A 3-year-old girl was diagnosed with constipation and treated with polyethylene glycol and dietary modification. Despite treatment, she had no bowel movements for more than 20 days and developed abdominal pain and distension. Two visits to the pediatrician and one local emergency department (ED) visit resulted in no management change. At follow-up, she was instructed to go to a children’s ED if symptoms persisted, with expected disimpaction.

Two days later, at the children’s ED, she was evaluated by a visiting female emergency clinician. The supervising male pediatric emergency physician attending documented: “I declined performing this procedure myself because of the size of my hands.” A female colleague was asked to supervise. Nursing and Child Life [services] were not available to assist, so the female attending clinician and parents restrained the patient while the resident performed the procedure. Using a lubricated finger and patient assistance bearing down, the resident removed multiple stool balls. After many repetitions, the father expressed concern that the resident’s finger entered the patient’s vagina. The resident believed she was in the rectum but acknowledged the vagina appeared irritated and that it was possible her finger entered the vagina. The attending finished the procedure. Parents remained upset, filed a police report, and a child abuse exam was limited by the child’s distress. Litigation followed. After depositions, the case was settled for a nominal amount.

Issues and Key Points in Care

1. Appropriateness of manual disimpaction in toddlers

In young children, fecal impaction is typically managed with oral, nasogastric, or rectal medical regimens. Manual disimpaction is rarely first-line. When required, it is commonly performed under sedation or anesthesia. In this case, the supervising male attending declined to perform the procedure because of hand size. This should have prompted reconsideration of whether an awake disimpaction was appropriate.

2. Supervision of intimate procedures requires full procedural capacity

Procedure supervision requires more than physical presence. The attending must be able to continuously visualize anatomy, monitor technique, and provide real-time guidance. In this case, the attending’s need to physically restrain the patient eliminated the ability to supervise. When parental concern arose, the attending should have spoken for the team to de-escalate and shield the trainee. This also serves as a learning opportunity for residents to observe de-escalation and boundary-setting.

3. Absence of pediatric multidisciplinary supports removed protective layers

Children’s EDs rely on pediatric nursing and Child Life services to prepare families, support positioning, reduce distress, and maintain procedural control. Their absence in this case removed key safety and trust-preserving layers that normally support pediatric care.

4. Procedural prerequisites: Staffing, sedation, and a clear abort plan

Intimate and painful procedures should not proceed without appropriate staffing, analgesia or sedation, and a predefined threshold to stop if conditions are suboptimal. Parents should not restrain their own child, as this escalates distress and increases the risk of perceived or actual harm. When proper resources are unavailable, deferring or escalating care is safer than proceeding under constraint.

5. Handoff failure and expectation-setting across care settings

The outpatient pediatrician’s instructions did not clarify that disimpaction could be medical, inpatient, or non-manual. This framed the visit as procedural, narrowed perceived options, and increased pressure on clinicians. This represents a handoff failure across care settings, underscoring the importance of clear communication when transitioning care.

6. Trainee vulnerability and shared responsibility

Having residents perform invasive procedures exposes trainees to disproportionate medicolegal and emotional risk. Attendings retain primary responsibility for ensuring meaningful supervision and safe procedural conditions, while residents must feel empowered to pause or stop a procedure if concerns arise.

Dr. Cohen is a dual board-certified expert in pediatric emergency medicine and emergency medicine with extensive experience in clinical practice, peer review, and medicolegal consultation.