A Minor Detail: Heidi Creston

Handling the medical treatment of a minor can be tricky. Heidi Creston is back to discuss some of these special circumstances.

Welcome back, Heidi!

I work in L&D, and by far, dealing with family issues is more demanding of my time and energy than anything else. There is one issue that continually pops up and more and more I am finding it in the books I’ve been reading as well. I’m not an expert but I’d like to toss my two cents in for whatever it’s worth.

There are three primary condition that will emancipate a minor WITHOUT a court order:

1. Marriage
2. Joining the Armed Forces
3. Reaching the age of 18

Marriage or enlistment in military service by a minor brings about a new relationship of obligation and responsibility between the child and someone other than the parents. The severing of the child-parent relationship in this manner constitutes as an implied emancipation.

Substantiated reports of desertion, abandonment, non-support and other conduct of the parent may constitute reasonable circumstances for implied emancipation of a minor depending on the age and maturity level of the minor.

Pregnancy, in most states, does not constitute for implied emancipation. The pregnant minor is MEDICALLY emancipated, meaning they can make medical decisions for themselves and their baby only. The best option is to research the emancipation laws in the state that your are writing about because regulations vary from state to state.

Some states are pretty liberal with their emancipation procedures and a judge can sign off on it without a hearing if all parties involved are in agreement. So if you are planning some animosity within your story with those teenagers, take a quick peek at the laws first.

Marriage is another minor detail as well. Some states, like Wyoming, the legal age of marital consent is 19, not 18. So there is good reason said boy had to talk to girl’s dad first.

Jordyn here: I did a series as well on HIPAA issues that you might find interesting. Several aspects of this law are violated by authors frequently. Check these links for further information.

1. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-13.html
2. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-23.html
3. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-33.html

Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished.

Treatment of Minors in the ED

It may surprise you to learn that there are circumstances where an underage minor can sign themselves into the ER for medical treatment without parental consent. In most states, if the patient is 13 y/o and up and requesting treatment over concern for a sexually transmitted disease or concern for pregnancy, they can seek treatment and we cannot call their parents.

This is one area that can be a huge source of conflict in the ED and most doctors and nurses I work with are very uncomfortable with the situation. More sticky would not be the patient who presents alone, but one that does present with a parent. Let’s take a situation where a teen girl presents with her parents over complaints of abdominal pain. We do a pregnancy test and guess what… she’s got a little bun in the oven. How do we disclose those results?

First off, we ask to speak to the teen alone. We will tell her the results. We tell her that legally we cannot tell her parents though we would like her to tell them and we will help her tell them if she would like.

Let’s assume the teen says “no”. She doesn’t want her parents to know. Then we can’t disclose it to them.

Now, parents are very smart and they will likely know what tests were performed. They may ask specifically, “What about the pregnancy test?” What we’ll say is, “Mom, I can’t legally tell you the results of that test. You need to speak to your daughter about that.” A mother’s intuition will kick in. After all, what would be the big deal if the test were negative?

Same goes for STD testing. I’ve had parents call back in a few days for these test results. Again, positive or negative, I can’t disclose if the parent knows the test was performed. If the parent doesn’t know the test was performed, I can’t even disclose they had the test.

Can they get the results through medical records? This is iffy. An astute medical records department will be savvy enough not to disclose but I can see this being a potential gap in the system.

Also, when the insurance bill arrives, the test may be disclosed on that. Or, the parent may call the hospital billing department and ask specifically what test was run. This may be a potential way for them to learn about the test. But again, billing personnel don’t have access to lab results.

I want to make clear that all ER professionals I know will make every effort to get the teen to disclose the results to their parent. Other potential areas of conflict. What if the parent is a drug user? An abuser? What should the ER team do then?

ED Treatment: Peds versus Vehicle (2/2)

We’re continuing with Mart’s question. Briefly from last post, a 16 y/o has been struck by a car. What would medical treatment be? She bounces off the hood and these are her injuries. Her elbow stung and her right leg turned back and blue almost instantly. Right hand is swollen. Her shin looked like a giant Easter egg lived under its skin.
EMS Response: Dianna

Contusion is the medical term for bruise. Contused areas don’t color immediately; it takes time – hours to days, sometimes only minutes depending on the injury and how easily the patient bruises, so include in her dialogue she bruises easily, but have most of the coloring appear later (not at the scene). However, patients feel contused pain immediately and a hematoma (mass swelling) can develop within seconds or minutes. The Easter egg you describe is called a hematoma.

Like human crutches, we’ll assist her inside the ambulance or we’ll place her on our stretcher and wheel her inside our ambulance. We typically assist the walking wounded instead of using the stretcher. Once inside our ambulance, I’ll ask her to lie on the stretcher. I’ll hook her up to our cardiac monitor to obtain a 12-lead just to verify her heart is functioning normal (heart rhythm is normal).
I’ll insert her index finger in a pulse ox to obtain her SPO2 level (blood oxygen saturation). I’ll calculate her breathing rate and heart rate and I’ll take her blood pressure and evaluate her skin and pupils. I’ll perform a rapid trauma assessment, head to toe, to ascertain full extent of injury.
I’ll disinfect all abrasions and control any bleeding. I’ll splint any suspected fractured bones or joints. We’ll offer her Fentanyl (pain reliever) but we’ll only administer it if she allows us to transport her — we can’t inject pain meds and then leave the patient (not transport to an ED).   
To clear the patient of C-spine immobilization: I’ll perform an examination of her neck, spine and all extremities, and if she denies any pain, tingling or numbness and I find no abnormalities, then it’s suspected the patient didn’t suffer any neck or back injury, thus no cervical collar or back boarding is necessary.
ER Care: Jordyn
When the patient arrives in the ED, if they are able to walk (a patient in C-spine precautions precludes this), we first obtain a weight. This is important in pediatrics because medications are dose dependent on that weight.
We’ll take report from the ambulance crew. Set of vital signs. Connect to a monitor. Assess pain level. Check IV site to make sure it is patent (lines can come out upon patient movement/transfer). Check splints to make sure distal part of extremity is getting good blood flow. The nurse will listen to her heart and lungs. Quick neuro exam. We’ll likely x-ray the right elbow, right hand and right lower leg. Even though suspicion of fracture might be minimal, the ED doctor has to disprove otherwise. Wounds cleaned and dressed.
Tetanus shot if none in the last five years. This is done for injuries that break the skin. Otherwise, you’re okay for ten years.
If the area is fractured, a splint will be applied. If no fracture, an ace wrap may be applied for comfort. It is important to note that often we will splint even if the x-ray is negative. This is both for support, comfort and compression. And also if the radiologist comes back and reads it as positive. The patient is instructed to leave the splint in place for about a week and if the extremity is still bothersome, to seek another evaluation of the injury. Some fractures won’t show up on x-ray initially but will later when they begin to calcify.
The patient is sent home with R.I.C.E instructions. Rest. Ice. Compression (leave your splint on). And Elevate. Generally, over-the-counter Ibuprofen is sufficient for pain control.