Special Populations

Question 1

ED patients with special needs

Answer 1

• Forensics
• Sexual Assault
• Domestic Violence
• Developmental delay
• Failure to Thrive
• Homeless
• Wheelchair, quad/paraplegia
• IVDU
• Under arrest, prisoner

Question 2

Forensics

Answer 2

• Forensic = pertaining to or belonging to the legal process
• ED providers are the interface between the patient and the state in public health, legal and justice systems
• Reporting requirements
• Medical record is discoverable; valuable as first record of event
• Victims of crime often present directly from crime scene to us
  
  • Coroner: if dead in the field, suspicious or unnatural
• “Evidence is fleeting”, time sensitive
• ED role:
  
  • Evidence detection/description
  • Evidence preservation
  • Evidence collection if appropriate
  • Documentation
  • Preserve “chain of custody”
  • Cooperate/work with Law Enforcement

Question 3

Principles of forensics

Answer 3

• Observe the state of the injury – acute or old?
• Don’t miss, lose or destroy evidence:
  
  • Thorough history, thorough exam
  • Measure, describe injuries
  • Don’t throw evidence away or wash it off
    
    • Clothing, debris, stains, foreign bodies, etc.
  • Do not alter the wound(s) if possible
  • Describe exactly and only what you observe
• Photos: police or by ED staff
• Avoid interpreting your findings

Question 4

sexual assault

Answer 4

• ~288,000 adult sexual assaults/yr in U.S. (2015)
• That’s ~one every 109 seconds
• Estimates: about 1/3 are reported
  
  • Forcible rape: carnal knowledge of a female without consent (Uniform Crime Reporting Program, FBI)
  • December 2011, UCR program changed the definition: “Penetration, no matter how slight, of the vagina or anus by any body part or object, or oral penetration by a sex organ by another person, without the consent of the victim”
• Campus, jails, military, LGBTQ, homeless, disabled, recent immigrant, sexually exploited minors/adults
• ED is where survivors are examined and evidence is collected
• SART = Sexual Assault Response Team
• SANE = Sexual Assault Nurse Examiners
  
  • Non-physician forensic examiners, specially trained in this field – adults and children
  • Examine, collect and control evidence and testify to findings
  • >600 programs in US
  • Team approach: Examiner, social services/advocacy, police, DA’s office, crime lab all collaborate
• Provides consistency, expedites care
• Familiarity with local crime patterns

Question 5

sexual assault: the exam

Answer 5

• Police, EMS or self-present
• Stabilize unstable pt first
  
  • Stability trumps evidence - always
• Police jurisdiction (where it happened) authorizes evidence collection
• Advocate is with patient at all times
• Detailed Hx of assault
  
  • California 923 form – state protocol
• Head to toe exam for injuries, forensic evidence
• External genitalia, speculum and anal/rectal
• Evidence collection:
  
  • Swabs, hair, vaginal secretions, etc…
  • Colposcopy, Toluidine Blue, photos
• Screening and prophylaxis for STI and pregnancy – HIV prophylaxis not routine

Question 6

Colposcopy and Toludine Blue

Answer 6

• Colposcopy for magnification
• Toluidine Blue highlights disrupted mucosa
• Most common sites for injury: posterior fourchette and fossa navicularis

Question 7

Myths of sexul assault

Answer 7

• Absence of genital injury is common: about 50%
• Sperm is found in only about 10% of survivors
• 85% of females know their assailant
• The absence of genital injury does not imply consent
• Absence of sperm does not imply that penetration did not occur
• Presence of sperm implies penetration took place – does not speak to consent

Question 8

after the assault

Answer 8

• The “system” is improving – exposure; news, part of national consciousness
  
  • Collaboration, training
  • National DNA Data Base – “cold hits”
  • Qualified Expert Witness pool
  • Police SVU, Sexually Exploited Minors Programs
  • University campus response
  • Addressing backlog of evidence kits
• The effects on the survivor
  
  • Post traumatic stress disorder common
  • Missed work, disrupted lives
  • Cost to society

Question 9

Domestic Violence/Interpersonal Violence

Answer 9

• Prevalent, insidious, destructive, cyclical
• Our Role
  
  • High index of suspicion, identify, acknowledge, inform, report, refer
  • Mandatory reporters in California
• Involve social services to help
• Collaboration: DV Reporting Project at HGH
• Documentation of injuries and history (quotes, exact phrasing) is key

Question 10

Red flags in DV/IPV

Answer 10

• Injury pattern: often central area of body, under clothing
• Injuries of various ages
• Delayed presentation
• Inconsistent history
• Partner’s behavior
• Patient’s behavior
• Sexually exploited minors
• Chronic, confusing complaints
  
  • HA, GI, pelvic pain
• Pregnant pt
• Mental Health issues
• Drug or alcohol abuse

Question 11

SAFE questions

Answer 11

• Safety/Stress
  
  • Do you feel safe now? Stressors?
• Afraid/Abused
  
  • Afraid now? Abused before?
• Friends/Family
  
  • Do friends/family know?
• Emergency Plan
  
  • Prepared and/or safe place to go?
• Prepare yourself for pt’s who do not wish to report or accept resources, help

Question 12

DV/IPV

Answer 12

• Lethality Index
• Behaviors that predict high risk for homicide
  
  • Choking
  • Gun in home
  • Threat to kill themselves/others
  • Alcohol/drug use in the home
  • Stalking behaviors
  • Sexual assault

Question 13

DV/IPV myths and facts

Answer 13

• Healthcare providers are good at recognizing DV.
  
  • False: only 8% of injuries/ailments are correctly attributed to DV.DV is common, but death is unexpected.
• DV is common, but death is unexpected.
  
  • False: 44% of women murdered by DV have ED visit for DV w/in 2yrs of death
• DV victims are not known to healthcare system.
  
  • False: 23% of DV pt’s have 6-10 ED visits, 20% have >11 prior visits before recognition

Question 14

Recognizing child abuse

Answer 14

• ***Injuries inconsistent with history
• ***Injuries inconsistent with stage of child development
• Multiple differing histories
• Poor eye contact, nutrition, hygiene
• Minimizing injury, delay in treatment
• Patient clings to suspected batterer
• Child excessively attached to or afraid of parent
• Child excessively ingratiating to examiner
• Patterned burns, classic injury patterns

Question 15

classic metaphyseal-epiphyseal injuries of child abuse

Answer 15

Question 16

elder abuse

Answer 16

• Hx does not match bruises or injury
• Weight loss
• Dehydration
• Depression
• Decubitus ulcerations
• Poor hygiene
• Medical “noncompliance”
  
  • Missed appointments, etc
• “Dropped off” at ED – no one available

Question 17

developmentally and intellectually disabled

Answer 17

• Down Syndrome, Fetal Alcohol Syndrome, Cerebral Palsy, Autism, neuropsych disorders, etc
• Hx and exam can be difficult
• 85% estimated to operate intellectually at 5th grade level – you must adjust
• 25% have significantly increased pain thresholds – atypical and late presentations
• Caretakers are key – establish baseline, clarify medical history, know approach, how to keep pt calm
• Anxiolytics often useful
• Medical issues increase with age

Question 18

Common medical issues in developmentally disabled

Answer 18

• Cardiovascular
  
  • Congenital heart dz, great vessels
  • CAD common as get older
• Infection
  
  • Skin (MRSA), otitis media, dental, UTI/pyelo, occult infections
• Injury
  
  • Self-inflicted (often d/t anxiety), abuse, neglect
  • Osteopenia common: fx
  • Pica, Foreign Bodies, bezoars
• Endocrine
  
  • Diabetes, hypothyroidism
  • Vitamin deficiency
• Psych
  
  • Agitation – consider acute delirium
• Neurologic
  
  • Seizures very common
  • Delirium more common
  • Hearing loss, vision loss (cataracts)
  • Atlantoaxial instability (Down’s)
• Gastrointestinal
  
  • Esophagitis, PUD
  • Constipation, fissures, impaction
  • Appy, volvulous, perf, etc…all harder to diagnose
• Abuse
  
  • DV, sexual assault (3-5x higher than typically developed)
  • Neglect, poor support

Question 19

Failure to thrive

Answer 19

• Pt’s who cannot adequately care for themselves in their current situation
  
  • Inadequate care, resources, food, situation, mental capacity
• How did they come to our attention?
  
  • Overwhelming medical condition
  • Sudden deterioration or delirium? Work it up
• Need placement; “social admit” – admit until placed by Social Services
• Prepare for admission: basic labs, CXR, EKG
• Difficult: loss of independence, privacy
  
  • Elderly – may minimize, deny situation
  • Desire to continue to use alcohol/substances common
• “Dumping” – family disappears, takes a break

Question 20

Homelessness

Answer 20

• Many definitions: nowhere tonight to current lifestyle
• ED is often the PMD
  
  • Follow-up, keeping appointments, participating in tx plan all related to priorities, transportation, resources
  • Chronic illnesses: neglected, out of control
• Exposure and self-care issues
  
  • The elements, prolonged walking, need to move
  • Inability to bathe, change clothes/socks
• Alcohol, drug use, psych disorders very common
• Crowded living conditions, shelters, food from unreliable sources - all predispose to illness
  
  • TB, pneumonia, hepatitis, GI complaints, STI’s, lice, etc
• How can we help you now?
  
  • Medical or social problem? Both?
  • Women – always ask about abuse, sexual assault
    
    • Common to exchange sex for food, drugs, protection
    • Homeless women with kids – very high risk
  • Chronic pain, drug seeking common
• ED work-up: undress, tx as any other pt
  
  • Vitals, pregnancy test; alcohol, utox
  • Assess suicide risk, psych issues
  • Worry about alcohol withdrawal
  • Feed the pt
• Social Services for shelter, if pt wants it
  
  • Is a complete lifestyle change really on the cards today?
  • Be realistic, watch your own agenda

Question 21

wheelchair, quad-/paraplegia

Answer 21

• Issues often related to:
  
  • Home support/transfer, catheter issues, infection, pressure sores, aspiration
  • Fever, abnormal VS always significant in someone wheelchair bound
• Biggies: always consider these w/ fever
  
  • Urinary tract infections – most common
    
    • Self-catheter or indwelling catheter
    • Huge risk for UTI/pyelo – change catheter, culture
    • “Silent” sx’s, hydronephrosis
  • Infected pressure sores, osteomyelitis
    
    • Inspect all, wound care consult
    • Chronic osteomyelitis common
  • Pneumonia; GI issues: perf, obstruction
• DVT and PE risk from immobility

Question 22

intravenous drug use

Answer 22

• The route is a problem
  
  • “Skin popping” when veins run out
  • Abscess, nec fasc, endocarditis, etc..
• Overwhelming priority to avoid drug withdrawal symptoms dominates lifestyle, choices – watch those judgments
• Lower pain threshold, require higher med doses due to tolerance – but treat their pain
• IV access often an issue: central line, US guided; try IM first until IV established
• Overdose reversed with Narcan
  
  • Observe for 60-90min. No sx’s? OK to d/c
• Methadone for admitted pt’s only
• Suboxone if ready to quit today and withdrawing

Question 23

IVDU medical issues

Answer 23

• IVDU with a fever: DDx
  
  • Endocarditis - Staph Aureus 50%, tricuspid valve 40%
  • Epidural abscess - back pain w/ weakness & IVDU: MRI
  • Pneumonia – often atypical organisms, TB
  • Dyspnea? Think septic pulmonary emboli - CXR
  • Abscess – fever is worrisome – necrotizing fasciitis
  • Wound botulism – descending weakness, ptosis, weak voice, DTR’s intact
  • Cotton fever – rapid onset flu-like sx’s, benign, resolves 24hrs
• “Pocket” shooters – pneumothorax if miss
• Foreign bodies – broken off needles – xray à
• Heroin withdrawal
  
  • N/V, diarrhea, chills, malaise - miserable
  • Tx with Benzo’s, IV fluids for dehydration
  • Suboxone if want to quit today

Question 24

Under arrest, prisoners

Answer 24

• “A society is measured by the treatment of its prisoners” -Winston Churchill
• ED often sees pt’s for:
  
  • Medical clearance for jail after arrest
  • Injuries sustained during crime or arrest
  • Forensic evidence – alcohol level, etc
  • Incarcerated pt’s with serious medical issues
• Issues:
  
  • Pt confidentiality – police stand by – can ask to leave
  • Pt’s will be restrained – cuffs, chains - disconcerting
  • Multiple pre-existing illness – infectious, cardiac, pulmonary
  • 70-80% some form of substance abuse
  • Don’t ask why they are under arrest – does not affect your tx