10 replies to this topic

[scubanurse]

You respond to a medical office building for a female patient who is combative/emotional.  Upon arrival with PD you find a 27YOF in an OBGYN office in the corner of an exam room visibly upset.  Doctor reports she did not receive bad news today or anything that could explain what happened.  Doctor was going to perform the pelvic when the female patient "freaked out" and would not let anyone touch her.  Staff there tried to calm her down but she appears to be in a state and unable to communicate.  (OBGYN is a male and has been her physician for 9 years).

 

 

This isn't as much of a skills call as a psych call and understanding what could be going on with this patient and how you handle it.

 

What is going on with the patient?

How do you approach the situation?

Should they be transported?

[Arctickat]

Hopefully my partner is female....if not, I'm calling for one.

[scubanurse]

And if no female is available other than staff?  Would you stay on scene for what is shaping up to be a very long call?

[Arctickat]

Perhaps others don't have the luxury, but I do, and i'll spend all day with her if she needs me.  However, if she refuses service, I'll leave.  Kind of a sexist organisation though...no female medics?  Really?

[scubanurse]

they could be tied up on other calls...can't always get what you want/need.

 

That's a great luxury.  This ties back to a previous issue though, can this patient be deemed competent to refuse service?  How can you assess what's going on to assess her competency.

 

You can ask the physician any question you would like and see her medical history if you think it might help you communicate with her.

 

What mental processes are going on do you think to cause her to react this way to a simple pelvic?

[Arctickat]

Shrug, what springs to mind is that she was recently sexually assaulted, likely hasn't told anyone. Doc's exam set off some PTSD.  If she refuses I'll accept that, reluctantly, and not without some heart to hert discussion. I'd get her NOK involved.

[scubanurse]

I'm curious what a few others think about this before I give some more details...

[medicgirl05]

I agree that a female medic is beneficial but here that's not always a possibility.

 

I would try to talk to her calmly. I'd give her some time to hopefully regroup. If she refused the ER I think I would put my head together with the treating physician and see what he thinks. I'm not sure she would really be helped in an ER setting anyway. She needs more long-term therapy than a chaotic ER setting where she knows nobody.

 

If she is unable to communicate can you for sure determine her current mental status?

 

I agree that she has probably had some kind of unpleasant sexual encounter and the idea of a pelvic probably caused her to relive that.

 

Great topic!

[scubanurse]

When a female member of the staff approaches her at her level, she is willing to communicate but only with that staff member.  The staff staff member reports that she is afraid and appears to be not entirely there.

 

You put your head together with the treating doc and he says the patient suffered an anoxic brain injury in 2008 and that is the only history they have for her.

Edited by Kate_826, 25 January 2013 - 12:09 AM.

[scubanurse]

So what happened was this.  I was doing a rotation a few months back in an OB office and this situation occurred.  I was able to connect with the patient because of a similar past and got her to open up.  A few months prior she had been having nightmares reliving a situation that occurred when she was a teenager that she had repressed until now.  The pelvic set her off and it apparently all came rushing back to her.  EMS did a great job of waiting and listening to her needs.  Ultimately she was able to drive home with a referral for psych services and victim resources and EMS cleared.  There were two male paramedics on the unit and both were fairly young but incredibly understanding and compassionate.

 

The reason I bring this up is that so often we encounter psych patients and have very few resources to help them.  The ER was the very last place this patient belonged during the crisis as with most psych patients.  Fortunately around Denver we have a lot of psych resources and Denver Health has a psych ER designed for people in crisis situations.