Dare I comment on the speculum?
It is a very underrated item, when you think about it – I mean, if you think about it… Uhmm, considering its job and everything… Ask any gynaecologist. Like shoes, one size does not fit all. In fact, continuing the analogy, there are many shapes and designs: long ones, short ones, wide ones, thin ones, metal ones, disposable plastic ones… And of course, uncomfortable ones that seek to transcend all categories.
Some doctors seem to specialize in one type or another, oblivious it would seem, to basic engineering mechanics, acolytes of the school where Function is a slave to Need –unchanged, some would say, from the glory days of Papanicolau where just seeing the cervix was deemed a success. Old habits die hard though, and so the equation is usually solved by asserting that benefits are worth two times more than discomforts. A handy, if unnecessary, deception if only because it is a justification rather than an explanation. A deafness -another barrier which does not encourage compliance except, as with some dentists, in extremis.
But I like to think that I have a specular selection from which I can choose the least uncomfortable member and am quick to point out that I have endeavoured to match Size to Need rather than the first item I happen upon in the drawer.
I long ago abandoned the disposable plastic speculum in favour of their autoclaveable metallic parents largely because of the greater selection of styles to minimize discomfort. True, never having had to endure what for some must be an unwelcome embarrassment, I nevertheless hope I am sensitive to the anticipatory dread that a gynaecological visit must engender. And I am a male; I would have nightmares…
But for all its putative advantages, there is one major downside to metal when compared to plastic: temperature. More specifically, temperature difference. I do not pretend to understand the physics of why they are always cold but personally, I suspect the First Law of Thermodynamics as defined by Wickipedia: The increase in internal energy of a closed system is equal to the heat supplied to the system minus work done by it. Think about it. The speculum is usually closed while it is in the drawer -and I must confess I do not heat my drawers- and of course its not doing any work in there either… An icicle just waiting for an opportunity.
So for years I have depended upon the hot water faucet in the sink to warm up my choice of speculum; unfortunately I am several floors distant from the boiler so running the water is usually interminable and makes us both uncomfortably aware of our respective bladders. No, the tap is not the answer. But I am a gynaecologist, not a plumber.
I used to joke about my inadequacies and I was getting quite good at innovative excuses. Too good: laughter may assuage anxieties and diffuse tensions, but it slowly and inevitably becomes too valuable an excuse to abandon. Especially when no other solution presents itself.
But although I may not be an engineer, nor a thermodynamicist, some of my patients are. Okay, one of them is.
One winter, when pipes were freezing everywhere in the city, a pregnant patient and I were forced to endure a spectacularly long faucet session. It was the beginning of her third pregnancy and I needed to do a Pap smear. Pregnancy, however, does not easily admit of prolonged personal water storage, and so after a few minutes she was becoming visibly agitated with the wait.
“For god’s sake, doctor, why don’t you just use a cold clamp and get on with it?”
I smiled and walked over to the drawer in the examination table and pulled out a speculum. “Here’s why,” I said, letting the ice cold device touch her leg. “And it’s called a speculum, not a clamp…”
“Should be called a specicle,” she said and giggled, careful not to attract the attention of her already disquieted bladder. Then she sat up suddenly and asked me to leave the room while she got dressed again.
After I went into my office and busied myself with paperwork, the roil of tap water suddenly stopped and I could hear doors opening and closing, and bare feet slapping hurriedly along the corridor leading to the waiting room. After a few minutes she reappeared and sat down across from my desk looking dishevelled, but relieved.
“You have to do something about this,” she said, her lips trying valiantly to smile through her blushing cheeks. “It was the same in the last pregnancy…” She considered it for a moment. “No, I think you were actually able to get the thing warm before I had to leave…”
“It was summer then,” I added after riffling around in her chart for a moment. “But you’re right,” I said trying to put on a professional face. “Maybe I should keep a kettle on the boil in there…”
Her eyes actually enlarged when I said that so I shrugged to diffuse the suggestion.
As a result, the large eyes rolled and the barest hint of teeth surfaced for a second. “What we’re aiming for is warmth, doctor. Tepidity. Not tea.”
Tepidity? I rather liked that word and vowed to try to slip it into a conversation some day. “Well, you’re a mechanical engineer aren’t you?” For some reason I had written this beside her name on the chart.
She nodded mischievously, the light from my desk lamp glinting in her now narrowed eyes. “You mean like I could apply the Second Law of Thermodynamics to your speculums?”
“I thought it was The First Law…”
“There’s a First Law?” she said and laughed so hard I thought she might have to leave again.
And then, as time passed, I forgot about specifics and reverted to humour to deal with the inevitable delays in warming the instruments. Forgot, that is, until almost a year later when she arrived for the first visit after her baby had arrived.
After the usual peek at the inconsolably crying baby her worried husband was carrying, the somewhat belated congratulations and then apologies for not being on call for the birth, and her assurance that all had gone exceptionally well, she sat back in her seat. Almost smugly, I thought.
I scanned her chart for a moment. “We never did do the…”
“The Pap smear,” she said, interrupting me as if she’d been waiting all along for me to bring up the subject.
Suddenly I remembered. “Do you want to visit the washroom now? Before I turn on the hot water, I mean?”
She shook her head and glanced at her husband. “I’m fine, thank you.” But her face lingered on him when he stayed sitting. The baby was quiet now, so I thought maybe she was just silently congratulating him. “I think Jennifer needs changing. Is it okay if we change her in the examination room, doctor? Now they were both smiling.
“Of course,” I replied. “Just let me know when you’re ready and I’ll come in.”
They disappeared into the other room wheeling the baby carriage with all their supplies, and closed the door. It is a rather thin structure, the door, and I could hear them whispering and giggling; the baby seemed to be sleeping through the procedure. Amazing.
“You can come in now,” she said after a few minutes in a too-loud voice -the voice of a child who has just hidden some cookie crumbs under the table.
I opened the door and saw her husband sitting quietly on the little chair I keep in the room. I could see the baby fast asleep in her stroller and the mother sitting on the edge of the examining table. There wasn’t much room in there at the best of times, and with the husband, the baby and the carriage, it was like being in a crowded elevator.
I smiled at her and headed for the sink to turn on the hot water.
But I had to thread my way past husband and stroller so before I could make it to the sink she said, “You know I was thinking about it after my little problem with that last Pap smear…” I stopped and turned to her. “I think it was the First Law after all…”
It took a moment for it to sink in. “Ahh, you mean the temperature of the speculums.” She nodded. “Well, it was just a guess,” I said modestly, and meaning it.
“So, I thought I’d correct that and actually apply the Second Law.”
“Closed system,” she said and laughed, pointing to the sink.
Her husband leaned back so I could see more of the counter. And there, proud as Punch, was a Slow Cooker -a Crock Pot- plugged in and partially full of water. There was even a speculum in it.
“Water’s probably not at the correct body temperature yet…” she said and smiled. “But it’ll do for now.”
I walked over to the counter and dipped my finger into the water, speechless for a moment. And then it came to me: “Not quite the correct degree of tepidity, you mean?”
I could see her smiling; she knew it was her word. “I mean, I don’t want to see a kettle in here,” she said and settled back on the table.