Firstly, where is the wound (does it need stitches from a cosmetic
viewpoint, and can it be treated with "delayed primary closure"?).
Secondly, is it superficial or penetrating (the later having a higher risk
of tetanus)?
>Allow home, shrug shoulders and write copious notes
>Give child choice and, if they accept immunisation, give it without
>parental consent (or if they accept prophylaxis)
I wouldn't expect to get away with this, because I doubt that the parents
would give you a chance. But I would try to get the child's opinion on the
matter.
>Contact paeds for help !
I don't see how they can help, to be honest. The only consultation that I
see a role for is a psychiatric assessment of the parents.
>Worry about when refusal to consent for treatement for a child constitutes
>negelect
I am not concerned about neglect (the parents are probably very caring, but
just misguided according to our knowledge-base). My concern is that
parental beliefs are being imposed unreasonably on a minor who is in their
care and unable to make a truely informed decision. Even if the child seems
competent, is he really, or has he simply been brainwashed by parental
lunacy? Is he really informed? (I doubt it). This is where the State may
have a role to step in and take the decision out of the parent's hands.
This is a prickly area and depends on community beliefs regarding the
rights of parents in determining their child's fate.
Where you go from here depends on:
1. How much you think the child is being endangered by parental beliefs
2. How much you think that intervening with the legal system may have other
serious effects on the child
3. Weighing up the balance between 2 and 3.
4. What legal powers you have, which generally reflect the current
community perspective as to what role the State should have over parental
choices with regard to their children's health care.
I would judge the risk to a child of this age who is otherwise fit and
well, is probably very small, IF the wound is not a penetrating one and if
it is well cleaned and left open. I admit however that good statistics to
back up this viewpoint simply aren't there. If I felt that the child was
being coerced (or if the wound was a dirty AND penetrating one), I might
ask for a bedside sitting of the Family Court. If I thought that things
were going to get out-of-hand, then I reckon I would just let things ride
(clean the wound and apply a non-occlusive dressing. Definitely no stitches)
Interesting case... JW insanity, only on a smaller scale! I will be
interested on other viewpoints.
What happened, or is this just a hypothetical case?
Simon Brown FACEM
Director of Emergency Medicine
Royal Hobart Hospital
Tasmania Australia
Ambulance Service Medical Officer
Tasmanian Ambulance Service
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