Suspected abuse

[WTEngel]

I wanted to know if any of you have any tips or pearls when it comes to interviewing patients who may be victims of abuse, specifically if they come in with their abuser.

I would want to try and interview the patient without the suspected abuser in the room, but I'm trying to determine some ways to ask that person to leave, without escalating the situation.

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[cbrons]

Be careful not to do anything rash without notifying the attending.

Last week I saw a 6 year old with a head lac, which the kids mother said occurred at his dads house (the dad was not present in the ED; the mother brought him in). The mother's story about how he got hurt was very ambigious about what happened - seemed at first to blame another sibling then said something about wrestling and immediately seemed to divert the conversation. Anyway he had what looked like 2 well circumscribed circular lesions in the lumbar region of his back (about half the diameter of a penny - looked immediately like cigarette burns to me). Also in his prior charting notes within our EMR saw claims about his father being "aggressive" (was a note from an outpatient visit to another physician).

This was the kids 3rd trip to the ER for a head injury within 2 years.

I let the attending know about all these things. He caught a glance at the scars I saw, but after I presented to the patient and he sewed the laceration, I don't think he did anything. All he said to me was, "Good job." Really hope that kid isn't getting thrown into walls at home, but then again I guess I trust my attendings can sniff these things out better than I can, or at least I hope so.

 

[WTEngel]

Be careful not to do anything rash without notifying the attending.

Last week I saw a 6 year old with a head lac, which the kids mother said occurred at his dads house (the dad was not present in the ED; the mother brought him in). The mother's story about how he got hurt was very ambigious about what happened - seemed at first to blame another sibling then said something about wrestling and immediately seemed to divert the conversation. Anyway he had what looked like 2 well circumscribed circular lesions in the lumbar region of his back (about half the diameter of a penny - looked immediately like cigarette burns to me). Also in his prior charting notes within our EMR saw claims about his father being "aggressive" (was a note from an outpatient visit to another physician).

This was the kids 3rd trip to the ER for a head injury within 2 years.

I let the attending know about all these things. He caught a glance at the scars I saw, but after I presented to the patient and he sewed the laceration, I don't think he did anything. All he said to me was, "Good job." Really hope that kid isn't getting thrown into walls at home, but then again I guess I trust my attendings can sniff these things out better than I can, or at least I hope so.

I completely agree, getting the attending involved is definitely my first move while in rotations and residency.

I guess I was just wrestling with this question because I honestly don't know how I'd go about this type of situation, if I was in the situation where I didn't have an attending to fall back to. I understand this is a hypothetical situation that won't happen until I'm out of clinicals and done with residency, but all the same, I was just interested in hearing some opinions on it.

I worked as a paramedic for 13 years before medical school, with around 5 years working as a flight medic. I have had to do the death and dying talk more than a few times, but never had to deal directly with issues like this. We usually dealt with the aftermath unfortunately.

Anyway, I completely appreciate you sharing your recent experience. I am not trying to start a big "what if" cascade of questions, but I am interested hearing what you would do if you felt strongly that there was abuse, and the attending still decided not to report it or take any action.

Like I said, not trying to start an argument, just genuinely interested in hearing your input.

 

[hamstergang]

I would want to try and interview the patient without the suspected abuser in the room, but I'm trying to determine some ways to ask that person to leave, without escalating the situation.

I'm in child psych, not EM, but isn't it standard to interview the kid alone regardless? I don't see why asking the parent to step out would be escalating unless you made it so with your tone.

Also, of you suspect abuse, call child protective services. You're not a detective, you don't investigate. You simply report suspicion (at least in NJ, I guess it could differ by state).

 

[smq123]

I'm in child psych, not EM, but isn't it standard to interview the kid alone regardless? I don't see why asking the parent to step out would be escalating unless you made it so with your tone.

Also, of you suspect abuse, call child protective services. You're not a detective, you don't investigate. You simply report suspicion (at least in NJ, I guess it could differ by state).

The OP hasn't clarified if the patients that he/she suspects are being abused are adults or children. Yes, with children there is a duty to report (report first, ask questions later), but not necessarily in adults.

 

[Daiphon]

I wanted to know if any of you have any tips or pearls when it comes to interviewing patients who may be victims of abuse, specifically if they come in with their abuser.

I would want to try and interview the patient without the suspected abuser in the room, but I'm trying to determine some ways to ask that person to leave, without escalating the situation.

I'm a big fan of:
1) getting registration to ask the partner to go up front and ask to clarify something, or
2) needing to do a pelvic, or
3) meeting them in the radiology suite where only patients & employees can go (and where the door closes).

Each only takes a few minutes, and that's all I need to screen.

 

[dchristismi]

Daiphon nailed it. In cases of Intimate Partner Violence, you must talk to the patient alone. Also, don't use a family translator. Reporting varies by state, so you'll have to check your state laws. In mine, IPV/DV is not reportable unless it's a lifethreatening injury (like GSW.) The wording is a little grey, so you have to use your best judgement. Overall, an adult victim might not see themselves as a victim, and may be too scared to say anything. Reassurance that the patient does not deserve this may lead to disclosure the next time. There isn't much you can do other than document and educate. To learn more, you can try www.futureswithoutviolence.org which is a national group, or reach out to your local shelter. They provide many more resources than just sheltering - they do education, provide counseling, court advocacy, and some even help with transitional housing and beyond. The hotline numbers are anonymous, and a victim can merely use that as a shoulder to cry on if that's what she needs. They also do safety planning and lethality assessments - a great resource.

I am also a fan of the radiology excuse - it's easy to arrange (hell, you can just have them take the patient out of the room for the discussion if you want.)

If you have specific questions, ask. I worked as an advocate for several years and answered the hotline myself.

 

[Old_Mil]

...chart in extreme detail with the knowledge that if you are right, you and the chart will end up in court.

 

[dchristismi]

...chart in extreme detail with the knowledge that if you are right, you and the chart will end up in court.

Yep. I saw a case not long ago that will definitely go to court - unless there's a plea. Most of the time, my documentation gets me out of going. In fact, I had a strangulation case (a high marker for future lethality and a stand-alone felony in Florida) where the defense decided that I was too much of an expert (even as a fact witness) after deposition, and wanted their own expert. Aaaand... the defendant plead out.

I always presume these cases will go to court, and document the hell out of them, including any injuries, bruising, patterns injuries, petechiae, neurologic deficits, vocal changes, hoarseness, prior injuries, threats, detailed descriptions of battery (struck with closed fist, open palm, stomped by boot, etc.) And yes, I actually am an expert, and am giving yet another lecture on IPV/DV/Strangulation next week.

 

[WTEngel]

Thanks for the great replies. That's exactly what I was looking for.

I'm in child psych, not EM, but isn't it standard to interview the kid alone regardless? I don't see why asking the parent to step out would be escalating unless you made it so with your tone.

Also, of you suspect abuse, call child protective services. You're not a detective, you don't investigate. You simply report suspicion (at least in NJ, I guess it could differ by state).

I should have been more specific about the patient population I was considering. Sometimes an interview alone with the minor patient can help to confirm or dispel a suspicion though.

As far as escalation goes, I complete agree, the tone you take and the manner in which you go about navigating the circumstances has a huge impact. I have seen in the past though, that the threshold at which these situations can escalate is typically pretty low, especially if abuse is truly present. If the abuser is present, they are already on edge it seems, and any one thing could set them off. That was the reason for asking the question initially, as I wanted to see what had worked for people in the past in order to facilitate an interview alone with the patient, and keep the alleged abuser calm enough to not start trouble. Also, raising their suspicion could lead to them bolting and not being able to the taken into custody. I have also seen this in the past. I would hate to have an abuser run off, only to discharge the patient later and have the abuser do something retaliatory.

Thanks again for the input everyone.