I Need A Refresher about Straddle Injuries

Patient Presentation

A 3-year-old female came to clinic for a pre-operative visit for pressure-equalizing tubes and a tonsillectomy and adenoidectomy. The patient was new to the practice and during the past medical history, the mother said that the patient had a previous surgery because she had jumped from a couch onto a chair when she was 2.5 years old. She had sustained a straddle injury that needed surgery “to fix her muscles down there” but had no problems since that time. She had no other emergency room visits or hospitalizations. The past medical history revealed multiple ear and throat infections. She also had a history of some snoring. The family history was negative for any bleeding, surgery or anesthesia problems including malignant hyperthermia. The review of systems was negative.

The pertinent physical exam revealed normal vital signs and growth parameters. HEENT showed scared, dull tympanic membranes with fluid behind them bilaterally. Her tonsils were 3+ bilaterally with a relatively large tongue. She had shoddy anterior cervical adenopathy. The rest of her examination was normal except for a small hymenal cleft at 7 o’clock. The diagnosis of a child with a physical examination consistent with chronic ear and throat infections was made with an ASA class III airway. The patient’s clinical course was that she underwent surgery without any complications and had significant improvement in the number of infections over the next year. The pediatrician later reviewed straddle injuries and their treatment.

Discussion
Presurgical evaluations are very important for any patient particularly if a patient does not have a medical home or consistent health care providers. They also are particularly important for patients with chronic or complicated medical conditions and therefore pediatric health care providers are often asked to assist their dental and surgical colleagues in pre-operative evaluations.

An overview of the elements of a preanesthesia evaluation can be found here, including the American Society of Anesthesiologists (ASA) airway classification. A careful history for any problems with anesthesia should always be asked and documented, especially for any difficulties with waking up from anesthesia, fever or muscle problems. These could indicate possible malignant hyperthermia and an overview of its symptomatology and emergency treatment can be found here.

Learning Point
Straddle injuries are a common form of unintentional female genital trauma. In one study of 105 patients, straddle injuries (81.9%) were the most common and fortunately most of these did not require surgery. Straddle injury trauma occurs because of direct trauma with compression of the vulvar tissues by an object (e.g. falling onto monkey bars, bicycle handle bar or center bar, etc.) or by forceful abduction of the legs and compression (e.g. falls onto a chair or other furniture, breakdancing injury). The trauma is usually non-penetrating, but penetrating trauma can also occur, (e.g. fall onto a piece of furniture and small toy that is co-located).

The most common straddle injuries are abrasions, bruising and lacerations. Hematomas can occur because of extravasation of blood into the loose tissue of the labia, clitoris, mons or vagina. Small lacerations often heal by themselves and do not need specific approximation of the tissues. Large lacerations, those that extend into the muscle or those where the exact extent of the injuries need to be further evaluated, probably will need surgical repair. Patients with vulvar hematomas that do not distort the normal anatomy and the patient is able to void spontaneously usually can be treated conservatively, with ice packs and pain control. If the anatomy is distorted, or there are voiding problems, then further evaluation and treatment are needed. Voiding usually can be treated with a Foley catheter until the swelling resolves. A large hematoma that distorts the anatomy may exert enough pressure to cause pressure necrosis and therefore the hematoma may need to be incised, drained and debrided.

Perianal, hymenal and vaginal trauma often suggests a penetrating injury which may be unintentional or could be associated with sexual abuse. Therefore, patients presenting with these injuries should have sexual abuse considered as part of the management.

Questions for Further Discussion
1. What are some indications for genital examination under general anesthesia?
2. Who are your local consultants for genital trauma?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Vulvar Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Heppenstall-Heger A, McConnell G, Ticson L, Guerra L, Lister J, Zaragoza T. Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics. 2003 Oct;112(4):829-37.

Dowd MD, Fitzmaurice L, Knapp JF, Mooney D. The interpretation of urogenital findings in children with straddle injuries. J Pediatr Surg. 1994 Jan;29(1):7-10.

Merritt DF. Genital trauma in the pediatric and adolescent female. Obstet Gynecol Clin North Am. 2009 Mar;36(1):85-98.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Is This Really Weed?

    Patient Presentation
    A 15-year-old male was brought to the emergency room by paramedics. After school, he and his girlfriend went to a nearby woods to smoke marijuana. His girlfriend had bought it from her usual supplier and he rolled the marijuana cigarette in front of both of them. Both of them commented that the marijuana seemed to look more yellow and smelled slightly different. She took a couple smokes of the cigarette and then he took a couple smokes. He then began to feel strange. He said he began to hear and see things but didn’t know if they were real or not, such as his girlfriend had on clown makeup. He asked his girlfriend to call the ambulance. In the emergency room he was agitated and continued to hallucinate such as seeing the walls move and having the machinery talk to him. He was given lorazepam and Geodone®. The past medical history showed previous cannibis and alcohol abuse. The family history was positive for drug abuse and heart disease. The review of systems was negative.

    The pertinent physical exam showed an agitated male with heart rate of 125 beats/minute, blood pressure of 120/65, temperature of 97.2° F and a respiratory rate of 20 breaths/minute. His pupils were 4 mm and reactive. He had a flushed face and trunk. Heart was tachycardic without murmurs. Bowel sounds were present. Neurological examination was normal. He would pick at his clothing or point to objects not present, but these appeared to be consistent with the type of hallucination he was having at the time. The rest of his physical examination was normal. The laboratory evaluation included a complete blood count and metabolic panel which were negative. A drug screen was positive only for cannibis.

    The diagnosis of acute hallucinations probably from marijuana contaminated with jimson weed or other substance was made. He was admitted and placed on monitors and over the night he became more lucid and aware of the situation. By morning he was totally coherent and gave a detailed history that was consistent with previous reports. He was evaluated by the chemical dependency team and was referred to outpatient drug treatment. His father also acknowledged that he himself had an alcohol problem and wanted a referral for his own chemical dependency.

    Discussion
    Marijuana (Cannibis sativa) is the most common illicit drug abused in the United States, but is also used in certain circumstances for pain and anxiety control in patients with chronic disease. It is estimated that 102 million Americans (~40%) have used marijuana at some time in their lifetime. Children who use marijuana, especially at a younger age, are more likely to abuse other substances such as cocaine or heroine. Therefore patients using any illicit substance should be evaluated for additional substance abuse. Acute problems caused by marijuana include tachycardia, impaired coordination, increased respiratory illnesses, and problems with learning, memory and social behavior. Chronic abuse has been associated with anxiety, depression, schizophrenia and suicidal ideation. Marijuana used long term can be addicting and withdrawal symptoms including drug craving, decreased appetite, irritability, and sleeplessness.

    Learning Point
    Jimson weed (Datura stramonium) belongs to the nightshade family and the plant is widely distributed. The plant has toothed leaves with a strong odor. It has off-white, trumpet-shaped flowers and a walnut-sized, spined seed pod. All parts of the plant carry active ingredients which are the alkaloids atropine, hyoscyamine, and scopolamine. The physiological effects of atropine can be remembered by the saying: “blind as a bat, mad as a hatter, red as a beet, hot as hell, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.” Atropine overdoses almost always have delirium with visual and auditory hallucinations. Atropine overdose can cause obtundation and coma, respiratory arrest, seizures and hyperthermia. Symptoms usually begin within 30-60 minutes and can last 24-28 hours.

    Because of its widespread distribution, jimson weed can contaminate other legal or illegal products. One MMWR report noted, “Because a large number of plants throughout the United States contain belladonna alkaloids, plants harvested for human consumption must be correctly identified. The public should be aware that all herbal products have the potential to be misidentified when collected, mislabeled, contaminated, or adulterated. Physicians and the public should report adverse reactions to herbal products to [the FDA.]”

    Questions for Further Discussion
    1. What other illegal drugs cause atropine-like symptoms?
    2. What is the telephone number for the national poison control center?
    3. What chemical dependency resources are available in your community?
    4. What is the differential diagnosis of hallucinations?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Poisoning and Marijuana.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Centers for Disease Control. Epidemiologic Notes and Reports Jimson Weed Poisoning — Texas, New York, and California, 1994. MMWR.
    January 27, 1995 / 44(03);41-44. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/00035694.htm (rev. 1/25/1995, cited 9/30/2009).

    Centers for Disease Control. Anticholinergic Poisoning Associated with an Herbal Tea — New York City, 1994. MMWR. March 24, 1995 / 44(11);193-195. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/00036554.htm (rev. 3/24/1994, cited 9/30/2009).

    Office of National Drug Control Policy. Marijuana Facts & Figures.
    Available from the Internet at http://www.whitehousedrugpolicy.gov/drugfact/marijuana/marijuana_ff.html cited 9/30/09).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Types of Community Services Are Available?

    Patient Presentation
    A 1 week old former 36-week-old female was admitted after a possible acute life threatening event. The infant was being bottle fed by her mother. Her father said that she stopped breathing while eating. He had to “shake her” and give her “mouth to mouth” to revive her. The parents disagreed whether there was a color change or not and how long the incident lasted, but both said less than 20 seconds. The mother stated that she had choked before stopping breathing.. She was taken to the local hospital where she had been born. The family became agitated with the emergency room staff because “they didn’t know about babies” and asked to be transferred to the regional children’s hospital. The past medical history showed no prenatal care, and mother was not sure about her last menstrual period. Gestational age was done by Ballard score at birth and was 36 weeks. Patient was the product of a spontaneous vaginal birth and maternal laboratory testing at that time was negative. The infant received a 48 hour course of antibiotics because of preterm birth and some initial temperature instability. Cultures were eventually negative.

    The social history was complicated by the low functioning mental capacity of both parents and recent job loss by the father. An older sibling had been voluntarily removed from the home because the parents stated “we couldn’t take care of him.” Both parents smoked. The family lived in a trailer that they rented from a family member. They had adequate clothing, a bassinet that they laid the infant on her back to sleep in, and plenty of formula for the infant and food for themselves. A social evaluation during the birth admission had been completed and the family was voluntarily being followed by the state’s Department of Human Services (DHS). The review of systems was negative.

    The pertinent physical exam showed a weight of 2.96 kg (~40%). Head circumference and length were 25%. Repeated Ballard examination was consistent with a 37 week gestation infant and the rest of the examination was normal. The work-up at the outside hospital included a complete blood count, electrolytes, and blood cultures. No urine or cerebrospinal fluid was obtained and no antibiotics were begun. The patient was placed on monitors and had no incidents over the 8 hours between presentation at the outside emergency room and admission to the children’s hospital. Additionally, emergency room personnel noted that the infant fed appropriately without difficulty, slept well and was easy to arouse during the observation. The diagnosis of a premature infant with choking during feeding causing a normal brief cessation of breathing was made. The infant also lived within a family with a difficult social situation.

    The patient’s clinical course at the children’s hospital showed that the infant had no adverse events seen by staff or on monitors and acted like a normal infant. She showed no signs of any infectious disease process or other abnormality. An extensive social evaluation was made and revealed that the family had several inappropriate ideas about infant care such as the infant should be able to sit upright by herself and hold her own bottle currently. After parental consent, the children’s hospital social worker contacted the local DHS social worker. Both agreed that the family would benefit from more intensive parental education in the home and supervision of the social situation. A visiting nurse and early intervention specialist from the local schools were to come to the home 5 days a week and the parents appeared grateful for the additional help. The social workers and physicians hoped that the additional services would improve the family’s caregiving abilities, but the professionals in the home could also report if the parents were not improving with their knowledge and care and if the infant was in an unfortunate dangerous situation. The family wanted to return to the children’s hospital for primary care but missed the appointment the next week and children’s hospital social worker contacted the family. They stated they now wanted to receive primary care closer to home and had made an appointment. Again after parental consent, the children’s hospital social worker contacted the local DHS social worker and communicated these new concerns. The local DHS social worker stated that “other concerns” had arisen since the infant’s discharge but he did not have parental consent to give more information. He stated that “additional services” had been arranged for the family and that the new primary care physician was aware of the family’s social concerns. He said that the patient would be followed closely.

    Discussion
    Health care providers often view the patient through the medical lens and may not see the full view of all aspects of patients and families lives. Even many who work in community centered locations may not be aware of the breadth of services wanted and needed by families. Medical and community services are diverse in every location and often change as funding becomes available or dries up.

    One of the most difficult tasks for a health care provider (and patients and families) is to move to a new location and need to locate and access various services. Health care providers who take care of patients and families from a wide geographical area are at an additional disadvantage as the practitioner often is not aware of the availability or non-availability of local community services. Social work professionals are often available through local hospitals, government agencies, non-profit organizations and schools. Questioning patients and families in the office about the types and quality of the community services they use can be a fountain of information for the health care provider to recommend to other families.

    Whether its the local Eskimo tribe providing native food to needy families in their community, a police officer going to the home of a family without a telephone to deliver urgent medical information, a rape crisis nurse who assists a patient, family and the emergency room physician though a sexual assault evaluation, or a service organization that modifies toys for children with disabilities, health care providers need to partner with many different community service providers.

    Learning Point
    Examples of community service providers:

    • Community Based Providers
      • Child care professionals
      • Churches and spiritual organizations
      • Cultural organizations
      • Counseling services – substance abuse, domestic violence, financial, legal services
      • Clothing
      • Crisis intervention – rape, mental health
      • Health insurance companies
      • Libraries – books and toys
      • Respite care
      • Transportation
      • Translation
      • Youth service organizations – Boy and Girl Scouts, YMCA, Big Brothers/Big Sisters, mentoring programs etc.
    • Government Based Providers
      • Department of Human Services
      • Medicaid/SCHIPP health insurance
      • Financial assistance
      • Food – Women, Infants and Children program, Food stamps
      • Housing
      • Law enforcement
      • Legal services
      • Transportation
      • Parks and recreation services including summer camps
    • Health Care Based Providers
      • Primary care providers
      • Specialty care providers including child maltreatment, dental, developmental disabilities, physical therapy, occupational therapy, speech and language services
      • Regional healthcare services – providing care across a region of a state or geographic area
      • Rehabilitation and skilled nursing care centers
      • Visiting nurses
      • In-home health care providers
      • Hospice and palliative care providers
      • Discharge coordinators – often nurses or social workers
      • Medical and non-medical social workers
      • Mental health providers
      • Complementary and alternative health providers
      • Public health clinics
      • Free medical clinics
      • Transient medical services – urban mobile clinics, immigrant clinics
    • School Based Providers
      • School based health clinics
      • Family centers within schools – often provides a wide variety of counseling and referral services
      • Early intervention programs
      • Head Start programs
      • Special education services
      • Disability services
      • Alternative schools or programs for troubled youth, or youth with different educational needs
      • Food programs

    Questions for Further Discussion
    1. Choose one of the community service provider groups above and list what local provider you would refer a family to?
    2. What other community service providers are not listed above?

    Related Cases

      Symptom/Presentation: Apnea

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Home Care Services and Family Issues.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    American Academy of Pediatrics Policy Statement. The Pediatrician’s Role in Community Pediatrics. Pediatrics 1999;103;1304-1306. Available from the Internet at: http://pediatrics.aappublications.org/cgi/reprint/pediatrics;103/6/1304 (rev. 06/1999, cited 9/30/2009).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Do You Define Professionalism?

    Patient Presentation
    A 17-year-old male came to the inpatient ward after an overdose of trazadone that he was taking for depression. He had had a fight with his girlfriend and decided to take several tablets. He became very sleepy and regretted taking them, so he confided in his mother. She took him to the local emergency room, where his urine drug test was negative for other substances. The local hospital did not have psychiatric beds available and the emergency room physician tried to contact his psychiatrist. The office answering machine did not have any contact information. Another town’s hospital where the psychiatrist also practiced also did not have any after hours contact information for the psychiatrist. That hospital also did not have any psychiatric beds available at that time. The emergency room physician contacted the regional children’s hospital who accepted the patient to the inpatient medical pediatric floor. The past medical history revealed that the patient had another similar suicide attempt 6 months previously and was begun on the trazadone.

    The pertinent physical exam showed a sleepy male who was arousable but not very communicative. BP was 66/46 and his heart rate was 64. The rest of his examination was normal. He denied acute suicidal ideation and showed remorse for taking the medication. The diagnosis of a suicide attempt versus gesture was made. A child psychiatrist evaluated the patient and felt that he was not acutely suicidal and could be followed by his outpatient psychiatrist. The pediatric resident contacted his local psychiatrist to arrange followup care. The resident was told that although there were no problems with the patient-doctor relationship the psychiatrist is refusing ongoing care of the patient because he didn’t want to see the patient again. The resident and the child psychiatrist arranged for outpatient followup and made an emergency/safety plan for the family, and the family agreed to continue his care at the children’s hospital.

    Discussion
    The American Academy of Pediatrics states “[p]rofessionalism has been a central and defining feature in medicine….Pediatricians have a special status in society as priviledged and trusted advocates for the well-being of children. Pediatricians have a responsibility to use their knowledge, skills, and influence to advocate for children and their interests in all domains of society, not just in health care.” The American Board of Pediatrics has endorsed eight components of professionalism for teaching and evaluation of resident physicians. These are: honesty and integrity, reliability and responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication and collaboration, and altruism and advocacy.

    Learning Point
    There are professional standards for any health care professional – basically agreement by both the provider and patient/family to enter into a therapeutic relationship with the provider providing services within the scope of his/her practice and the patient/family agreeing to work in good faith with the provider including payment for services. The relationship can be terminated by either party. Families will often terminate the relationship without a formal process – they just don’t come back. But a health care provider wishing to terminate a relationship should have a formalized process with the patient/family notified in person if available and also in writing usually by registered mail. Notification should include the reasons for needing continued treatment by a qualified provider, reasons why this specific provider cannot continue treatment, reasonable efforts to refer the patient to another provider (specific options/recommendations) and a specific termination date that allows enough time to reasonably expect that a successful transition will occur. Notice of the need to consent to transferring medical records to another provider is often added to remind patients/families that this is a separate consent. Some providers also add recommendations for emergency care after the termination date, in case the patient/family has not successfully transitioned. There may be specific state regulations that a provider must also follow. According to the Iowa Board of Medical Examiners for instance – “A physician may choose which patients to serve. If your physician no longer wants to provide care for you, he or she should provide you with written notice 30 days before terminating your care. Your physician should ensure that emergency medical care is available to you during the 30-day period following the written notice. This does not mean that he or she must provide the care himself or herself.”

    While this may seem straightforward that a provider has a duty to care for patients/family, there are many nuisances which ultimately depend on the relationship. As an example, was the relationship a time-limited relationship such as a specialist being asked their opinion about a specific problem? The service was provided, the opinion given and usually if there are no ongoing issues, the relationship is then terminated. It could be re-constituted, if the problem recurs in the future but this is a different relationship. Another reason to terminate a relationship is that the problem that initiated the relationship has resolved. For example, a patient with resolved Henoch-Schonlein purpura was treated by a nephrologist, but as there is no ongoing renal disease the patient maybe “discharged” back to care of her primary care provider. In an ongoing relationship, if a problem is revealed by the patient/family or detected by the healthcare provider that is outside the scope of practice of the healthcare provider, the provider also does not have to provide care for that problem. Usually the provider will assist the patient/family in seeking appropriate care though. For example, a pediatric cardiologist is seeing an adolescent female who discloses a gynecological problem.

    Information about the relationship may be kept confidential to outside entities because of HIPAA or other reasons, such that it may appear that there is an ongoing relationship when in fact there may not be. This could be one reason for the psychiatrist’s actions in the above case. Some practices have very specific agreements under which they will treat patients/families and if the patient violates the agreement then they could be terminated. Some practices within their agreement with patients may not provide emergency care. If a patient is in acute medical crisis, care needs to be given to the patient but the provider themselves does not have to provide the service him/herself. For example, a patient becomes violent and is a danger to himself and others. The provider does not have to provide care to the patient, but by calling safety officers, police officers and/or other emergency personnel, the provider has begun to provide emergency care and is meeting the duty to care for the patient. Basically, if a provider had a clear relationship with a patient/family (particularly a continuous one over time) and the patient had a medical crisis that was within the scope of practice of the provider, and then the provider refused to continue services without a clear therapeutic cause and/or appropriately diligent effort to assist in finding appropriate alternative care options, then the provider may be negligent.

    The American Academy of Pediatrics states that “[a] pediatrician has broad authority to enter into or decline a medical relationship with a family except in emergency situations. Once a relationship is established, however, the pediatrician should assume responsibility for the medical care of the child and also recognize when the child needs to be referred to a pediatric medical subspecialist, pediatric surgical specialist, or other physician or qualified clinician for diagnosis or treatment of a condition or symptoms complex outside of the physician’s scope of practice.”

    Questions for Further Discussion
    1. How do you personally define professionalism?
    2. If you were the physicians in this case, how would you have handled the case above?
    3. If you believe a healthcare provider has been medically negligent and/or liable, what local, state or national organizations could/should you report the provider to?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Patient Rights and Depression.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Van Sustern L. Psychiatric Abandonment: Pitfalls and Prevention. Psychiatric Times. 2001;18.

    American Academy of Pediatrics Technical Report. Professionalism in Pediatrics. Pediatrics. 2007:120;e1123-1133. Available from the Internet at: www.pediatrics.org/cgi/doi/10.1542/peds.2007-2230 (rev. October 2007, cited 9/23/09).

    Iowa Board of Medical Examiners. Available from the Internet at http://medicalboard.iowa.gov/Questions.html (cited 9/23/09).

    American Psychiatric Association The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. 2009.
    http://www.psych.org/MainMenu/PsychiatricPractice/Ethics/ResourcesStandards.aspx (rev. 2009, cited 9/23/09).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital