Hot Seat Case #105: 17 year old intoxicated female
Posted on: January 10, 2018, by : Michael Hrdy
Michael Hrdy, MD Children’s National Medical Center
with Asha Payne, MD Children’s National Medical Center
You received sign-out from the overnight ED provider about a 17yo F who was under arrest,. The patient was brought in shortly before shift change. The patient was found driving a car and believed to be under the influence of alcohol or other drugs so she was taken to the ED for medical clearance. The patient endorsed drinking “two glasses of wine” prior to getting in the car.
PMHx: None
Meds: None
Allergies: NKDA
ROS: Denies fever, nasal congestion, chest pain, syncope, vomiting, neck pain or muscle pain, no headache, no numbness, tingling or weakness
Vital signs: Afebrile, P 98, R 12, BP 110/70, 99% on RA
General: Alert. Slightly confused and answered questions using short but appropriate answers. not agitated, not uncooperative, not withdrawn.
Skin: Warm. intact. moist palms, no other diaphoresis
Head: Normocephalic. atraumatic.
Neck: No lymphadenopathy
Eye: pink conjunctivia, pupils 2-3mm and reactive b/l, no mydriasis, no nystagmus
Ears, nose, mouth and throat: Oral mucosa moist
Cardiovascular: Regular rate and rhythm. No murmur.
Respiratory: Lungs are clear to auscultation. respirations are non-labored.
Gastrointestinal: Soft. Nontender. Non distended. No organomegaly.
Neurological: Alert. No focal neurological deficit observed. CN II-XII intact. normal sensory observed. normal motor observed .
Psychiatric: Cooperative. not agitated.
The decision was made to obtain a urine drug screen and urine pregnancy test and to not pursue blood testing at this time. At time of shift change the patient is sleeping but has not provided a urine sample. When the patient is awakened and re-examined she continues to have markedly injected conjunctivae bilaterally but appears alert and is able to notify the provider that she does not speak very much English. An over-the-phone interpreter is used to obtain further history and the patient denies any substance abuse besides the wine previously reported. The rest of the exam is normal.
Shortly after re-examination, the patient provides a urine sample. The pregnancy test is negative. The urine drug screen is presumptive positive for marijuana and cocaine .
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Interesting case and timely, with the recent national attention re the nurse in Utah being handcuffed after refusing to draw blood for police from an unconscious patient who was not under arrest.
The crux of the issue to me seems to be around divulging results. Specifically, am I compelled and/or does HIPPA allow me to divulge PHI to a law enforcement agent who does not have a warrant/subpoena/court order? My understanding is that there are specific caveats under the Privacy Rule to release PHI if for example, the patient is a victim of a crime (does not apply here), the PHI is evidence of a crime that occurred on the premises of the covered entity (driving the car while intoxicated, and the drug use are the alleged crimes here but no evidence that it occurred on the hospital premises), or a more vague clause about medical emergency and informing law enforcement about nature of/commission of a crime…. Ultimately I would call and document my discussion with on-call Legal/Risk. I have found them incredibly helpful with cases like this.
Caleb
Agree with Caleb on talking with the legal team to figure out what we can share with the police on the patient’s lab results. I would err on the side of not telling them – if the patient remains under arrest and charges are pressed, I would assume that the investigator and/or prosecutor could then request the medical records.