A former comedian, Dr. Sparkle now works in the Emergency Room of a major American city. No, her name isn’t really Dr. Sparkle, but everything else you’re about to read is absolutely true.
Though this story begins like a joke, it’s really more of a riddle: a woman walks into the ER with right lower quadrant pain, vomiting, and fever. Any ER professional automatically considers the possibility of appendicitis with this triumvirate, as I did. She was ill-appearing and very tender on the lower right abdomen, which compelled me to begin an appendicitis workup. I ordered a CT abdomen/pelvis with oral contrast, which would light up her intestines demonstrating the fecalith, or poop rock (not to be confused with my preschooler’s favorite type of music), most likely causing the inflammation and infection of her appendix. I called surgery for an early evaluation so they could prepare their minds and their OR for a probable appendectomy.
A couple of hours later, the CT results came back, negative for appendicitis. I was stymied. I called the radiologist to discuss his findings. He said that there was definitely “something” causing problems in the lower right quadrant, and he asked me if I had done a pelvic exam. Shamefully, I had not yet done so. He said, “There is something in her pelvic cavity, and I bet that’s where the money is.”
I grabbed the necessary items for a pelvic search and recovery mission: a pelvic speculum, an exam light, giant plastic clown-sized forceps and an open mind. As soon as the exam began, I knew this was indeed where the money would be. Her nethers smelled like a skunk crawled up her vagina, barfed on itself, then shat himself, then endured a slow, disgusting death in there. Time to mouth-breathe, girl. Then, I visualized a shiny, wrinkled object in the far reaches of the right vaginal fornix. Using my trusty purple forceps, I snagged it, pulled it out gently and showed the patient a pungent, purulent, old condom. She was as disgusted as I was, though she noticed something quickly that I did not when she ejaculated, “Whoa! There’s still nut up in it!”
For those of you not fluent in this vernacular, by “nut,” she was of course referring to the remaining semen that stayed in the reservoir tip of the condom. Perplexed that she was more surprised that the condom had “nut still up in it” rather than that the condom was rotting inside her pelvis, I reluctantly replied, “Yes, there is still nut up in it. But do you happen to remember how long ago you had sex?” She could not even remember when this forgotten soldier was left behind in the battleground. She said that maybe it had been a month. This woman went from a slam dunk appendicitis to a Toxic Shock Syndrome caused by a month-old decomposing condom, with residual nut.
There is an expression in medicine that “When you hear hooves, think horses, not zebras.” Usually the signs and symptoms that you discover in a patient are probably not the obscure things you would never think about, but rather they’re usually the most common diseases or diagnoses. But after evaluating this patient, I have since come back to that adage and reconsidered it. Now, I refer to this classic teaching and I say, “When you hear hooves, think horses, but make sure it’s not a Zebra with a nut-filled condom in its vagina.”
Illustrations by Kelly Harper