Things are never what they seem

My patient was a petite, thin 16 year-old. She sat on the exam table, shoulders hunched and staring at the floor while her mother told the story.

"I found a towel saturated with blood in her hamper." I listened but mentally wondered exactly saturated was. People tend to over-estimate the amount of blood.

The girl said she had started her period and had bled more than normal. She had awakened after it started and used the towel to clean up. She said the bleeding had pretty much tapered off and showed me a half saturated pad that she said was over an hour old.

I wondered if she was pregnant and miscarried and was trying to hide it from her mom. I started an IV and drew blood for chemistry, blood counts and type and screen. I explained that we would have to do a pelvic exam. She had never had one before so I spent some time explaining the procedure and getting her ready.

The doctor, a woman, had a reputation for unshakable calm. We positioned the girl in the stirrups and she gently inserted the speculum. As she opened the speculum a huge clot came loose followed by an unstoppable torrent of bright red blood.

The doctor said to me "Get some help in here."

I hit the code button.

I'd never seen that blood coming out of a woman's vagina before - it was horrifying. The doctor was using suction to try and locate the source to no avail so she started packing the vagina. Fluid boluses were hung and pressure bagged. The patients pulse was climbing and blood pressure falling. After 2 liters of saline we hung uncross-matched blood. The OR crew arrived and stood outside the door waiting for the GYN doc to arrive.

Shortly after that he arrived. The room looked like a slaughter-house. Two 1.5 liter suction buckets were filled - more than half the patients blood volume. Uncross-matched blood was being infused via the rapid transfuser. The ER doc had her hand in the patients vagina putting pressure against many yards of vaginal packing. The patient lay limply on the stretcher, semi-conscious.

Within minutes the whole entourage was whisked up to the OR. The ER doc was gone for over an hour. When she returned she told us that the patient was slightly more stable - the GYN surgeon had found a huge, jagged vaginal laceration that had torn an adjacent artery. It was a wonder that the patient hadn't bled to death at home. But how had it happened?

The sad story emerged days later. She had gone on a date with an older boy. He became angry when she wouldn't have sex with him and raped her. He was rather a large male and she was a small, petite girl and a virgin besides and she tore inside. She was bleeding heavily when she got home but was too ashamed to tell her mother. When the bleeding stopped she hid the towel and went to bed, terrified but trying to forget the ordeal.