CASE #3
An 18-year-old man presents to your ED for being “too drunk.” His friend brings him in but cannot stay. The patient looks younger than 18 to you. He is not able to participate in a history at this point but his glucose is normal, he has no signs of trauma above the clavicle, and he is maintaining and protecting his airway. The charge nurse places in him on a one to one to prevent an unsafe elopement and you carry on with your shift.
Many hours later the technician comes to you because the patient is crying and will not say why. You go to the patient room, sit on the bed, and ask him what is wrong. “Is the hangover really bad?” The patient complains of a headache and some nausea, but even after symptom control, he is still tearful.
What do you do next?
Answer: Ask the patient what is wrong!
You sit down and say, “You seem really upset for a hangover. Is something else wrong?” He tells you he does not want to talk about it, and asks to leave. You tell him as long as you can determine that he is clinically sober, and as long as he has no other complaints that he needs treated, he can leave. But you would like to help if something else is wrong, and if you can. You tell him that sometimes whatever is wrong is not a medical problem, but you may be able to connect people to other resources or organizations. “And sometimes, depending on what’s wrong, I have to tell someone else about the problem; but sometimes that can help. Do you want to see if I can help with whatever else it is?”
The patient briefly tells you that he has been homeless for about a year, after he ran away from home. He has been “sleeping with people” so he can have a place to stay when it is cold or wet outside.
What do you do next?
Answer: Remember that you thought this patient was younger than 18 years old. If he is, what he has just shared qualifies as sex trafficking, even though there is no third-party facilitator, and you are a mandated reporter under the 2015 Child Abuse and Prevention Treatment Act; you would report to your state agency that receives reports about child maltreatment.
You ask if he is crying because he is homeless, or because of something else. He tells you he is embarrassed about how he is living. He wants to go home, but feels too ashamed. You ask who he lived with before, and he tells you he lived with his father and older sister. He knows his father’s phone number and is willing to call his father, if you will talk to his father first. You accept the request, and ask how old he is. He tells you he just turned 17 last night, and was celebrating with his friends, and that is why he was drunk.
What do you do next?
Answer: Tell the patient the truth: You are a mandated reporter about concerns of abuse of minors. Ask him if he wants to be involved in making the report but be clear you have to make the report, either way.
You tell the patient that you are required by law to report concerns about child abuse; what he told you about using sex to have safe places to sleep counts as abuse. He is not in trouble, but you have to make a report about what happened to him. You ask if he wants to talk with the authorities (depending on your state, that may be “Child Protective Services” or law enforcement). He says he does not care that you have to call them, “it’s not like you can find those guys anyway. I just want to go home, and I don’t think I can.”
What do you do next?
Answer: You dial his father with him, and explain that his son is in the hospital.
His father explains that the patient has been struggling with a substance use disorder for a couple years and never came home one night. He was reported missing the next morning. The patient’s father says it will take him an hour to get to the hospital from where he is, but he is on his way. He asks to speak with his son.
What now?
Answer: After the patients speaks to his father, and while waiting for the father to arrive, you let the patient know that you will let his father know about the report you are required to make. You can let the patient tell his father the details (you do not need know them anyway) when he is ready. You speak with a social worker and together you follow the institutions anti-trafficking response protocol. You suggest empiric STI therapy, given his potential exposure. You both offer relevant local resources to the patient and his father. Then you make the required report.