Case presenting to a rural hospital

A keen aspiring CCFP-EM resident managed an interesting case the other day in a small town hospital. It was an unfortunate young lady, 9 years old, who had a straddle injury followed by copious vaginal bleeding. Unable to do a pelvic examination without the presence of conscious sedation, the resident chose to get pelvic xrays and observe the patient. Peds ER was contacted and were agreeable to see the patient but suggested direct referral to Gyne although the resident felt more comfortable if at least a better exam could be done before speaking to Gyne. In the end seeing, as the patients were anxious, the resident agreed to transfer the patient to Peds ER without a full exam or bloodwork. We felt a little sheepish initiating this transfer. What would you do in his place. Anything different?

4 thoughts on “Case presenting to a rural hospital

  1. I had a similar case in Woodstock! The patient was 14 with straddle injury, lots of PV bleeding. During the exam I had trouble delineating the anatomy because of all the swelling! Luckily we had Gyne in house and we were able to perform a conscious sedation with ketamine. It was a very complex layered repaired as it extended up to the urethra and down to the pelvic floors muscles.

    I think your choice to transfer care is completely reasonable; the exam can be traumatizing on a young patient and if the possibility exists to have the exam/repair done in one shot, I think that is the way to go. In terms of blood work, not sure it would change your management unless you are thinking they are loosing enough blood to consider a transfusion (?) I heard a about a case where a young female had a straddle injury water skiing and lacerated the uterine artery! Apparently her hgb was 40 by the end of it all.

    I would have done the same!


  2. I’ve learned to respect vaginal bleeding from trauma – they bleed a lot! I had a patient whose hgb went to 60 from trauma secondary to coitus. She required two units of blood along with repair in the OR.

    I agree with Alexis – I would have deferred the exam as well so that it can be completed at the same time as the repair. The bleeding can obscure the area and you need good exposure to make sure you’re not missing anything. Using right angle retractors/speculums in a 9 year old would be very painful.

    I’m not sure if this is practiced, but for patients who are in a community further away from gyne and bleeding a lot, would you consider putting in a tamponade for transport? I’ve seen gyne use tamponades such as packing vagina with sponges and putting in a catheter (to allow patency of the urethra). Thoughts?


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