Another "sex assault" allegation

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
J

Jlaw

Full Member
10+ Year Member
Joined
Apr 15, 2009
Messages
812
Reaction score
275
Now this one sounds like BS, but another reminder to be careful out there. Basically the woman is suing Stony Brook because her rectal exam was too rough. FWIW I've seen quite a few people scream stop during rectal exams, I probably would too. Never seen a double finger approach though.

She alleges it was a sexual assault but there is no mention of anyone getting gratification from the incident, just that they were rough with her and she felt they were dismissive.

http://nypost.com/2016/05/12/finance-exec-says-er-doctor-sexually-assaulted-her/
Members don't see this ad.
 
If the encounter and exam went as described, the physician isn't about to win any doctoring awards (and should be advised to use some danged lube and a single finger next time), but it's far from "sexual assault," especially if the patient consented to the exam.
 
And what kind of GI doc sends their patient to the ED for a rectal?
 
Members don't see this ad :)
If there was no one else present, how did the hospital records show that no lube was used? Or is "lube used" and "single finger used" now something that must be charted for rectal exams in addition to guiac positive/negative, control positive, & chaperone's name?
 
  • Like
Reactions: 1 users
Who knows what really happened?
I don't always get a chaperone for rectals, but I would get a female chaperone for a younger female patient in most cases.
 
that seems super odd. nowhere in my documentation does it say if i used lube. if gi sent me a patient to do a rectal exam on, id refuse and send them back and file a complaint with the hospital.

Sent from my VS986 using Tapatalk
 
looks like BS, sounds like BS, Feels like BS, Smells like BS, even tastes like BS.
 
gman33 said:
Who knows what really happened?
I don't always get a chaperone for rectals, but I would get a female chaperone for a younger female patient in most cases.
Click to expand...

Really bad idea to not use a chaperone for elder women. Had a friend who personally knew a doc who got accused of sexual assault on a lady in her sixties.
 
  • Like
Reactions: 1 user
Always use a chaperone, describe what you're going to do, make it clear that they can defer, and stop if they say stop. Putting my finger up someone's butt or checking their genitals isn't the highlight of my day and has increasingly questionable value. That's not the hill I'm going to die on...
 
  • Like
Reactions: 10 users
Agree. Biggest issue: Always, always, always use a chaperone. It is much, much easier to defend against frivolous allegations if you do so. If not, the tendency will be to side with the accuser, valid or not.
 
  • Like
Reactions: 1 users
Do you guys name your chaperone in your note? I always have a nurse in the room for rectal exams of the opposite sex (as well as drunk or crazy men), but I've never mentioned it in my note and have only seen a few nurses notes documenting that they were there as a chaperone. As unnatural as it seems, I feel like I should probably start doing that.
 
  • Like
Reactions: 1 user
I always put the name of the chaperone in the note. They are supposed to put a not in the EMR as well by protocol, but I always ask just to make sure.

If I went the rest of my life and never did another rectal, I'd be very content with that. Right now, I only do them as CYA for the back pain patients who want to go down the every-symptom-on-wikipedia route and for GI bleeds.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Yeah I say we fund some studies to prove rectals and pelvics to be unnecessary. Especially in light of such cases. For GI bleeders, for instance, does the rectal really need to be done emergently? Can't we just defer it to the butt doctor?
 
  • Like
Reactions: 3 users
Ok I'm actually a bit serious here... When has the rectal exam ever been necessary? Even when ruling out cauda equina, has the rectal ever actually been the decider? If not, then why are we doing it? We're just increasing the chances of getting accused of assault, and for real, it's not a pleasant thing for the patient or the doctor. Let's get rid of this nonsense.

Here are some more serious people who are saying the same thing:

http://www.bmj.com/rapid-response/2011/11/02/cauda-equina-syndrome-and-rectal-examination

Should we be doing rectal exams for possible appendicitis? Especially now that we have CT scans? Here is a relevant article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071072/

Key point: "It should be performed only when the results will change the management plan."

I'm totally 1,000% biased here, since I hate doing them. But really, I have as of yet never made a decision based on a rectal exam... I've only been an attending for a short period, but still.
 
Anemic transfusion patients (w/ no clear source until exam) and 1 cauda equina pt it changed things on for me.


Angry Birds said:
Ok I'm actually a bit serious here... When has the rectal exam ever been necessary? Even when ruling out cauda equina, has the rectal ever actually been the decider? If not, then why are we doing it? We're just increasing the chances of getting accused of assault, and for real, it's not a pleasant thing for the patient or the doctor. Let's get rid of this nonsense.

Here are some more serious people who are saying the same thing:

http://www.bmj.com/rapid-response/2011/11/02/cauda-equina-syndrome-and-rectal-examination

Should we be doing rectal exams for possible appendicitis? Especially now that we have CT scans? Here is a relevant article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071072/

Key point: "It should be performed only when the results will change the management plan."

I'm totally 1,000% biased here, since I hate doing them. But really, I have as of yet never made a decision based on a rectal exam... I've only been an attending for a short period, but still.
Click to expand...
 
  • Like
Reactions: 1 user
I almost never do rectals. Perhaps the only time now is for questionable GI bleeding in a stable patient. If they result is negative they go home, and if it is positive they get admitted. I never do it for trauma, abdominal pain, hemorrhoids anymore.
 
GeneralVeers said:
I almost never do rectals. Perhaps the only time now is for questionable GI bleeding in a stable patient. If they result is negative they go home, and if it is positive they get admitted. I never do it for trauma, abdominal pain, hemorrhoids anymore.
Click to expand...

How do you get away with not doing it on hemorrhoids? What if its thrombosed? (Although I understand a wait, watch, and refer to surgeon is an option.) Just curious. Thanks.

Doesn't the patient find it odd that you're not looking at his a-hole when he comes in with that as the main complaint? "Doctor, aren't you going to look at my a-hole at all?"
 
  • Like
Reactions: 1 user
I try not to do many invasive exams.
I find that they rarely change management.
Usually the only point of the rectal is checking for blood. Give a bed pan and ask for a sample.
It's usually not super urgent.
Now in some cases it is, like as above, the stable
pt that is likely going home.

If they are getting admitted it usually doesn't matter.

I should probably start using a chaperone for all of these. Maybe I will.
 
Angry Birds said:
How do you get away with not doing it on hemorrhoids? What if its thrombosed? (Although I understand a wait, watch, and refer to surgeon is an option.) Just curious. Thanks.

Doesn't the patient find it odd that you're not looking at his a-hole when he comes in with that as the main complaint? "Doctor, aren't you going to look at my a-hole at all?"
Click to expand...

I'll look but I don't touch. No finger in the bunghole.
 
  • Like
Reactions: 1 user
I won't argue against the wisdom of chaperones, and I always let patients refuse invasive exams. But we would all do well to read the actual story and note that the patient reported hearing the doctor say “I’m already done, the show’s over” after walking out of her room.

Does that constitute sexual assault? Absolutely not. But it is probably what ultimately prompted the patient to file charges.

If you want to avoid this sort of crap be safe and be careful, but most of all don't be an a$$hole - at least not within earshot of your patients.
 
  • Like
Reactions: 1 users
Some might argue that an acutely agitated and demented geriatric patient with no other discernible cause for delirium deserves a rectal exam to rule out constipation as the cause. You can do it after the haloperidol and your risk of litigation is pretty low...
 
Dane07MD said:
Some might argue that an acutely agitated and demented geriatric patient with no other discernible cause for delirium deserves a rectal exam to rule out constipation as the cause. You can do it after the haloperidol and your risk of litigation is pretty low...
Click to expand...

Yeah........NO!
 
  • Like
Reactions: 1 user
Let's take a moment to pay respects to our old physical-exam friend, "Rectal exam: Patient declined."
 
  • Like
Reactions: 7 users
Who knows what really happened. The original article sounds like a burnt-out resident trying to quickly dispo a non-sick patient without offering adequate explanations. Definitely not "sexual assault" but does sound like poor communication/people skills, also, no lube, wtf?

I don't do rectals for trauma/abdpain/hemorrhoids either but it's still a fairly common procedure. Most commonly to rule out GIB as a source of anemia. You could wait for the patient to provide a sample, but usually that takes forever. The majority of patients who come in with "30 episodes of diarrhea in the past 24hrs" can't provide a stool sample during a 2hr ED visit so how could an 80 y/o w/ a hct of 24 be expected to? I always use a chaperone and document their name in the procedure note, along with explaining the procedure, and afterwards telling the patient the results. Every patient, every time.
 
e30ftw said:
I don't do rectals for trauma/abdpain/hemorrhoids either but it's still a fairly common procedure. Most commonly to rule out GIB as a source of anemia. You could wait for the patient to provide a sample, but usually that takes forever. The majority of patients who come in with "30 episodes of diarrhea in the past 24hrs" can't provide a stool sample during a 2hr ED visit so how could an 80 y/o w/ a hct of 24 be expected to? I always use a chaperone and document their name in the procedure note, along with explaining the procedure, and afterwards telling the patient the results. Every patient, every time.
Click to expand...

Yes, but the solitary fecal occult blood test is not very sensitive, is it? Isn't it like 30%? So, does it really change your immediate management or treatment/dispo algorithm? If you get a negative FOBT, and it's not a sensitive, why rely on the test result?
 
I've had a couple of gi bleeds lately that were sort of so-so... but gross blood or melena changed the plan, generally *where* I admitted them. One in particular, with a VAD, was just a borderline hypotensive "near syncope" until I checked. And then he got some o-neg and a helicopter back to his VAD center rather than admit to my hospital... because by the time the hgb of 6 resulted, there wasn't enough time to T&C.

I don't care about occult blood. Well, I care, but I'd rather know if it's a LOT of blood that isn't occult. Hell, I'd prefer to check the bedside commode.

Still, I'm not a fan of unnecessary, invasive exams, and honestly, if it isn't going to change anything, I don't do it. For example: first trimester vaginal bleeding. I've already got a quant and an ultrasound. Unless she specifically mentions vaginal discharge, I give the option to do the exam, fully disclosing that it really isn't going to change anything, but I'm happy to tell her if the os is open or closed, etc. And the vast majority decline. "Pelvic exam offered and declined" goes in the note.
 
Angry Birds said:
Yes, but the solitary fecal occult blood test is not very sensitive, is it? Isn't it like 30%? So, does it really change your immediate management or treatment/dispo algorithm? If you get a negative FOBT, and it's not a sensitive, why rely on the test result?
Click to expand...

Is the solution serial rectal exams?

I'd agree a negative result is usually not the deciding factor whether to admit or d/c, but the presence of GI bleeding in an anemic patient getting admitted to the hospital is better known on admission than 3 days later, hence the ED exam on higher risk patients. In my experience, if I have a hunch that the patient might have a GIB as the source of anemia/tachycardia/BUN/etc, more often than not the FOBT is positive..
 
  • Like
Reactions: 1 user
As someone who gets snagged to chaperone rectals on occasion, should I be documenting that I chaperoned? I've got plenty of places I could do it in the EHR, but it's never occurred to me to do so. Not sure my docs document that their exam was chaperoned anyway...


Sent from my iPhone using SDN mobile app
 
njac said:
As someone who gets snagged to chaperone rectals on occasion, should I be documenting that I chaperoned? I've got plenty of places I could do it in the EHR, but it's never occurred to me to do so. Not sure my docs document that their exam was chaperoned anyway...


Sent from my iPhone using SDN mobile app
Click to expand...

Yes!
 
In residency, a druggie came in for her back pain and was really playing up her symptoms, so I did a rectal exam on her to make sure she had good tone. When she did, I discharged her. She went flying off the handle, yelling out loud to the entire ER: "I came for pain, and all you did was stick a finger up my a**!"

It was a true statement. You're welcome.
 
  • Like
Reactions: 4 users
Considering the New York Post has all the literary credibility of Goebbels, it's hard to know what about this story is true or not
 
Dane07MD said:
Some might argue that an acutely agitated and demented geriatric patient with no other discernible cause for delirium deserves a rectal exam to rule out constipation as the cause. You can do it after the haloperidol and your risk of litigation is pretty low...
Click to expand...

Is rectal exam really your best way to discern constipation? Ya can't just do an abdominal exam to come up with that? I know that I've never seen a case of significant constipation that didn't declare itself on simple observation/palpation. Or, maybe peek at a plain, single shot belly film? If you are concerned enough about abdominal pathology to stick your finger up their bum, wouldn't it make sense to get at least one picture, just to see if there is anything else going on that you can't feel by going caving?
 
Druggernaut said:
Do you guys name your chaperone in your note?
Click to expand...

Absolutely. If you didn't chart it, and the nurse didn't chart it, you didn't do it. Remember the guilty until proven innocent aspect if medical practice in the US.
 
  • Like
Reactions: 2 users
Promethean said:
Is rectal exam really your best way to discern constipation? Ya can't just do an abdominal exam to come up with that? I know that I've never seen a case of significant constipation that didn't declare itself on simple observation/palpation. Or, maybe peek at a plain, single shot belly film? If you are concerned enough about abdominal pathology to stick your finger up their bum, wouldn't it make sense to get at least one picture, just to see if there is anything else going on that you can't feel by going caving?
Click to expand...

There is an old joke that when a medical student sees:
-one of something, it's "In my experience..."
-two is "In case after case..."
-three is "In a series of cases..."

But medical student bashing aside, you are wrong. Abdominal X-rays are notoriously unreliable one way or another to assess for constipation. If you don't believe me:

-adults: http://www.sciencedirect.com/science/article/pii/S0022534710035950
-children: http://archpedi.jamanetwork.com/article.aspx?articleid=486071

Sure, I use the lots of stool on an Xray to explain away the unexplainable abdominal pain sometimes (but never tenderness), but if you are more concerned about it, and in delirium you should be, you need to dig deeper (no pun intended). Also, you are not so much concerned about there presence of a large amount of stool burden as you are about fecal impaction. It does not take a lot of hard stool to block things right up, and all you might see on imaging is some dilated loops of bowel. I would rather do a rectal exam than diagnose fecal impaction via CT scan or surgical consult.
 
  • Like
Reactions: 3 users
gro2001 said:
There is an old joke that when a medical student sees:
-one of something, it's "In my experience..."
-two is "In case after case..."
-three is "In a series of cases..."

But medical student bashing aside, you are wrong. Abdominal X-rays are notoriously unreliable one way or another to assess for constipation. If you don't believe me:

-adults: http://www.sciencedirect.com/science/article/pii/S0022534710035950
-children: http://archpedi.jamanetwork.com/article.aspx?articleid=486071

Sure, I use the lots of stool on an Xray to explain away the unexplainable abdominal pain sometimes (but never tenderness), but if you are more concerned about it, and in delirium you should be, you need to dig deeper (no pun intended). Also, you are not so much concerned about there presence of a large amount of stool burden as you are about fecal impaction. It does not take a lot of hard stool to block things right up, and all you might see on imaging is some dilated loops of bowel. I would rather do a rectal exam than diagnose fecal impaction via CT scan or surgical consult.
Click to expand...

Fair enough on the xray issue. I just tossed that in there because lots of people prefer to put their faith in imaging over physical exam.

I am a medical student, but one who has manually disimpacted quite a few more than just two or three demented/delirious patients along the way. (And once for a fully conscious, same age as me gentleman with 3 weeks of constipation s/p trauma. That was uncomfortable for both of us, but it got him on his way to being discharged.) I am not opposed to (or only scarcely experienced in) getting up in there if it is indicated. Still, easily palpable stool lumps in a firm (not rigid, not tender) abdomen are a good first clue as to whether that disimpaction is necessary. If I'm already double gloving up, I'm going in ready to treat what I already suspect is going on, not just fishing around in the dark. So to speak.
 
You must log in or register to reply here.
Next unread thread

Similar threads

Boatswain2PA
Another Rural hospital down...
Replies
48
Views
3K
CoolDoc1729
CoolDoc1729
E
Another One Bites the Dust: My Emergency Medicine Eulogy
Replies
36
Views
5K
miacomet
M
namethatsmell
Another hospital closing
2
Replies
54
Views
4K
Kryptocoin
K
Boatswain2PA
Another EMTALA question - transferring in labor
Replies
23
Views
2K
maxxor
M
SeekerOfTheTree
Another Residency - Bloomington Indiana
Replies
23
Views
3K
VA Hopeful Dr
VA Hopeful Dr
Top