# Did we screw this up? 14yo, ETOH



## adamjh3 (Apr 2, 2011)

Called to an adolescent psych screening facility last night, AOS at approx 2030 to find a 14yo F, 5'4 approx 140lbs laying in bed responsive only to pain. There's a small puddle of vomit on the floor next to the bed. 

Info from the Nurse states she was BIB CVPD on a 5585 hold (72hr psych eval for minors). Facility was advised that Pt was found by her mother passed out drunk at a park. Mother got her in the car and took her immediately to the police department. The only solid time we (the EMS crew) were able to get was 1855, when the 5585 hold was written by PD. Pt states she's "depressed about her parents divorce" and feels she shouldn't be alive. 

Facility states Pt has vommited twice since her arrival, most recent being 5 minutes prior to our arrival.

We're able to get out of her that she was with a group of people and was in a fight, physical exam shows a bruise approx 3cm in diameter left and superior to pt's left eye, dried blood on pt's L elbow with no associated wound or bruising. Chest and abd negative. Pt denies pain, states nausea, does not recall vommiting earlier. 

We load the pt into the ambulance approx 7 minutes after arriving on scene
V/S as follows:
P: 112
R: 14, shallow but effective, 99% R/A
BP: 98/58
Eyes: PERL 6
Lungs: clearx4
A&ox2, person, place, unaware of date, time, claims minimal recollection of event, states LOC but cannot give a specific time 
Skins pink, cool and dry. Ambient Temp of about 70 degrees farenheit, Pt. states she feels cold. 

As far as treatment, Tx in POC, ASPT, Heater turned on and patient wrapped in blanket to keep warm. 

ER we're Tx'ing to is directly across the street, 1 minute Tx, we get there and turnover care w/o change or incident. 

Here's the part my partner is kicking herself over. She noticed her nylons were torn on the inside of the thigh and crotch area (Pt. was wearing a very short black dress) but didn't think anything of it until we were already back at station. 

How badly did we screw up by not asking about sexual activity?


EDIT: Oh and, if we responded to this as ALS, would you run a fluid bolus and give some Zophran even though you're across the street from the hospital?

EDIT #2: forgot to mention, pt stated she drank two 4lokos and "a bunch" of shots of vodka


----------



## ffemt8978 (Apr 2, 2011)

adamjh3 said:


> How badly did we screw up by not asking about sexual activity?


Let me ask you this.  Given your stated transport time, what would have changed if you HAD asked that question, especially of a patient who is AOx2?


----------



## adamjh3 (Apr 2, 2011)

ffemt8978 said:


> Let me ask you this.  Given your stated transport time, what would have changed if you HAD asked that question, especially of a patient who is AOx2?



Point, even if she said no, she's not a reliable source as there was LOC and she's only AOx2. But would it help to ask just as something to pass on to the ED if the answer was affirmative? Or are we better to leave that to the folks in-hospital who may be more specialized in dealing with instances of sexual assault?

I suppose the question is, when there is LOC with ETOH involved, is it proper or expected for pre-hospital providers to ask specifically about sexual assault?


----------



## MMiz (Apr 2, 2011)

A few points:
1.  I don't think you messed up.
2.  In the situation you posted I would not ask the patient about her sexual activity.  I don't see how it would have impacted your treatment, and I would imagine that it would be part of the hospital's more thorough exam.
3.  Most ALS units I worked with would have started an IV before we transported.  They liked to keep their options open should the patient's condition change.

Life isn't a DVR.  You can't rewind and go back and change what's already been done, and I'm not sure that you'd want to in this case.


----------



## ffemt8978 (Apr 2, 2011)

adamjh3 said:


> Point, even if she said no, she's not a reliable source as there was LOC and she's only AOx2. But would it help to ask just as something to pass on to the ED if the answer was affirmative? Or are we better to leave that to the folks in-hospital who may be more specialized in dealing with instances of sexual assault?
> 
> I suppose the question is, when there is LOC with ETOH involved, is it proper or expected for pre-hospital providers to ask specifically about sexual assault?


The hospital is going to do their own history and exam, and most of the hospitals I've seen don't put too much faith in what information is provided to them by EMS.  They run down their checklist of questions to ask, regardless of what they've been told by the ambulance.


----------



## JPINFV (Apr 2, 2011)

ffemt8978 said:


> The hospital is going to do their own history and exam, and most of the hospitals I've seen don't put too much faith in what information is provided to them by EMS.  They run down their checklist of questions to ask, regardless of what they've been told by the ambulance.




Would you not reask pertinant questions to your patient even if reported by someone else, regardless of the level of the person you're receiving report from? Do you not repeat exam components regardless of what is reported? If you're on an IFT and received report from a pulmonologist that the patient has rales, would you not listen to the lungs because a pulmonologist said the patient had rales? It has nothing to do about trust, it has to do with the fact that you [general "you"] are responsible for the care you render and if an exam component can be repeated easily and unobtrusively, should be repeated.


----------



## ffemt8978 (Apr 2, 2011)

JPINFV said:


> Would you not reask pertinant questions to your patient even if reported by someone else, regardless of the level of the person you're receiving report from? Do you not repeat exam components regardless of what is reported? If you're on an IFT and received report from a pulmonologist that the patient has rales, would you not listen to the lungs because a pulmonologist said the patient had rales? It has nothing to do about trust, it has to do with the fact that you [general "you"] are responsible for the care you render and if an exam component can be repeated easily and unobtrusively, should be repeated.


True, but with a one minute transport time, how much should you do before driving across the street?


----------



## JPINFV (Apr 2, 2011)

adamjh3 said:


> Here's the part my partner is kicking herself over. She noticed her nylons were torn on the inside of the thigh and crotch area (Pt. was wearing a very short black dress) but didn't think anything of it until we were already back at station.
> 
> How badly did we screw up by not asking about sexual activity?



Did you screw up? Meh, how much training on taking a sexual history do you have? How many times in the past have you taken a sexual history? More importantly, how many times have you asked about sexual assault? Was the torn nylons reported to who ever you turned care over to? 

Should you have asked about it? Probably. Is it something likely to be missed by people further down the line? Probably not. Would I expect the average EMT to ask about it? No, but who wants to be average?


----------



## JPINFV (Apr 2, 2011)

ffemt8978 said:


> True, but with a one minute transport time, how much should you do before driving across the street?



That can be asked about anything, though. If it's a 1 minute transport, why even bother conducting a physical exam or obtaining a history if it's not going to change the transport decision?


----------



## MMiz (Apr 2, 2011)

JPINFV said:


> Did you screw up? Meh, how much training on taking a sexual history do you have? How many times in the past have you taken a sexual history? More importantly, how many times have you asked about sexual assault? Was the torn nylons reported to who ever you turned care over to?
> 
> Should you have asked about it? Probably. Is it something likely to be missed by people further down the line? Probably not. Would I expect the average EMT to ask about it? No, but who wants to be average?


I would have serious concern about asking a 14 year old intoxicated and disoriented female about her sexual history as a medical provider that is going to treat her for only minutes.  I can't see how the answer of that question will impact my treatment.

As a male provider that did many psych transports in the wee hours of the morning, I tried to minimize my patient contact and interaction with female pediatric patients.  I was professional and brief.  Lights on bright, me on the bench seat, and patient on the PulseOx was the norm.  I focused on assessing the patient in the sending facility with my partner and staff present, while I monitored the patient's condition while transporting.  In this case I certainly wouldn't ask a pediatric patient about his or her sexual history in the back of my rig.  I would document what I saw and pass along any concerns to the receiving facility.


----------



## abckidsmom (Apr 2, 2011)

MMiz said:


> I would have serious concern about asking a 14 year old intoxicated and disoriented female about her sexual history as a medical provider that is going to treat her for only minutes.  I can't see how the answer of that question will impact my treatment.
> 
> As a male provider that did many psych transports in the wee hours of the morning, I tried to minimize my patient contact and interaction with female pediatric patients.  I was professional and brief.  Lights on bright, me on the bench seat, and patient on the PulseOx was the norm.  I focused on assessing the patient in the sending facility with my partner and staff present, while I monitored the patient's condition while transporting.  In this case I certainly wouldn't ask a pediatric patient about his or her sexual history in the back of my rig.  I would document what I saw and pass along any concerns to the receiving facility.



This is a really good point.  A provider I know who is completely trustworthy and follows rules similar to what you set out had an allegation of inappropriate touch recently with a teenaged intoxicated patient that was only dismissed AFTER his two other (female) partners gave separate stories that matched his and not the patients.

If he had not had the third provider in the back of the ambulance with him, that could have been a devastating, career-stopping court case.  As it was, it was just a terrifying morning in the cheif's office.

I would report physical findings to the receiving facility, but I probably would not ask a patient with an altered mental status anything about a potential sexual assault.  It could plant memories that aren't there, it could include me in a subpeona when I don't have any reliable information for the court, and it could make the patient think of me when she recalls her assault. 

No thanks.

I don't think you guys messed up at all, OP, and I would have given her fluid and zofran.  I don't let people with an altered mental status puke if I can possibly help it.


----------



## Veneficus (Apr 3, 2011)

adamjh3 said:


> How badly did we screw up by not asking about sexual activity?




I wouldn't say it was an issue.

All females between the ages of 9 and 55 are pregnant until proven otherwise. 

Since there are no documented cases of asexual human reproduction, and you would have a very difficult time proven divine conception, by default they are also sexually active.


----------



## Aerin-Sol (Apr 3, 2011)

I wouldn't have asked even with a longer transport time, especially as I'm BLS. What would be the benefit to the patient? It won't change anything I do, so why make her think about it before we get to someone who can actually do something about it?


----------



## abckidsmom (Apr 3, 2011)

Aerin-Sol said:


> I wouldn't have asked even with a longer transport time, especially as I'm BLS. What would be the benefit to the patient? It won't change anything I do, so why make her think about it before we get to someone who can actually do something about it?




Let me make this real clear...if she's been assaulted and has a normal mental status, she IS thinking about it.  Your talking about it or not has no bearing on that.  If you talk about it, she may get upset, she may cry, she may close down, but if someone is fresh from a sexual assualt, they are going to be thinking about it one way or another.

The riskiness here is the altered mental status.  She may insert memories into her assualt story, she may later say almost anything that seems like the truth to her, but might even get you involved in the assault story.

Sexual assualt patients:  assess them as needed, then cover them well.  This functions to create a barrier between you and the patient that can prevent allegations, their modesty is indulged, and you are preserving their clothes and any evidence that may be on there.

Let them talk if they  want to, and tell them they *can* talk if they want to, but don't drill them for details.

What you *can* do is confirm your suspicions and make sure your are taking the patient to an ER with forensic nurses, and that you convey your suspicions to the staff.  The nurses are usually on the ball, but if you saw something on the scene that leads to your conclusion, you need to make sure they know what that was.  Without the scene in the picture, sometimes it isn't completely clear what's happened to the patient.

This is not a lecture at you, I just don't like hearing EMS providers say, "What can *I* do?  I'm just giving her a ride."  You're a member of the team, and if you always act like a healthcare provider, eventually everyone will.


----------



## adamjh3 (Apr 3, 2011)

JPINFV said:


> Did you screw up? Meh, how much training on taking a sexual history do you have?


Just what I got in Basic class, so... next to none.


> How many times in the past have you taken a sexual history?


Just once, 17yo F out of the same facility complaining of abd. pain/nausea, w/ menstrual cycle late by ~8 weeks.


> More importantly, how many times have you asked about sexual assault?


Never. 



> Was the torn nylons reported to who ever you turned care over to?


 Negative. Partner gave the turnover, and as I said, she thought nothing of the torn nylons until we were already in quarters.


> Should you have asked about it? Probably. Is it something likely to be missed by people further down the line? Probably not. Would I expect the average EMT to ask about it? No, but who wants to be average?


That's reassuring, this thread has given me a lot to think about.



abckidsmom said:


> Sexual assualt patients:  assess them as needed, then cover them well.  This functions to create a barrier between you and the patient that can prevent allegations, their modesty is indulged, and you are preserving their clothes and any evidence that may be on there.
> 
> Let them talk if they  want to, and tell them they *can* talk if they want to, but don't drill them for details.



This is basically what I learned. Though, I never learned anything of dealing with possible victims with AMS. As I said in this very post, this thread has given me a lot of material to mull over. Thanks, everyone.


----------



## cruiseforever (Apr 8, 2011)

What do these mean?  BIB CVPD    There are to many abrevations used when people are telling stories.  What might be common for you has a totally diffrent meaning for me.


----------



## adamjh3 (Apr 9, 2011)

Ah, I was literally copying exerpts from my partner's PCR without checking over abbreviations. Brought In By a local Police Department


----------



## reaper (Apr 9, 2011)

Good reason why you should learn not to use abbreviations in charts. Does not take much effort to write it out and there is no confusion.


----------



## adamjh3 (Apr 9, 2011)

Eh... the company has a list of approved abbreviations, and the narrative box is very small on our forms, making it almost necessery to abbreviate.

But I do agree, when speaking with others outside of the company, I should avoid abbreviations.


----------



## reaper (Apr 9, 2011)

Most companies do have a list. Does not mean you have to use it! You can attach a sheet of paper for your narative too.


----------

