Transcript Physical violence: The medical response

Domestic Violence:
The medical
response
Objectives:
• Review Data on DV
• What is a forensic
• Discuss how victim
exam and how is it
different from a routine
exam.
• Evidence collection
• Recognizing
Strangulation
• Treatment options
• Testimony of the
forensic nurse
may enter healthcare
system
• Reporting vs. non
reporting
• How is a forensic
exam helpful
• Victim
• Judicial system
Domestic Violence
• Domestic violence is an
assault on our society. It
encompasses all
manner and form of
injury: Physical, mental,
financial, and property
Violence & Trauma in Texas:
2009
• 111 women lost their
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lives to domestic
violence/ trauma
179,435 hotline calls
12,905 Adults sheltered
35,588 Adults receiving
non-residential care
15,588 children required
emergency shelter (not
counting those sent to
other family members)
Texas Council on
Family Violence
How big is the problem?
DV Cases seen in hospitals
Best estimates report that
between 20 & 30 percent of
women and 7.5 percent of
men in the United States
have been abused by their
intimate partner.
What if?
• Physical violence without
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forensic exam
Mary. Late 70’s
Triaged with husband.
Accidental fall
Seen by ER MD
X-rays performed
Treated for bruises and
sprain
Followed up as directed with
PMD 3 days later.
• Physical violence with
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forensic exam
Mary is triaged with husband
Accidental fall
Seen by ER MD who
examines patient without
husband present
Notes that patient gives
inconsistent history
Patient admits to being
abused by husband.
Due to Mary’s age, LE is
involved and a Forensic
Exam is ordered.
Which evidence is more compelling?
• Sterile ER record
documenting bruises
and statement by patient
and patients husband
that she fell down in the
home…several times
over the past two days.
• Comprehensive medical
and forensic
examination with use of
diagrams and photodocumentation.
• Patient statements
admitting that her
husband hit her arms
and legs repeatedly with
her purse because she
did not make what he
wanted for dinner.
What is the difference?
• Non forensically
trained medical
personnel
• MD’s
• Little to no education on
specialty of forensics
• “See one- Do one- Teach
one” method of learning.
• RN’s
• BON requires 2 hrs. of
forensics….once in a
career
• Forensically trained
• MD’s
• University level specialized
training
• Child Abuse
• Elder Abuse
• Sexual Assault
• RN’s
• University Level training
• Professional Association
Certifications
• State Certifications
Case Review: Police involved
• Patient arrival/
report screening
• Determine if they
want police involved
• Contact police for
appropriate
jurisdiction
Police Arrive
• Depending on agency
policy
• Police arrive within
minutes of call
• Talk to victim
• Obtain authorization to
have Forensic Nurse
Exam
• Authorize FNE to
provide exam
Activation of Forensic Nurse
• Charge nurse/
physician activates
SANE/ FNE
• SANE/ FNE contacts
Victim Advocate on
Call
• SANE/ FNE reports to
hospital to see patient
Consent and explanation
• Written and or verbal
consent prior to
starting exam
• Right to refuse
• Right to have advocate
present (specific to
SA)
• Right to retain clothes
• Right to stop at any
time
• Right to refuse blood
or urine collection
History of event
• Key to understanding
events as they
happened.
• Medical examination
NOT a criminal (forensic)
investigation interview
• We need some of the
same information as LE
but are primarily
concerned about signs,
symptoms, and potential
outcomes (physical and
emotional)
History continued
• Medical Need to Know
• When did it happen?
• Time line for injuries
• Where were you?
• Safety planning
• What happened to you?
• What type of injuries can I
expect to find?
• What did the person,
who hurt you, do?
• Injury (physical and
emotional) expectations
• Positions during event
• Injury potential
• Types of injuries
inflicted, if known?
• Treatment options
• Did you attempt to
injure or ward off the
other person? How?
• Emotional/physical
powerlessness
Purpose of history
• True purpose
• To determine actual and
possible injuries as they
are conveyed by
mechanism of injury.
• i.e. “He hit me on the left
side of my face with a
pillar candle”
• Given the history, the
patient would need a
CNS exam, possible CT
of the head, and sutures
for the large laceration.
• Secondary, legal
advantage for the
patient
• Medical personnel who
obtain a history during
the course of an
examination may testify
as to what the patient
told them as a part of the
medical examination.
• Exception to the
Hearsay Rule.
Importance of history
• Without a history the
caregiver is made to
rely solely on what can
be seen. Many injuries
do not appear until
hours, days, or weeks
later.
Who should be present during history
taking
• Differing schools of
thought
• Patient has the right to
have the persons of their
choosing
Interpretation of the law is
varied.
• Discussion:
• Advocate
• Family
• Nurse only
• Law Enforcement
Value of history to LE
• Provides details of the
incident as it pertains
to injuries, time,
persons involved.
• As a rule, nurses are
confided in more often
than law enforcement.
The assumption by
most individuals is that
nurses are here to take
care of me while the
police have to figure
out where the truth
lies…..
Difference
• Medical history
• Used to determine type
of injuries
• Render a diagnosis
• Formulate a plan of care
• Provide treatment
• Fault not a consideration
• LE Interview
• Used to determine what
kind of crime occurred
• Who was involved?
• Who is the perpetrator?
• What connection does
the victim have to the
perpetrator?
• Is the complaining
witness the victim?
BREAK
Physical portion of exam
Head to toe looking for trauma
Provide compelling testimony
Why trauma?
• Trauma informed care
• Trauma informed care in very simple terms, means that we
evaluate the patient based on an assumption that trauma occurred,
either mental or physical or both, and apply nursing process to that
ends.
Linking history to exam
• When a history is
taken we use the
information gained in
the history to guide us
in our overall physical
and mental
assessment.
• Person
• Place
• Time
• Acts
• Responses
• Actions during
• Actions after
• Discharge options
Head
Torso
Extremities
Ano-genital with consent
Female / Male
Cervix
Vaginal
Anal
Evidence Collection
• Medical exam findings
• Forensic
• Labs
• History
• X-rays
• Exam
• Medications
• Swabs
administered
• Pain
• Infection prevention
• Referrals to specialists
• Photos
• Treatment
Kit
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CONTENTS:
1- 999-550 FDA Manufacturer’s Insert
2- KCP118 Integrity Seals
1- KCP206 Biohazard Label, 1” x 1.25” (2.5cm x 3.2cm),
Black on Orange
1- VEC1001 Kit Box, Factory-Sealed
1- VEC1002 Kit Instruction Sheet
1- VEC101 Authorization for Collection & Release Form, 3Part
1- VEC102 Victim Medical History & Assault Information
Form, 3-Part
1- VEC103A Foreign Material Bag with 23” x 35” (58.4cm x
88.9cm) Paper Sheet
1- VEC103B Panties Bag,br> 2- VEC103C Outer Clothing
Bags
1- VEC104 Debris Collection Env. w/Paper Bindle, Swab
Box & Nail Scraper
1- VEC105 Pubic Hair Combings Env. w/Towel & Plastic
Comb
1- VEC106 Pulled Pubic Hairs Env.
1- VEC107 Vaginal Swabs & Smear Env. w/Slides, Sterile
Swabs & Boxes
1- VEC108 Rectal Swabs & Smear Env. w/Slides, Sterile
Swabs & Boxes
1- VEC109 Oral Swabs & Smear Env. w/Slides, Sterile
Swabs & Boxes
1- VEC110 Pulled Head Hairs Envelope
1- VEC111 Known Saliva Sample Env. w/Specimen Disc
1- VEC112 Known Blood Sample Env. w/6ml ACD & 7ml
EDTA Blood Tubes
1- VEC113 Anatomical Drawings Form, 3-Part NCR
1- VEC114 Law Enforcement Forms Env.
Photo documentation
Documentation
Interpretation
of findings
What does it all mean?
• Discussion with LE
• Discussion with MD
Testimony
• Expert
• Fact
Questions
• Please be advised that
we are unable to
answer ANY math
questions.