THE COLOR PURPLE | Paul Rousseau
“Complains of colored vaginal discharge and possible foreign object in vagina.”
That’s all the chart said. I hesitantly entered the exam room, accompanied by a clinic nurse. A 15-year-old female, looking much younger than her age, sat in a chair, nervously wringing her hands. She was alone. The Free Clinic, where I was doing a gynecology rotation, did not require parenteral consent for treatment. I introduced myself, explained that I was a 4th year medical student, and that I would examine her and then have Dr. Jones, the attending physician, see her.
“Is that okay?” I asked. She nodded ‘yes.’ We were young; it was awkward for both of us.
“Can you tell me what’s going on?” I asked.
Her eyes fell to the floor.
“Um…” She paused as she anxiously opened and closed the zipper on her purse.
“Um…I had sex with my boyfriend up in the loft of our barn two days ago.” Her face blushed.
“And the next day, I had horrible pain down there.”
“Yes sir. Pain every time I pee.”
“What color is your urine?”
“Um…I’m not sure, everything that comes out is purple.”
“Yes sir, purple.” She paused. “I think I got somethin’ up there, you know, in my sex organ.”
My brow glistened with beads of sweat; this was embarrassing for both of us. “You think you have something in your vagina?” I asked.
“Yes sir, I think I got a piece of straw in my sex organ during sex.”
My mind stuttered, not sure what to say or do.
The nurse interrupted. “Doctor, why don’t you step out while I get this young lady ready for a pelvic exam?” I breathed a sigh of relief. Finally, an avenue to escape the clumsiness of my inadequacy.
I found Dr. Jones and explained the situation to him. He rubbed his chin, scribbled a few notes, uttered “That’s interesting,” then told me to do a pelvic exam and slide preps to look for a sexually transmitted disease. “When that’s done, I’ll see her with you.”
The clock on the wall slowly scratched away the minutes. I wanted the time to pass more quickly; in fact, I wanted to be anywhere but where I was. I’m sure she was just as nervous, but I was the one with authority, the one supposed to make a diagnosis, the one supposed to help her. I felt so inept.
The door to the exam room opened. “She’s ready doctor.”
I really don’t remember much about the pelvic exam, my nerves were so frayed, but what I do remember was using almost a whole tube of KY Jelly on the speculum, so much KY that it dripped on my pants, so much KY that I dropped the speculum and two slides to the floor. The nurse frowned and handed me another speculum. I fumbled as I inserted the new speculum, also dripping with KY. Finally, with the nurse’s help, I glimpsed a purple-colored vagina with what appeared to be clots, at least what I thought were clots—but no piece of straw. I swabbed the slides, finished the exam, and hurriedly left the room. Soon, the nurse followed.
“What do you think that is? Could it be gentian violet?” I asked.
She shrugged her shoulders. “I have nooooo idea.”
The slides, as best I could tell, were negative for any sexually transmitted diseases, although the purple color made it difficult to see anything; her urine was negative for pregnancy but full of bacteria and pus. I pulled a gynecology textbook from the shelf (this was the days before cell phones, iPads, and omnipresent computers) and read a few paragraphs on urinary tract infections, but was unable to find anything on purple vaginal discharge. I searched for Dr. Jones, then presented my findings.
After reviewing her slides, he looked over the rim of his glasses and asked, “Where’s your history? You told me about her intercourse, the burning, and your limited physical exam, but that’s it. You didn’t tell me her story, who she is…”
He stopped midsentence and grabbed my shoulder. “Son, listening is a form of respect. It’s how you learn about people, about illness and being sick, about disease, and most importantly, about yourself.”
He patted my back. “Let’s go see her.”
After introductions, Dr. Jones soft-spoken and folksy approach put her at ease. She began to talk openly. We sat quietly and listened to a story of pubescent peer pressure, hormones, libido, and sex, and the isolation and boredom of life on a farm with authoritarian parents.
“Sounds like it’s been a little tough for you.” She nodded.
Dr. Jones transitioned. “Tell me some more about what you did once you started to have pain.”
Her eyes looked to the floor. “Sir, I used some jelly. My momma told me to use some jelly…you know, down there, that it might help the burning.”
She hesitated for a moment. “I wasn’t sure what my momma meant, so I went to the kitchen and found some jelly.”
She hesitated again, picking at her fingernails.
Dr. Jones encouraged her. “Go on.”
“Sir, it was grape jelly, but it didn’t help the burning.”
The room was silent.
“I see,” said Dr. Jones.
He slapped his hands on his knees and stood up. “Well, the good news is there’s no piece of straw inside you, but you do have a bladder infection which we can treat with an antibiotic. So you’re gonna be fine, don’t you worry. But we’re going to have one of our counselors speak with you about having safe sex so this doesn’t happen again.”
As we left the room, I hung my head in shame, my adolescent medical skills in shambles. Dr. Jones was right; listening to patients, and listening to their’ stories, is how you learn about people and how you learn about disease. It’s like a narrative scaffold that holds everything together; after all, diagnoses are really nothing more than the stories of life, colored by the pain of disease.1
1. Rousseau P. Unspoken words. J Palliat Care 2015; 31: 268-269
Paul Rousseau is a palliative medicine physician/writer, with published essays in JAMA, Annals of Internal Medicine, Journal of General Internal Medicine, Lancet Oncology, Blood and Thunder, and The Healing Muse, just to mention a few. He dabbles in poetry and fiction, but his home is essays. Writing helps him cope, and learn, from the patients and families he sees, for suffering needs a home, and it needs a balm.