Drs Gary Quick, Theodore Ruff, and Pam Wilson's "What's Wrong With This
Picture?" case of a woman with splenic laceration resulting from an assault by a
male friend (CONSULTANT, May 2002, page 714) seems to have missed the
"elephant in the living room." The description of the hospital course and follow-up
provides a comprehensive guide to care for an injured spleen; however, the issue of domestic violence is
An estimated 5% to 14% of American women are currently in abusive relationships.1 Domestic violence leads to significant health problems both for those who experience the abuse and for their children.2-4 Through routine screening and intervention, health care providers can help reduce the incidence
of this common and serious problem--and possibly save lives.
How best to address domestic violence? Here is an approach:
- First, show support with a nonjudgmental statement such as, "I am glad you told me. You are not
alone, help is available."5
- Second, find out about immediate safety. Is it safe for the patient to go home?
- Third, offer information about advocacy services and emergency shelters and/or a follow-up appointment
with a social worker or mental health professional.
- Finally, document the incident in the medical record, including photographs of injuries whenever possible.
There are many excellent resources for clinicians.6,7 Information is also available on activities to
address domestic violence that involve the entire health care community.8-11
-- Krista Kotz, PhD, MPH
-- Brigid McCaw, MD, MS, MPH
We thank Drs Kotz and McCaw for highlighting the important issue of domestic
violence. Although the focus of our presentation was the diagnosis and nonoperative
management of splenic injuries, we perhaps should have indicated in a
sentence or two that the domestic violence involved in the case was addressed.
However, a detailed discussion of issues that might affect legal actions or patient
safety is not appropriate in an article in which the physicians and hospital are specifically identified.
More than 2 years ago, the Oklahoma State Health Department designated domestic violence
as a reportable incident. This status requires that physicians ask all female patients over the age of 18 years about domestic violence when they present to the emergency department (ED), and that
physicians report cases in accordance with the Health Department protocol.
Once a patient has been identified as a possible victim of domestic violence, various actions follow,
depending on the patient's circumstances. Names of shelters and other resources or contacts
may be secretly slipped to the patient on a commonplace item, such as an emery board, name tag,
or key ring. The ED nurse or physician attempts to interview the patient without the presumed perpetrator
of violence present. Offers to contact a "safe house" or shelter may be made. Sometimes
a case worker is called to the ED.
We follow extant protocols for all of our patients in the ED as part of standard patient care.
Domestic violence is a blot on our society and must be addressed at every opportunity.
-- Gary Quick, MD
Department of Emergency Medicine
Oklahoma Heart Hospital
-- Theodore Ruff, MD
Midwest Regional Medical Center
Midwest City, Okla
-- Pam Wilson, DO
Midwest Regional Medical Center
Midwest City, Okla
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2. Wisner CL, Gilmer TP, Saltzman LE, Zink TM. Intimate partner violence against women: do victims cost health plans more? J Fam
3. Campbell JC, Lewandowski LA. Mental and physical health effects of intimate partner violence on women and children. Psychiatr Clin
North Am. 1997;20:353-374.
4. Hathaway JE, Mucci LA, Silverman JG, et al. Health status and health care use of Massachusetts women reporting partner abuse. Am
J Prev Med. 2000;19:302-307.
5. Gerbert B, Johnston K, Caspers N, et al. Experiences of battered women in health care settings: a qualitative study. Women Health.
6. Alpert EJ, Albright C, Webb S. Massachusetts Medical Society Seminar Series on Domestic Violence. Acad Med. 1999;74:589-590.
7. Salber P, Taliaferro E. The Physician’s Guide to Domestic Violence: How to Ask the Right Questions and Recognize Abuse. Volcano, Calif:
Volcano Press; 1995.
8. McCaw B, Berman WH, Syme SL, Hunkeler EF. Beyond screening for domestic violence: a systems model approach in a managed
care setting. Am J Prev Med. 2001;21:170-176.
9. Cohn F, Salmon M, Stobo J. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington,
DC: Institute of Medicine; 2001:6.17-6.18.
10. Larkin GL, Rolniak S, Hyman KB, et al. Effect of an administrative intervention on rates of screening for domestic violence in an
urban emergency department. Am J Public Health. 2000;90:1444-1448..
11. Swenson-Britt E, Thornton JE, Hoppe SK, Brackley MH. A continuous improvement process for health providers of victims of domestic
violence. Jt Comm J Qual Improv. 2001;27:540-554..