam table, and I’m not exactly sure what to do with her.”

“Okay, well, I can try to help.”

“Well, the patient is saying that during sex last night she had a “gush of blood” and now she is also having some pelvic pain. I’m just not sure what to do. You see, I’m just a floater here…”

I couldn’t help but think of her swimming in the toilet even after a flush or two…

“Well, is she bleeding now?” I asked.

“No, not really. I don’t think so.”

“Well, I’d do a pregnancy test, and I would definitely take a look inside.”

“Ok, well, but, as I said before, I am just a floater here. I’m not even sure I can do that here.”

“You mean you don’t have speculums down there?”

“No, no, of course we have speculums; it’s just that, I was hoping you could see her?”

Long story short, after being interrupted for a 2^nd time by this same “floater”, the patient was sent upstairs to see me.

It turns out, she did have a gush of blood while she was having sex. A “gush” that she describes as “filling the cup of her hand”. Then the bleeding almost immediately tapered. She reported only having brown spotting today. She had no pain before or during the episode of bleeding but now she has diffuse pain in her lower abdomen. She’s been sexually active for 2 years. She’s on the pill and has not forgotten to take her pill, ever. Her last period was normal. Her pregnancy test today is negative. This has never happened before.

I tell her that I have to take a look inside. She understands though is squirming and uncomfortable with the idea. The pt has minimal problems/discomfort with the insertion of the speculum. I can immediately see blood in the vagina and as I look around and use the speculum to push away vaginal mucosa, it’s clear that the bleeding is no longer brown but bright red. Not tremendous amounts but there is no question that something is actively bleeding. There was blood on the cervix but it wasn’t clear that the bleeding was actually coming from the cervix. I pulled my light around even more to get a better look at the sidewalls. And then I saw it. The right side of her vagina was completely intact and I could visualize the entire thing from introitus to cervix. But the left side was not right. There was a fairly large laceration that was running down the length of her insides.

“You aren’t in any pain in here?” I asked as I dabbed the gash with a q tip.

“No. I can’t feel that.” She said.

It’s true that there are less nerve endings inside the vagina. If the wound had been on the outside or up near her cervix I am certain she would have been in more pain, but presently, she was generally comfortable. Just embarrassed and anxious.

“Was there anything in your vagina besides a penis?” I asked.

“No.”

“Like, no toys? No fingers?”

“No, nothing.”

“Well you have a pretty significant cut in here.”

“I do?”

“Yes, you do. I can’t see it very well but I’m pretty sure that is where your bleeding is coming from.”

“That is so gross.”

“Well, it happens, I guess.” I had never seen this before. “But I definitely do not want you to have anything in your vagina for a while. Until this heals. And I’m going to let the doctor know what I found and see what she wants to do.”

I grabbed one of the docs who was in the office that day and let her know what was going on. We got a pelvic US to r/o any kind of hematoma (which not surprisingly was normal) and the doc told me to pack the vagina for today, give the patient good warning signs for increased bleeding and pain and to have her come back tomorrow to see if it has healed. Initially I was a little frustrated that the doctor didn’t want to see (confirm) my “diagnosis”. I mean, if she saw the extent of the laceration, maybe her plan would be different. Plus, I just didn’t trust myself. Maybe it wasn’t a gash. Maybe the blood was coming from somewhere else and I just didn’t see where…But after I packed the pt’s vagina and made her an appt for the next morning to see another clinician I checked in with the doctor.

“So, you think that packing will be enough for tonight?”

“I hope so. It might just be enough to tamponade the area. I’d like to avoid suturing the vagina of such a young girl if we can just use expectant management. And tomorrow when she comes in, I can help assess and if she’s still bleeding we’ll just have to suture her.”

That made sense to me. And since the patient’s bleeding was well under control, her CBC was normal and I could bet any amount of money she wouldn’t sticking anything inside of her for a long time, I felt better.

It turns out, she was one of the patients I thought about all night and well into my next day on call. Around noon (I knew the pt’s follow up appt was at 11am) I called the office and spoke with the midwife who saw her. It was definitely a laceration just where I had thought it was. It was still bleeding when the packing was pulled and the doc and CNM advised the patient that she would need to have the wound stitched. And she refused. She just refused. She wanted to just let it heal and bleed and not have anyone else touch her. Which, is absolutely her prerogative. I just couldn’t help but think it was the wrong decision. And I couldn’t help but think it was only embarrassment and fear that made her refuse. And I definitely couldn’t help but think that I would most likely be seeing her again. I’ll have to remember to do better education on lubricating agents the next time she makes an appointment…