Thursday, August 5, 2010


[The following is a composite description of a common scenario, and does not describe any individual patient.]

You are an emergency medical services provider. A woman walks into your facility stating that she's been raped.

There's a fairly extensive procedure for this. Immediate placement in a private room, contact the police, examine and treat injuries, do a rape kit, write a super-detailed report, treat everything as evidence and turn everything over to the police, and connect the victim to community resources to support her in the aftermath and recovery. And as a good provider, you want to follow this procedure to the letter and supplement it with as much victim advocacy and hand-holding as you can possibly spare time for. You know that your actions could make the difference between a rapist getting caught or going free, and between this woman being psychologically supported or devastated.

The problem is, the woman who says she's been raped is a psychiatric patient with numerous paranoid delusions. She's a "frequent flyer" at your facility and is well known for fabricating bizarre stories. Last week she was here because "the men are stealing my thoughts," the week before that she was here because "the CIA put a chip in my eyeball," and this week she says she's been raped.

The details she gives you are sketchy and inconsistent, but this is the case with everything she says, whether it's about the CIA or about where she sleeps at night. You know that mentally ill people are more vulnerable to rape, because they are less able to detect red flags and defend themselves--and because attackers know their stories will be doubted. But you also know that sexual abuse is a common paranoid delusion.

Taking a rape accusation seriously is, to be blunt, a huge pain in the ass. It'll cost tens of thousands of dollars that will never be paid back, and more importantly, it'll take up a tremendous amount of staff time--basically a nurse's entire shift and more than an hour of a doctor's time. This isn't your bon-bon eating time; this is coming out of the treatment of other patients. Every other patient in the facility, everyone suffering pain or distress or risk to their life, is going to have their care delayed because of this.

There's also tremendous staff resistance to playing along with delusions. The patient's assigned nurse argues that doing a rape kit (and all that entails) will encourage attention-seeking behavior and reinforce the patient's belief that her delusions are real. The nurse recommends the patient be evaluated for psychiatric treatment.

Last month, this woman came in claiming she was raped, you did a rape kit, and you found no evidence of rape and the police found no suspects. Doesn't mean she definitely wasn't raped then, just means there was no evidence. And now she's back again, with the same story.

What do you do?


  1. You treat her like you would any other woman you'd never met before who came in with the same exact complaint. Unless somebody up the line from you directly states otherwise, there isn't really another option. I was taught that, in the absence of contradictory evidence, you have to take a patient's complaint at face value.

  2. Maybe this is me being a far-too-serious EMT-b student, but... "Run the call" is my answer. It's not really my place to "triage" care based on concerns that the pt might be lying, unless there's either a blatant safety concern or a blatant delusion. ("My arm has been shot off!" when you can see both of them perfectly clearly, for example.)

  3. Lokidude - That's what I was taught too. That's certainly what I did when I worked on the ambulance. (I had more independent decision-making power then; now I just follow orders.)

    But you don't always follow everything a patient says. If someone tells you they have intractable pain and they're allergic to everything except Fentanyl, you do investigate causes and treatments for this pain, but you don't give them all the Fentanyl they want. And when this woman said the CIA put a chip in her eyeball, you called the psychiatrist, not the opthamologist.

    So while my inclination is also to take a patient's word for it, it's not an absolute rule.

  4. Perlhaqr - I agree; in the role of an EMT that's what I would (and did, many times) do. But in this example you're the imaginary doctor, so it is your role to assess the validity of the patient's complaint.

  5. This is a decision that needs to be made by the (attending) physician or the medical director of the ED (Preferably both). That individual has the duty to triage--supposedly they also have the training and experience to do it properly, a lisence and insurance.

    Medicine is a hierarchical profession--this call is the attending's.

    William the Coroner

  6. William the Coroner - Absolutely right (and I hope I didn't imply that this is a floor tech or nurse's decision, obviously it's not), but in this example you're the imaginary attending physician.

  7. My opinion on this is as a non-medical professional, so FWIW...

    Run the rape kit. Hand the evidence off to the police. Rape is a crime, and a report of a crime needs to be handled by police. If the answer is "I didn't find any evidence of rape" then that also belongs in the report, but run the kit anyway.

    The costs are always recovered. Hospitals recover through various means, including passing costs on to other patients/insurance companies, and through Federal claims for non-payment, so "non-recoverable costs" are not an issue.

    The doctors' time can't be recovered, but patients are prioritized based on their need for immediate attention care. If the need for additional medical professionals arises, there are almost always additional doctors that can be called in.

  8. Mithras61 - The money issue probably isn't a huge deal factor in the decision (although passing along costs is not easy or popular, and good luck with those simple and speedy government claims), but the staffing is.

    Other doctors are not coming in. In a disaster an ER might be able to get an additional nurse from another floor or the float pool--maybe--but I've never seen a physician come in just because the ER was swamped.

    If the patient gets the sexual assault Full Meal Deal, other patients will have to wait significantly longer for care--definitely distressing them and possibly allowing their condition to worsen.

  9. The eternal laws of the universe and Mr. Murphy dictate that the time you slack off, whether it's the first or the fifth, will be the time she really was raped. If that seems like a superstitious and maybe selfish reason to do the right thing when you don't want to . . . well, yeah, that's about right.

  10. Don - Now that is a convincing argument.

  11. I know very little about ER procedure, so I could easily be talking about decisions already implied, but it seems that there's something missing from the discussion here: the other patients.

    What kind of risks does doing the rape kit expose them to? If you've got a bunch of sucking chest wounds, I presume you deal with them first. If you've got fevers and very uncomfortable but not doubled-over abdominal pains, I presume you do the rape kit. If you've got a dog mauling with broken bones, and bacteria are heading for the marrow right now, maybe you clean that and then do the rape kit before stitching?

  12. I forgot, you don't stitch over broken bones, do you? Bad example.

  13. I had a smarmy, smart-assed comment, but really, you run the kit.

    I've been the patient put on hold for 6 hours... it sucks horrible ass.

    but once the kit shows no evidence, you drop the level of support and care to bare minimums.

  14. Mousie00 - A trauma takes precedence over just about anything, but the fevers and (probably are doubled-over, actually) abdominal pains will probably end up waiting, and you can't be certain whether that's just inconvenience or actually harmful.

    Anon - Rape kits don't "show evidence" as such. They're attempts to get samples of the perpetrator's DNA, but often they don't, and that does not mean a rape didn't occur--and you won't know about the DNA results in the ER. It's a rape kit, not a rape test.

    There's no way to be certain, from a physical exam, that someone wasn't raped.

  15. Mouseioo: I don't see what the other patients have to do with this at all. If a doctor is theoretically pulled away from another patient they aren't going to pull from the theoretical "sucking chest wounds" patient.

    Seriously - this is the health care system and it is built (we assume) to handle emergencies.

    @ Holly: I am not entirely certain where you get your figure of "tens of thousands of dollars" for rape kits. Are you talking about every single rape kit the hospital runs throughout the year? Because the average cost per rape kit is approx $1600 - that includes materials and the drs and nurses time.

    Also, rape victimization and violent criminal victimization is very high among the mentally ill because they are a vulnerable class which most attackers know health care professionals and law enforcement have a hard time taking seriously.

    ERs are supposed to be available for emergencies like this. The problem - as I am sure you know - is that people come in for minor injuries that could wait for a regular clinic or end up seeking emergency care for preventable illness (like asthma) because they don't have access to health care.

    The problem isn't that you have a crazy lady wandering in taking up the ERs time with a rape emergency - it is that ERs are over-worked and understaffed and that leads to compromising services which in my mind is wrong but is becoming increasingly necessary because of the pressures on the system.

    Makes you wish there were some sort of comprehensive health care reform, no?

  16. Well, for one, you run the rape kit. Not just because it's an allegation of a felony offense, which has to be taken seriously, but also because of the aforementioned Murphy's Law.

    Then you recommend her for psychiatric care, because seriously, CIA installing a chip in her eye?

    In the meantime, you operate on a basis of (mostly) good faith, as long as there isn't someone with a medical emergency, which is how the triage system works anyway, right?

  17. Ellie - If a doctor is theoretically pulled away from another patient they aren't going to pull from the theoretical "sucking chest wounds" patient.
    At night in a lot of small and medium ERs, there's one doctor on. There's no point asking which patient loses a doctor, because EVERYONE loses THE doctor. Still, a sucking chest wound would get the doctor over like pronto, no matter what--trauma trumps everything.

    Maybe this is regional or maybe I'm just off, but $1600 sounds low. I had a head injury once and the ER costs (thankfully covered by my employer) came to about $4000. And I received a lot less time and resources than a rape victim.

    Comprehensive health care reform might help the situation in ERs--it would not fix it. Because how do you adequately staff a department that will get 50 patients one night and 300 the next, with absolutely no advance warning or discernible pattern? Even with healthcare reform, no hospital wants to pay for excess staff that will spend non-crisis nights playing Sudoku. (And getting on-call staff to come in is, as discussed above, a "maybe in two hours one person will show up if they feel like it" at best.)

    I feel like I should be clear--I am NOT saying we shouldn't believe this lady or shouldn't treat her! I am saying that it's not simple.

  18. Of course it isn't simple - that's always the easiest point to make :-P

  19. I saw an article a while back, about these frequent fliers.

    Someone did a pilot study where they went into an ER, found who the ten people in the community with the worst case of frequent-flyer-itis, and intervened. They rented them each an apartment and assigned a social worked to make regular visits, made arrangements for them to receive primary medical care, etc. Doing all of this cost a whole lot less than dealing with them in the ER had cost. And it was better for the frequent flyers themselves.

    Unfortunately, programs that provide resources to improve the lives of the "undeserving", are never popular, even if the maintenance program is cheaper than the emergency triage and life support that those same people will require if they don't get their maintenance.

  20. Ellie - No. The easiest point to make (on the Internet) is "I would totally believe her and do everything!"

    "I would like to believe her and do everything, and at when it's my decision I do, but when this happens very often and our resources are stretched very thin, it's hard and we're often conflicted or resentful about it" is at best the second-easiest point.

  21. Anon - Now that is cool, and I wish we were able to do it more often.

  22. @Holly: Yeah, you have a point. I'd like to think that everybody understands that any given problem - especially social problems like this - are complex and not easily solved. But you are correct in pointing out that people prefer a black-and-white solution to a multi-faceted issue.

    One of my areas of study (undergrad) is sociology and we always end every discussion with, "... of course it isn't that simple but this gives us a way at looking and talking about it."

  23. It depends on how much demand there was, and how often the patient had made the claim before, and the physical examination.

    None of these are the gold standard, and there will be errors. but were I the attending, the first claim--run it. The second claim--run it. If this is a recurrent problem, do a good physical examination--look for bruising, abrasions, and other signs of trauma.

    Yes, the problem is, in someone who cries "wolf" there is a chance with this decision tree that you will miss forensic evidence. This is bad, and not a decision to be made lightly.

    Now, if someone has come in with this scenario, and there have been multiple negative rape kits/exams, and you miss the positive, in that scenario, the multiple negative exams pretty much have caused reasonable doubt. So in absence of a confession--the legal system isn't going to be able to do anything with the results. Now, this does deprive the patient of confirmation of the story, and that is important. But when resources are finite, where do you draw the line? At some point, for financial reasons and lack of time, the kit ain't gonna get done.

  24. I run into this, but from the other end of the spectrum, kind of. I run a program in Boston for developmentally disabled adults (maybe half of whom have psychiatric disabilities as well, ranging from 'minor' to 'florid' to 'ohmygodthatsabigfuckingknife' levels of difficulties), all of whom are highly behavioral (attention-seeking, etc.). My guys sadly make false claims by the bazillions -- phantom pain, broken bones (when there's been no trauma or physical stress, etc.), the all-time favorite "I feel unsafe and I'm going to hurt myself (unless, of course, I get ice cream, attention and cuddling from a variety of ED personnel)," and (fortunately, relatively rarely with my population at least) false rape claims.

    There's no good answer, or productive answer, or efficient answer, and usually not even a psychiatrically thereapeutic (for them or you) answer. At least, in fifteen years I've never found an answer that makes you feel good at the end of the shift. The only practical answer (IMNSHO) is, you just do it (run the kit, provide the care, etc.). The more false claims the person has made, the more you turn down (or should, from a strictly behaviorist perspective) the attention and empathy, but at a minimum, you provide the diagnostic treatment and go where that leads you.

    There's two big negatives to this:
    1) Those with real trauma (actual injury, actual emotional trauma, or actual rape [big helpings of both]) can get the coldly-efficient attitude the one time they actually need the care and compassion. Rare -- my experience with a half-dozen EDs across Greater Boston is that out of compassion, fear of lawsuits, or just habit, ED staff will do the expected work, each and every time -- but it happens.

    2) The false reporter gets tons of attention (feeding into the behavior and/or psychiatric issues), and eats up the crucial resources that EDs just don't have, which leaves the EDs shorting others who legitimately need the care, and worse, I think, burns out the ED staff (fuck knows it burns me out on my end), so that the next disabled person with a complaint gets ignored, and suffers (and Murphy's Law is always in effect: that's the one with the real issue).

    I guess I'll take D) -- 'No good answer.'


  25. Anonymous at 2:07 -- I remember reading that article. If I'm not mistaken, it was this New Yorker article:

    It discusses data showing that "The homeless problem, like the bad-cop problem, is a matter of a few hard cases." I remember it as being really fascinating, but you have to have a subscription to read the whole thing.

  26. Ah, didn't realise I was supposed to play attending physician. I change my answer to "hell if I know", 'cause that's way above my pay grade. If I ever get there, I hope like hell I'll have gotten enough training to have a better idea of how to behave. :)

  27. I'm just a rural volunteer BLS guy, so we don't deal with rape kits nor do we push drugs. So I do encounter drug seekers, but since I don't have the drugs they want (and the seekers know what BLS means!) we just end up transporting them (and I've only had a license for a day, so for me that has always meant driving anyway.) By some consensus, we settle for rolling our eyes when we're pretty sure no one can see us.

  28. Please bear in mind while reading this that I'm a male who has counseled women through rape trauma and, in the words of one shrink, done a damn fine job of it, particularly for an amateur with no training. I take rape and trauma responses very seriously, but I'm also a pragmatist.

    My response to Holly's original post:

    "Innocent until proven guilty, but consider the probability she's making it up and remember that life, being high on demand and short on time, requires triage."

    Translation: If someone comes in and says they've been raped, the default position can and should be to not only to take them seriously, but to be as commodious as possible, particularly with respect to procedures that can save their sanity, their future, or both if indeed they HAVE been raped.

    On the other hand, if they have a history of making things up, you consider the probability that they might be making up the rape, and then you start performing triage and trimming back what you do for them to the absolute necessities: the most immediate and basic precautions from both a legal and a medical perspective: as you said, the mentally ill have fewer defenses against such things, so it's quite possible she HAS been raped, and it would be nice if she were covered.

    But anything NOT pressing should be deferred in favor of people who have a higher probability of medical problems. It seems harsh, but life sucketh: there are more problems than there are resources to fix them and time is running out, so you put your resources where they'll do the most good.

    On battlefields, this procedure is called triage, and it essentially means playing god: "This guy gets immediate surgery because there's a good chance he'll make it; this guy gets to tough it out for a while until the more pressing cases are sorted out; and this guy probably won't make it, so he gets a priest and dose of morphine.

    In the case of your frequent flier: which category does she fit into?

    In my defense: borderline personality disorder is NOT a fiction. It exists, and I've seen it in action. Though I have provided care and counsel to people who have been raped, I have also had the opportunity to hear a young woman confess that she was, in fact, raped when she was younger... but I later learned that there is convincing evidence, evidence that could not be manufactured and was certainly not tainted by patriarchal pretenses, that no such thing could possibly have happened in the manner she described it. In addition, said young woman has a history of inventing tall tales.

    Let me put it this way: if I were an emergency medical provider, and she walked into my work area, and if I knew her history as I do... I'd do the absolute minimum to find out if she was, indeed, raped. In the meantime, I'd do my damndest to make sure that others got the care they needed.

  29. One thing that's always interested me in the debate between the "She's probably faking it, like all the other dumb bitches who try to destroy men" side and the "How can you doubt the word of a woman? The Goddess Within Her is incapable of lying, and besides, it's just confirmation that some dumb bastard did what dumb bastards do all the time"* side is my anecdotal experience, which would tend to lead one to believe that women occasionally threaten to make up rape allegations but rarely (anecdotally never) follow through even if they don't get their way.

    Does that mean I should find allegations that a woman is faking her rape accusation more credible, since I have experience with women threatening to do just that in order to get their way?

    Or does that mean I should find those allegations less credible, because I have experience with women threatening fake allegations but have never seen one actually go through with it?

    Or does it mean I overthink limited anecdotal evidence? Probably.

    *If neither of those offended you personally . . . I can probably rewrite them.

  30. If "ancedotal" precedes it then it isn't really evidence.

    Real evidence is that only 2% of reported rapes are fake accusations but at least 60% of rapes go unreported.

  31. I'm pretty sure that statistic is correct. But from a rules of evidence point of view, how do you know how many rapes are unreported except from a series of unverifiable anecdotes?

  32. It's from the United States National Crime Victimization Survey which is a scientific survey run by the Bureau of Justice Statistics.

    Here is the methodology if you're interested:

  33. That seems as good a source as you could possibly get. An impersonal survey like that would tend to leave out anyone seeking attention; it would leave in actual crazies, but they are probably too few to alter the statistics.

  34. I'm going to be a boring Brit and say "thank fuck" for the NHS. Seriously, Holly, your head injury would have cost you $4000 if your employer hadn't covered it. How can people in a society which claims to have morals be happy with that? I just don't get it.

    But I know this isn't a blog post about healthcare being free at the point of need. I'd go with do the kit ASAP and as quick as possible, and refer to psychiatric care. Shouldn't rape victims have access to some kind of psychiatric care ASAP anyway? I'd have thought so.

    As far as the frequent-flyer thing goes, it doesn't surprise me at all that you can run a fairly intensive welfare programme that still works out cheaper than the cost of the ER time and resources, but these things just don't get the funding. There was a great trial called the Perry Preschool program (in Illinois I think) that gave deprived kids good quality pre-school and then looked at their outcomes later in life. It was also randomised, which is rare for these kind of things. Anyway the programme didn't do so well at raising earnings but it had dramatic effects on the amount of crime these kids ended up getting involved in - and paid for itself 8 times over! Of course, the policy makers didn't take a blind bit of notice.