ACS FSC-Intimate Partner Violence

You realize that the man is a surgery chief resident. The woman finished her residency two years ago and is currently a junior attending at your hospital.

It seems clear to you from her physical exam, particularly with her pattern of bruising, that she has had other recent trauma.

Following the bolus of 500cc LR and O2 by face mask, her BP is 110/70, her pulse 90 and her respiratory rate still 22.

Chest Tube Placement and Pain Control

You should be aware of how to properly place a chest tube. If you are not, the ACS/APDS Surgery Resident Skills Curriculum-Phase 1 contains a module that teaches how to place a chest tube in a simulator, including step-by-step instructions and a video demonstration.

Additionally, you should familiarize yourself with how to place a nerve block.

Patients must have their pain controlled following a chest tube placement. Some patients may require only an oral NSAID, but if this doesn’t adequately control their pain you should be aware of other options. Appropriate solutions in this case would include a nerve block of the fractured ribs and a PCA or epidural.

Following insertion of the chest tube while still on face mask oxygen, her 02 sat is 99, BP is 120/60, P 90, and RR 19. An epidural was placed for pain control. She is on morphine PCA for breakthrough pain. She is not on any other medications. She is feeling improved and her pain is minimal.

She asks what she should do about feeding her baby, because it is getting close to a normal feeding time. She wishes to breastfeed the infant as she prefers the baby to not receive formula.

It is very important for physicians to understand that breast feeding is important for mothers and infants. Routine cessation of breast feeding is now frowned upon.

It is the general view of pediatricians that mother’s milk offers improved immunity to infants and is recommended to be the exclusive source of nutrition for the first six months. Therefore, nursing is the recommended method for feeding an infant for as long as the mother chooses. Nursing also assists in maternal bonding. Women who choose to nurse are often traumatized if they are unsuccessful at nursing, or if they are forced to discontinue before they are emotionally ready to do so.

On some medications it is appropriate to continue breast feeding with close monitoring of the infant. When the milk is viewed as unsafe for the child to consume, you should continue to allow the mother to pump and dump the milk until their milk is safe for the infant. LactMed provides a database of which medications are safe or unsafe for a nursing infant.

Even if, as a surgeon you are unaware of the exact way of obtaining mother’s milk, you should know it is an option to obtain frozen mother's milk for patients who temporarily cannot safely nurse. You may get information from lactation specialists, social services, the OB/GYN, the pediatrician, or the local La Leche League as to where to obtain frozen mother's milk.

You should be aware there are multiple options for providing nutrition for this infant. It may be an option to obtain frozen mothers’ milk for patients who temporarily cannot safely nurse. The American Academy of Pediatrics’ guidelines for banked milk can be found here. You may get information on the appropriate feeding of this infant from a lactation specialist, social services, OB/GYN, pediatrician, or local La Leche League. Formula is an appropriate alternative for this 3-month-old infant.

Source: American Academy of Pediatrics

The patient is now stable and is transferred to a hospital room.

After obtaining milk, the patient’s husband has gone home to care for the infant.

You are concerned that her injuries might not be the result of an accidental fall, but rather, were caused by the patient’s husband, so you go to visit the patient to address your concerns. When you ask how she’s doing, she begins to cry.

She asks if she can get discharged soon, because her husband has been working long hours and is very stressed. She’s concerned that because her baby hasn’t been sleeping through the night and because her husband is already stressed, he might get angry if the baby wakes him tonight. She says she’d like to get home so she can take care of their child so her husband can rest.

Intimate Partner Violence (IPV) should be considered with the following characteristics. Although it may be uncomfortable for you to challenge the patient about IPV, it is your ethical responsibility.

Source: Government of Western Australia Department of Communities, Child Protection and Family Support

In addition, the CDC has evaluated a number of screening tools, and you may be interested in their report, which can be accessed here. One commonly-used screening tool is HITS, which you can read about here.

Mandatory Reporting

All states have laws requiring the reporting ofsuspected cases of abuse or neglect of vulnerable populations. The laws vary state by state, but generally cover children, elders, and the disabled, and mandate reporting by people such as physicians and teachers. In many states, other health and education professionals and paraprofessionals are mandatory reporters as well. Most states have laws that prevent disclosure of the identity of the reporter to the alleged perpetrator at the time of the initial report.

Most hospitals have a specific policy about how this should occur in the hospital setting and you should be familiar with your institution’s policy as well as the laws in your state, which should include who to contact, what populations are covered, and whether your identify will be disclosed to the alleged perpetrator after the initial allegation.

Particularly when the patient requires your physical care, getting social services involved early is wise.

The text of the HIPAA regulation can be found at the U.S. Department of Health & Human Services website. It is important to know your state's and institution's regulations in carrying out this law.

You tell the patient that you have been given reason to suspect that her child may be at risk and, therefore, you have had to report your suspicions. You tell her you are also worried about her.

When screening for IPV, it is important to ensure the patient is SAFE by inquiring about the following factors:

SAFE Mnemonic

Stress and safety

Do you feel safe in your relationship?

Afraid or Abused

Has your partner ever threatened you or your children?
Has your partner ever abused you or your children?

Friends and Family

If you were hurt, would your friends or family know?
Would they be able to help you?

Emergency Plan

Do you have a safe place to go in an emergency?
Do you need help in locating a shelter?
Would you like to talk to a counselor about this?

If you suspect intimate partner violence, it is your responsibility as their assigned physician to have a conversation with the suspected victim. If you do not feel qualified to inquire, it is important to consult a case manager or social worker to ensure the suspicions are addressed while the patient is still in the hospital. Most institutions have guidelines regarding instances of suspected IPV. If you do not know these guidelines, you should seek them out.

If the patient discloses IPV, you do not have to handle the situation alone, and most hospitals have people on call to handle these situations.

Since the suspected victim of IPV and/or suspected aggressor is an employee of the hospital, it is even more critical that you adhere to the HIPAA rules on disclosing personal health information.

List of ACS Resources on IPV

List item

	Upon completion of this scenario, you will have assessed a patient for trauma, analyzed the underlying etiology, and made recommendations for remediation.

The patient appears to be having trouble breathing and is grasping her left side in pain.

You are the resident on duty in the ED on Sunday evening when you answer a page from the nurse:

“A woman was just brought into the ED by her husband who said she is in pain and is having trouble breathing after she fell and hit her left side on the coffee table. We have placed her on a stretcher in the trauma room. She says she has pain in her left chest and is short of breath. She is holding her left side and breathing shallowly. She has a temp of 37, a HR 100, BP of 100/60, and a RR of 24. Pulse oximeter reads 92.”

You ask the nurse to place monitors and a large bore IV, and tell her you will be there right away.

The nurse wants to know when you will come to evaluate the patient.

Immediately

Within one hour

Within two hours

Any postoperative/vascular patient with decreased urinary output should be seen immediately.

	Congratulations! You have recognized intimate partner violence (IPV) in a trauma patient while caring for their injuries. You have also learned to assure proper care for a nursing mother and her infant.

You have learned:

To recognize and treat rib fractures complicated by a pneumothorax.
How to respect patients’ right to confidentiality in a sensitive situation.
To recognize signs of intimate partner violence and make recommendations to intervene.
Your obligations to screen suspected cases of IPV in your patients, and your responsibilities as a mandatory reporter.
How to treat nursing mothers in a trauma incident.

Ideally, you should be able to
navigate this case with no red dots
and few yellow dots.

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References	Available
Acute Renal Failure	Click here
Diagnostic Evaluation of Acute Renal Failure	Click here
Indications for Hemodialysis	Click here
Causes of Postoperative Acute Renal Failure	Click here