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Man sodomized in NYC ED
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We've always assumed this would happen sooner or later. He may have a case. I do think it's interesting that the assault charge against him for hitting a staff member was dismissed. The last time I saw a nurse try to press charges on a patient for an assault in the ED the cops laughed at her.
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There was a pretty funny episode of Family Guy with a similar plotline. When you find yourself imitating Peter Griffin, it's time to take a good look at the direction your life is going...
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Welcome to the trauma bay! The same thing happened to my homophobic husband after he got into a car accident (thank god he was alright). Although he tried to stop them, he realized later on it was for his own good! 
I say screw this guy. In the trauma bay, you don't have time to distinguish a patient who is agitated from neurological injury/shock and one who just REALLY doesn't like rectals. Of course, the utility of the rectal per se is the subject of another thread....
"he may have a case"?? do you really think so? We do this all the time.. someone comes in, MVC with head wound, combative ie: altered, who here wouldn't RSI this guy for a head CT?
I had a guy just yesterday with a T11 and T12 fracture after a fall, when I came back to check on him he was standing in the middle of his room reaching up to change the channel on his bedside tv.. people are idiots about their care, and sometimes it's up to us to do what's right.
Don't you think this same guy would be suing if he had a neurological impairment from a spinal injury (and also had a head injury) and the ER team said "oh well, he doesn't WANT the rectal, so we should'nt check.. You might as well sign over your house and first born on the spot.
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You guys have it all wrong. This poor man was minding his own business at a construction site trying to apply a band-air to his scalp laceration when he was abducted by some paramedics! The degenerates put him on some freaky orange plastic S&M equipment with nylon belts and brought him to the ER's "special room" where they have some freakshow called an "intern" whose sole job it is to sodomize everyone who comes in there...for kicks! And all the other people in the room just stand there and watch for the fun of it because they have nothing else to do.
Lucky for this man, a lawyer, the only person who really cares about him as an individual has taken up the cause of this man's injustice for the sake of liberty, justice, equality (and a contingency potentially worth millions of dollars).
Lucky for this man, a lawyer, the only person who really cares about him as an individual has taken up the cause of this man's injustice for the sake of liberty, justice, equality (and a contingency potentially worth millions of dollars).
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Sometimes we have Bruce Willis sitting around with a Samuri sword just in case any of the interns get a little too thorough.
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While I encourage the discussion on the matter, if anyone thinks this has anything to do with anything other than money, your mistaken.
From my uneducated legal mind, I think this one may be a slam dunk.
"Now Doctor, were you informed by the EMT that the patient was GCS 15"
"yes"
"Aaaaaannnnnddddd Doctor, did the patient refuse or voice his objection to the rectal exam"
"yes"
If it actually gets to the Jury though it will be hard to prove harm done and it will hinge on how much pain and suffering you award some one for a rectal exam.
Caveat: I'm not a lwayer I just stayed in a Holiday Inn express last night.
From my uneducated legal mind, I think this one may be a slam dunk.
"Now Doctor, were you informed by the EMT that the patient was GCS 15"
"yes"
"Aaaaaannnnnddddd Doctor, did the patient refuse or voice his objection to the rectal exam"
"yes"
If it actually gets to the Jury though it will be hard to prove harm done and it will hinge on how much pain and suffering you award some one for a rectal exam.
Caveat: I'm not a lwayer I just stayed in a Holiday Inn express last night.
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To play devil's advocate here, is there no room for patient autonomy in the trauma bay? If the patient is alert, oriented, understands the reason for the DRE, and STILL refuses, do physicians then have the right to RSI him and just go for it? Of course not.
Other than for reasons of tradition, is there any reason to do a DRE in a trauma patient in the era of ultrasound anyways? (yeah, I could medline it, but figure with all the smarties on here, somebody would know already)
Other than for reasons of tradition, is there any reason to do a DRE in a trauma patient in the era of ultrasound anyways? (yeah, I could medline it, but figure with all the smarties on here, somebody would know already)
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Seriously, though, he could have been GCS 15 per EMT but rapidly decompensated and become combative. Happens all the time, no opportunity to think it over or reason with the patient. In fact, it sounds like he was so combative they had to RSI him for the protection of himself and others (I doubt the 3 days unconscious and tube was just for the rectal).
Bottom line: if he was truly AAOx3 at the time and THAT combative, he probably deserved what he got.
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Well, no, and I think most people know that and don't particularly get off on the DRE. So I'd be surprised if they fought him and did RSI JUST for the rectal (ie, a totally compliant pt who only fought to avoid the rectal). Seems kinda weird...
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I don't think that I would hang my hat on a slam dunk win for the patients attorney.....Agitated, combative in a patient with a head injury of signifigant force. Add on unable to follow instruction (not a 15) and it becomes more and more difficult to argue that they didn't intubate to protect the c spine and then.........
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He may have a case, given that the recent trauma literature suggests that the rectal exam (in trauma) is not useful for ruling in or out much of anything.
If I'm conscious, and in a trauma, and I tell you guys no rectal, you'd better not do a rectal or I'm hunting you down one by one!
If I'm conscious, and in a trauma, and I tell you guys no rectal, you'd better not do a rectal or I'm hunting you down one by one!
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[youtube]http://www.youtube.com/watch?v=GWwSybKD4Nc[/youtube]
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I don't think we're getting the entire story. For someone who became agitated and assaulted a staff member, it sounds like he was RSI'd because of combativeness and fear that he had a head injury. He wasn't RSI'd to perform a DRE.
To play Devil's advocate: is there any research to support DRE's in trauma? I seem to recall a study done a few years ago that showed it to be pretty much useless.
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The DRE represented the old way of surgical thinking (a tube or finger in every orifice) There really has not been any evidence to show it does anything, other than turn on chief surgery residents.
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You know what sucks is I highly doubt it was the attending who DRE'd. That means some poor CC4/Intern is gonna be dragged into the middle of this. Welcome to an early education in real world medicine....
GCS of 15 doesn't mean anything.. this guy had a head injury and was combative.. maybe he was pissed about the rectal exam, but in a combative (altered) patient with a head injury after trauma, you've gotta bite the bullet and put him down for the CT.. i've seen many a head bleed with a GCS of 15.. there's no case here at all.
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Usually when you're combative and acting inappropriately, most would consider that as being confused, and thus your GCS would be knocked down a point to 14.
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Here's what I mean by "he might have a case." Unless you have thoroughly documented that he was altered or intoxicated and therefore lacked the capacity to make his own decisions he has a case. The fact that we do it all the time just doesn't matter in court. The jury, which will be full of people with no medical training and all of whom don't want to get an unnecessary DRE will be sympathetic. It's just not about what we do all the time or even if he needed it or not. It's all about if he had the capacity to refuse and informed consent.
The fact the the lit is starting to say that the routine trauma DRE is not needed is just extra ammo for the plaintiff.
The fact the the lit is starting to say that the routine trauma DRE is not needed is just extra ammo for the plaintiff.
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We are forgetting the "other" reason for the DRE, which is to assess for overriding prostate, a direct contraindication for foley catheter placement. Surely this inubated patient would have had a foley placed at some point....
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The physician, in my opinion, stuck his foot in his mouth when pressing charges against the patient (which were dismissed). The fact that the physician felt the patient should be held responsible for his actions is a slippery slope -- are you trying to prove the patient had capacity thus now should be punished for hitting you? Smooth, now when the subpoena arrives you don't believe the patient had capacity to refuse the rectal... just my 2 cents.
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I see your point about turnabout, but at the same time that double standard is applied all the time by law enforcement. People are arrested for committing crimes like assault, rape, mansalughter, etc while drunk. Drinking doesn't excuse that behavior in most cases, even if the level of intoxication was high enough that the patient was not competent to refuse medical care. It might be possible to make the same argument to a head injury patient. Someone could be perseverating, and not know the date but still be with it enough to not be excused for throwing a punch. Fine and dubious distinction I know but laywers make their ducats on those distinctions.
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This is a really good point. You can't have it both ways. I do notice that when you commit assault against a police officer while impaired you get charged and if you assault a helth care worker you get nothing. The fact is that society has tacitly decided that we are to accept violence against health care workers because the people doing the violence are impaired, mentally ill, emotional, cranky (literally and figuratively) and so on.
My understanding of the incident was that the patient was tubed after he became violent over the DRE. Yes he needed a foley once he was tubed. Did he need it before?
I have long thought that we are on risky ground when we push minor trauma patients through "the system" and do DRE and other invasive things as a matter of course. We all know that very minor traumas get upgraded by stuff like intrusion, language barriers, etc. and get violated when they really don't need it. We also all know that unless we had several gun shot wounds or a missing limb none of us would ever allow ourselves to be taken to a trauma center and put through the system. Who hasn't seen this coming?
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Your comment about the drunk driver doesn't hold water -- from the trial attorney perspective the case will proceed even if the individual was "under the influence of intoxicating substances" - we don't allow these individuals to plead out based on "state of mind" thus holding him to his actions, basically justifying the decisions he made, legally stating he was in the state of mind to make those decisions, and now must face the consequences (even though likely altered at the time).
Now we are really looking at apples and oranges, but if you make this argument, you have to be prepared to let your patient, even when under the influence, make their own decisions, even if that includes refusing the DRE. What if a patient was hit in the head with a board and then drove his vehicle striking a person on the way to the hospital, mortally injuring them? Would this driver be charged with a crime... if direct causation was based on medical illness out of the control of the individual affecting decision making capacity and therefore culpability... I think not. So then you can understand why often charges are dismissed or not even brought when an ED staff member is involved in an assault (not saying this is right or wrong).
Now my clinical judgement leads me down the informed consent/refusal route, but if the patient cannot describe back to me the risks involved in refusing treatment I don't believe I can take their word, with that being said, I usually proceed with a work-up focused on things that will acutely harm this patient. If its something that can wait then it should NOT be completed simply as part of the "standard" work-up, especially if the patient was voicing refusal in prior.
Now we are really looking at apples and oranges, but if you make this argument, you have to be prepared to let your patient, even when under the influence, make their own decisions, even if that includes refusing the DRE. What if a patient was hit in the head with a board and then drove his vehicle striking a person on the way to the hospital, mortally injuring them? Would this driver be charged with a crime... if direct causation was based on medical illness out of the control of the individual affecting decision making capacity and therefore culpability... I think not. So then you can understand why often charges are dismissed or not even brought when an ED staff member is involved in an assault (not saying this is right or wrong).
Now my clinical judgement leads me down the informed consent/refusal route, but if the patient cannot describe back to me the risks involved in refusing treatment I don't believe I can take their word, with that being said, I usually proceed with a work-up focused on things that will acutely harm this patient. If its something that can wait then it should NOT be completed simply as part of the "standard" work-up, especially if the patient was voicing refusal in prior.
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God forbid I end up in a trauma bay as a patient, I will vehemently refuse a DRE or foley, unless I'm really sick. And if I was sick / physiologically unstable, I'm guessing my GCS would not be 15 anyhow, so it would be a moot point.
I can just imagine myself now, shouting at the EP to do a MEDLINE search on the utility of the DRE.
I can just imagine myself now, shouting at the EP to do a MEDLINE search on the utility of the DRE.
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Yeah, a general rule, if your patient is refusing care and is quoting EBM as the basis for their refusal you can assume they have capacity to refuse. On the plus side you could say that their informed consent was even more informed than your own.God forbid I end up in a trauma bay as a patient, I will vehemently refuse a DRE or foley, unless I'm really sick. And if I was sick / physiologically unstable, I'm guessing my GCS would not be 15 anyhow, so it would be a moot point.
I can just imagine myself now, shouting at the EP to do a MEDLINE search on the utility of the DRE.
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I'm still not sure why so many ED residents and attendings absolutely love doing DREs. DRE for abdominal pain. DRE for vomiting. DRE for acute MI. DRE for finger laceration. I'm beginning to think some of my colleagues have a fetish.
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Someone call Bruce Willis!
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On the DRE thing... I wish we could all play together nicely and only do ONE DRE on each patient.
In the ED, when appropiate, the DRE should be done.. however, we know it will be done again... so we could stop doing DREs...that is, until we miss something, then again we would be the laughing stock..
Trauma does the DRE regardless if the ED did it and told them the results because nobody can interpret the results 'as well as they' (when in fact its usually a med student, intern, or an off service guy doing it).
Ortho comes and repeats the DRE now a third time on the trauma patient because the 'ER guys and Surgery guys are stupid and dont exam it properly'.
I was on Ortho and saw all the above pretty much happen. Poor old man, fell like 10 feet. NO defecits... of course, the ED resident did a quick neuro exam with the DRE. Trauma was called since it was over so many feet fall. They looked at the patient, a collegeaue of mine did the rectal exam (EM resident #2). Patient had only an isolated like TP fracture of T spine or something... Ortho Spine called for isolated spine trauma when cleared by regular trauma. I see the patient, dont do a DRE (he doesnt need it, and clearly the poor man has had TWO fingers in his bottom by MY other residents). I tell the ortho uppers I am with about the patient and exam, they pipe up about the DRE, I mention I didnt do it and why.. they go off on why the DRE is important and I should not be turfing off part of a good exam blah blah and that OUR OWN exam is important since you cant go by what other people report and send me (EM #3) in to do the exam once again.
In the ED, when appropiate, the DRE should be done.. however, we know it will be done again... so we could stop doing DREs...that is, until we miss something, then again we would be the laughing stock..
Trauma does the DRE regardless if the ED did it and told them the results because nobody can interpret the results 'as well as they' (when in fact its usually a med student, intern, or an off service guy doing it).
Ortho comes and repeats the DRE now a third time on the trauma patient because the 'ER guys and Surgery guys are stupid and dont exam it properly'.
I was on Ortho and saw all the above pretty much happen. Poor old man, fell like 10 feet. NO defecits... of course, the ED resident did a quick neuro exam with the DRE. Trauma was called since it was over so many feet fall. They looked at the patient, a collegeaue of mine did the rectal exam (EM resident #2). Patient had only an isolated like TP fracture of T spine or something... Ortho Spine called for isolated spine trauma when cleared by regular trauma. I see the patient, dont do a DRE (he doesnt need it, and clearly the poor man has had TWO fingers in his bottom by MY other residents). I tell the ortho uppers I am with about the patient and exam, they pipe up about the DRE, I mention I didnt do it and why.. they go off on why the DRE is important and I should not be turfing off part of a good exam blah blah and that OUR OWN exam is important since you cant go by what other people report and send me (EM #3) in to do the exam once again.
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No ****. I agree 100%. If courts won't help him I hope he gets justice other ways. I hope there is a settlement and that is hurts both the doctor and the hospital just so doctors learn some respect for people. Medical care is about people, not flow charts and turf wars over which specialty knows the inside of a rectum the best.
Thank goodness for those three magical words...Against Medical Advice.
"I do not want by blood taken"...Great then! Please sign here. Please close the door on your way out.
"I do not want a NGT"...Great then! Please sign here. You take care now.
"I do not want..." (interrupting) Great then! Please sign here. Merry Christmas.
"I do not want by blood taken"...Great then! Please sign here. Please close the door on your way out.
"I do not want a NGT"...Great then! Please sign here. You take care now.
"I do not want..." (interrupting) Great then! Please sign here. Merry Christmas.
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I happen to enjoy:
"I'm having 10 out of 10 abdominal pain, but I don't want an IV because it hurts too much!"
"I'm having 10 out of 10 abdominal pain, but I don't want an IV because it hurts too much!"
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I'll just put this orange catheter in you then...don't worry, orange is the smallest size.
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(I used to draw blood, and the nastier they were to me was proportional to the size of the needle. And was I laughing when I saw this kid from my past who bruised me and broke my toenails (kid was in a special ed camp but seemed to just need discipline - had 'adhd') but then someone came and told me he was a special one that got a butterfly (those weren't allowed even in our kits) - that burst my happy bubble)
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Whoa there! No one ever learned anything from getting sued. Lawsuits are about money, not right and wrong. Lawsuits are the reason everyone wants to do so many DREs that are likely unnecessary anyway.
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Holy Uninformed bystanding trolls batman!!!! As long as DRE is part of the ATLS training (national training here not some wierd voodoo science ****), I think someone will still be doing them (EM, Surg, Med Student, perverted nurse, whoever), in the trauma setting if they are in any way indicated by the current standards (ATLS I mean, not the most recent literature. I could quote no less than five articles that say no finger should go anywhere near that dirty plumbing). This would be say: altered patients, I mean the kind that are drunk beligerant, combative and less than a 15 GCS after blunt head trauma (or any signifigant trauma for head, neck and back...Supposedly we are looking for spinal injury right.). Will we care what they say after they hit us in the chin.....Hell no.!!! No resonable normal person (i.e able to make informed decisions about their health) would assault a MD, EMT, RN, LPN, CNA, MBA, JD, pHd, MF, BA, BS, MF, DH, whatever, who is just trying to help them....(believe me, despite what my junior residents say I have no desire to stick my finger up someones *ss.) That being said, I would probable have knocked them out and tubed them as well to treat their possible head wound (and likely to prevent further mortality secondary me turning around and beating them to a bloody pulp).....In short: Does the MD deserve to be screwed...NO! Has he taken care of people for the last ten years of his life dutifully?....Yes!!!...Will he take it up the a** for this? Yes!!! Most likely because of people like you on the jury. Congradulations. I hope your career is long and lucrative to the JD's.
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Sorry. Double post.
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1st, patient had a lac above the eyebrow, so that implies a blow to head. In that instance, you can't get informed consent due to an implied head injury. So the patient can't really refuse at that instance. If he is not struck in the head, that may be a different story, but this patient was.
2ndly, what role does U/S in replacing the rectal? I don't know any documented uses of U/S obtaining spinal cord status or bleeding in the the rectum, or possible urethral injury, all of which the rectal could tell you. Maybe I'm missing something (also needless to say a trauma rectal takes all of 5 seconds)
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Ok, so remember that in the case where you get sued for NOT doing a DRE....A DRE is a part of the physical exam, and off trauma, some feel it is useful, others don't, but its not going to dissappear so quit whining about it.
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i apologize ahead of time for the lameness, but I can't seem to control myself...
So basically, you're sued if you do, and sued if you don't!
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Exactly. Now you've got it. That's the system we are stuck with. As I've explained before, everyone loves it but us.
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I don't think that an "implied head injury" is going to be enough to show that the patient lacks capacity to refuse care such as the DRE. You really need to be able to document that the pt is cognitively unable to understand the risks of refusal.
You have to remember that you're going to be trying to sell your point of view to 12 people who don't want fingers in their butts either.
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Dumb question from the unexperienced: to determine if they have capacity, do you ask the questions to get them marked as alert and oriented x3 and then also have them memorize 3 things and have them repeat it later, or less than that?
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Not meant to derail the topic at hand (or finger), but the same thing seems to be happening in the tPA for CVA...You get sued either way....
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They have to answer yes no questions consistently, and be cooperative with exam. Anyone uncooperative gets the tube.
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That's actually a really good question. It's very subjective and complicated. Just being A&Ox3 doesn't make them able to refuse. They have to be able to understand the risks of refusing. Clearly making that distinction is problematic. A&Ois a part, if they're not A&O they usually don't have capacity, but they can be A&Ox3 and be intoxicated or injured so that they are impaired.
I usually demand they be A&Ox3, able to repeat back the main risks I give them and have a decent plan. A decent plan is "I'm going to go home and take it easy and my friends will be with me." A poor plan is "I'm going to walk up I15 to get back to Salt Lake City."
There's always a question on the oral boards about the guy who's intoxicated and wants to leave AMA. Don't do it. He always has a subdural.
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