BCE 65 Intimate Partner Violence – A Silent Epidemic

This is EM Cases’ BCE 65 – Intimate Partner Violence – A Silent Epidemic

I was taken aback when I came across the statistic that approximately every 6 days a woman in Canada is killed by her intimate partner. Every 6 days a woman is killed at the hands of her partner. Victims of intimate partner violence and domestic violence that we see in the ED typically involve an abuse story of repeated escalating violence over time that ends up in a crisis situation. The woman is often financially dependent on her abuser and has no one to turn to for help. In one of her worst cases ever from Janus General, Dr. Meeta Patel and I discuss the notions that Emergency providers have a unique opportunity to identify patients who are victims of intimate partner violence; that we should begin by thinking of how we can screen every woman of childbearing age about intimate partner violence in a private, safe and respectful way. We describe the quick Partner Violence Screen and finally how to offer supportive, empowering statements and connect your patients with resources like assaulted women’s helpline and shelters in your community…

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Written Summary by Anton Helman and Meeta Patel, January 2018

Intimate partner violence is a universal problem. It crosses all boundaries, all ages, all cultures & religions, and even all levels of education. So we really should be screening every woman of childbearing age even if there is only the tiniest hint of any historical inconsistencies or physical findings that don’t fit with the mechanism of injury, if not every woman, child and older person. Abuse unfortunately happens in all of these populations not infrequently. But of course it’s challenging to take the time to do an extensive screening in the ED. There are, however quick screening tools that are highly specific for intimate partner violence.

Universal Screening for Intimate Partner Violence

Start with a normalizing statement

“Because violence is so common in many women’s lives and because there’s help available for women being abused, I now ask every patient about domestic violence.”

While there are multiple screening tools for intimate partner violence in the literature and there is no evidence that one is better than the other, The Partner Violence Screen has been shown to have  94% specificity for intimate partner violence.

The Partner Violence Screen

1. Have you been hit, kicked, slapped, punched or otherwise hurt by someone in the past year?
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship who is making you feel unsafe now?

This could be done at triage or in the ED by a nurse and if the patient screens positive, a useful thing to do is to then place a small colored paper on top of the chart that should alert the ED physician. The ED doc can also administer the screen.

Both the CDC and the American College of Obstetrics and Gynecology recommend universal screening for intimate partner violence. So if your ED doesn’t already have a screening protocol, you might want to consider speaking with you administration team and get a protocol up and running.

Management of Intimate Partner Violence in the ED

You may find it uncomfortable to know exactly what to say and do once you have discovered intimate partner violence in the ED. There are 3 recommended steps:

1. Validate and empower the victim
2. Assess safety
3. Set up a plan

Validating and empowering the victim

“What you are experiencing is called abuse, and it is not your fault.”

“It takes courage to talk about your abuse with me.”

“I want you to know that you are not alone. There are many others going through this and I’m here to listen and to help.”

Assess safety

“Do you feel safe going home?”

If there are children, ask about the safety of the children.

Set up a plan

First you need to ensure that any information that is given to the patient must be done with discretion so that the perpetrator doesn’t find out because violence is very likely to escalate if the perpetrator finds out the victim is planning on leaving. Ask your patient about where they could go in case of an emergency, offer them information on women’s shelters and encourage them to speak to your ED social worker, or call a helpline for assaulted women.

It’s easy for ED docs to see ourselves as resuscitationists and experts at managing true emergencies. But we’re fortunate to be in a unique position where we have the opportunity to change a person’s life or even save a life with just a couple of quick questions. We need to start thinking beyond just the razzle and dazzle of emergency medicine and start to think more holistically about our patients. The ED is often the only chance a patient gets the opportunity to seek help before it’s too late. We need to think outwardly, beyond the walls of our EDs.

Drs. Patel and Helman have no conflicts of interest to declare

References

Heise L, Garcia, Moreno C. Violence by intimate partners. In: Krug E, Dahlberg LL, Mercy JA, et al., Editors World report on violence and health. Geneva (Switzerland): World Health Organization; 2002. p. 87-121.

Ernst AA1, Weiss SJ. Intimate Partner Violence from the Emergency Medicine Perspective. Women Health. 2002;35(2-3):71-81.

Esther K. Choo, Debra E. Houry. Managing Intimate Partner Violence in the Emergency Department. Annals of Emergency Medicine. April 2015Volume 65, Issue 4, Pages 447–451.

Hammock A, et al, Evaluation of a short intervention on screening for intimate partner violence in an ED, Am J Emerg Med (2016)

Dicola D, Spaar E. Intimate Partner Violence. Am Fam Physician. 2016 Oct 15;94(8):646-651.