Home is supposed to be a safe port in a storm. But sometimes, home is the storm…and that storm ends up in your trauma center, clinic or office.
Caring for the Intimate Partner Trauma Patient: Life Saving Tips
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#domesticviolence#intimatepartnerviolence#domesticabuse
According to the American Medical Association, intimate partner violence (IPV) is defined as a pattern of coercive behaviors that may include repeated battering and injury, psychological abuse, sexual assault, progressive social isolation, economic deprivation and intimidation.
The facts:
- One in 50 women presenting to an orthopedic clinic with an injury have been injured from intimate partner violence.1
- On average, 24 people per minute are victims of rape, physical violence or stalking by an intimate partner in the United States.2
- 1 in 4 women (24.3%) and 1 in 7 men (13.8%) aged 18 and older in the United States have been the victim of severe physical violence by an intimate partner in their lifetime.3
Those statistics are alarming.
Luckily, there are orthopedic physicians and staff who are making a meaningful difference. One of those is Paul Tornetta, III, M.D., chief of orthopedics at Boston Medical Center.
Dr. Tornetta, who is also the director of orthopedic trauma at that institution, told OTW, “We know from the World Health Organization that while women can be violent in relationships with men, and violence does occur in same-sex partnerships, the overwhelming burden of partner violence is borne by women [who are abused] by men.”
Traditionally, says Dr. Tornetta, those trying to address intimate partner violence have faced skepticism from their peers. “Twelve years ago, an editorial reviewer from a prominent orthopaedic journal wrote to us after reviewing our study saying, ‘I don’t think it adds much to the clinical practice of the orthopaedic surgeon.’ At the same time, a note from the editor of a different, highly respected journal read, ‘It is unlikely that your article would be of sufficient interest to the clinicians who practice orthopaedic trauma.’”
And yet, says Dr. Tornetta, “You open the door to exam room and see a woman who says she fell down the stairs. You examine her, ask the traditional clinical questions, but something in your gut alerts you that she is not telling the whole story. You are triple booked…but if you take a few extra minutes you could be a hero.”
“But I don’t save lives, I save limbs,” you think.
Think again…
Escalation of physical violence is a key factor for intimate partner homicide.
The stark and brutal reality is that this woman sitting in your exam room may not survive a ‘next time’ to make it back to you.
Dr. Tornetta, “Orthopaedic surgeons have a unique opportunity to intervene as we are in a position to establish ongoing relationships with our patients. The leading cause of death 2002-2009 after domestic violence in North America was trauma. We should absolutely inquire about mechanism of injury and violence in the home/relationship.”
Dr. Tornetta, who has done research on surgeon perceptions of intimate partner violence, explains, “The first rule is, ‘Don’t make assumption about how something happened. If a woman says she fell down the stairs don’t assume that it was an accident.’ We are definitely missing many opportunities to serve our patients…only 12-17% of abused women have their experiences documented in a medical chart!”
“I am pleased to say that at Boston Medical Center our Emergency Department and social workers have led efforts to identify intimate partner violence and intervene early. Our center has devoted real resources to this problem, yet despite this, patients will fall through the cracks as they are not always honest about their injuries. The situation at many other institutions is not as aggressive or responsive and most of these physically and psychologically scarred patients are falling through the cracks.”
Joining Dr. Tornetta in this critical research is Dr. Mo Bhandari, chair of the division of orthopedic surgery at McMaster University, his wife—a social worker—Sheila Sprague, Ph.D., associate director at the Centre for Evidence-Based Orthopaedics at McMaster University, who for years have led international efforts to assess and address intimate partner violence, Gregory J. Della Rocca, M.D., Ph.D. and Prism S. Schneider, M.D., Ph.D.
Barriers to Progress…
Dr. Tornetta and his colleagues are committed to educating physicians about intimate partner violence. “You have a woman coming in who feels ashamed and scared and who may feel that she doesn’t deserve help. You might hear, ‘He is not always abusive’ or, ‘My injuries aren’t that bad.’”
“On the physician side, there is an enormous lack of education of this subject. And even when providers do get the appropriate information, they often feel that is it not their place to intervene.”
“In two surveys of members of the Canadian Orthopaedic Association, 56% had seen intimate partner violence in at least one case, and 73% had no guidelines for identification or management. When respondents were asked if there was a lack of knowledge of the appropriate resources, 95 agree, 19 were unsure, and 66 disagreed.”
A Delicate Situation in Many Ways…
Dr. Tornetta: “In a potential intimate partner violence situation, providers are in a position where they have to perform their routine clinical work but must also delicately inquire about abuse. The situation is complicated if the spouse or partners is with them. The physician needs to ask about potential violence when alone with the patient. If the spouse/partner won’t leave, then one can say something like:
‘As part of my practice I make sure I meet with all of my patients alone for a few minutes, can I please ask you to wait in the waiting room and your wife will be right out?’
OR
‘Mrs. Smith, I’m going to have the technician take you for an X-ray now. Mr. Smith, can you please wait in the waiting room and I’ll have the technician come and get you in a few minutes when your wife is finished with her X-ray.’”
“When speaking with the patient,” says Dr. Tornetta, “assess their immediate safety, be non-judgmental, and avoid the use of stigmatizing terms such as ‘abuse’ or ‘battered.’”
Dr. Tornetta and his colleagues suggest the following as possible ways to communicate with a patient you suspect has been abused:
- The injuries you have suggest to me that someone hurt you. Is that possible?
- In my experience, women often get these kinds of injuries when someone has hurt them. Has this happened to you?
- Violence can be a problem in many women’s lives, so I now ask every female patient I see about their safety in their relationships. Do you feel safe in your relationship?
- From my experience, I know that being hurt physically or emotionally at home is a problem for many women. Is it a problem for you in any way?
- We know violence in the home affects many women and directly affects health. Have you ever experienced being hurt physically or emotionally at home?”
“Also note that it doesn’t have to be the physician who asks these questions. At the AOA meeting, one member explained that at their facility, a female x-ray technician often tells the spouse/partner that it is routine practice for them to wait outside during the x-ray process and these technicians are trained to ask the question.”
Planting Seeds
It can be disheartening and frustrating if your patient does not accept help…you know they are walking back into a situation where they will likely endure more abuse.
As Dr. Tornetta explains; “While you can’t force someone to accept help, keep in mind that you are laying the groundwork for the future. If you seem irritated with them for not accepting help in the moment, then they are less likely to reach out to you when they are ready. There is a good chance that moment will come and if you are kind and let the patient know that you will be there when she is ready for help, then you may become her future lifeline.”
“At BUMC [Boston University Medical Campus] all patients are screened, are asked if they are always isolated and are asked if they feel safe at home. There are warning signs that physicians should look out for.
- The patient is hesitant about being examined.
- The partner answers the questions.
- Prior injuries with delays in medical attention.
- Missed appointments.
- Depression or vague symptoms.
- Noncompliance with treatment.
Preventing Trauma Readmissions by Addressing Intimate Partner Violence
Dr. Tornetta continues: “Intimate partner violence impacts the fracture clinic and our caseload. Physical abuse can create a revolving door of women coming into our clinics with injuries. If we can help stop this cycle, we can free up resources and reduce the burden on our clinics and the overall healthcare system. Also, identifying IPV before it has escalated to extreme physical violence may help reduce magnitude of the injuries seen.
Power and Control
We’ve all heard the saying, “Control what you can control.” The dark side: Intimate partner violence is about power and control over someone else.
The light: Surgeons can indeed control many things. Sometimes, just taking a deep breath and asking THE question can make you feel out of control…maybe because you don’t want to hear the ugly truth…or maybe because you are opening the door to more work (much of it in an area with which you are not familiar).
And while you can’t control whether a woman leaves her abuser, at least you will know that you have done your best to prevent further physical and psychological harm—or even death.”
For additional information, please visit: http://www.ipveducate.com
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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