Author: Jon Andereck, MD (EM Resident Physician, PGY-1, NUEM) // Edited by: Jordan Kaylor, MD (EM Resident Physician, PGY-4, NUEM) // Expert Reviewer: Lauren Whiteside, MD
Citation: [Peer-Reviewed, Web Publication] Andereck J, Kaylor J (2016, March 1). The Silent Killer: A Life-Threatening Diagnosis Missed By 7 Out of 8 ED Physicians. [NUEM Blog. Expert Peer Review by Whiteside LK]. Retrieved from http://www.nuemblog.com/blog/the-silent-killer/
Chief complaint: Shoulder pain, struck by car. Triage level 4.
Twenty minutes later, I found myself in the patient's room, heart racing, feeling lost, frantically thinking about how we could save this woman’s life. I was overwhelmed. I felt unprepared for the crisis that had unfolded.
She had not coded. She did not have a tension pneumothorax. She was not exsanguinating. She was being abused at home.
It was not why she had come in, but there had been enough clues to tip us off to something suspicious going on with her husband. Her complaints were vague. Her story was strange. Her husband answered most of the questions I asked and then adamantly refused an X-ray when offered. There was a strange vibe in the room, so I had the nurse get the husband and friend out of the patient's room for “a more thorough exam.”
By the time I stepped in to speak with the patient alone, she was already in tears. Her eyes portrayed a deep and chronic fear. She pleaded “please let me go home!” After gentle but repeated inquiry, she passively admitted to being physically abused by her husband, but adamantly denied that he beat their children. In less than two minutes, the husband was already knocking on the door to come back in. We had tried multiple times to convince her to stay, to get help. She would not, but she promised to come back later without her husband.
In the end, we let her go home and had to hope she would return. To date, she has not.
We are expertly trained in the physical emergencies that we encounter in the emergency department (ED). But here was an emergency situation in which we had only minutes to try to redirect the course of this patient’s life, and I felt completely unprepared for doing so. I hope this short discourse on inter-personal violence (IPV) can help all of us be more prepared for the next time we find ourselves caring for someone in this situation. As it turns out, it is common enough that it may happen on your next shift. Are you ready?
Scope of IPV
IPV accounts for over 2 million injuries and 1300 deaths annually in the US. 44% of those who died had presented to the ED within two years of death, almost always with at least one injury on presentation . Studies on prevalence of IPV suggest that as many as 52% of women presenting to the ED are current or past victims of IPV . Rates of IPV among male populations are generally much lower than in women, though among men who have sex with men (MSM), estimates of prior IPV range from 12%-34% .
Risk Factors and Red Flags
Common risk factors for IPV
- Female (odds ratio [OR] 7.8)
- Past suicidal ideation (OR 6.6)
81% of patients with prior suicide attempt report history of domestic violence, compared to 19% among those without prior suicide attempt .
- Family history of IPV (OR 6.4)
- Previous psychiatric history (OR 4.2) 
- Alcohol or drug abuse in the home (28-fold risk of patient death over homes without drug/alcohol abuse) 
- Young, pregnant patients
- IPV more common in pregnancy than gestational diabetes, pre-eclampsia, and placenta previa 
- Screening pregnant patients for any of 5 risk factors (age<20, less than high school education, history of trichomoniasis, alcohol use, or marijuana use) has 80% sensitivity for predicting current IPV 
- Blunt trauma to head, neck, and/or face
- Relative risk of IPV in those with head, neck, and/or facial trauma 14.1 (92% sensitivity) 
- 56% of those with head, neck, and/or facial trauma have associated facial fractures 
- Partner will not leave patient’s side
History and Physical
Only 3% of patients claim they would directly seek help from a medical professional for IPV, and this is only after seeking the help of a family member or friend .
As such, the vast majority of chief complaints for people suffering from IPV are vague and typically not directly related to IPV. Some common chief complaints include:
- Frequent headache
- Chronic pelvic pain
- IBS-like symptoms
- Vague history of injury or history inconsistent with injuries
Dorris Tyson from Vanderbilt uses normalizing language to frame the history:
“Many of the patients I see in the emergency department deal with issues of violence within their own personal relationships. I now routinely ask all persons seen here about domestic violence.” 
Others recommend thanking the patient for trusting the provider with an admission of abuse and then expressing concern for the patient’s safety . Tyson presents the mnemonic “SAFE” to help guide the critical questions in IPV patient encounters:
S (safe/safety): “Should I be concerned for your safety today?”
A (afraid/abuse): “Are you in a relationship where you are threatened or afraid?”
F (friends/family): “Are your friends/family aware that you have been hurt? Could you tell them and would they be able to give you support?”
E (emergency plan): “Do you have a safe place to go in an emergency? Help locating a shelter or developing a plan?”
Your suspicion is key, as studies have shown that only 13% of women being abused have the abuse directly addressed in the ED visit .
If the abuser accompanies the patient, it is necessary to isolate the patient to obtain an accurate history. This can be extraordinarily difficult, so get creative. Make the argument that we need a urine sample, and have someone speak with the patient in the bathroom. Take the patient to x-ray and interview them there. Figure out how to inconspicuously isolate the patient, and make sure the nurses and techs are on the same page. As soon as you suspect IPV, talk to social work and work together to come up with a sound game plan.
In the flurry of activity around the social history in these encounters, do not neglect the physical exam. Address the chief complaint fully, but also be sure to do a full head-to-toe examination looking for other injuries, and particularly for injuries at various stages of healing. If the patient plans on pressing charges, accurate descriptions and/or pictures of the injuries are important.
Specific findings to look for include:
- Injuries at various stages of healing
- Bilateral injuries, especially to extremities from defensive maneuvers
- Bite marks
- Scratch marks
- Cigarette burns, rope burns
- Abrasions, welts
- Signs of choking, including conjunctival hemorrhage and bruising on neck
The priorities for treating patients with IPV are:
- Treat acute injuries and stabilize the patient
- Ensure safety after discharge (which may require admission)
- Provide all necessary referrals and resources
Directly addressing IPV in the ED and creating a safety plan can lead to >90% of patients feeling safer at 12 weeks of follow-up, with over 50% of patients reporting making progress toward those plans . This is particularly important because only 50% of people show up to post-encounter appointments, which means the initial encounter in the ED may be the most important for the majority of victims of IPV.
Treating victims of IPV is similar to approaching sexual assault victims. The key is to give them back as much control as possible, which is likely unusual for them at home. Let them decide their disposition (unless they do not have capacity), and let them decide the amount of legal involvement they would like. Offer admission to ensure placement and safety plans are secured if the patient so desires. Give print materials (in our ED there is a nice handout for local and national resource numbers and websites). If they are being discharged home, recognize that patients find law enforcement and legal referrals most helpful .
Do not acknowledge domestic violence in the discharge paperwork, do not prescribe sedating medications as these can reduce the patient’s ability to protect him/herself, and do not give specific recommendations such as “you need to leave your partner” as this can potentially lead to more harm to the patient .
Mandatory reporting standards vary from state to state. In Illinois, we are mandated to report abuse or suspected abuse of children under 18, elderly, and disabled persons within 24 hours after developing such belief. Recognize that most victims of IPV do not fall under this purview, and that 44% of victims do not support mandatory reporting, so do not try to coerce your patient into involving the authorities. If they are not ready for that step, give them resources but let them make their own choice.
If we only recognized 13% of ED patients at risk of dying of an MI within 2 years, we would be out of business as a profession. We admit people all the time for low-risk chest pain for provocative testing to make sure they have proper follow-up and get appropriate risk stratification. Yet for victims or people at high risk of IPV that can be equally morbid, we often do them a disservice by sending them home without appropriate resources and follow-up. Worse, we often fail to even recognize those at risk or currently suffering from IPV. This disease is more common than we think. As emergency physicians, we have a responsibility to our patients to maintain a high index of suspicion for IPV and respond with the same level of care that we do for other diseases.
Dr. Andereck provided an excellent review of inter-personal violence (IPV) and makes some important suggestions about how we as emergency medicine physicians can provide care for these patients. As the case points out, patients do not commonly come to the ED with a chief complaint of ‘IPV’ and thus the symptoms are often vague, the patient may not be in a situation to be open about the story and we are often feeling rushed by a busy ED and competing priorities. Additionally, as front-line Emergency Medicine providers, we are often tasked with multiple public health efforts and can feel overwhelmed with every recommendation to screen patients for high risk behaviors including IPV, alcohol use, drug use, suicide, HIV, etc. The list can often feel exhaustive, especially for a patient with a seemingly minor complaint such as that presented in the case. You are not alone in this endeavor! Understand your hospitals resources including social work and nursing capacity for helping with referrals and planning for safety after you conduct the initial screening. I urge you to recognize the impact you can have on someone’s wellness and life by incorporating this public health screening into your clinical work. Due to the morbidity and mortality associated with IPV, it is important to treat this as a true emergency much as you would an unstable trauma or cardiac arrest. For this reason, I offer the following points:
- The USPTF recommends universal screening for all women of child bearing age. As the summary above suggests, pregnancy is a particularly vulnerable time. Other vulnerable populations can include undocumented or immigrant women. Men can also be victims of IPV and it’s important to keep an open mind with screening practices.
- If you always take time to conduct a portion of your exam and/or interview in private (e.g. without family and friends present), it will be easier to ask questions about IPV and other sensitive topics. If you do this every time it becomes part of your work flow.
- Have an introductory stock statement you always use. This will make your IPV or other public health screening inquiry seem less awkward and more patient-centered. I usually start by saying, ‘Do you mind if I ask you a few questions I ask all my patients?’ Asking permission is a motivational interviewing technique that can lead to an open-ended conversation about difficult topics. This also normalizes the question(s) that follow and gives the patient an open space to talk about IPV, drug use, alcohol use, etc.
- Much like a cardiac arrest, have an algorithm!!
- First, have a screening question you like to use. The SAFE mnemonic was presented in the case and has some great screening questions. I also like the questions outlined in the Annals of Emergency Medicine article published by Dr.’s Choo and Houry in 2015. Specifically, asking ‘Have you been hit, kicked, punched or otherwise hurt by someone in the past year’ is a good initial screening question.
- After a positive screen, have a statement ready to validate the patient. ‘What you are experiencing is called abuse and it’s not your fault’ or ‘Thank you for sharing your experience with me today and I want you to know that you are not alone. I’m here to listen and help’. There is nothing worse than fumbling along after a positive IPV screen and not having the words to transition to a referral.
- Next, have a referral plan. If you have access to social work, make sure you involve them in the care of the patient. Provide the patient with assurance and resources and know where these resources are located within your ED.
- Make sure you address safety. Your social work colleague can help with this, but make sure you ensure the immediate safety of your patient. Using a phrase such as ‘Do you feel safe at home’ is a good starter, but you can also ask about weapons in the house, recent threats made by the perpetrator and if the violence has increased in frequency recently. Follow this up with a safety plan tailored to the patient.
- Hankin, Abigail D. and Debra E. Houry. “Intimate Partner Violence.” In Emergency Medicine: Clinical Essentials. 2nd Ed. Ed. James G. Adams. Philadelphia: Elsevier, 2013. p. 808-810. Print.
- Abbott, Jean, Robin Johnson et al. Domestic violence against women: Incidence and prevalence in an emergency department population. JAMA. 1995. 273(22): 1763-1767.
- Tran, Alvin, Lavinia Lin et al. Prevalence of substance use and intimate partner violence in a sample of A/PI MSM. Journal of Interpersonal Violence. 2014. 29(11): 2054-2067.
- Ernst, Amy A., Steven J. Weiss et al. Domestic Violence in a University Emergency Department. Southern Medical Journal. 2000. 93(2): 176-181.
- Tyson, Dorris. “The medical evaluation of domestic violence in the emergency department.”November, 2015. PowerPoint presentation.
- Datner, Elizabeth M., Douglas J. Wiebe et al. Identifying pregnant women experiencing domestic violence in an urban emergency department. Journal of Interpersonal Violence. 2007. 22(1): 124-135.
- Perciaccante, Vincent J., John W. Carey et al. Markers for intimate partner violence in the emergency department setting. J Oral Maxillofac Surg. 2010. 68: 1219-1224.
- Liebschutz, Jane M. and Emily F. Rothman. Intimate-partner violence – what physicians can do. NEJM. 2012. 367(22): 2071-2073.
- Kendall, Jayne, Maria T. Pelucio et al. Impact of emergency department intimate partner violence intervention. Journal of Interpersonal Violence. 2009. 24(2): 280-306.
- Rodriguez, Michael A., Elizabeth McLoughlin et al. Mandatory reporting of domestic violence injuries to the police: What do emergency department patients think? JAMA. 2001. 286(5): 580-583.
- Choo EK, Houry DE. Managing intimate partner violence in the emergency department. Ann Emerg Med. 2015 Apr;65(4):447-451.
- 320 Ill. Comp. Stat. 20/4(a-5); http://www.americanbar.org/content/dam/aba/migrated/aging/docs/MandatoryReportingProvisionsChart.authcheckdam.pdf