domestic & sexual violence: a health & safety issue -one health region’s strategy to...
TRANSCRIPT
Domestic & Sexual Violence:A Health & Safety Issue
-One Health Region’s Strategy to Reduce Risk
Presenter: Linda McCracken RNSexual Assault Nurse Examiner
AHS-Domestic Violence Program Coordinator
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The Essential Message
• Overview of associated adverse health conditions, & potentially lethal outcomes related to Domestic & Sexual Violence/Abuse that often go undetected when no one
raises “the question”
• What denotes a medical emergency
• Opportunities do exist for primary prevention
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What’s in it for you?What’s in it for you?After this presentation,After this presentation,
you’ll have a better understanding of: you’ll have a better understanding of:
• Injury recognition & chronic illness in the context of abuse
• What to ask & or look for from a medical standpoint• How collaboration can enhance response to this
public health issue
Relevance
*AB shelters find that the health effects of their clients:•Are varied
•Often severe•Have gone on for many years without resolution
ACWS-Position Statement
Responding to the Health Needs of Women & Children involved in Domestic Violence
Issues from a medical perspective
•What are the most common health challenges experienced
by clients you see?
•What concerns you the most?
•What about their children?
Long Term Effects of Stress
Cardiovascular system
Gastrointestinal system
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Stress & The Immune SystemStress and Disease: New Perspectives
By Harrison Wein, Ph.D.
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Consistent high level of Cortisol Is Toxic To Brain Development
• The stress response system in the brain is fully formed at birth but the cerebral cortex is not
• Babies can experience stress but are highly dependent on caregiver to manage stress
• Chronic stress can impair the developing brain
Genetic Risk Factors Emerging Earlier
…and harder to control
Key message for Health:Key message for Health:Many don’t associate their health problems with abuse
and therefore, may not disclose abuse.
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The Mind/Body: Inseparable!Inseparable!
• Hx of sexual abuse: 2.8 times more likely to have a functional bowel disorder, chronic abdominal pain,
Irritable Bowel Irritable Bowel SyndromeSyndrome
Talley, N.J., Helgeson S, insmeister AR. Are sexual & physical abuse linked
to functional gastrointestinal disordersGastroenterology 1992; 102:A52
Vulnerable population + cultural beliefs
Some believed that the stress in the relationship caused the
cancer
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• Chronic or recurrent headaches• Temporomandibular disorder• Musculoskeletal complaints• Chronic back pains
…but is it always all ‘just in their head’?
Or are they related to old injuries,
most often recurrent
and untreated
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Many injuries of physical abuse are focused on the head & face
•Evidence of pulled hair
Photos used with permission: Domestic Conflict Unit DV Presentation-CPS
Injury Patterns Among Female Trauma Patients: Recognizing Intentional InjuryCrandall ML, Nathens AB, Rivara FP
J Trauma. 2004;57:42-45
The “Shut-up” Blow
Mild Traumatic Brain Injury*L.O.C. not required
One of the most undiagnosed, prevalent, and serious One of the most undiagnosed, prevalent, and serious consequences of IPVconsequences of IPV
•““Subtle Concussions”/ Soft Neuro SignsSubtle Concussions”/ Soft Neuro Signs
““chronic headaches”chronic headaches”
•Second Impact Syndrome RiskSecond Impact Syndrome Risk
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Variations of “amnesia” or “seizures.”
Despite an expectation that full recovery
should occur within 12 weeks of the
MTBI (Belanger et al., 2005) a sizable minority
continue to experience persistent symptoms
(Wood, 2004) and have difficulty with
returning to work, school or play. (Bazarian,
Blyth, Mookerjee, He, & McDermott, 2010).
Cognitive indicators of MTBI, such as, “feeling slowed down” or “mentally foggy” or “difficulty concentrating”
Intimate Partner Sexual Violence
•common expression of domestic violence (esp. during
reproductive yrs)•likely to be raped may times
•physical violence also possible
•Reproductive Coercion
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…In IPSV
• Genital injuries: vaginal stretching, lacerations (tears)
• Miscarriages, still births
• *Anal injuries
• Pelvic pain
• Frequent vaginal and urinary tract infections, painful intercourse
• Recurrent STI’s
• HIV/AIDS HIV/AIDS • Hepatitis BHepatitis B
• Substance Abuse
Public Health Issues
““No negotiation of condom use” No negotiation of condom use” Jacqueline CampbellJacqueline Campbell
What denotes medical urgency in the context of DV
•Airway•Breathing•Circulation•‘Disability’
…Level of Consciousness•Suicide Ideation
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Strangulation-a Case of Medical Urgency
Photo used with permission: Domestic Conflict Unit DV- CPS
“It hurts to swallow”
**Victims may have no visible injuries
-but underlying injuries may kill the victim up to 36 or more hrs later due to
de-compensation of the injured structures
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Chrisler & Ferguson, 2006
More than
of victims are strangled at least once
{ the average is 5.3 times per victim }•Injuries identified in non-fatal strangulation cases were similar to injuries found in fatal IPV strangulation assaults (Hawley et al, 2001)
•under-assessed & underappreciated by health care (Sheridan & Nash, 2007)
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Vessels: arteries & veins
CAROTID ARTERY
CAROTID ARTERY
JUGULAR VEINJUGULAR VEIN
THYROID CARTILAGE (with fracture shown)
THYROID CARTILAGE (with fracture shown)
TRACHEAL RINGS
TRACHEAL RINGS
• HYOID BONE
• HYOID BONE
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If they don’t tell…“Ask”If they don’t tell…“Ask”
• Hoarseness or complete loss of voice
• Swallowing changes- pain, difficulty, drooling
• Breathing changes/difficulty, coughing
• Headache, weakness
• Passed out ?, loss of memory since assault
• Nausea or vomiting• Mental changes, restlessness,
and combativeness• Urinary or bowel incontinence
during event
Seek Medical Attention Immediately !
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Strategies to Reduce Risk
• Opportunities do exist to incorporate questions
about Domestic Violence into routine patient encounters to determine points of intervention with the
goal of preventing lethal outcomes
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Nearly one in three women who presented to emergencydepartments (34.8%) or academic clinics (31.4%)
reported severe physical abuse or forced sexual activityin their lifetime
One in seven (13.7%) women inthe emergency departments reported severe physical
abuse in the past yearAlice Kramer, RN, MS* Darcy Lorenzon, MS and George Mueller, PhD
Aurora Health Care, Milwaukee, WisconsinWomen’s Health Issues 14 (2004) 19–29
One study on “Prevalence”*Accessing Health Care
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Top 10 Diagnostic Codes with ‘+ disclosure’‘+ disclosure’ of DV when asked
Source:Kelly Nelson, CHIM
Health Information Analyst, Health Information Reporting
Data Integration, Measurement & ReportingAlberta Health Services - Calgary
One Site’s : Emergency Department Data 2008/09
Adjustment disorders
Depressive episode, unspecified
Examination and observation following alleged rape and seduction
Other symptoms and signs involving emotional state
Physical abuse
Other and unspecified abdominal pain
Threatened abortion, unspecified as to episode of care, or not applicable
Acute pancreatitis, unspecified
Mental and behavioural disorders due to use of alcohol, acute intoxication
Mental and behavioural disorders due to use of alcohol, dependence syndrome
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Part of Assessment *at some point during their stay
• We know that violence and the threat of violence in the home
is a concern for many people and can directly affect their health.
• Abuse can take many forms: physical, emotional, sexual,
financial or neglect.
• We routinely ask all patients and parents about maltreatment or violence in their lives.
• Is this a concern for you or your child(ren) in any way?
Awareness/planting the
seed
Education-providing
explanation
Why we’re asking you
Risks to kids when
exposed to DV
Is it “Screening”?
Different from most other health care screening interventions
•Not unaware•Not asymptomatic
•Violence is not a mere risk factor awaiting identification
……getting a ‘yes’ or ‘no’ is not our goalgetting a ‘yes’ or ‘no’ is not our goal
Taken from: Intimate partner Violence Consensus StatementSociety of Obstetricians and Gynaecologists of Canada (SOGC)
April JOGC 2005 pgs. 365-388
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“not our job to rescue”
• Supportive not curative• Validate their experience
• Find out what they wish to do …Provide OptionsProvide Options• Try to ascertain their level of risk for serious harm
““CONNECT”CONNECT” them with resources
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*CONNECT www.connectnetwork.ca
*Rural Referral Assistance Available
Single Point Access Single Point Access
Enhanced information and referralEnhanced information and referral
For victims, their families &/or the professionals that are concerned
“ a shelter without walls” Deb Tomlinson, Project Manager CONNECT
* Also Available for Consultation 24/7
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Age/Gender
20-something yr old Female-
presented to 2 sites over course
of 3 yrs
*6 of those visits at same site
Date Presented Coded Diagnosis ?Asked& Response
June 1. Injury that required surgical intervention and hospital stay
2. Physical abuse3. Maltreatment by
spouse during unspecified activity & place of occurrence
4. Pregnancy State
“YES”
January 1. UTI2. Unspec. Abdominal
Pain
Blank
November 1. Panic Disorder BlankOctober- (visits 2 & 3) 1. Cellulitis Upper Limb
+ IV TherapyBoth visits-
BlankOctober (visit 1) 1. Burns-Wrist & Hand-
FireBlank
June 1. # Multi Site-Metacarpals
2. Assault
Blank
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…some words of wisdom from a survivor
“I really think that it’s the compassion, the asking of the question, the referral which can happen in a matter of minutes, which can be
the hinge, the gateway to the way out” Excerpt from “The Voices of Survivor
Documentary”
“I know it saved my life” words of a patient seen in the Strathmore Emergency
Department
Closing Comments for Reflection:Client-Centered Evolution of Response
•What additional resources would help your client address their medical needs in your community?
•Is there opportunity for a more collaborative response that involves all designations & disciplines?
•Do “turf issues” get in the way?Do “turf issues” get in the way?
