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Emergency Medicine Module 3 > Special Populations > Flashcards

Flashcards in Special Populations Deck (24):

ED patients with special needs


•Sexual Assault

•Domestic Violence

•Developmental delay

•Failure to Thrive


•Wheelchair, quad/paraplegia


•Under arrest, prisoner



  • 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


Principles of forensics

  • 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


sexual assault

  • ~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


sexual assault: the exam

  • 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


Colposcopy and Toludine Blue

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


Myths of sexul assault

  • 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


after the assault

  • 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


Domestic Violence/Interpersonal Violence

  • 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


Red flags in DV/IPV

  • 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


SAFE questions

  • 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



  • 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


DV/IPV myths and facts

  • 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


Recognizing child abuse

  • ***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


classic metaphyseal-epiphyseal injuries of child abuse


elder abuse

  • 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


developmentally and intellectually disabled

  • 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


Common medical issues in developmentally disabled

  • 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


Failure to thrive

  • 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



  • 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


wheelchair, quad-/paraplegia

  • 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


intravenous drug use

  • 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


IVDU medical issues

  • 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


Under arrest, prisoners

  • “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