SPONSORED BY The MOUNT SINAI EMERGENCY MEDICine DEPARTMENT, the AMERICAN OSLER SOCIETY, the AMERICAN MEDICAL STUDENT ASSOCIATION, & the BROWN alpert MEDICAL SCHOOL

 CASE #2

A 27-year-old woman presents with a chief complaint of a painful left forearm and hand; her primary language is not English and her friend speaks for her. The patient looks anxious. The friend reports that the patient got into a fight with another girl over her boyfriend, but there is no facial trauma. Upon physical exam of the patient’s left arm and hand, it is clear that some bones are broken; you order pain medication and X-rays. Both the patient and the friend are wearing short skirts and form-fitting tank tops; your patient is wearing fishnet pantyhose and both are wearing very high heels. You assume they are sex workers (check your implicit bias).

What do you while you wait for the X-ray results?

Answer: Any time a patient does not speak English, a certified medical interpreter should be called in and the patient should be interviewed in the absence of the visitor. Every patient has the right to communicate directly and confidentially with their healthcare practitioner. Only trained interpreters can facilitate the development of the patient-practitioner relationship when the patient and practitioner do not communicate via the same language. In situations like human trafficking, people may be brought to the E.D. by their trafficker. In this case, though the visitor claims to be a friend, she still may not be speaking in the best interest of the patient. As a healthcare practitioner, it is your job to advocate for your patients and protect their right to a confidential and safe space to receive healthcare.

You ask the friend to sit in the waiting room while you complete the medical exam; she declines, saying she has to get back to work but she’ll come by later to pick up the patient. Before the friend leaves, you ask her to tell the patient that the interpreter is on the way and ask her to provide urine in the provided cup. The friend tells the patient something; the patient nods meekly, and the friend reports that she is still in quite a lot of pain. You thank her and ask her to come back in a few hours. The patient looks up as the friend leaves the room; she seems to get more tense.

What do you do now?

Answer: Try not to leave the patient alone for too long, as it may increase her feelings of isolation; you want to make her feel that she is in a safe place where people care for her. Use an in-person, telephonic, or video interpreter if your institution has access.

You bring her some water when she returns from X-ray. The interpreter arrives and you let her know that you are concerned the patient may be a trauma survivor, though you are not sure. You introduce the patient to the interpreter and explain the interpreter’s role in her care. You ask the patient what happened to her arm; she tells you she got into a fight with another woman. You tell her you would like to finish your medical exam to look for any other injuries; you ask her to change into a hospital gown. You and the interpreter leave her bedside while a technician helps her change. The technician tells you she noticed bruising on the patient’s belly when she was changing. When you return, make sure to examine her abdomen; the patient is somewhat tender and has bruising on her abdomen and along the left side of her chest. You asked her if she was kicked or punched, and she replies affirmatively.  

You tell the patient that X-rays show that she has broken a bone in her left forearm and the thumb of her left hand. You explain that you need an ultrasound and to send her back to X-ray to check her ribs.

The point-of-care ultrasound was negative for traumatic intra-abdominal or pelvic free fluid, the X-ray did not show rib fractures.

Now what do you do? 

Answer: You are concerned for the patient’s safety and ask if she would like to talk with the police about her assault. She becomes even more tense, and asserts she does not want the police and she will leave now. You sit down and share your concerns about her safety. You inquire about her safety in returning home, and ask if she has any concerns she would like to share.

You are concerned the patient is in an abusive or dangerous situation. Human trafficking is on your differential; what are the potentially concerning findings?

 Answer:

·      She was brought in by a friend who did not wait for her

·      She was scantily clad, as was her friend

·      She has an anxious and tense affect that worsens at the offer to speak with police about her assault

·      She was badly beaten

The patient tells you she is not allowed to talk to you about where she lives, and asks you to please finish taking care of her so she can leave when her friend returns. You offer that you do not want to get her into trouble, but would like to make sure she gets the best care possible. “I don’t want you to be unsafe,” you tell her. She remains steadfast that she needs to leave. You express concern again, as well as understanding that she may not be able to share more right now. You explain the medical care plan, and ask if she can return for a follow up appointment with the hand surgeon. She says she will. You ask who will help her with her general activities, since she cannot use her left arm and hand. “My friend will help me,” she replies. As you are splinting, you ask if she needs a note to be excused from work. She explains, “I can’t use that. I have to work anyway.” She tells you she is a private contractor, when you ask what kind of work she does.

 Now you are more concerned that this patient is being trafficked; why?

Answer:

·      She is not allowed to talk about where she lives

·      Despite multiple and significant injuries, she has to work anyway

·      She answers vaguely when asked about her work

After you complete the splint, and while she is getting post-immobilization X-rays, you prepare her discharge papers. You two have decided she will come back for your next shift to reassess her pain control, and she will call the hand surgeon for a follow up appointment too. You ask if she will be able to pick her up and afford her pain medications, and she nods. “My boyfriend will get them.”

You remain concerned for some kind of trafficking and/or intimate partner violence, but are concerned about pushing too hard for more information. How will you close this clinical encounter?

Answer: You assure your patient that she is currently in a safe place and you are a safe person; you remind her that you are a healthcare practitioner and you want to make sure you are doing everything you can to help her be healthy and recover from these injuries. You tell her you are concerned that she is in a dangerous situation and does not feel safe getting help. You ask if she would like to speak with the hospital social worker or someone else before she leaves, or if she wants to tell you anything else before you see her again in a few days. She declines; you offer that she can wait in her stretcher and have some hospital food while she waits for her friend to come back. You tell her that if anything changes and she wants or needs to come back before your next shift, she is welcome here, anytime.

 Is there anything else you should do?

Answer: Because she is an adult, you respect her stated wishes; treat her emergent medical condition and assure her that this is a safe place and you are a safe person to come to for help. Together, you have made a discharge plan using harm-reduction principles. It may be helpful to her care if she sees another clinician to document your general safety concerns in the medical record. Read more about documentation here.