CASE OF THE MONTH – JANUARY 2023
EMS responds to a private home where a 15-year-old female complains of abdominal pain. She is at her friend’s home. The 16-year-old friend called 911 because the patient was “getting worse and worse”. The patient provides little history, but the friend states that the patient has been at her home for the last day and has been complaining of abdominal pain the entire time. On initial survey, the patient appears pale. She is alert and oriented, cool to touch, and appears weak. Her abdomen is diffusely tender and mildly distended. There are no adults present.
Her initial vital signs are Temp 98.7 BP 70/48, HR 128, RR 20, SpO2 98% on room air. Her pain score is 8.
The patient is less than eighteen years of age and therefore a minor. She is hypotensive, tachycardic and in significant pain and therefore, has an emergency medical condition. EMS personnel shall make the effort to inform parents/guardians, but the parents’ absence should not delay care or transport to the emergency department.
Minors require parental consent for non-emergency medical care. Minors not requiring parental consent in California, include minors that are:
- Married or were previously married.
- Not married and have an emergency medical condition and parent is not available.
- On active duty with the Armed Forces.
- Self-sufficient 14 years of age or older, living separate and apart from parents, and managing own financial affairs.
- An emancipated minor with a declaration by the court or an identification card from the Department of Motor Vehicles.
- Seeking care related to the treatment or prevention of pregnancy.
- In need of care for sexual assault or rape.
- Seeking care related to an abortion.
In this case, we have a minor patient with an emergency medical condition so she shall be treated and transported to the appropriate receiving center as per Ref. No. 832, Treatment and Transport of Minors.
Multiple etiologies must be considered. While an obvious provider impression is abdominal pain/problems (ABOP), complications from pregnancy or trauma could result in a similar presentation. Since the patient is hypotensive, treatment should begin immediately. The patient is hypotensive with signs of poor perfusion given her pallor and “weak” appearance, therefore, TP-1207, Shock/Hypotension applies and treatment should begin immediately. Establish vascular access and administer Normal Saline IL IV rapid infusion, reassessing after each 250mL. If the patient’s poor perfusion does not rapidly respond to the initial IV fluids, her provider impression is Shock (SHOK), which can be utilized with a secondary PI, as applicable. It is reasonable to treat in accordance with TP-1205, GI/GU Emergencies with a secondary PI of abdominal pain problems (ABOP), while obtaining additional history.
EMS establishes an IV and administers Normal Saline. The patient does not respond rapidly to fluids and paramedics select a provider impression of Shock (SHOK). Repeat vital signs are BP 72/44, HR 124, RR 22, SpO2 99% on room air. Fentanyl 50mcg (1mL) slow IV push is administered for pain with improvement. Paramedics ask if parents or adult guardians are available for them to call. The patient and her friend state that they are not available.
Additional history from the friend is that the patient is staying with her and doesn’t want to contact her parents. The patient states that she has had abdominal pain since yesterday afternoon. She tried over the counter pain medications hoping that the pain would go away. She has no past medical history, no chronic medications, and no allergies. When asked if paramedics can contact her parents, she refuses tearfully, stating they got into an argument and “they don’t care about me anyway.”
Abdominal pain in a female patient of child-bearing age can be caused by a broad spectrum of underlying diagnoses. In addition to asking about the characteristics of her pain including provoking factors, quality, region/radiation, severity, and time/duration (PQRST), one should also consider the entire clinical picture of a hypotensive female patient with severe abdominal pain. Some possible underlying causes include:
- Abdominal infection leading to sepsis (e.g., ruptured appendicitis)
- Trauma leading to hemorrhagic shock (e.g., splenic or liver laceration)
- Gynecologic or Pregnancy related emergencies leading to hemorrhagic shock or sepsis (e.g., ectopic pregnancy, septic abortion/miscarriage or tubo-ovarian abscess)
- Urinary tract infection (e.g., pyelonephritis)
Relevant additional history would include details of the onset of pain and duration, including a PQRST history. Paramedics should ascertain if the patient experienced any trauma and examine for any injuries or bruising. A gynecologic history including last menstrual period (LMP), possibility of pregnancy, and presence/absence of vaginal bleeding would be relevant as well.
No. This patient is not an emancipated minor and cannot refuse transport AMA. As per Ref. No. 834, Patient Refusal of Treatment/Transport and Treat and Release at Scene, she “should be transported to an appropriate receiving facility under implied consent”.
Seeking care for a pregnancy related condition would make her a “minor not requiring parental consent” and if determined to have decision making capacity, she would be in the category of minor patients that could refuse transport AMA. Although she may be pregnant, and pregnancy related conditions are to be considered, a pregnant status has not been endorsed by the patient, she is not seeking pregnancy related care at this time, nor has a pregnancy been confirmed. She is hemodynamically unstable with an emergency medical condition requiring immediate resuscitation, further diagnostic testing, and definitive care at a hospital. Transport can occur under implied consent.
One should still attempt to obtain the minor patient’s agreement or assent to treatment and transport, respecting the patient’s dignity and rights to self-determination. This approach minimizes confrontation and earns “buy in” from the patient. Using force to evaluate, treat, or transport a minor should be reserved for situations where all efforts to negotiate respectfully with the minor have failed and the patient is at risk for serious harm if force and/or restraint is not used1.
Base contact is made as required given the provider impression, Shock (SHOK). In the interim, paramedics are also able to explain to the patient that her blood pressure is very low, consistent with shock, and that she could die if she does not go to the hospital for treatment and further testing. She agrees to transport with encouragement from her friend, stating that she is afraid to go to the hospital because her parents will find out.
Base orders an additional Normal Saline 1L IV/IO and Push-dose epinephrine if there is no improvement after the additional fluids.
Upon arrival to the hospital, a pregnancy test is positive. Ultrasound demonstrates free fluid in her abdomen consistent with internal hemorrhage. She receives an emergency blood transfusion in the emergency department to improve her hemorrhagic shock. She is diagnosed with an ectopic pregnancy and taken to the operating room by the obstetrics and gynecology physician.
Because she is now receiving care for a pregnancy related condition, parental consent is not required by law, but given the severity of her condition, the hospital team is able to obtain consent from the patient to contact her parents and update them on her condition and location. The patient recovers after surgical management and is discharged home a few days later with her parents.
- EMS can and shall administer care and transport by implied consent for minors with an emergency medical condition when a parent/legal guardian is not available.
- Certain minors, listed above, do not require parental consent for treatment.
- Abdominal pain in a female of child-bearing age can be due to many underlying causes, including ectopic pregnancy, which is life threatening.
- Always attempt to gain agreement or assent from a minor whether or not a parent/legal guardian is present. This respects the patient’s dignity and right for self-determination which leads to “buy in.”
- Committee on Pediatric Emergency Medicine and Committee on Bioethics. Consent for emergency medical services for children and adolescents. Pediatrics. 2011 Aug;128(2):427-33.
- Simmons M, Shalwitz J, Pollock S. Understanding Confidentiality and
Minor Consent in California: An Adolescent Provider Toolkit. 2002. San Francisco, CA: Adolescent Health Working Group, San Francisco Health Plan
Author: Denise Whitfield, MD, MBA