1. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ GYNECOLOGY

2. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Anatomy and Physiology of the Female Reproductive Organs The Menstrual Cycle Assessment of the Gynecological Patient Management of Gynecological Emergencies Specific Gynecological Emergencies

3. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology

4. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Female Reproductive Organs External Genitalia Internal Genitalia

5. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ External Genitalia Perineum –Muscular tissue that separates the vagina and the anus. Mons Pubis –Fatty layer of tissue over the pubic symphysis. Labia –Structures that protect the vagina and the urethra. Clitoris –Vascular erectile tissue that lies anterior to the labia minora. Urethra –Drains the urinary bladder.

6. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Internal Genitalia Vagina –Female organ of copulation. –Birth canal. –Outlet for menstruation. Uterus –Site of fetal development. Fallopian Tubes –Transports the egg from the ovary to the uterus. –Fertilization usually occurs here. Ovaries –Primary female gonads.

7. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Menstrual Cycle Monthly hormonal cycle, usually 28 days. Prepares the uterus to receive a fertilized egg. The onset of menses, known as menarche, usually occurs between the ages of 10 and 14.

8. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Phases of the Menstrual Cycle The Proliferative Phase The Secretory Phase The Ischemic Phase The Menstrual Phase

9. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Proliferative Phase This is the first two weeks of the menstrual cycle. Estrogen causes the uterine lining to thicken and become engorged with blood. Secretion of LH day 14: ovulation takes place. If the egg is not fertilized, menstruation takes place. If the egg is fertilized, the corpus luteum produces progesterone until the placenta takes over. Cilia sweep the egg toward the uterus. A fertilized egg normally implants in the lining of the uterus. If the egg is not fertilized, it is expelled from the uterine cavity.

10. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Secretory Phase The secretory phase is referred to as ovulation. Progesterone increases and estrogen drops if the egg is not fertilized. The uterus becomes more vascular in preparation for implantation of a fertilized egg.

11. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Ischemic Phase Estrogen and progesterone levels fall without fertilization. The endometrium breaks down.

12. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Menstrual Phase The Menstrual Cycle Premenstrual Syndrome Menopause

13. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment of the Gynecological Patient

14. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ History Initial Assessment—SAMPLE. Does the patient complain of pain? Use OPQRST. –Dysmenorrhea/dyspareunia Associated signs or symptoms. Has she ever been pregnant? –Gravida/parity/abortion Document last menstrual cycle. Medications—Contraceptives.

15. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

16. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Physical Exam Respect patient’s privacy. Be professional. Explain procedures. Observe patient. Check vital signs. Assess bleeding or discharge: Do not perform an internal vaginal exam in the field. Abdominal examination.

17. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Gynecological Emergencies General management of gynecological emergencies is focused on supportive care. Do not pack dressings in the vagina.

18. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Specific Gynecological Emergencies Medical and Trauma

19. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Medical Gynecological Emergencies Gynecological Abdominal Pain –Pelvic Inflammatory Disease –Ruptured Ovarian Cyst –Cystitis –Mittelschmerz –Endometriosis –Ectopic Pregnancy

20. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Gynecological Abdominal Pain Make the patient comfortable and transport.

21. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Vaginal Bleeding Nontraumatic –Menorrhagia –Spontaneous Abortion

22. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Treatment for Vaginal Bleeding Do not pack vagina. Transport. Initiate oxygen and IV access based on patient condition.

23. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Gynecological Emergencies Causes of Gynecological Trauma –Blunt Trauma –Sexual Assault –Blunt force to Lower Abdomen –Foreign Bodies Inserted in Vagina –Abortion Attempts

24. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Gynecological Trauma Apply direct pressure over laceration. Apply cold pack to hematoma. Establish IV if patient is severe. Transport.

25. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ It’s 0345 hrs, and you and your partner are dispatched to a college dormitory for a reported intoxicated person. Upon arrival, you note that there are three first responders from the university volunteer ambulance squad, two members of campus security, and two police officers in the room. Dispatch Information © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

26. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Dispatch Information Photo 1.5-1 © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

27. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ You are presented with a 19 y/o female, conscious and alert, though lethargic. Initial Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

28. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ You note that she is crying and overhear her angrily tell the male EMT who is interviewing her, “I don’t know who he was, and I would not have had sex with him if I knew what I was doing!” Initial Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

29. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ What are your concerns at this point? What would you do to change the dynamics of this situation? Why is it important to change the atmosphere that exists? Discussion © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

30. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment Being female, you tell your partner, “I’ll handle this one.” As you introduce yourself to the patient, your partner quietly suggests that everyone except one member each from security, police, and EMS exit the room to give the patient some privacy. © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

31. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The patient is conscious, alert, and oriented and tells you that She went to a party around 4 p.m. She “met a guy” who gave her “two beers.” She felt “way too drunk” after the two beers. She and the male returned to her room about 5:30 p.m. She woke up, unclothed, about 3 a.m., unable to remember anything, but she “can tell that I had sex.” She dressed herself in clean clothes. Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

32. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment The patient denies any pain, difficulty breathing, dizziness, or nausea but states that she feels “groggy.” When asked if she was physically injured, she replies “No,” and states, “I even looked down there, and I’m not bruised or bleeding.” © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

33. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Vital signs HR = 82 regular RR = 12 regular BP = 116/78 SpO 2 = 97% on room air Assessment Photo 1.5-5 © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

34. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ With the information provided, is a detailed physical exam necessary? Why or why not? If an exam is necessary, how thorough should it be? Discussion © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

35. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Based on your initial assessment findings, the patient’s history of the event, and your gut impression, you decide that foregoing a detailed ongoing assessment would be appropriate. Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

36. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Treatment After confirming with the police officer that it is okay to transport at this time, you ask the patient if she would like transport to the ED for evaluation, which she accepts. The patient asks if she can shower and brush her teeth before leaving. © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

37. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ What concerns must be addressed with regard to the preservation of evidence? As you prepare for transport, what are some ways that you can help preserve patient privacy, modesty, and dignity? Discussion © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

38. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ You persuade the patient not to shower or brush her teeth. She points out to the police officer the clothes she wore earlier that night. When asked if she would like to walk out or use the stretcher, the patient chooses to walk. You ask a female EMT from the volunteer squad to assist you with the patient. Treatment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

39. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ You offer a blanket to the patient, which she accepts. Treatment Photo 1.5-7 © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

40. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ You ask security to secure a maintenance elevator and a side door to avoid taking the patient out through the dormitory lobby. During transport, the patient states that she feels “more awake, and less groggy.” Treatment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

41. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Vital signs HR = 80 regular RR = 12 regular BP = 122/76 SpO 2 = 98% on room air Ongoing Assessment Photo 1.5-8 © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

42. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Patient is placed in a private, quiet, well- lit room. Female nurse and rape counselor greet the patient in the room. A more detailed event history and physical exam are performed. A “rape kit” is utilized to collect specimens. ED Treatment and Beyond © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

43. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Review Material Sexual Assault © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

44. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sexual assault accounts for about 1% of all violent crime reported in the U.S. Most assaults reported are female rapes. > 300,000 female rapes reported a year > 90,000 male rapes reported a year About 65% of rapes go unreported. “General body trauma” is reported in 45%–67% of sexual-assault victims seeking medical care. Epidemiology © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

45. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Definitions of rape and sexual assault may vary by state. A common element among variations is sexual contact without consent. Sexual assault Unwanted oral, genital, rectal, or manual sexual contact Rape Penetration of the genitalia or rectum without consent of victim Pathophysiology © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

46. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ It is generally accepted that the causes of sexual assaults are the result of inappropriate violent impulse, not sexuality. Rape is often motivated by the need for power and control or by anger. Pathophysiology © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

47. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Bodily injury to the victim is common. 45%–67% of victims seek medical care. Incidences of genital injury from 9%– 45% Lack of injury does not imply consent. Pathophysiology © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

48. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Drugs are commonly used to facilitate sexual assault. Alcohol Rohypnol GHB Ketamine MDMA Pathophysiology © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

49. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Ideally, caregiver of same sex should perform examination. Your objectivity is important. Attitude of prehospital care providers may affect long-term psychological impact. Clinical exam should be performed tactfully and compassionately in a private environment. Respect patient’s modesty. Clinical Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

50. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Physical exam General rule is to be as minimally invasive as possible. Physical exam is based on patient complaint, presentation. Avoid unnecessary exposure of patient. Genital exam is unnecessary unless patient complaint or exam findings indicate necessity. Clinical Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

51. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ As a rule, victims should not be questioned in the field about the specifics of the assault. Specific questions determined by patient complaints and presentation Should be done in a private environment When situation demands potentially troubling questions, a tactful, caring, professional method is obligatory. Clinical Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

52. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Past medical history, present medications, and allergies Attempt to ascertain, tactfully, if a date- facilitated drug or alcohol was involved. Interactions with patient medications CNS depression Can be determined with physical exam, questioning Clinical Assessment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

53. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Patient has physical as well as psychological needs. Care best provided by member of same sex as victim Treatment for specific injuries same as in nonsexual assault situation Provide a safe environment for the patient. Preservation of physical evidence a concern Treatment © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

54. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hospital staff will secure more detailed account of assault and medical history. Detailed physical exam including Inspection of genitalia, rectum, oral cavity Use of Wood’s lamp, toluidine blue, colposcope Anoscopy, sigmoidoscopy, speculum examination Evidentiary examination Use of rape kit Treatment: Hospital © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

55. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pregnancy test to identify preexisting pregnancy Pregnancy prophylaxis Sexually transmitted disease prophylaxis HIV testing Counseling Treatment: Hospital © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ

56. Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Summary Anatomy and Physiology of the Female Reproductive Organs The Menstrual Cycle Assessment of the Gynecological Patient Management of Gynecological Emergencies Specific Gynecological Emergencies