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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.
"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.
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).
Caveat: I'm not a lwayer I just stayed in a Holiday Inn express last night.
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)
Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information.
Esposito TJ, Ingraham A, Luchette FA, Sears BW, Santaniello JM, Davis KA, Poulakidas SJ, Gamelli RL.
Division of Trauma, Critical Care and Burns, Department of Surgery, The Burn and Shock Trauma Institute, Loyola University Medical Center, Maywood, Illinois 60153, USA. [email protected]
BACKGROUND: Performance of digital rectal examination (DRE) on all trauma patients during the secondary survey has been advocated by the Advanced Trauma Life Support course. However, there is no clear evidence of its efficacy as a diagnostic test for traumatic injury. The purpose of this study is to analyze the value of a policy mandating DRE on all trauma patients as part of the initial evaluation process and to discern whether it can routinely be omitted. METHODS: Prospective study of patients treated at a Level I trauma center. Clinical indicators other than DRE (OCI) denoting gastrointestinal bleeding (GIB), urethral disruption (UD), or spinal cord injury (SCI) were sought and correlated with DRE findings suggesting the same. Impression of the examining physician as to the need and value of DRE was also studied. Patients with a Glasgow Coma Scale Score (GCS) of 3 and pharmacologically paralyzed were excluded from the SCI analyses. UD analysis included only males. RESULTS: In all, 512 cases were studied (72% male, 28% female) ranging in age from 2 months to 102 years. Thirty index injuries were identified in 29 patients (6%), 17 SCI (3%), 11 GIB (2%), and 2 UD (0.4%). DRE findings agreed positively or negatively with one or more OCI of index injuries in 93% of all cases (92% seeking SCI, 90% seeking GIB, 96% seeking UD). Overall, negative predictive value of DRE was the same as that of OCI, 99% (SCI 98% versus 99%, GIB, 97% versus 99%, UD both 100%). Positive predictive value for DRE was 27% and for OCI 24% (SCI 47% versus 44%, GIB 15% versus 18%, UD 33% versus 6%). Efficiency of DRE was 94% and OCI was 93%. For confirmed index injuries, indicative DRE findings were associated with 41% and OCI 73% (SCI 36% versus 79%, GIB 36% versus 73%, UD 50% versus 100%). OCIs were present in 81% of index injury cases. In all index injury cases where OCIs were absent, positive DRE findings were also absent. DRE was felt to give additional information in 5% of all cases and change management in 4%. In cases where the clinician felt DRE was definitely indicated (29%) it reportedly gave no additional information in 85% and changed management in 11%. CONCLUSION: DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.
PMID: 16394903 [PubMed - indexed for MEDLINE]
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.
Sometimes we have Bruce Willis sitting around with a Samuri sword just in case any of the interns get a little too thorough.
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 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)
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.
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.
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.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.
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.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.
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.
Someone call Bruce Willis!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.
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)
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'll just put this orange catheter in you then...don't worry, orange is the smallest size.
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.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.
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.
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.
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.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)
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.
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.
Exactly. Now you've got it. That's the system we are stuck with. As I've explained before, everyone loves it but us.So basically, you're sued if you do, and sued if you don't!
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.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)
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.
Exactly. Now you've got it. That's the system we are stuck with. As I've explained before, everyone loves it but us.
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?
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.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?
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.