Special Populations Flashcards
1
Q
ED patients with special needs
A
- Forensics
- Sexual Assault
- Domestic Violence
- Developmental delay
- Failure to Thrive
- Homeless
- Wheelchair, quad/paraplegia
- IVDU
- Under arrest, prisoner
2
Q
Forensics
A
- 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
3
Q
Principles of forensics
A
- 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
4
Q
sexual assault
A
- ~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
5
Q
sexual assault: the exam
A
- 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
6
Q
Colposcopy and Toludine Blue
A
- Colposcopy for magnification
- Toluidine Blue highlights disrupted mucosa
- Most common sites for injury: posterior fourchette and fossa navicularis
7
Q
Myths of sexul assault
A
- 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
8
Q
after the assault
A
- 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
9
Q
Domestic Violence/Interpersonal Violence
A
- 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
10
Q
Red flags in DV/IPV
A
- 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
11
Q
SAFE questions
A
- 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
12
Q
DV/IPV
A
- 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
13
Q
DV/IPV myths and facts
A
- 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
14
Q
Recognizing child abuse
A
- ***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
15
Q
classic metaphyseal-epiphyseal injuries of child abuse
A
