One of the things that I’d like to do with this blog is to help pass along things I’m learning in medical school that I wish I was taught in EMT class. Assessment tidbits, documentation, common diseases, etc. Sometimes there’s a lack of time to cover important topics properly in EMT class. Sometimes it’s just squeamishness on the part of everyone involved. After all, it does no one any good to just say, “Well, this is a part of a good history and physical, but you’ll rarely need it, so we won’t cover it.” Rarely needing it still means needing it. A perfect example is the sexual history.
First thing first, get the giggles out. One of the interesting parts of medicine (including EMS) is that we don’t observe traditional societal bounds. We ask questions on taboo subjects. We invade private spaces with even the simplest procedures like listening to lung sounds. So, if you have a problem with the word “sex” giggle now, while you’re in front of the computer screen. You won’t be the first healthcare provider to do so, and you won’t be the last. Similarly, get past your biases now. If the answer to the question, “men, women, or both” is answered with “both,” you can’t skip a beat, just keep moving to the next question regardless of what your views on homosexuality or bisexuality is. STIs and UTIs don’t care about who passed what to who.
A sexual history is an important part of the history for some EMS patients, however completely inappropriate for other patients. Patients who get a sexual history taken should include anyone complaining about genitourinary problems, have disease manifestations of STIs or abdominal, flank, or back pain which you think is related to GU or reproductive problems. This includes any female of child bearing age with abdominal pain (pregnancy, including ectopic). In regards to STIs, an example of a manifestation is Argyll Robinson pupils. This is when the pupils do not react to light, but do react to accommodation and is a sign of syphilis. Like a prostitute, they accommodate, but do not react (medicine has the best memory aids).
The first step in the sexual history is to set the stage. Be someplace private (like the back of the ambulance) with a minimum number of people, preferably no one that isn’t the patient or a provider. Are you really going to expect an honest answer to “one partner or many” when asking in the same room as the patient’s significant other? Congratulations, you might have herpes, but you definitely have a divorce. Similarly, you need an opening to put everyone at ease. Mine goes along the lines of, “I need to ask a few personal questions in order to get a better overview of your health. The answers are completely confidential, but are important to help determine what’s going on.”
Now comes the sexual history. “Are you sexually active? [if “no,” clarify that this isn’t limited to just intercourse.] Men, women, or both? [I haven’t heard a better way to ask this one] One partner or many? Do you use protection? What type? When was the last time you had intercourse? [since we are asking for something that is happening now in contract to a general screening or history and physical] Have you and your partner(s) been tested for STIs?
The value of the individual questions should generally be apparent on their own, and with all assessments, this is an art. What’s important is getting the information, not the specific words or sequence you use. Additional questions may come to mind based on the answers, feel free to pursue those pathways provided you can use the information and both you and the patient are comfortable. Professionalism breeds comfort with these questions. Similarly, be prepared to answer the “why” question. For example, UTIs in females can be associated with intercourse. If you are working up a patient with flank pain, hematuria, (Blood in the urine. Additional assessment tip, use the fancy medical words with patients, but immediately follow up with the lay description), and pain on urinating, knowing the last time she had intercourse all of a sudden becomes important. Hence, “why” is answered with, “I need to know because one of the problems associated with your symptoms is a UTI, which can be associated with intercourse.”
Finally, incorporate this with the rest of your assessment. Other important assessment questions includes questions about urethral or vaginal discharges, smells, changes in urination, first day of last menstrual cycle, etc. No part of the assessment is done in isolation.
Now all you need to do is practice. Practice asking to yourself, practice asking with a mentor, practice asking your significant other. Who cares what answers they come up with, the purpose is to get used to asking the questions without thinking too much into the “I’m asking about sex. ::snicker::” You know you have it down when you can deadpan the questions to almost anyone.