Transcript Domestic & Sexual Violence: A Health & Safety Issue

Domestic & Sexual Violence:
A Health & Safety Issue
-One Health Region’s Strategy to Reduce Risk
Presenter: Linda McCracken RN
Sexual Assault Nurse Examiner
AHS-Domestic Violence Program Coordinator
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?
After this presentation,
you’ll have a better understanding of:
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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
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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
Stress & The Immune System
Stress 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
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Genetic Risk Factors
Emerging Earlier
…and harder to control
Key message for Health:
Many don’t associate their health problems with abuse
and therefore, may not disclose abuse.
The Mind/Body: Inseparable!
• Hx of sexual
abuse: 2.8 times
more likely to have
a functional bowel
disorder, chronic
abdominal pain,
Irritable Bowel
Syndrome
Talley, N.J., Helgeson S, insmeister AR.
Are sexual & physical abuse linked
to functional gastrointestinal disorders
Gastroenterology 1992; 102:A52
Vulnerable population +
cultural beliefs
Some believed that the stress
in the relationship caused the
cancer
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…but is it always
all ‘just in their head’?
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•
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Chronic or recurrent headaches
Temporomandibular disorder
Musculoskeletal complaints
Chronic back pains
Or are they related to old injuries,
most often recurrent
and untreated
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Injury Patterns Among Female Trauma Patients: Recognizing Intentional Injury
Crandall ML, Nathens AB, Rivara FP
J Trauma. 2004;57:42-45
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
The “Shut-up”
Blow
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Mild Traumatic Brain Injury
*L.O.C. not required
One of the most undiagnosed, prevalent, and serious
consequences of IPV
•“Subtle Concussions”/ Soft Neuro Signs
“chronic headaches”
•Second Impact Syndrome Risk
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”
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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
…In IPSV
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Genital injuries: vaginal
stretching, lacerations
(tears)
Miscarriages, still births
*Anal injuries
Pelvic pain
Frequent vaginal and
urinary tract infections,
painful intercourse
Recurrent STI’s
Public Health Issues
• HIV/AIDS
• Hepatitis B
• Substance Abuse
“No negotiation of condom use”
Jacqueline Campbell
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What denotes medical urgency in
the context of DV
•Airway
•Breathing
•Circulation
•‘Disability’
…Level of Consciousness
•Suicide Ideation
Strangulation-a Case of Medical Urgency
Photo used with permission:
Domestic Conflict Unit DV- CPS
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“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
More than
of victims are strangled
at least once
{ the average is 5.3 times per victim }
Chrisler & Ferguson, 2006
•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
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(Sheridan & Nash, 2007)
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Vessels: arteries & veins
•
CAROTID
ARTERY
JUGULAR VEIN
HYOID
BONE
THYROID
CARTILAGE (with
fracture shown)
TRACHEAL
RINGS
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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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One study on “Prevalence”
*Accessing Health Care
Nearly one in three women who presented to emergency
departments (34.8%) or academic clinics (31.4%)
reported severe physical abuse or forced sexual activity
in their lifetime
One in seven (13.7%) women in
the emergency departments reported severe physical
abuse in the past year
Alice Kramer, RN, MS* Darcy Lorenzon, MS and George Mueller, PhD
Aurora Health Care, Milwaukee, Wisconsin
Women’s Health Issues 14 (2004) 19–29
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Source:
Kelly Nelson, CHIM
Health Information Analyst,
Health Information Reporting
Data Integration, Measurement & Reporting
Alberta Health Services - Calgary
Top 10 Diagnostic Codes
with ‘+ disclosure’ of DV when asked
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.
Awareness/
planting the
seed
Educationproviding
explanation
• 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?
Why we’re
asking you
Risks to kids when
exposed to DV
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Is it “Screening”?
Different from most other health care screening interventions
•Not unaware
•Not asymptomatic
•Violence is not a mere risk factor awaiting identification
Taken from: Intimate partner Violence Consensus Statement
Society of Obstetricians and Gynaecologists of Canada (SOGC)
April JOGC 2005 pgs. 365-388
…getting a ‘yes’ or ‘no’ is not our goal
“not our job to rescue”
• Supportive not curative
• Validate their experience
• Find out what they wish to do …Provide Options
• Try to ascertain their level of risk for serious harm
“CONNECT” them with resources
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* Also Available for Consultation 24/7
*CONNECT
www.connectnetwork.ca
Single Point Access
Enhanced information and referral
For victims, their families &/or the professionals that are
concerned
“ a shelter without walls”
Deb Tomlinson, Project Manager CONNECT
*Rural Referral Assistance Available
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Age/Gender
Date Presented
Coded Diagnosis
?Asked
& Response
20-something yr
old Femalepresented to 2
sites over course
of 3 yrs
June
1.
2.
3.
4.
*6 of those visits
at same site
Injury that required
surgical intervention
and hospital stay
Physical abuse
Maltreatment by
spouse during
unspecified activity &
place of occurrence
Pregnancy State
“YES”
January
1.
2.
UTI
Unspec. Abdominal
Pain
Blank
November
1.
Panic Disorder
Blank
October- (visits 2 & 3)
1.
Cellulitis Upper Limb
+ IV Therapy
Both visitsBlank
October (visit 1)
1.
Burns-Wrist & HandFire
Blank
June
1.
# Multi SiteMetacarpals
Blank
2. Assault
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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
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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?
[email protected]
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