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In truth, I don't expect patients to know when something is wrong. That's my job. But I'd like to care for just the ones who are pretty sure something is wrong, as opposed to those who feel OK but just want my confirmation. I'm pretty sure the Farouks would never have come in for that final degree of reassurance if they had thought they'd have to pay up.

This is our dirty little secret, the biggest gripe of emergency doctors and nurses everywhere: The only patients we truly despise are the ones who would never come in if they had to exchange money for their peace of mind.

Here's how this ludicrous, egregiously excessive episode looks from inside the pit: We had to evaluate six patients who had already recovered from a minor gastric irritant, tying up the ambulance people, triage and treating nurses and keeping the doc (me, goddamn it!) from taking care of someone else who might actually have been sick or injured.

Candidates for the SPY, like contenders for the Museum of Bad Art, are not as plentiful as it might seem at first glance. The shortlist is colorful and instructive all at once.

To wit: In the midst of an ice storm, I once treated a store clerk who had sprained his ankle four or five days earlier; it looked mildly swollen but otherwise unharmed, and signs of resolution were clearly evident. And while I had not actually watched the guy walk in on his own two feet, he crossed a sheet of ice to get to me, which indicated he could get from place to place.

Hemming us in on all sides were literally dozens of other people with freshly fractured bones. I put on my "honest guy" face and told the clerk squarely that he was clinically clear, that I was relying on my judgment, and my judgment alone, to penetrate through the layers of skin to see that his ankle bones were intact. He looked right back at me, in his "honest guy" face, and told me that he would feel much better if the final say came from an X-ray.

I traded my "honest guy" face for my "customer is always right" face, but just for a second. Then I tried to be a hero. "Honest guy" face came back and said that the backup in X-ray was hours, and that it would take even more time to look at his film and then have the radiologist confirm my reading. I really wanted to save him the wait.

But he put on his "what do you take me for, some kind of a chump?" face and told me he wanted the X-ray. So I put back on my "customer is always right" face and promised I'd be back in a jiffy. And sure enough, hours later, he found out that nothing was wrong.

Now while you may find his story intriguing, just wait until you hear about the progenitor -- and the inspiration for the SPY award. Her story comes from the category with a fathomless pool of aspirants: stupid genital tricks.

The amateurs vying for this award have run through a numbingly familiar ensemble of tricks: the lock around the testicle, the exotic-lotion burns on moist mucous membranes, the items inserted into various openings. Yadda yadda. But the most sublimely ridiculous encounter of my entire medical career, one that has nestled itself quite fondly in my heart, occurred when I was a resident. Janey (not her real name) showed up one day in the pelvic room after her boyfriend found something in her vagina that, try as they might, they couldn't get out.

"Did you put anything in there?" I asked.

"Not really," she said. She knew I was going to ask this; she had already been asked by the triage nurse. The registration clerk had duly noted her chief complaint as "FB vag," or foreign body in the vagina.

"What do you mean, 'Not really'?"

She and her boyfriend had been playing "rough" a week earlier, and he may have put something up there in order to just take it out again -- like a game. "I don't remember leaving anything in there, but, you know, something might have gotten lost. You know?"

No, I don't know about these things, but I do know fishing, and this was a fishing expedition. A female (nurse or tech) always escorts male physicians who perform pelvic exams, and the nurse helping me that day relayed (out of earshot) the string of things that had at one time or another been recovered from vaginas in the E.R.: a condom, a dildo, a french fry, an egg (in the shell), a marble, a Tylenol bottle, a light bulb (small, décor-style), a roll of film, a set of keys, one of those poofy-hair voodoo dolls.

After several attempts outside the door to quell our hysterics, we returned to the room to position Janey in the stirrups and trawl for treasure. I opened the speculum and looked.

Nothing. Empty.

"Ummm ... " I started. (How does one go on in such a situation? What would Miss Manners do?) "There's nothing in here. Are you sure it didn't come out?"

"No, I felt it in there just before we got here."

Alrighty, then. I looked at the nurse and she shrugged, biting her cheeks. "You look," I told her. She didn't see anything, either.

I stood up to do a manual exam. Maybe it was really small and somehow hidden behind a fold or recess. I pushed on Janey's cervix to see if there was any tenderness.

"That's it. You got it."

"This?" I said, wiggling it.

"That's it. It feels round."

"What did you find?" the nurse asked.

"When did you lose this in there?"

"I don't remember. Maybe a couple of months ago."

Months? I thought. "This is your cervix, it belongs there. You're supposed to have one of these." I jiggled it again. The nurse lost it, bending over in a fit of choking laughter.

"That's what my boyfriend was grabbing on to."

I hope he didn't try too hard to get it out.

When, as sometimes happens, I burst into spontaneous laughter, it's because I find myself thinking of Janey's acceptance speech for her lifetime achievement award.
salon.com | March 3, 2000

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