Domestic Violence: The medical response

Objectives:• Review Data on DV• Discuss how victim may enter healthcare system

• Reporting vs. non reporting

• How is a forensic exam helpful• Victim• Judicial system

• What is a forensic exam and how is it different from a routine exam.

• Evidence collection• Recognizing Strangulation

• Treatment options• Testimony of the forensic nurse

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 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 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 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 photo-documentation.

• 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• Labs• X-rays• Medications administered• Pain• Infection prevention

• Referrals to specialists

• Forensic• History• Exam• Swabs• Photos• Treatment

Kit • CONTENTS:1- 999-550 FDA Manufacturer’s Insert2- KCP118 Integrity Seals1- KCP206 Biohazard Label, 1” x 1.25” (2.5cm x 3.2cm), Black on Orange1- VEC1001 Kit Box, Factory-Sealed1- VEC1002 Kit Instruction Sheet1- VEC101 Authorization for Collection & Release Form, 3-Part1- VEC102 Victim Medical History & Assault Information Form, 3-Part1- VEC103A Foreign Material Bag with 23” x 35” (58.4cm x 88.9cm) Paper Sheet1- VEC103B Panties Bag,br> 2- VEC103C Outer Clothing Bags1- VEC104 Debris Collection Env. w/Paper Bindle, Swab Box & Nail Scraper1- VEC105 Pubic Hair Combings Env. w/Towel & Plastic Comb1- VEC106 Pulled Pubic Hairs Env.1- VEC107 Vaginal Swabs & Smear Env. w/Slides, Sterile Swabs & Boxes1- VEC108 Rectal Swabs & Smear Env. w/Slides, Sterile Swabs & Boxes1- VEC109 Oral Swabs & Smear Env. w/Slides, Sterile Swabs & Boxes1- VEC110 Pulled Head Hairs Envelope1- VEC111 Known Saliva Sample Env. w/Specimen Disc1- VEC112 Known Blood Sample Env. w/6ml ACD & 7ml EDTA Blood Tubes1- VEC113 Anatomical Drawings Form, 3-Part NCR1- 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.