Emergency medicine providers must have keen interviewing skills, an ability to convey openness and kindness to the victim, and use a multidisciplinary treatment approach

A 19-year-old female presents to the ED with complaints of cough; rhinorrhea; sinus pressure; nausea; body aches; and mild, intermittent cramping abdominal pain. Her vital signs: T 100.1, HR 99, RR 18. She appears tired and thin and has a blunted affect. She is wearing open-toed pumps, leggings, and a tank top. It is winter and very cold outside. Accompanying her is a man who appears to be in his late 20s and is introduced by the patient as her boyfriend. He gives the registrar the patient’s identification.

The boyfriend insists upon accompanying the patient into the room. The patient is guarded during history and gives short, abrupt answers. She avoids eye contact with the examiner and keeps looking at her boyfriend. He interjects that he just wants her to get some antibiotics so they can get out of there.

Chart review reveals the patient was seen in the ED about two months ago for an arm injury. Today’s history is brief and focuses on the patient’s URI symptoms. No questions relating to social history and very few questions relating to past medical history are asked. The physical exam is performed quickly and is unrevealing.

The provider is pulled away to address another patient’s needs. The patient is given ibuprofen. Her boyfriend becomes agitated and tells the nurse they need to leave. The patient is discharged with a prescription for ibuprofen and for guaifenesin. She is instructed to call the referral line for PCP follow-up.

Four days later, the patient returns to the ED with severe abdominal pain and is pale, hypotensive, and tachycardic. She is septic. A girl claiming to be her cousin brought her in. The patient disrobes, and a thorough examination reveals several scars from cutting on her forearms, cigarette burns around her breasts and upper thighs, and the name “King Daddy” tattooed on her lower back. The patient has several healing bruises on her chest and abdomen. The pelvic exam reveals a large volume of pus and a retained “baby wipe” in the vagina. The patient is diagnosed with pelvic inflammatory disease and sepsis.

Case Commentary

The patient was actually a 15-year-old girl with counterfeit identification. The boyfriend was her “pimp,” or sex trafficker. The girl was reported as a runaway six months earlier. She left home to escape sexual abuse by her stepfather, a businessman in the community who was also having his “friends” come over to have sex with her for money. She was approached after school by a young man who told her he could get her away from her situation and help her become a model.