# Presentation: 132815

## Domestic Violence 

- Identification of Domestic Violence Victims
- Rachel E. Locker MD

## What is Our Role in Health Care?

- Identify
- Assess
- Document
- Educate

**Notes:**
As a physician regardless of your practice type you will see victims of domestic violence
	ent -nasal fractures
Pediatrics- children with behavioral concerns

Surgeouns - truamatic and and chronic abdominca pain

Pathologist- autopies

ER injuries

FP depression, anxiety, pain
Ob pelvic pain, pregnancy

## Who are the victims?

- From all races, religions, social groups, educational levels, and sexual orientations.
- Male or female
- Adolescent to elderly
- No specific personality traits
- Any level of physical ability

**Notes:**
Listen for victim blaming attitudes, dispel myths

Note that violence is more prevalent  in African American  and more so in 
Native American  
No statistics to quote

- So Who should I ask ?

**Notes:**
Listen for victim blaming attitudes, dispel myths

Note that violence is more prevalent  in African American  and more so in 
Native American  
No statistics to quote

- Multiple injuries in various
- stages of healing

## Presentation

- Delay between onset of injury and seeking care.
- Laceration “cut on broken glass last week”
- “Think I broke my ribs- wrecked my 4-wheeler 2 weeks ago”
- “She tripped and hit her head 2 days ago, I thought she was just tired “

## Presentation

- Injury inconsistent with the explanation.
- Both eyes blackened- “ I shut the door on my head”
- Fracture humerus- “she’s just clumsy”

## Any Physical Trauma

- Nasal/ facial bone fractures
- Lacerations to the eyes
- Rupture eardrum
- Dental injuries
- Ligature marks
- Rope burns
- Bruising
- Patient reports an assault

## Emergency Room Visit

**Chief Complaint :**
- “I have jaw pain, it pops and sticks. someone stomped on my head last week?”

## Other particulars 

- Injury during pregnancy
- Injuries consistent with strangulation
- Injuries centered around sex organs
- Injuries to the torso and abdomen

## Suspicious Physical Findings

- Bilateral injuries
- Grip marks
- Pattern injuries
- Weapon patterns
- Bite marks
- Burns

## Mental Health Issues

- Alcohol or drug abuse
- Psychosocial distress
- depression
- suicidal – gestures, thoughts, attempts
- anxiety
- sleep disorders

## Partner Interactions...

- A partner who will not leave the exam room.
- A partner who does all the talking for the patient

## Labels

- Vague psycho-somatic complaints
- Chronic pain syndromes
- “Borderline personality disorder”
- Manipulative
- “Crock”
- Hysterical
- Somatitization disorder
- Angry
- Demanding/Difficult

## Pediatric Clinical Signs

- Concerns of child abuse or neglect
- Depression
- Psychosomatic complaints
- Eating disorders

- Suicide attempts or gestures
- Behavior problems
- Nightmares
- Insomnia

## We couldalso  Just Ask!

## Health Screening

- Patients don’t tell us they have it
- Cervical Cancer
- There is a high incidence in the population- HTN
- It may be contagious
- TB

**Notes:**
Give examples

Patients don’t tell us they have TB, HTN, cervical cancer  all things we screen for (TB skin test,  BP, pap smear)
				Patients don’t routinely tell us about abuse in the home 

There is a high incidence of HTN, cervical cancer, TB in certain populations  there is also a high incidence of DV

TB is contagious as are the effects of Domestic violence 

## Health Screening

- It may cause other illnesses
- HTN
- It may cause an early death
- TB
- Early intervention makes a difference in outcome- Cervical Cancer

**Notes:**
HTN causes stokes , MI’s and heart failure

TB, cervical cancer, and HTN can cause early death as can DV through homicide,and suicide

Early intervention in HTN can prevent MI, CHF, cardiomegly and 
TB treatemnt  can prevent active illness
Education and intervention on DV can prevent early death, victim and children ilnesses a, homicid and suicide

## Why Should We Screen?

- 	Medical practitioners are often the _first or the only_ professionals  that individuals in abusive situations come in contact with.

## Who Recommends?

- AMA
- American College of Physicians
- ACOG
- American Nurses Association
- American Academy of Pediatrics
- JCHO
- GPRA

## Who Should We Screen	?

- All Females over the age of 14 with or without signs or symptoms of domestic violence
- Children - Screen female caregiver/parent
- Any patients who present with clinical findings that may indicate abuse

## When Should We Screen?

-     In a perfect world...
-       Every time you see them

## When Should We Screen	?

- Recommendations
- Pregnancy – each trimester
- At least once per year
- Well child exams
- Any patient presents with clinical signs or symptoms

## How to Screen	

- Screen in a safe and private environment.
- Separate any accompanying persons from the patient.

## Frame the Question	

- Use your own words in a non-threatening, non-judgmental way.
- Be Direct and easy to understand.

- Consider a written questionnaire or standard set of questions to ask

## Video

- What do I do when she says yes?

## Document... screening

- Document  if your screening was     	positive or negative
-        past or present
- Document your findings as a diagnosis
- Adult maltreatment syndrome  995.81

- Your job is not to “fix” the problem
- The patient needs documentation ,support and information.
- Find your comfort level

## Educate/Support/Refer

- Let her know she has options and that help is available if she should find the need.
- “You are not alone, there are people you can talk to.”
- “It must be difficult for you to leave your situation, help is available  if you decide to leave ”
- “would you like me to call an advocate to talk with you”

**Notes:**
Review medical power and control wheel , empowerment /advocacy wheels

Note that this may be where we can make the biggest impact.  The patient needs to know that she can trust us and rely on us for help and confidentialty

## Educate/Support/Refer

- If she declines  the  need for an advocate...
- Give her/discuss with her information on safety planning.
- Give her info/discuss with her info on available resources

## Listening...

- With an open mind but don’t be judging
- Abused women often believe their abusers negative messages.
- She likely is confused and  feels responsible for the violence.
- She may fell ashamed, inadequate and may be afraid she will be judged.

## Documenting Acute Events

- Use the patients own words when ever possible.
- “ He grabbed me by the hair and pulled me out of the car”
- Record “excited utterances” and use descriptive terms in regards to emotions and appearances
- “Patient appears extremely anxious and distraught.“

- Photograph all injuries,  (obtain written consent)
- Label with the date, time,  patient name  and your initials
- Use a standard scale to show size
- Use a standardized form so as not to leave out important issues
- Sexual Assault Exam if indicated
-  use Forensic Sexual Assault kit

## Periortibal ecchymosisLacerations to the lips

## Defensive injuries

## Use a size standard

**Notes:**
Point out that physical injury may be the most obvious but is not  necesarrily the most harmful.

## Body Charts

## Assess Danger

- Increase in the frequency or severity of violence .
- Increasing or new threats of homicide or suicide.
- Threats to children
- Using alcohol or drugs?

- Used a firearm or weapon in past threats
- Public Displays of violence?
- Hostage taking or stalking?
- Will she be in any immediate danger if she returns home?

## Document... acute events

- Remember...
- Accurate documentation
-  will help the patient’s legal case
- against the assailant.

## Document... acute events

- Know your local
-  reporting laws