CASE

A 25-year-old woman with a past medical history of anxiety presents to the emergency department with right sided chest pain. She describes approximately two hours prior to arrival, she tripped in the bathroom while bathing her child, striking the right side of her chest on the tub. She denies head strike or loss of consciousness, shortness of breath or abdominal pain. She denies any other specific complaints. Her physical exam demonstrates unremarkable vital signs in a patient appearing stated age, without acute distress. Primary survey including airway, breathing, and circulation (ABCs) is unremarkable. Secondary survey is significant for mild tenderness to right lateral chest wall with ecchymosis in the same area. There is no crepitus. Additionally, the patient has a healing ecchymosis to the left thigh.  A chest x-ray was obtained which demonstrated an acute fracture of the right fourth rib without associated pneumothorax.  

DIAGNOSIS

Acute right 4th rib fracture

DISCUSSION

As emergency medicine physicians, we are trained to manage traumatic injuries and stabilize trauma patients.  Ingrained in our minds are the differentials for chest trauma and the possible complications associated with these injuries. This discussion is not about the management of a trauma patient, nor is it about the management of rib fractures. It is about domestic violence. 

Our patient didn’t hit her chest on a tub. She was punched by her fiancé. This was her third visit this year for “accidents.” Domestic violence is obvious when a person comes into the trauma bay stabbed or thrown down a flight of stairs. How about our patients with less obvious injuries? Or frequent, seemingly small injuries? Do we think of domestic violence then? 

Amongst medical and social organizations there is not one concrete definition of domestic violence.  One of the most succinct definitions comes from the Canadian government, “any form of abuse, mistreatment or neglect that a child or adult experiences from a family member, or from someone with whom they have an intimate relationship.” [2] Domestic violence can be experienced at any age. The most frequently observed forms of domestic violence are child abuse and neglect (CAN), intimate partner violence (IPV) and elder abuse and neglect (EAN). All types of abuse can manifest as emotional, physical, economic/financial, intentional or unintentional neglect and/or sexual abuse. [3]

According to the CDC National Intimate Partner and Sexual Violence Survey, 20 people per minute are physically abused by an intimate partner in the United States. This equates to approximately 10 million men and women experiencing abuse annually. For children, it is estimated that at least 1 in 7 children have experienced child abuse and/or neglect in the past year. The elderly are difficult to estimate but it is thought that 1 in 10 people aged 60 and older have experienced a form of elder abuse. [7, 9]

These numbers are simply estimates, the true extent is unknown. Most people don’t seek help. Amongst those who do, healthcare professionals, and especially emergency medicine providers, are usually the first individuals with an opportunity to identify domestic violence and provide help. [3] As emergency providers, what can we do to increase our chances of identifying and treating this disease?

Firstly, we need to educate ourselves on the prevalence of domestic violence in our communities and maintain a high suspicion in our patients. Particularly, providers must be able to recognize when patients arrive to the emergency department with common injury patterns. 

This discussion of common injury will exclude pediatrics, as injury patterns including specific fractures, particular bruising and burns are seen as pathognomonic for non-accidental trauma. Common injury patterns of domestic violence in adults and the elderly are much more difficult to discern from accidental trauma. The clinician must have high suspicion when patients present with: facial/head injuries, multiple injuries or, defensive wounds of upper extremities. [3] In the elderly, pressure wounds and poor hygiene are signs of neglect. [1]

Secondly, we need to ask about domestic violence when concerned; ideally, in a nonjudgmental, caring and supportive manner.  A possible screening template is the SAFE pneumonic. [4]

STRESS/SAFETY: Do you feel safe in your relationship or where you live?

Afraid/Abused: Have you been physically hurt or threatened by your partner/family?

Friends/Family: Are your friends and family aware of what is going on?

Emergency: Do you have a safe place to go in an emergency?

Lastly, we need to be aware of resources on the state and national level. Nationwide, there are hotlines offering 24/7 assistance. The National Domestic Violence Hotline 1-800-799-7233. [5] The National Organization for Victim Assistance 1-800-879-6682. [6] Locally, in Rhode Island there is the Rhode Island Coalition Against Domestic Violence 24/7 helpline 1-800-494-8100. [8] Many local police departments throughout the country have a designated officer as a domestic violence liaison who can assist victims with resources in their area. And of course, patients can always come back to the emergency department if they are unsafe. 

CASE RESOLUTION

Our patient disclosed that it wasn’t an accident. She is not ready to leave her partner or press charges. She was willing to take resources from our social worker. She denied any sexual violence. She has a safe place to stay tonight, with her parents. Her daughter was at her parents and wasn’t present for the abuse, nor has her partner ever hurt her daughter. She was discharged with supportive care for her rib fracture and resources provided that she can utilize as needed. 

TAKE-AWAYS

• Domestic violence is prevalent all over the country and our patients are victims

• THINK about domestic violence in our patients 

• Common injury patterns include the facial fractures, multiple injuries and defensive wounds

• Screen for domestic violence through pneumonic SAFE

• Provide resources both locally and nationally 

AUTHOR: Katie Miller, MD is a fourth-year emergency medicine resident at Brown University/Rhode Island Hospital.

FACULTY REVIEWER: Victoria Leytin, M.D. is an attending physician at Brown Emergency Medicine

REFERENCES

1. “Elder Abuse |Violence Prevention |Injury Center |CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 2 June 2021, https://www.cdc.gov/violenceprevention/elderabuse/index.html. 

2. Government of Canada, Department of Justice. “Family Violence.” Government of Canada, Department of Justice, Electronic Communications, 7 Mar. 2022, https://www.justice.gc.ca/eng/cj-jp/fv-vf/index.html. 

3. Heucker, MR, et al. “Domestic Violence - Statpearls - NCBI Bookshelf.” National Center for Biotechnology Information, Feb. 2022, https://www.ncbi.nlm.nih.gov/books/NBK499891/. 

4. Mary Louise C. Ashur, MD. “Asking about Domestic Violence: Safe Questions.” JAMA, JAMA Network, 12 May 1993, https://jamanetwork.com/journals/jama/fullarticle/405953. 

5. “National Domestic Violence Hotline.” The Hotline, 26 Feb. 2022, https://www.thehotline.org/. 

6. “National Organization for Victims Assistance .” NOVA, 2022, https://www.trynova.org/. 

7. “Preventing Intimate Partner Violence |Violence Prevention|injury Center|CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 2 Nov. 2021, https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html. 

8. “RI Coalition Against Domestic Violence.” Rhode Island Coalition Against Domestic Violence, 2022, http://www.ricadv.org/en/. 

9. Smith, Sharon G, et al. “2015 NISVS Data Brief|violence Prevention|injury Center|CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 19 July 2021, https://www.cdc.gov/violenceprevention/datasources/nisvs/2015NISVSdatabrief.html.