The Physician Assistant Experience

Last Friday night I had the pleasure of spending my evening in the basement of the medical school in a room with four instructors and six students. It was a cool breezy evening and after much misdirection and locked doors I found myself in a classroom wearing my white coat and being lectured to on the not so subtle nuances of the Speculum. For those that are male and have never had a cervical exam, the speculum is the instrument used to expand the introitus of the female vagina in order to view and culture the patient’s cervix. 

Here  is an informative site for as to the procedure and equipment used: http://www.speculum.com/    

In the world of speculums there are three sizes (Grave’s, Pederson’s and Huff’s) but there are really only two materials that they are made of. There are the plastic speculums which must be first observed and handled as to decrease the likelihood of sharp edges. The plastic products are entirely plastic so all of the locking mechanism create a “clicking” sound for the provider and a “clicking” sensation to the patient. This might not be a sufficient reason for its disuse but does require the a verbal ”heads-up” for the patient as to the sensation during the procedure.  The metal speculums seem to be all the rage at the moment. They are less likely to have sharp edges, and they can be reused once taken apart and autoclaved (cleaned by the same medical sanitation department that  cleans all of the surgical equipment). Metal as a great conductor  is often found at room temperature, which for most patients feels cold on their skin. It is important to warm up the speculum with warm water before insertion. Water is suggested as the only form of lubricant because the results are still out as to the affect of the lubricants on the cultures that you are trying to obtain. The use of lubricant in a cervical exam seems like a “no brainer” but the discomfort of the procedure and the need to do it again if results are inconclusive weight heavily in favor of warm water and good lab data. 

The speculum chat that we got that Friday night was short and informative. (Earlier in the semester we were briefed on the procedure, technique and all equipment used)  Out of the six students that were there we were broken up in to two groups of three. Each team of three went with one model and one instructor to a room where the cervical exam would be demonstrated and then each student would conduct the procedure once.

I did know that this is why I drove to the medical school that night. I fully understood the depth and seriousness that a procedure like this carried. I had seen a couple videos and had been told numerous stories about different experiences some good, some bad. But I couldn’t really say that I felt ready for it.

The cervical exam was demonstrated on an attractive middle aged woman and the exam was carried out by another middle aged women, both of which were instructors. The part of the cervical exam that should not be understated in its importance is the subtle use of appropriate language and touch.

If you sit and think for a real long time, no matter your gender, you are hard pressed to conjure up a position more awkward and compromising that than of lithotomy. Lithotomy is the position that the patient is sitting in during a cervical exam. The patient is leading back at roughly a 45 degree angle on an exam “table” with her feet in  ”foot rests” and the legs separated at the knees for ease of viewing and room to maneuver. The patient is not wearing any clothes below the waist and its covered only by a sheet.  Though this position in optimal for the exam, it is embarrassing to even to think about and often elicits much guarding and insecurity on behalf of the patient.

The use of the quotes (“) in the above paragraph speaks to the importance of correct language during this exam. The phrases “bed”, “feel”, “spread your legs” are removed from the vocabulary and substituted for “table”, “touch” and “could you please move your knees out to meet my arms?”. Words like these are used to desexualize the experience for the patient. A female patient with a male practitioner administering the exam can escalate in to an uncomfortable situation when terms are used loosely and without forthought and care. What is going on prior to, throughout the exam is nothing more than a part of the medical model for the inspection of the human body. But when the organs being inspected are  sex organs the importance of respect and professionalism are paramount.

So there I stood about to watch my first cervical exam. I stood with hands clasped and noticed all too late that the room was a little warm and kinda stuffy. The exam had begun and as students we were allowed to move about to gain better angles of viewing the procedure in order to ask questions and clear up any uncertainties. Well, uncertainty was about all that I was feeling at the time.  I was in a room with 2 other female students and two female instructors. I had arrived with 3 other female students and they paired off with their female instructors as well. It was late at night and I not only felt like I was the only male in the building but that I was quite possibly the only one left on earth at that given moment.  I started to fade from the exam, I remember hearing voices and then the voices started to echo a bit. I knew that I was about to pass out. If anyone had bothered to turn around to look at me they would have been able to visually recognize what I was already feeling. There was no longer any color in my face.  I felt the warm rush of blood draining from my face and pooling behind my ears thus creating a feeling of light-headedness that is never desired. I started to enter the fog bank that suddenly appeared in front of me. The room got quite and the lights developed halos around them. I took a step back and rested against the other “table” in the room. No one noticed me as I sat there trying desperately not to loose consciousness. I worked on my breathing and talking myself in to thinking that this was the first of many cervical exams that I would be giving in my career, so why not start now? The sweat started to dry and the temperature dropped withing my chest. The room came back in to view and the noises were again recognizable voices.

I was not embarrassed. You get to a certain point in the medical field when you have seen so many people pass out and heard horror stories of people passing out in labor or while observing a surgery or bedside procedure. If you remain straight and tall and never flinch, it does not make you strong nor your peers envious of your ability. People pass out for all kinds of reasons, fear, sadness, joy, orthostatic hypotension, sickness, and the general feeling of being overwhelmed.

I was about to pass out for the same reason that I almost passed just prior to drawing someones blood for the first time. I was fearful that I was going to cause someone pain. It is a different thing watching someone who is pharmacologically incapacitated during an open heart surgery. That patient is mentally somewhere else and is hopefully not going to have any recollection of the procedure. But when you are about to stick someone with a needle and you know full well that it is going to hurt a bit, it seems you are under a mountain of pressure to do it fast, correctly and while causing as little discomfort as possible. Emotionally, that is where I was that Friday night in the basement of the med school. I was worried that I was going to cause even the smallest amount of pain to the young woman who sat  in front of me, while she was awake and cognisant of my every move.

With my head now clear of any fog and my vision no longer clouded by halos, I was able to recognize that the cervical exam that has just been demonstrated was now finished. Few.

And then came the question. So, who’s scared? asked the instructor.

I raised my hand. And then realized that I was the only one with my hand in the air. “GREAT, you’re gonna go first!”  On the spectrum of possible outcomes when admitting that you are scared or full of fear,  being elected to go FIRST was not even a consideration.

There was no turning back. There was no one in the room that wanted to go first and I had somehow in the most unintentional way ever, elected myself to do so. I had a thousand thoughts running through my head, not limited to but including:

• Really, I was just completely snowed in over there in the corner during your demonstration.
• I missed the demo and almost passed the F&#k out and you want ME to go first!!
• I can see myself settling down on to the stool, regaining that warm, clammy feeling, starting to sweat and passing out face first in to a vagina.
• I’m the only person in the room not in possession of a vagina and you think I should lead off!
• Is this a JOKE!
• DAMNIT.

But you take a couple deep breaths, and do it for the sake of learning and understand the privilege that is, working with real patients,  while respecting and appreciating the the women that volunteer.  These ladies allow students like me to view and inspect them in THE MOST vulnerable position ever known.

To those women, I sincerely thank you.