Domestic violence – Recognising and responding

Domestic violence – Recognising and responding

Jan 29, 2019 0
emergency,onthepods,sexual health

Interpersonal violence or partner violence

James chats to Rosemary Isaacs about recognising and responding to situations of domestic violence in the Emergency Department, specifically interpersonal or partner violence.

Summary Writer: Jane McDonnell

Script Writer: Rosemary Isaacs

Editor: Rosemary Isaacs

Interviewee: Rosemary Isaacs

About Dr Rosemary Isaacs

Dr Rosemary Isaacs works at Royal Prince Alfred and Liverpool hospitals in the medical and forensic response to Sexual Assault, Domestic Violence and child abuse. Rosemary is a Fellow of the Faculty of Clinical Forensic Medicine in the RCPA and also a Fellow in General Practice of the RACGP.

Rosemary is convinced that this is an area where doctors with specific training can make a big difference to vulnerable people in our community. In addition, the anxiety and distress for health staff are much reduced when they have a framework for responding to these issues.

Domestic violence: Recognising and responding

With Dr Rosemary Isaacs, Forensic Specialist and former Director of Sexual Assault Service at Royal Prince Alfred Hospital, Sydney, New South Wales, Australia

Introduction

The focus of this podcast is interpersonal violence or partner violence, including opposite or same-sex partners and including violence by an ex-partner. In circumstances where there has been violence in a former relationship, the time of separation is often a time of increased violence so ex-partners are important to consider.

Australian Bureau of Statistics figures show 1 in 6 Australian women and 1 in 19 Australian men had experienced physical or sexual violence from a current or former partner. (2012 Personal Safety).

Case

You are working in the Emergency Department as a junior doctor. A 33-year-old teacher presents with a bruised, swollen nose. She is requesting an x-ray, concerned there may be a fracture. You notice she is holding a young child. Her partner is present. He is concerned and keen to support her. On history, she states she tripped over the child’s toy and fell into a door yesterday. The swelling has gotten a bit worse since then and they are worried that the nose may be broken.

  • Yes – most adult fractured noses are from sports injuries or from a fight.
  • With any injury, the thought of domestic violence should be in the doctor’s mind.
  • Red flag in this scenario: delayed presentation.
  • Don’t ever assume you don’t need to ask about domestic violence because of how the relationship appears.
  • The concern about causing offence can be managed by giving context and normalising the question.
    • “For all injuries, I ask this question…”
    • “Domestic violence is common in Australia and for this reason, I need to ask you…”
    • “I need to ask you a sensitive question; has anybody hurt you?”
  • You need to be creative in how you can get alone time with the patient.
    • E.g. Take the patient to radiology for x-ray yourself.  It is essential to have privacy in asking about Domestic Violence.

You take further history and ask what else was happening at the time of the fall. The patient states that she was stressed because her partner was angry about some bills. She was upset and tried to leave the room when she fell.

  • When the patient gives this history, you need to ask directly
    • “Has someone hurt you?”
  • A history of domestic violence is not likely to be in electronic medical records.
  • There may be previous presentations with unexplained injuries.
    • There is a higher injury rate in domestic violence when there is a male perpetrator and female victim.
  • If the patient discloses domestic violence, ask what happened on this occasion.
  • Document in the patient’s own words as much as possible.
    • This documentation may be relevant in years to come (e.g. child custody case).
  • Any previous occasions of domestic violence?
  • Instances of emotional/financial abuse?
  • Any children involved?
    • Witnessing domestic violence is a form of child abuse in New South Wales.
    • About 50% of domestic violence in the home is witnessed by a child.
  • Recommend referral – “It would be beneficial if we could get someone who can help more.”
    • The patient may fear their partner will discover they are disclosing this information.
  • If the patient declines, the junior doctor must do a risk assessment.
    • Serious injury (including strangulation).
    • Presence of a firearm in the house (bigger issue in rural areas).
    • Weapon (e.g. knife, gun) was used or threatened.
    • Escalating violence – there is a risk of death in a pattern of escalating violence.
    • Can the patient access help if needed in future. The perpetrator may be isolating them from supports.
  • Discuss with a senior.
  • In New South Wales Health, there is mandatory reporting for serious injuries caused by domestic violence.
    • Definitions of Serious Injury mandating reporting are currently under review to be made clearer.
  • Examination:
    • Look around the room.
      • Has the child got any obvious injuries?
    • Try to do a head to toe examination.
      • Getting the patient to change into a hospital gown can help expose parts of the body which may show other injuries.
    • Victims of domestic violence can wear long-sleeved shirts and hide injuries.
      • May need to think of an excuse e.g. pulling a sleeve up for a BP reading.
  • The most important thing is to validate the patient.
    • “I’m sorry that this has happened to you.”
  • Reassure the patient that it is not her/his fault.
  • Ask what you can do to help.
  • In Australia, we have a national phone number: 1800 RESPECT
    • This service can return patient’s calls so they do not fear running out of credit.
    • They offer over the phone information and advice.
    • They have a confidential email service.
    • National counselling services for victims of domestic violence and sexual assault.
  • Working in a team is important – debrief with people in the team before you go home rather than taking it home with you.
    • Advice from the social worker can be particularly helpful.
  • Accept that the patient may not want to leave their situation – this can be difficult for the treating doctor.
    • The patient may fear he or she is at greater risk by leaving the relationship.
  • Hospitals in New South Wales have Employee Assistance Programs available 24/7.
  • The Doctors’ Health Advisory Service is freely available for doctors in Australia.
  • Domestic violence is common and hidden – we need to be on the look out.
  • Affirm the patient and his or her strengths.
    • Do not take control of the situation on the patient’s behalf – this disempowers the patient even further. (The exception is an emergency e.g. when it is not safe for the patient to leave the hospital. The doctor and health team may need to take control.)
  • Document the history and examination findings carefully.

Resources

Tags: #1800respect,#Doctors Health Advisory Service,#domestic violence,#DV,#Employee Assistance Programs,#forensic medicine,#partner violence,#recognising,#responding,#serious injury,#sexual assault

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