Gynecological diagnosis I

"Mittleschmerz" the old man who sat on the edge of my bed said to me "literally means 'pain in the middle' or midcycle pain." He was explaining this the morning after the alleged "mittleschmerz" hit me.

We were in my college's infirmary. I had spent the night there, medicated but still in so much pain that my legs were constantly moving and I would drift off only lightly then wake up in a cold sweat, crampy and feeling like I had to urgently evacuate from both ends. I'd make a staggering walk across the cold floor to a restroom where I sat hunched up on a toilet, gagging and crying, and then I'd return to bed when it felt the spasm had passed. I was just barely 19, at college, and sick. This sucked.

It all started when I was at work. I had been accepted the year before at a university my parents could not afford but which was one of the more prestigious universities I had applied to. So when I got in, my parents wouldn't hear of my not going. We had all the usual loans a working class family sending a kid to an overpriced college had. In addition to the loan money I am still paying off (18 years later), I was approved for work study. This meant working two on campus jobs in addition to my outside job in order to afford books, food, and phone service. Frequently, I went without phone service.

My outside job was a part time evening weekend shift job as an inpatient clerk (aka "unit secretary") at one of the hospitals in the NW Boston suburbs. It didn't pay much during the semester, but it allowed me to pick up overtime shifts on holidays and breaks, which I did often. I floated to and worked per diem on many floors aside from my own, the inpatient surgical unit. Oh, this was back when there were inpatient surgical units. These days, most of the procedures we housed pre and post op patients for would be performed on an outpatient basis in a day surgical clinic. But this was the roaring 90s, barely even. This was the day of pre-op chest x-rays and EKGs for everyone, routine metabolic labs, and post-op care which included not going home until your pain, eating, and elimination were all well under control.

One of my work study jobs was at the very infirmary, where I now lay with this old man leaning over me, a too thin blanket and my growing annoyance between us. At the infirmary job, I pulled charts and made appointments, handled the front desk, learned (to my great horror) which of my friends were and which weren't using condoms, and refered patients to outside medical facilities. The last one I did with great enthusiasm. It was a necessary service since all of the very few actual MDs we had on staff were only part time and worked what seemed like erratic hours. The appointments filled up far in advance. For gynecology, we routinely booked well into the next semester. Fortunately, we had a roladex which had the names and numbers of several area doctors, gynecologists included. I worked with many of them at the hospital clerical job since so many of our inpatients were gynecological patients. I once asked one of the older nurses "hey how come so many of our patients are gynecology?" in all innocence. She laughed ruefully, then announced my question to the other nurses at the station. They treated me as if I had asked "where do babies come from?" Only when I was about 15 years older did I realize the full reality of why most of the surgical patients were gynecological patients, or possibly vice versa.

My third job was the one I was at the night the pain that won me a stay in the infirmary hit me. I worked for the campus safety escort service. This is the service that runs the shuttles and employs students to work in pairs at various locations around campus to walk with students who do not want to walk alone at night. My co-worker that night was J____, a sort of fluffy superficial young woman who lived on my hall. J____ had pulled strings to get us to work together, something I was supposed to be thankful for but which I was finding difficult to handle. My shift was at the library, and due to the general attitude of safety and privilege among the undergrads at my university, I got to spend most of my time at the library shift sitting at the library instead of walking anyone anywhere. This was ideal since it meant I could read. Except when J____ was there. When J____ was there, it was more talk than study.

When we finally got a walk, I was happy for the break at least from the chatter and what was becoming a stuffy late evening library feeling. We set out, J_____ and I wearing our little vests which marked us as safety escort walkers, walkie talkies attached to our belt loops of our pants. We were in charge. Except when I doubled over in pain a few yards out. I started retching into the bushes and J____ called in a request for another walker. The dispatcher was swamped and told us to sit tight and wait. J____ was sensible enough to decide she wouldn't put me through a wait. The poor girl we were walking looked horrified. She and J____ ended up walking me to the infirmary, half dragging me at times down the hill and into the pit where the infirmary buildings were clustered.

When we got to the infirmary, the doors were locked. There was a sign directing us to a side entrance where we stood and waited after J____ rang a bell. A nurse appeared in the doorway, holding the door just open enough to peek out like a frightened old lady checking her door at 2 AM in a bad neighborhood. Jenn explained our situation and the nurse grilled us there on the doorstep. "How much has she had to drink tonight?" she asked. "What? Nothing! We're working!" J____ huffed, personally offended now. Finally, the nurse let me in, shooing J____ and the other young woman away. The nurse was curt but efficient. She gave me some pain meds after checking my vitals, then showed me to a bed where I was left for the night.

Which brings us up to the morning with the doctor on my bed.

"'Mittle' is German for 'middle' and 'schmerz' is the German word for 'pain'" he told me in what I could only hear as a condescending tone. "Isn't that more of a description than a diagnosis?" I asked, incredulous that something this horribly wrong feeling could have suddenly happened to my body but didn't warrant an investigation more thorough than this...which I saw even then as a dismissive pat on the head. He explained very briefly that it was normal for some women. I pondered a life of this as a normal state of affairs. I was 18. I had no idea what that would be like. I know now.

The doctor gave me a dose of donnatal and discharged me. I walked back to my dorm alone. My dorm was at the bottom of another hill, a hill which at least one student took on his face at the start of each semester. I remember walking the long way around to avoid the hill, but feeling like the ground was tilting in a sickening way as I walked over it. It was relatively flat going, but my feet slipped and dragged in response to the messages from my brain that I was going up, down, and sideways. I finally made it back to my room. I recall looking in the mirror and seeing myself, pale, dark circles under my eyes, and very very high looking. I looked closer. My pupils were huge. I called my mother, the nurse. "Donnatal has bella donna in it" she said. "That's why your pupils are big. Do you have someone there? Do you need to come home?" Home was the last place I wanted to be, as much as this sucked, home always sucked more. "No, I'll stay put. Get some sleep, you know?" I told her with as much good feeling confidence as I could muster. My belly still hurt pretty bad, except now I felt looped.

About two years later, I had three more experiences like this in rapid succession. The first was at my then boyfriend's house, when I locked myself in the bathroom of his parents' house because the cramping and bowel urgency was so horrible I couldn't be away from a toilet. I pooped, puked, and then passed out. I woke up shaking and sore, having hit my head on something on the way out.

The next was on a train home from dinner in Boston with a group of friends. There was no bathroom, just the long commuter rail trip north from an overly rich dinner which I'd only been able to eat a very little of before feeling suddenly and badly full. I lay on the floor of the train crying, going in and out of consciousness, puking, and (according to one fo my friends) looking green. "Honestly," this friend told my mother at breakfast a few days later "I've never seen anyone look that color!"

The last one landed me in the hospital. My then boyfriend (the same one whose parents' house I had passed out in about a month before) and I had had a huge fight. It was around valentine's day. I threw a vase of flowers at him, slammed the door to my room, and then got hit with that same horrible pain. I made my way to the women's room and went through the usual toilet routine. Nothing. Just pain and feeling like I had to GO, but nothing. The pain got worse. I made my way back to my room to find my boyfriend looking for more argument. He saw me and the angry hostile look evaporated. "My god are you ok?" he asked. "No..." I grunted and climbed into bed.

Some time later, the campus EMT team was called. This crack squad of health care providers consisted of pre-med college students, some of whom were in fact EMTs but most were kids whose entire medical experience thus far consisted of working as volunteers on the ward where daddy admitted most of his patients. One of these kids was taking my blood pressure. I had passed out after vomiting into the trashcan, at least I think that's what happened because leaning out over the trashcan was the last thing I remembered before waking up to feel a cuff on my arm and hearing a young man's voice asking someone "hey, the top number's getting higher and the bottom one is dropping. What does THAT mean?" "I think it means I'm going into shock" I said. The boy noticed I was awake, leaned in, and yelled into my face "HOW MUCH DID YOU HAVE TO DRINK TONIGHT?"

I tried to explain how much soda and water I had had that night, thinking in my somewhat muddled state that he was asking about my fluid intake. It became clear he wasn't when he repeated the question adding "WHAT ELSE DID YOU DRINK?"

I knew at this point that these kids were trouble. Well intentioned, but pretty much only there for first aid in cases of mild ODs, acid freakouts, and alcohol poisoning.

Finally the real EMTs showed up. We had a short argument about what hospital I could go to. They wanted to transport to the nearest and I wanted to go where I and my mother worked - mostly because the closest had a reputation as a wreck of a place where negligence was part of the daily practice. My mother worked in the ER of our hospital and would bring home stories of people dismissed and discharged from the ED of the more local hospital and who ended up admitted through our ER within one day.

The EMTs were having none of it. I thought if a patient was conscious, he could request to go to a particular hospital, but they argued my insurance would not pay for this luxury. I insisted. We argued. It was solved by a quick phone call to my father, the junior low level insurance executive. The folks in my now rather crowded dorm room stood around waiting while I made the call. My phone was shaped like a bright red high heeled shoe. God, in retrospect this is a truly odd scene.

"Dad, does our insurance cover transportation to the other hospital?" I asked him after very briefly explaining what was going on.

I am still sort of amazed at how much charge I took that night. I think I had to, but I think part of what necessitated it was that since adolescence, I have felt like I am the best person to be in charge of any such peer based emergency. I was the kid who didn't drink or get high but hung out with the drinkers and stoners. I was the girl who had the first aid supplies, the condoms, the extra tampon, the saftey pins, the scissors. I came equipped.

I think my friends, having learned this is the way it would be with me, tended to step back and wait for me to do what needed doing even when I sincerely was not in a position to do it. So my needing to run the room that night was in part my own fault. I'm nearly 20 years older now and I like to think I've gotten at least a little better at letting other people be in charge, but I am by no means good at letting others be in control of my body and my medical situations - even when it is necessary.

My dad, confused but knowing not to argue, said "yes, it'll cover it" that night and we were on our way. Sort of. I refused to be carried down the stairs on a stretcher. We had some more words and finally they very reluctantly walked me down. I made it to the outer doors, sat on the stretcher, and lost consciousness.

I came to fighting and slapping at what felt like someone trying to suffocate me. In reality, it was just the emergency technician trying to put an O2 mask on me. As we passed the doors of the ambulance bay, I heard my mother's voice saying "well they called in a 20 year old with acute pelvic pain from your university and I thought 'that's probably my daughter'" She was charge that night, as she usually was. She'd been a nurse manager, head nurse (back when they were called that), staff nurse, and nursing supervisor at nearly a half dozen different Boston area hospitals since the 1970s. She's worked on burn units, one of the first transplant units, and emergency departments. I dislike her as a person, but she's an extremely competent and very well qualified nurse.

My mother took me as a patient that night and got me settled in a room. I had an ultrasound and was admitted to the GI service rather promptly. I'd been seen by a Boston pediatric GI group for something like 8 years at that point, so the natural assumption was that this was GI related. However, the ultrasound showed evidence of a ruptured ovarian cyst. As soon as that result came in, the GI service dropped me faster than you could say "endometriosis". They left me without diet or med orders. Finally an on call doctor from my private gynecology service called in a few reluctant orders. When he came in to see me the next day, he sat in a chair across from my bed and explained about the cyst. He explained very minimally, telling me I should schedule a follow up appointment to talk about this with my regular gynecologist when I was discharged.

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