"Get your finger off my clitoris"

I expected a beast. I almost hoped for a beast. I would have been happy with a lunch-lady looking behemoth sporting foul breath, a hairy mole, and a gunt that hung down to her knees. She was supposed to be ornery too. Like a drill sergeant who just found a jelly doughnut in your footlocker, barking orders and screaming at you to drop and give her 50 for inserting the speculum incorrectly. I walked into the examination room and sitting on the table in a loosely-fitting hospital gown was a very good looking athletic woman in her early 30's.

"Hi guys, my name is Capeli and I am going to teach you the breast and pelvic exam! Aren't you excited! I sure am!"

The four of us, Minerva, Aladdin, Torres and I, somewhat shocked, smiled and nervously introduced ourselves. I didn't shake her hand. You have to understand that the person giving us the instructions on how to perform the female exam is also the person upon whom we were to perform the exam. As in "gently insert your index finger into MY vagina, being careful not to touch MY anus, and now see if you can spread MY labia with your free fingers." She was clearly working hard to put us at ease with her upbeat attitude. Either that or she was just one big bucket of crazy.

We started out with the relatively easy breast exam. Capeli had a sing-song way of going through the procedures of how to perform the maneuvers of the exam such that it felt like we were learning gynecology from Sesame Street.

One of these lumps is not like the others,

One of these lumps just doesn't belong...

We settled on the batting order for the evening. I was first up on the breast exam followed by Torres, Minerva and then Aladdin. For the pelvic portion, Torres was leadoff, Aladdin was in the two spot, Minerva was our three batter and I was hitting cleanup.

The breast exam went off pretty well. We all performed the exam as directed and save for a little extra "good job" pat Torres gave the nipple at the end of his exam, we were consummate professionals. But really, that was the breast exam. That was child's play compared to the real challenge of the evening, the pelvic exam.

Torres was first to perform after we had a complete run through of the procedure. Because he was first to act, there was a fair amount of fumbling and questions of "is this it?" In the end, he managed to see everything that he needed to and was congratulated by our fine instructor. Aladdin was up next. Aladdin is left handed. Everything he saw and was taught he had to translate to his dominant hand. He was doing great until he was asked to move his hand into a fornix to attempt an ovary palpation during the bimanual exam. So here is Aladdin standing at the end of the exam table, between the footrests, with his left hand inside, palpating the cervix. Capeli then said to him, "now move over here to my left fornix" and patted near her hip with her left hand. Aladdin, wanting to do exactly as he was told, started to walk over toward Capeli's left flank and stand next to her ovary. He looked as if he was going to climb, hand still inserted, over the footrest and to her side to where she motioned him to move.

Capeli started asking vehemently "Where are you going!? Where are you going!?"

Aladdin froze, wondering himself why he took her literally when she said to move to her left fornix.

Capeli began to laugh. A lot.

I began to laugh. A lot.

Torres began to laugh. A lot.

Capeli's laughter caused her pelvic muscles to contract around Aladdin's hand. A lot.

Capeli began to apologize for crushing Aladdin's hand, while laughing. A lot.

I quickly moved from laughing a lot to that uncontrollable, I-know-this-is-inappropriate-but-I-can't-help-it, yeah-dude-let's-pack-the-bowl-again laughter.

Minerva started punching me to get me to quit laughing.

So this is the picture of our learning our first gynecological exam: Aladdin's hand is being crushed inside the vagina of a woman laughing hysterically, tears literally rolling down my cheeks as I grab my abdomen trying to control myself with Minerva repeatedly punching me in the shoulder to get me to stop laughing, and Torres simply standing back, hands in the air like he's being arrested with that "is this really happening?" shit-eating grin on his face.

Next it was Minerva's turn. She was a natural. But as you know, when you own the equipment, you can practice any time you want. She did have a little trouble keeping her extra-vaginal digits tucked into her palm and at one point Capeli admonished "Tuck those fingers, don't you dare put your thumb in my butt".

By the time I went, I had seen the exam four times. I managed through it without too many fumbles. The speculum was in a little off-center, but I could still see the cervix. As I was examining the external genitalia, Capeli said, rather loudly and a little angrily, "Hey, get your finger off my clitoris!" All I could think to myself was "Doesn't that just fucking figure. The ONE time I'm not supposed to hit it..."

Then it was over. It only took us 2 hours to learn all the procedures. We made a few mistakes and were a little embarrassed, but we made it through and are the better for it. I'm also happy to report that Minerva and Aladdin respected the gas barrier.

Next semester, we tackle prostate exams.

T minus 2 days to vagina

I almost forgot!! My pelvic and breast exam date has been moved up. This Tuesday, October 24th, I am scheduled to perform my first breast and pelvic exam. Included in this exam will be:
1. Complete breast exam, including nipple discharge check
2. Single digit vaginal exam
3. Bi-manual vaginal/uterine/ovary palpation
4. The always-a-crowd-pleaser bi-manual recto-vaginal exam.
5. Fecal occult blood test

I think Minerva and Aladdin are in my small group for this.

The gas barrier

Where to start, where to start? I have so much to write/brag/bitch about. Well, it’s mostly bitching, but that’s no surprise; it’s really what I’m best at. I’m feeling very relaxed having just returned from a weekend in Vermont at Minerva’s family vacation house. I’ll break this post down into vignettes:

The saga of the scrubs:
Last year I was chosen to be on the board of our school’s Emergency Medicine Society (EMS). The EMS is simply our little interest group where we hold events about the specialty. As a member of the 4 member board, I am responsible for organizing events and scheduling physicians to be at them and various and sundry other crappy obligations that go along with the job. One of these jobs is to run the annual fund raiser that the EMS puts on. This fundraiser is simple, the EMS sells scrubs (those green pajama-like uniforms that nurses and physicians wear) to the first year students. The first year students traditionally wear them in anatomy lab because 1) everything that goes into anatomy lab comes out smelling like a cadaver and better it be a set of cheap scrubs than your new Lacoste polo with the freshly popped collar, and 2) they want to look just like real doctors and wear scrubs. So here’s the strategy: first years order scrubs from me, I assemble these small orders into a large mega-order and get a bulk discount, I then charge the first years slightly less per set of scrubs than they would pay if ordering independently yet more than I pay for the bulk order. Nothing could be simpler, right? In walks the US Postal service. There were 11 boxes in the shipment of 352 sets of scrubs. I received 10 boxes and one little 3x5 index card telling me that I had to go to the post office to get #11. I figured it was a small pain in the ass, but at least they all showed up somewhere, so I went to get the final box. On my third visit to the post office, they finally admitted that they had no idea where the box was. On my way home from the post office that same day, I got a voice mail message that says the box has been located and is ready for pickup at the post office I WAS JUST AT. So the next day I go back to the post office and show them the little card, they go in the back for another 20 min and finally come back to tell me that the box is out for delivery to my house. Then they ask me if I will be at my house to take delivery.

I ask “when?”
They say “now.”
I say “I am here now, how can I be there now?”
They say “That’s OK, the delivery person will leave a little 3x5 card and…”
Then I make the New York Times afternoon edition in which my friends describe me as a normally quiet guy who kept to himself a lot.

The Devil
About 2 weeks ago we took our first of two Nervous System and Human Behavior exams. The exam, she was a bitch. We, as a class, did not do as well as usual. Minerva, Aladdin (Minerva’s boyfriend) and I also did not do as well as we normally do. We didn’t fail or anything, but relative to the amount of work we put in and our self-perceived level of understanding of the material, we did poorly. On all of our exams we have attached to it what is referred to as the “ambiguity sheet”. This is the area in which we have an opportunity to let the course faculty know about questions we found hard to interpret or were otherwise shitty. Many, many students filled out the ambiguity sheet for this exam. I can only imagine that reading these sheets was a lot like that scene in “Good Morning Vietnam” where they read all the hate mail Lt. Hauk gets after he takes over for Adrian Cronauer. “ ’Hey, Hauk. Eat a bag of shit. You suck.’ Now that's pretty much to the point, sir, not much gray area in this one.” So the course leader decided to reply to these constructive criticisms and prove just what a douchebag he really is. Here are some excerpts:

Someone raised a question as to why we were testing on a historical theory that is now obsolete. One of the problems with multiple choice questions is it is very difficult to write questions that test "important knowledge" without giving the knowledge away and thus making the quesiton (sic) important but trivial to answer. And it is very easy to write a question that is of trivial importance that is hard to answer.

Guess which difficulty option he went with.

About half the ambiguity comments showed not that you didn't understand the question because it was ambiguous but rather that you didn;t (sic) understand the question because you didn't understand the material.

You’re right, just like when someone makes a shitty movie, it’s the audience’s fault.

The fact that you were given the final diagnosis should just have reinforced what I have said many times; it isn't about getting the right answer, it's about having a list of possibilities that include the right answer.

Is it too much to ask that your multiple choice questions have a list of possibilities that include the right answer?

We hope peer pressure and cooperation will work where testing falls short.

And here I was hoping for a cogent presentation of the material coupled to clear educational objectives.

I’m a little unhappy because I truly enjoy the material in this class. It’s probably my favorite class information-wise of all my med school classes so far. However, the course leader is such a perfect jack-ass that it ruins what should be a terrific experience. His ass-clownery has even drawn the ire of one of the other course faculty members who now refers to him and the other co-leader of the course as “the axis of evil” and to him specifically as “the devil”.

Getting comfy with friends

I have written about Minerva and Aladdin before in this blog. She was my anatomy lab partner and is also my general study partner. Aladdin is her boyfriend and also studies with us. The three of us went up to Vermont this weekend to hang out at Minerva’s family vacation house. It’s beautiful up there.

The weekend consisted of apple picking, cooking, drinking, cheese tasting, drinking, hiking, watching "The Office", and drinking. Minerva and Aladdin took the opportunity of showing how close we all have grown as friends by breaking the gas barrier. The gas barrier is the point in a friendship where open flatulence becomes acceptable. The real problem lies in the fact that I am famously shy about gas. There are very few people with whom I have felt comfortable enough to stray from the very best in gas control behavior. I am simply not there yet these two yet. Now, after the weekend, I am pretty sure that humans were not intended to consume, within a 24 hour period, grass-fed beef chili, asparagus, crab bisque, gorgonzola cheese, artichokes, tilapia fillets, apple crisp with vanilla ice cream, and copious amounts of double-brown ale. At the very least you should not consume these with other humans who ignore the gas barrier.

And finally, just for Joe:


















I like what I’m seeing in your blog pics.