Sydney, Australia (Winter 2011)
The list on the Emergency Department computer screen displayed that the first patient waiting was Gavin Hunt with an anal abscess. The second on the list was Holly Bester with a vaginal abscess. The resident saw me eyeing the list and smiled his crooked smile. “They’re a couple,” he said. I laughed.
I stopped what I was doing and double-clicked to assign the anal abscess under my name; I didn’t want to get stuck with seeing the vaginal abscess. I was four weeks into my internship and had already discovered a couple things. First, it was best to steer clear of the gynecology specialist who I would ultimately have to consult for any vagina cases. Secondly, butt abscesses were easy to manage.
The resident came over again, “I saw you just assigned yourself Gavin. He’s got a violence alert and has been inappropriate with female staff before. I think it’s better you take his partner Holly, and I’ll take him.”
“Oh. Ok,” I said.
Bugger. I picked up Holly’s notes from the triage desk.
“She has to have a security search first,” the triage nurse snapped. “And you can’t take her into the main ED. You can see her in C4, and you have to leave her in the waiting room once you’ve seen her. She’s been caught stealing needles from the trolleys before.” Okay, so they both had violence alerts.
Holly and Gavin were searched, and Holly’s handbag was locked in a Perspex locker. I led Holly into consultation cubicle 4, which was attached to the waiting area, and pulled the curtain shut. She was preoccupied, “Where are they taking Gavin? He’s going to leave me. He always does this. Can I have my purse back? It’s got my money in it and he’s going to take it.”
Holly was 41, a natural blonde, sturdy-looking, but pretty. Gavin was 27, good looking, but with one lazy eye. Or was it a prosthetic eye? I reassured Holly that her purse was locked up, Gavin couldn’t access it, and he was being examined in another cubicle.
“What’s brought you to the hospital?” I asked.
“It’s this,” she pointed to a red area on the left side of her abdomen, “It’s really sore.”
It was clearly an abscess, most likely from her injecting drugs in that location, although she denied this.
“I wouldn’t do that,” she said, “I’m pregnant.”
“How pregnant are you?”
“Well, my last period was about nine weeks ago and I had an ultrasound and they said that’s about right. I really want this baby. For me and Gavin. My other kids have been taken away by Child Protection, but this baby is going to love me.”
“When you came in, you told the triage nurse you had something wrong in the vagina, is that right?”
“Yes it’s itchy. I think I have thrush. I’m a sex worker and I had an STD check just three months ago and it was all clear. I’m working you see; that’s why I’ve got money in my purse that Gavin wants.”
“Does Gavin work?”
“No,” Holly said. “He steals off people. He’ll break someone’s leg just to steal their money. It’s horrible.” I couldn’t help wondering about the story behind Gavin’s funny eye. Did he have a fight which resulted in severe eye injury requiring a prosthetic eye?
“I don’t want him to steal off people so that’s why I work.”
I couldn’t believe that this man was letting the mother of his unborn child prostitute herself to support him. And she was petrified of his leaving her.
“And how much of your money does he use?” I asked.
“All of it,” she said. “He buys points with it. I want to stop using, but he buys it with my money and gets high on it, and so I want some too.”
“When did you last use?” I asked. I needed to determine whether she was injecting drugs while pregnant; because if she was, this unborn child was at high risk of harm, and I should consider reporting it to Child Protection.
“This morning,” she said.
Wow, it was much easier than I expected to obtain that information.
I tried to think objectively about this patient. I drained the pus out of her abdominal wall abscess while she cried that it was hurting. I explained that I needed to do a vaginal examination to look for the cause of her itchiness, and maybe look for an abscess down there too, although she now had no memory of saying anything about that to the triage nurse.
She undressed from the waist down, put her ankles together, and let her knees fall apart. Externally I couldn’t see anything abnormal, but I hadn’t actually seen that many vaginas, so I wasn’t sure that I would recognize an abnormal one if I saw it. As she lay there exposed, my mind turned to the fact she was a prostitute. I thought about all the men that had been inside her. Pushing that thought aside, I put lubricant on my gloved fingers and explained what I was doing as I commenced the examination, trying to feel for anything abnormal. I moved the cervix to test for signs of infection.
“Is that painful?” I asked, looking up at her face for signs of discomfort.
She had a relaxed and peaceful look on her face, with her eyes closed. “No, it feels beautiful,” she murmured.
I was aghast. I removed my fingers. I was unable to bring myself to proceed with the examination. I was disgusted and embarrassed. I cleaned away the equipment and took off my gloves.
“Ok, you can get dressed, and I’ll get you to sit just outside the cubicle in the waiting room area. I’ll come back.”
I went and presented the case to one of the senior emergency doctors. I omitted the part about the patient’s response to the internal examination.
“Yeah, send off the aspirate for micro; give her some clindamycin to clear up the abscess. She should probably take it for 10 days … and did you take swabs for STIs?”
“No, I didn’t,” I stated. I didn’t explain why I had not.
“Yeah, you should take swabs for chlamydia, gonorrhea …. She’s a sex worker. Get her to see her GP to follow up the results.”
I went off in search of some antibiotics for her to take away. I couldn’t bring myself to take swabs for STIs. I knew that if she did have an STI, then she would be at high risk of miscarriage should the infection be left untreated. But a large part of me felt that it might actually be better if she did miscarry rather than bring an innocent child into her world, an innocent child who was probably already brain-damaged because of her heroin use.
I sent her away from the waiting room with her pack of antibiotics that she would probably forget to take. I watched her walk out the door clutching her purse in one hand and Gavin in the other. It was a picture of sorrow. I swallowed my sadness as I turned to the computer to see what was next on the list in the ED waiting room.
All characters appearing in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
DR. EMILY GREGORY-ROBERTS, BSc, MBBS (hons) is a writer, actor and doctor. She has written for theatre and film, and her publications range from poetry to medical research. She has performed on screen and stage in Australia, with notable appearances in All Saints, Home and Away, GP and Troy’s House. She works as a Resident Medical Officer at St Vincent’s Hospital, Sydney, and is an active member of the Australian Medical Association NSW Creative Doctors’ Network.