Domestic violence (Strangulation and documentation)

Domestic violence (Strangulation and documentation)

Feb 5, 2019 0
emergency,onthepods,sexual health

James chats to Rosemary Isaacs about domestic violence in the Emergency Department and how to recognize and document situations of strangulation and assault.

Summary Writer: Emily Qian

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 RCGP.

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 (strangulation and documentation)

With Dr Rosemary Isaacs, Forensic Specialist, General Practitioner and Medical Director of Sexual Assault services at Royal Prince Alfred and Liverpool hospital in Sydney, New South Wales, Australia

 

Introduction

Strangulation is a potentially lethal act owing to the temporary obstruction of major blood vessels and compression of the airways leading to asphyxia (Queensland Health, 2017). Its true prevalence in our community is likely underestimated, however, it is regarded as a common and serious form of domestic violence. The recognition of non-lethal strangulation is challenging as there may be minimal features of external injury. Recognising the subtleties of presentation remains imperative as it is a strong predictor for future severe domestic violence and subsequent homicide. Dr Rosemary Isaacs is the Medical Director of Sexual Assault services, with a breadth of experience in domestic violence through her work as a forensic physician and general practitioner. Today, she speaks to us regarding how to detect presentations of strangulation and the features of accurate documentation.

  • Symptoms can be divided into immediate (during the time of strangulation) and delayed onset of symptoms
  • Delayed symptoms from strangulation are often subtle and in 50% of cases there is little or no evidence of injury after an incident of strangulation (Queensland Health, 2017)
  • Symptoms can be divided by organ systems:
    • Musculoskeletal – Neck pain, cervical spine tenderness, hyoid fractures
    • Respiratory – Shortness of breath, sore throat, hoarse or raspy voice
    • Neurological – Urinary or bowel incontinence (after unconsciousness), seizures
    • Cardiovascular – Presyncope, syncope, Palpitations (arrhythmias – rare)
    • Psychological – Confusion, Agitation and longer term: Depression, anxiety, PSTD, drug abuse
  • History
    • Previous history of domestic violence
    • Mechanism of injury – Method of strangulation, duration, additional physical or sexual assaults
    • Immediate symptoms during event – Presyncope, syncope, shortness of breath, urinary or bowel incontinence, seizures, palpitations
    • Current symptoms – Sore throat, neck pain, cervical spine tenderness
    • Red flags: Inconsistencies in history and examination, pregnant women (high risk group), frequent presentations for ongoing issues (e.g. headaches, depression, alcohol abuse, chronic pelvic pain)
  • Examination
    • Hoarse or raspy voice
    • Bruising around the head and neck
    • Swelling and erythema of the head and neck
    • Superior vena cava obstruction signs – Petechiae over head and neck (classic feature) including, external auditory canal and under hairlines and subconjunctival haemorrhage on sclera
    • And from associated head injury:
      • Bruising behind the ears
      • Ruptured tympanic membrane with conductive hearing loss
      • Facial tenderness
  • Patients must overcome many challenges in order to escape ongoing domestic violence
  • Early introduction of resources can help empower patients to find safety and support
  • The hospital social worker or domestic violence counsellor should be engaged early
  • Telephone, online and person-person counselling services are available (e.g. 1800 RESPECT)
  • Telephone counselling services for men with violent tendencies (Men’s Domestic Violence Helpline e.g. at mensline.org.au)
  • Accurate and thorough documentation is a medicolegal requirement which is important in providing continuity of support and assistance to individuals affected by domestic violence
  • All history and examination findings must be clearly documented and include the exact mechanism of the assault and any previous assaults to date
  • History should be documented verbatim where possible
  • Examination should include both positive and negative findings with particular reference to type of injury (blunt or penetrating), location and size of injury, patterned bruises (e.g. fingertip bruising with multiple 1cm diameter bruises in an arc or line)
  • Use of body diagrams or clinical photography is recommended
  • Investigations and management provided including referral to telephone, online or person-person resources should be included in documentation
  • Notification of the patient’s general practitioner should be included
  • It is assumed that discharge summaries may be read by the perpetrator of domestic violence which could place the patient in danger of further assault
  • However, documentation in the electronic medical record remains paramount as it serves as a medicolegal document with the aim of protecting and providing evidence for patients
  • In the case where there is a concern for safety, the patient can be given an amended letter with the details of domestic violence omitted
  • The complete discharge summary must be faxed to the general practitioner and ideally personally notify GP regarding concerns such that ongoing help and support can be provided
  • Strangulation is a strong predictor of future severe domestic violence and subsequent homicide
  • The clinical features of strangulation are subtle however should be considered in any patient with a history of domestic violence, inconsistencies within their history and examination including unexplained delayed symptoms
  • Early mobilisation of resources including the social worker, domestic violence counsellor, telephone/online counselling and person-person counselling is important
  • Documentation is a valuable medicolegal resource which can empower patients to take action
  • Consider the safety of the patient when providing discharge summaries by providing them an amended copy while ensuring the general practitioner has a complete discharge summary with all relevant details of domestic violence concerns

Related Podcasts

Resources

Tags: #1800respect,#assault,#documentation,#domestic violence,#forensic medicine,#partner violence,#sexual assault,#strangulation

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