In cases involving trauma, a rectal exam is one way to assess for neurological damage. In our malpractice-mad society, this resulted in a frivolous lawsuit:
A construction worker claimed in a lawsuit that when he went to a hospital after being hit on the forehead by a falling wooden beam, emergency room staffers forcibly gave him a rectal examination . . .. . . says in court papers that after he denied a request by NewYork-Presbyterian Hospital emergency room employees to examine his rectum, he was “assaulted, battered and falsely imprisoned.”
His lawyer . . . later learned the exam was one way of determining whether he had suffered spinal damage in the accident.
Related posts:
- Why do I need a rectal exam, and what can doctors find with the gloved finger?
- Get your forced rectal coverage here
- The rectal exam
- A nursing mother wants extra exam time
- Are doctors finding the physical exam useless and obsolete?
- Worrisome exam
- Edith Isabel Rodriguez: Hospital response
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ERMurse, if what you write is an indication of your view about the work of your emergency department, then I have doubts about your fitness for nursing. You seem to have an oppositional attitude toward doctors, and your claims at being motivated by patient advocacy is unconvincing, more a sublimation of your root hostility. Sadly, that seems to be common in nurses.
You have appropriated superficial reasons for objecting to physical examination–here, low sensitivity of a rectal exam in an ER trauma assessment–without offering any example of a meaningful alternative. Does that mean you propose no alternative? I find that a casually easy and self-righteous position to take, but maybe that is to expected from someone who really doesn’t have to bear responsibility for omission of critical examination findings or diagnoses in injured patients.
You pretend to be in the game, but you criticize from the sidelines.
Setting aside the issues that as a layperson I don’t understand, and looking from common sense, logic point of view, I see a gap in logic of this case.
1. If the guy is incompetent because he had a head trauma, then he shouldn’t be held responsible for accidentally hitting someone when resisting the procedure he didn’t want. Why did they put him in jail and filed charges against him?
2. If the guy is competent enough to be responsible for his actions, how come he is not competent enough to give informed consent?
Additionally, it is not clear if the purpose of the test was explained to him.
The rectal exam is generally a low yield test but absolutely critical when the chart is examined with the rectrospectoscope.
I do a rectal examination on all lawyers no matter what their chief complaint is to show they are:
1. Neurologicaly intact. (However this is difficult when so many have loose tone in this patient cohort.) It is best to do this in front of the whole medical team so you can’t be accused of not doing it. This includes the bulbocavernosis reflex — if you can find the penis somewhere within in the jiggling rolls of fat.
2. There is no rectal mass (not placed there on purpose that is)
3. No occult blood — key documentation for virtually any chief complaint.
I don’t get all the docs that still say they do this exam as common practice. The second comment points to a study showing this exam basic has low sensitivity for all the things you think it’s good for.
In other words, you might as well insist on mumbling “Oooglie Booglie!” and get similar results.
When docs start ignoring the research because “they know better,” that’s a clear sign of ignorance and tradition winning over rationality and data.
Ten years from now, nobody will be doing digital rectal exams anymore in trauma, because they stink for what they’re supposed to measure.
It may have low sensitivity, but it has fair amount of specificity. It may not be a perfect test, but it gets the job done and it gets the job done fast.
I am sure we could probably wheel in an some machine somehow to look at nerve function and have near perfect sensitivity, but that is expensive and time consuming.
The same people on this board who are complaining about rectal exams are the same people that lament how much the ER costs, yet they don’t want cheap screening tests. They only want the ones that are the gold standard and they want it STAT! OH yeah, and they don’t want to pay any more for the gold standard and speed. Give me a break.
A rectal exam takes two seconds, it’s only mildly uncomfortable, and there’s no lasting damage. Anyone who wants to bellyahce how the guy is “scarred” mentally (probably cultural, right?)and his rights were violated is a whiner, the kind of person who wants general anesthesia for a cavity.
As long as the sensitivity is greater than zero, its worth doing. It is not “invasive”. There’s no blood loss, its fast, and you can directly check several organs, no incision is made. If a nuerologist jabs a sharp ended stick to check your sensory tracts, would that also be a battery?
Why is there no priority given to true injustices in medicine and society in general? Is this event truly worth 26 million dollars? Doesn’t anyone have any sense? For any doctor or nurse who has “been there”, it’s a no brainer.
I don’t think the issue here is rectal exam and whether it is needed as much as that of informed consent and if the guy was competent enough to give it. BTW – a question to the doctors. Why did he wake up with a tube in his throat? If they wanted to sedate it, couldn’t they have done so without it?
Sure maybe he shouldn’t have refused. But he did. The issue here if he was competent to do it or if his head trauma rendered him incompetent. As I pointed in a couple of posts above, the doctors who accused him of assault thought he was competent enough to be responsible for it. How come the same doctors thought that he was not competent to refuse a test?
I think in this era of defensive testing, the issue of whether or not we have a right to refuse a test when we come to the ER – provided we are in the position to do so – is a whole lot more important than whether or not rectal exam is needed in this case. Because if we can be forced to have a test that is needed, we may also be forced to have a test ordered solely for defensive purposes and than made to pay for it. If the guy was incompetent it is another matter entirely.
All patients in head trauma situations are evaluated for alertness and orientation–competency. If he was competent and had refused the rectal examination–all the hospital had to do was present him with a form to opt out and the hospital would not be held liable. Forcing a rectal exam on an oriented person is illegal.
>>”Forcing a rectal exam on an oriented person is illegal.”
That might be your personal opinion, but I very much doubt a court will find that anything illegal occurred or that the patient suffered compensable harm.
If for no other reason the argument of the greater public good can be made that emergency medical personnel should not be required to parse the elements of a comprehensive neurological examination done in a trauma care setting vis-a-vis consent and to have to decide whether each patient is competent to decide–rationally or not–whether particular steps in an examination can be done. Needing to clear a patient’s spine of injury in an acute setting requires respecting the timeliness with which that assessment must be done. It just isn’t practical to stop everything in a trauma code to go fetch release AMA forms so a patient can opt out of the rectal.
If this court is finding reasonably, then they will likely find that if you come to the hospital in a c-collar and on a backboard, then you have de-facto consented to whatever assessment is necessary to get you safely out of those devices. That goes for rectal exams, CT scans and any other reasonable examination techniques.
If our society wants an effective medical response to trauma, a balance of interests will have to curtail the notion of unlimited right to refuse evaluation so that first responders and ED responders can do their jobs without fear of unreasonable litigation.
If this court is finding reasonably, then they will likely find that if you come to the hospital in a c-collar and on a backboard, then you have de-facto consented to whatever assessment is necessary to get you safely out of those devices.
Did he come on a board and in a c-collar? The article didn’t say he did. Again, if he was incompetent, why did they jail him for resisting the test? Either he is competent or not, you cannot have it both ways.
The emergency room staff performing the medical evaluation didn’t arrest and jail the plaintiff, and the police, who presumably arrested the patient did not perform the exam the patient objected to. There is no inherent inconsistency here. The police apparently were not deferring to the ED doctor’s judgment about whether the patient should be arrested, and there is no reason to suppose they should have.
The doctor believing the patient is not rational to make consent decisions has nothing to do with the policeman trying to decide whether the assaultive patient is dangerous. Two different people looking at the same person for two different reasons, so your question is pointless.
The story does not say what sort of devices were brought with this patient; but paramedics usually bring trauma victims in in immobilizing devices, and those devices are usually not removed until after a physical examination of the patient is done and sometimes not until after a CT is done as well.
“The emergency room staff performing the medical evaluation didn’t arrest and jail the plaintiff, and the police, who presumably arrested the patient did not perform the exam the patient objected to. “
Is police generally present in examinations rooms in the ED and watches examinations? Or was it someone from the stuff who actually did the examination who called the police and pressed charges?
There is no inconsistency. Unless policeman was there in the emergency room and reacted on his own accord, it was someone who did the examination who choose to call the police and press charges.
According to Brian Persaud himself, he was driven to the emergency room,simply to get stitches. Brian Persaud is a credible man. I Have seen and heard him in interviews, and I believe him. Patient advocate, Art Levin, believes him too.
A competent person can refuse treatment, even in an emergency setting. Hospital records describe Persaud as ‘alert and oriented’.
Don’t dismiss this case. It won’t be decided by doctors. I once sat on a jury in a malpractice suit. There was zero sympathy for the doctor, and the hospital involved.
It wouldn’t surprize me to see a settlement, before trial. that is Less risky for Cornell. You cannot second guess what a jury will do.
Persaud’s lawyer is hardly an ambulance chaser. He has represented Mafia figures, and got them acquitted. Beating the feds isn’t that easy.
Since my dad is a personal injury attorney, who has won many malpractice suits, I can say this.
High dollar attorneys do not pursue this kind of case, for five years, unless they have a great deal of confidence in winning. The hospital was hoping it would be dismissed. It wasn’t. We shall see. Never bet against a really smart lawyer. Remember Johnny Cochran.
Regarding the study showing the rectal exam is not useful…just because someone can pop onto google and find a result (and I doubt anyone read more than the title or a few lines in the abstract), doesn’t mean the study is significant. As a researcher, I don’t rely on a single result, but rather a collection of results, each of which I critically assess, to come up with a conclusion. I doubt most people commenting on the “effectiveness” have read the quoted article itself, or any of the cited articles (which argue both for and against the use of the exam).
Basically, the doctors were trying to perform a reasonable test that might indicate a larger, more life threatening problem. I’m happy the courts saw that the doctors were trying to perform a thorough diagnosis/treatment on their patient.
Some pretty disturbing responses, seemingly down the medical line. Meds on the “Do it” and civilians on the “We have rights”. As a person with specific religious beliefs I can ssure you that many people have many reasons for denying consent to certain procedures. The guy was not in a coma and the fact he refused consent after being told what they wanted to do shows me he was not in a position to be deemed “incapable of making decsions about his person”. I as a concious and lucid person have the right to refuse any tests I so choose, that is MY right and medical “professionsals” have a concrete “Butt cover” in that cute little AMA form they have a patient sign when they refuse any part of, or request, by the medical staff. He wasn’t offered that option. He was assaulted and I would be enraged. The only persons creating this “us verses them” mentality are the medical professionals themselves who refuse to stop treating patients like animals who are visiting a vet. Just because you are a Medical Heath Care worker does not mean you can view people who come to you for help to be but dumb animals with no right to control their own person.
I as a patient have the responsibility to listen to your “Suggested courses of action” and any tests you would “like” done or think would help. It is then totally 100% up to me which tests I consent to and it is my responsibility to deal with the reprocussions. I sign your form, do the tests I will consent to, and take the help you offer. You give said help and do your best. That is the way it is suppose to be…equal respect.
This story is yet another reason why I hate hospitals, distrust doctors and nurses. If a patient says NO to anything (such as rectal exams, catheters etc.) then have him or her sign a release and or waiver of responsibility and let him go. I so loathe the “Medical Profession”. What a dispicable thing to force on anyone capable of deciding no. Whatever happened to patient rights? Doctors humph, God I hate ‘em all!
Anonymous 8:35 – I hope you’re never in a serious trauma situation. The cops and medics who will risk their lives standing in traffic to scrape you off the road and bring you to the ER where the doctors and nurses just had a gun pulled on them for not seeing somebody’s dad fast enough for non-cardiac chest pain will still do their best to make sure you get the best care available. Heck, they will even save your life without so much as a please or thank you.
When I was an MS3, my VA attending had a rule: A rectal on every admission. Why? He had once missed a neurological injury that could have been caught with one.
Yes, patients have the right to refuse… and sure, if the plaintiff was competent at the time he can leave AMA.
BUT…
Anyone who will swing at you in the ER is baseline unstable. Period.
I know too many ER doctors, nurses and techs and clerks who have been assaulted because, “Mister Jones was angry and upset.”
Truly defensive medicine is when somebody has your 5′2″ nurse by the throat against the wall…
Anyone who thinks this guy should win his case… should be ashamed. You just said it’s ok to assault the very people (from the cop and medic to the nurse and doc) who put their lives on the line for you every day they walk into work.
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