PTSD in Gynaecology?

Post Traumatic Stress Disorder (or PTSD) is an anxiety disorder caused by being exposed to a traumatic or frightening event. It has been described in various guises since antiquity: http://www.bbc.com/news/health-30957719, but although we have traditionally ascribed it to military veterans, it is by no means confined to those who have been in the midst of battle. Paramedics, police officers, and various other sorts of first-responders are also exposed to frightening and traumatic events. The DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders) has even allowed a variant for those emergency workers even if they are only exposed to disturbing videos in the conduct of their jobs.

So I suppose it should not come as too much of a surprise that someone would take the leap and wonder whether the public, exposed as we all are to social media, would be at risk as well: http://www.bps.org.uk/news/viewing-violent-news-social-media-can-cause-trauma   There followed the usual offence at what seemed like an attempt to demean the diagnosis of PTSD in those felt more worthy of its acquisition, and in conditions far more important and deserving, but nonetheless there is a spectrum of manifestation inherent in most diagnoses.

The BBC posted a helpful primer on PTSD http://www.bbc.com/news/health-26867615 but in brief, the diagnosis requires: flashbacks to the event, avoidance behavior, sleep disturbance, and mood changes.

I have to say I was skeptical that we should even consider that anything found on social media could have such an important impact that could in any way be considered PTSD –however attenuated. It seemed almost an insult, a belittling of those who had undergone real trauma. Until, that is, I remembered Lucille.

She was a young lady visiting from another province who had been sent to me for a second opinion from the emergency department at the hospital across the street. Her problem was abdominal pain –chronic and unexplainable pain in the pelvic region, for which she had been thoroughly investigated elsewhere with ultrasounds, CT scans, an MRI and even –no doubt in desperation- a laparoscopy four or five years ago to view the area more directly. And all, said the accompanying note, were normal.

She was not what I was expecting; rather than an anxious woman sitting quietly in the waiting room with her face locked in pain, instead I found a smiling, smartly dressed young lady happily talking to the pregnant woman in the seat beside her. She smiled when I walked over and immediately extended her hand for me to shake.

“I’m so happy you could see me on such short notice,” she said as I led her down the corridor to my office. And she did indeed seem cheerful and, well, normal as she seated herself across from my desk by the window. “What a wonderful view of the ocean from here,” she almost purred, staring past the buildings and traffic at the almost-invisible water far in the distance. “Vancouver is such a wonderful city…”

I sensed her cheer was other than completely genuine, as her words wound down and slowed. Sometimes, with chronic conditions like pain, I like to wait until the patient is ready to speak -unprovoked, as it were. Unencumbered by a line of questioning known all too well to her that leads… nowhere. She was silent for a while as she turned her attention to the office itself, her eyes alighting like sparrows first on a painting on the wall, then on a wooden carving from Ethiopia I had placed on the desk so it looked out between the leaves of a plant. They stopped no place for long, revisiting their favoured twigs almost at random.

“Offices are all different, aren’t they?” I said, to begin the conversation.

She nodded thoughtfully. “I suspect they reveal a lot about the doctors…”

“And the patients who notice.” It provoked another smile.

Her face became serious –a major change. “Look, I don’t want to waste your time, doctor. I’m certainly grateful you could see me, but maybe I should wait until I get back to Ontario to get it checked out.”

“It..?” She looked down at her lap, as if the little sparrows were tired of flitting about. “The note from the ER said you were having some pain… Care to tell me a bit about it?”

She still seemed reluctant to look up. “Oh, I get these pains every now and then. No big deal, though.”

She risked a glance and I immediately seized the opportunity. “Well, suppose I just take a brief history and then if you feel you want to wait till you get back to Ontario, I can fill your doctor in as to what happened while you were here in paradise.”

She nodded her assent and for the first time, her eyes didn’t flee from my face. Was it hope? Or merely resignation that it was beginning again?

We all expect that we will be able to find the treasure where nobody has succeeded before, but the only thing I could discover in her history that might be remotely related to her pain was an episode of Chlamydia –a sexually transmitted condition- several years before. It had been treated and subsequent cultures had demonstrated cure. “When did the pain start?” I asked, almost as an afterthought, but I think she could see through my strategy.

The memory seemed uncomfortable to her, and she looked out the window again.

After an awkward moment of fidgetting silence, I said, “Sexual diseases are always difficult to talk about, I think…”

“My friend didn’t think so,” she suddenly blurted out before I could even finish my poorly worded attempt to console her. “She got an STI and had to be hospitalized when it spread through her abdomen… They even had to operate to remove the pus. She sent me a picture of her tubes they took during the operation…” She looked as if she were about to cry, but grabbed a tissue from the desk and dabbed her eyes to recover. She lapsed into a morose silence and turned her head so she could see the door.

“You know, I’d been fond of the guy who gave it to me; I’d gone out with him for a couple of years… And yes we used condoms!” She stabbed me with a sudden glare and turned her head away again. “I did everything right, but I still got it.” She sighed heavily and stared at her lap again. “I mean, how do I know I don’t still have it -but without symptoms? Or that I haven’t gotten it again from somebody?” Her hands were nervously clasping and unclasping. “They did a laparoscopy shortly after the infection and it was normal, but that was years ago…”

The time for my questions was over; I let her talk.

“I read that PID [pelvic inflammatory disease] can be silent after an infection and the damage can be going on even without symptoms…” She considered that for a second or two. “I suppose I twisted my doctor’s arm to do the laparoscopy. But anyway, she didn’t find anything. Nothing abnormal.” Another sigh. But my girlfriend kept warning me about it, so of course I read as much about it as I could online. I even looked at videos of operations for PID…” Her eyes teared up immediately. “I couldn’t stop looking at them,” she managed to whisper between sobs. “They were terrible! Frightening: great slimy fat tubes stuck to bowels and everything… And in some of the videos, when they tried to dissect them, there was blood everywhere! And pus oozing out of dark little spaces the tubes had walled off…” She considered the implications of what she’d said and closed her eyes briefly. Hid behind her face. “I’ve hardly had sex since that Email and I’m never going to trust anybody again,” she blurted out abruptly with her fists clenched. “I mean I keep thinking about those videos; I wake up in the middle of the night, and there they are, running through my mind!”

She stared at my face for a second. “You think I’m stupid for watching all those videos, don’t you?” she yelled at me. “But I couldn’t help it! I just knew that it was going on inside of me: big fat greasy sausages filled with sticky white ooze..!” And then, just as suddenly she stood up and pinned me to the wall with venomed eyes. “You’re the same as all the rest, you know. And I know you don’t believe me!”

She turned and walked to the door. “And don’t bother sending anything to my doctor in Ontario, either. I’m gonna find another one.”

She disappeared through the door leaving me wondering how I could have handled things differently. But in a moment a head poked around the door again –but only briefly. Awkwardly. “I’m sorry doctor… You’re really great! Honestly.” And then it disappeared into whatever hellish world it was forced to inhabit.

Did she have PTSD? A variation of it somewhere on the spectrum? Or was she just embarrassed that she’d disclosed so much to a stranger? I suppose I’ll never know, but I hope that somebody, somewhere, takes her seriously. She, just like anybody else with PTSD has a life to live. Deserves to live.

The Crown Jewel

 

Ahh, those were the days! The days when naivete reigned. The once-upon-a-times when my practice was young and everyone around me seemed old. They spoke a language I had not anticipated in my training; they seem to have subscribed to different dictionaries, or the words were smudged so they did their best with what they could make out. I began to wonder if my background in the prairies had hidden me from modern descriptive English. Cloaked me in innocence. After all, it was the place where I was assured by a teacher in grade three that Winnipeg was the only place in the world where we did not speak with an accent.

Of course, since then I have lived in many places, and my vocabulary has expanded accordingly -but it is the jargon of common things by and large: words we might use with a person in the office, or a friend at a coffee shop. Every day things… Doctors generally do not unwrap their esoteria in public, and their user-unfriendly descriptives for particular bodily parts or conditions go largely untranslated. Unappreciated in the main. And anyway, most people have their own names for the stuff.

But when you’re first starting and building a practice, the world is freshly scrubbed and terminology an adventure. I quickly discovered that patients are wont to try new doctors in a never ending quest for clarity –someone whose explanations they can understand. Someone who doesn’t have to resort to pointing at the area in question. We are all under somebody’s microscope.

*

It was only my second month in practice, and I wasn’t very busy.

“Doctor, I hope you can help me,” the olive-skinned woman said as soon as she sat down. Her long black hair was carefully pinned on her head, but as she gestured, little strands would escape and cross her eyes like windshield wiper blades. Far from annoying her, she hurried the transit in a trained fluid sweep of her head as if it was an integral part of her everyday speech.

She was a heavy woman, but dressed in a stunning green blouse and black jeans, she wore her weight, like her height, as a gift. The most striking feature about her, though, was her eyes. Intense and brown, they prowled the room in search of prey, then fastened upon me like a cat, and once engaged, stapled me to my chair.

I struggled to disengage and tried to focus on her chart for a moment. Usually there is an explanatory referral letter, but there were only three words scrawled in pencil –hurriedly, I think, because they were almost undecipherable.

My face must have fallen, because she unlatched her eyes, scanned the upside-down letters, and said, “Dr. Edwards is a man of few words, eh?”

I looked up, embarrassed at my inability to decipher the letters, and turned the page so she could read it. “Any idea what it says?”

She studied my face to see if I was kidding. “He was kind of puzzled by my stuff, so he told me to explain it to you… Anyway, it says ‘something quadrant pain’ –whatever that means.” A mischievous look snuck onto her face and her body shivered ever so slightly, the movement slowly descending like a wave. “I’ve got pain in my parts… My private parts,” she added quickly, concerned that fancy might draw me to more public venues.

“And when do you get pain… there?” I asked, hoping for more clarity.

She thought about it for a moment. “Well, mostly during my monthlies I suppose, but occasionally during his act.” I must have looked blank, because her eyes dropped briefly as she searched for a more apt description. “You know,when he… walks through the door,” she said, and sat back in her chair convinced she had simplified the term.

She struggled through her history with a litany of words I had never heard before. Things like ‘tweenie-legs’ and ‘bloaty-stuff’ surfaced briefly, then sank just as quickly after I’d made a stab at translating them into something I could dictate to her doctor.

But when we’d plodded through the symptoms and I’d had a chance to examine her, it seemed likely that she had endometriosis –a painful condition where some of the endometrial cells that normally line the uterus and are expelled during menstruation, are forced back through the Fallopian tubes into the abdominal cavity where they can grow.

The condition is usually diagnosed and treated with a laparoscope –a telescope inserted through the belly button under an anaesthetic. Pretty standard stuff. But this seemed to worry her more than the condition itself. “I’m kinda worried about my crown jewel,” she said, her brown eyes watering.

I smiled and assured her that I would not be taking anything out of her. I had heard the expression ‘crown jewels’ before but always in the plural, and never referring to women. But, summoning up a vague memory of trash talk in the YMCA locker room, I assumed it was a code for ovary and not wanting to become entrapped in another of her semantic vortices, I left it at that.

*

The last thing she said to me in the OR before the anaesthesiologist put her to sleep was “Careful of the crown jewel, eh, doc?” I touched her shoulder reassuringly and watched her close her eyes as the medication took hold.

“What was that about?” the scrub nurse said as she was prepping her adomen.

I shrugged. “I was hoping I was the only one who didn’t understand…”

Belly buttons are interesting areas, I have come to realize. They exist in all sizes and shapes. Their contours run the gamut from vertical alignment to transverse and since the laparoscope has to be inserted through it, the incision has to be similarly tailored so it is inapparent after it heals. Hers was distorted, however, so I found I had to be creative. I ended up cutting a short horizontal line about as long as my little finger nail on its lower edge much to the surprise of the resident doctor who was assisting me.

“I’ve only seen it cut vertically,” she said with some hesitation evident in her voice. It wasn’t exactly a criticism –residents don’t usually criticize their staff- but I could hear the implied judgement in the tone. I smiled beneath my mask, and said something to justify my decision. But it was a bluff; I recognized my heresy all too clearly. If it healed with a ridge, or a scar, there might be complaints. It made me all the more determined to leave her ovaries unharmed.

And then, after dealing with the endometriosis, and dictating the operative report, I promptly forgot about the navel issue. Until, that is, she returned to see me several weeks later.

*

She sat down opposite me as she had that first time, but her eyes were so intense I could barely see her face. “What did you do, doctor?” she said in an accusatory tone before I could even open her chart.

“Do you still have the pain?” I asked carefully –almost shyly, given the spotlight of her eyes. I felt naked in their allegation. Like I had done something wrong.

She turned down the wattage and I could finally see the smile that had been in possession of her face all the while. “No, of course not…”

‘Of course not’? I took a deep breath as the memory of her umbilical incision rose slowly and painfully into my chest; my resident had been right.

“How did you do it?” she said a little too loudly, her eyes firmly grasping my head. “My friends all noticed; everybody’s been commenting.”

“I’m sorry,” I managed to mumble, my cheeks no doubt red with the effort. “I don’t underst…”

“The belly button!” She interrupted and then almost jumped across the desk in her frenzy. As it was, she leaned so far she was almost touching me. Then she relented and retreated slowly into her chair. “You know what I do, don’t you?”

Actually, I didn’t –in those days I rarely noticed if a profession was written on the chart- but I could hear the word ‘lawyer’ humming softly in the background.

“I dance professionally,” she said. “I specialize in the danse du ventre, to use my favorite description.” I think I must have accidently raised an eyebrow, because she rolled her eyes impatiently and added “A belly dance!”

“I still don’t…”

“My crown jewel,” she said, carefully enunciating each word as if speaking to a slow child. “I wear a ruby in my belly button as part of my act.” My face stayed blank. “It always falls out unless I glue it in. Those kittens are heavy, you know. Especially when you’re moving everything around.”

“So..?” I didn’t know where she was going with this, so I tried to stay neutral. Sensitive.

“So whatever you did worked… Sits in there like a baby in a blanket now.”

I allowed myself a smile.

“The girls in the troupe are all impressed,” she said, positively beaming. “I told them to pretend they had pain in their parts so they could get to see you.”

Well, I guess it’s a start, eh?

 

A Medical Dilemma

Here’s an outrageous assertion: there are some things that we just cannot control. Worse, sometimes they are undefineable – or at least so vague as to defy placing them on some scale or other. Ranking them in terms of importance either to us, or to others. Naming them for future reference. And if we cannot even assign a name, categorization is slippery, too.

All of us experience these uncontrollables. Sometimes we are suddenly enveloped –a fog that obscures direction so completely that we are lost, abandoned in a terrifying limbo- but as often, we wade in from familiar territory until, over our depth, we panic.

Doctors, among others, seem to gather these fractious elements like apples in a basket we scarcely notice we are carrying. Its not that we are incompetent –although circumstances often determine competency, don’t they? It is that situations pile up like obstacles -and detours, of necessity, require changes in direction. Unintended changes. Routes that, until they are explored and charted, make regaining the original destination difficult, if not time consuming.

A recent example from my practice: suppose, for a moment, you are a gynaecologist who has been referred a young woman with a benign tumour, a uterine fibroid, say. Even though fibroids –benign overgrowths of uterine muscle tissue- are fairly common in middle age, fibroids of significant size are unusual in young women. You are reassured by many factors in your investigations thus far, however: the ultrasound appearance, the blood tests measuring tumour markers, and her general good health. She has no pain; she has no symptoms, and the fibroid is small -only 1 cm in diameter. And, as important, a clinical examination does not hint of cancer, or demonstrate a lack of mobility of the lump in her pelvis that might indicate malignant attachments. She has simply been plucked from the realm everyday existence by a test done for something else but which found a tiny mass on her uterus.

She is barely out of her teens and as yet unattached, but dreams of a relationship and children –the proverbial girl next door. Her life has been turned upside down in an instant, and intimations of mortality that should not be collecting outside her door for years are suddenly apparent -a tree branch scratching her window in the night.

You discuss the features of fibroids, show her what she has on a diagram, then answer her questions and attempt to calm her down. Finally, after considering all the factors in her case, you speak to her of what you would recommend: observation and reassessment with another ultrasound in 6 months. Perhaps sooner if she develops any symptoms –pressure, or pain with sex, for example.

But she is worried, and all of your explanations have only served to reify the alien lump, hitherto hidden and unnoticed. It is real for her now, and it shouldn’t be there. The fact that her mother required a hysterectomy for them in her forties after years of heavy periods and pelvic pressure, has always weighed heavily on her.

You put down your pen, and listen as she tells you how she has researched the various therapeutic options online. You have already discussed them, of course, but have counselled against their use because of the small size of the lump. She smiles at you, because she agrees she is not a candidate. No, she wants the lump surgically removed –a myomectomy- before it gets too big. Before it causes symptoms. Before it interferes with becoming pregnant.

It is always difficult to disagree with a thoughtful person who presents her arguments in a cogent and reasonable fashion, but one always has to help the patient weigh the risks and the benefits more objectively. More contextually. Especially when you feel that surgery is not indicated. There are risks to surgery –major risks. Risks that are obviously assimilable under certain circumstances, but in your expert judgment, not hers. Fibroids grow slowly, so there is certainly time to consider less invasive options. Some sort of a compromise is in order.

You attempt to do this, to help her stand back and consider her request within the landscape of her actual needs. You try to help her to separate her concerns about the fibroids her mother had to have treated when she was much older, and her own situation.

But she is adamant. It can be done laparoscopically –belly-button surgery- so she will not even need much time off school, she points out.

When you still are hesitant, she breaks down in tears and heads for the door, sobbing. You relent and say you are willing to refer her for a second opinion, secretly hoping the other surgeon will be able to convince her to wait. But she is not listening any more; you have failed her.

But have you? At what point can failure be assigned? Does a reluctance to acquiesce to demands which are predicated on fear and misunderstanding constitute failure? Or is failure actually the opposite: going against your considered judgment to please the patient?

Years ago, I saw a very similar person –the daughter of a doctor in another part of the country she immediately informed me. She was adamant about wanting surgery –felt she was entitled to it, in fact. And encapsulated in the trappings of my recent specialist status, I was equally certain of my opposition to it. She was quite verbally abusive to me when I wouldn’t change my mind and also walked out of the office, but not in tears… She had a smirk on her face.

She was a heavy woman, a smoker, and although in her twenties, not in the best of health. We weren’t doing many difficult laparoscopies in those days, so any surgery would have required a large incision –her abdomen was obese and pendulous- and several days in hospital to recover. In her case the fibroid was only 2 cm in diameter –still small. Still observable over time.

I was puzzled by the expression on her face until I learned from my secretary that she was actually scheduled for a myomectomy with another surgeon in another town –but not for a month or two. She had been hoping I could schedule it sooner in my hospital.

I felt guilty, although I couldn’t really understand why. She was a poor operative risk despite her age, and the surgery was unnecessary anyway. I wondered whether I had made the correct decision, or whether I had been unduly influenced by her being rude to me when I’d tried to present the reasons for my opinion. Had pride clouded my judgement? Had she been right all along?

So, did I fail her? Or did the other surgeon? Were we both manipulated?

There is a condition called pulmonary embolism that occurs when a clot formed in a vein breaks free of its source and travels to the lungs to obstruct the blood supply. Some factors increase the risk of forming clots –major surgery, obesity, smoking, immobility… An embolus can kill if not treated immediately. Nowadays, we recognize these risks more readily and will prophylactically employ anticoagulation –blood thinners- to decrease the likelihood of clot formation. We ambulate patients more quickly and educate them about the risks.

In those days, I think we were more concerned with the risks of anticoagulation –bleeding internally, for example- than we are today. And so, especially in the non-teaching hospitals in small towns, prophylactic anticoagulation was not a routine standard of care. In fact, it was usually only considered in patients with more extreme and identifiable risks –cancers, for example. The regimens and even the choices of medication were limited then; surgeons were rightly as afraid of the treatment as of what it prevented. Risks had to be balanced. Managed.

I mention pulmonary embolus, because that patient died from one. I only found out weeks later when the surgeon phoned me after he discovered my consultation letter that the referring GP had forwarded to him. He was devastated, as were we all.

It’s easy to be revisionist in retrospect –especially years hence when protocols have changed, not to mention knowledge and available medications. We see the world through modern lenses and judge in the light of current knowledge. Things change. It was –and is- a tragedy that it happened. And it’s a burden which that family –and that surgeon- will carry forever. But in fairness, how critical can we be? Should we be? The assimilability of risks varies over time and things we might consider preventable nowadays, were understandably viewed differently then. Not only do things change, things happen.

Hopefully we learn from them.