Domestic abuse victims undergo more surgeries
Domestic abuse victims undergo more surgeries
Help staff ID, aid victims with subtle symptoms
The patient kept coming to Debra A. Zillmer, MD, an orthopedic surgeon in LaCrosse, WI, with persistent tennis elbow. "We tried everything to treat the elbow, but the pain was unrelenting," says Zillmer.
She reviewed the patient’s chart and noticed several emergency department visits as well as repeated visits to physicians in the patient’s medical history. "At her next visit, I asked her what else was going on in her life," she says. After discovering that the woman was in an abusive situation, Zillmer offered referrals to agencies that could help her. Zillmer says the woman used the resources provided to confront her problems at home, and her elbow pain dramatically improved.
Surgeons and same-day surgery staff do see victims of domestic abuse for procedures that include surgeries to diagnose unexplained pain or treat chronic pain, says Debra P. Hastings, CNR, MSRN, a New Hampshire same-day surgery nurse.
Hastings reviewed the medical charts of 110 women older than age 18 who were seen in a primary care practice and found that women who experienced domestic abuse were twice as likely to undergo major surgeries as women with no history of domestic abuse. Hasting’s study, co-authored by Glenda Kaufman Kantor, PhD, research professor at the University of New Hampshire in Durham, NH, was presented at the recent National Conference on Health Care and Domestic Violence sponsored by the Family Violence Prevention Fund (FUND) in San Francisco.
"For this study, major surgery was defined as any exploratory laparoscopy, knee surgery, back surgery, abdominal surgery, thoracic surgery, pelvic procedures, or reconstruction," says Hastings.
Minor surgeries included dilation and curettage, dental extractions, and nasal or ophthalmic surgeries. "There were no significant differences in the number of minor surgeries between the group of women with history of domestic abuse vs. women without a history of domestic abuse," she says.
Although most people are aware of the traumatic injuries associated with domestic abuse that are usually seen in emergency departments, most symptoms are more subtle, says Zillmer. "The most important thing that those of us in a surgery setting can do is to be observant," she says. "We have an opportunity to notice signs of abuse on a person’s trunk or limbs that may normally be covered by clothing."
The most important role that physicians and same-day surgery program staff members can play is to have a high level of awareness of the subtle symptoms of domestic abuse, Zillmer says.
First contact is crucial
The first contact with a potential victim of domestic abuse is crucial, so it is important that your staff and physicians know how to identify victims and how to refer victims to resources, says Sherrie Munson, MSW, department manager of WomanKind, the domestic violence program at Fairview Health System in Minneapolis.
Policies and procedures in all Fairview departments, including ambulatory surgery, outline specific questions and suggest how to word the questions so the patient is more open to answer, says Munson.
"We ask all patients about domestic abuse as part of our preadmission procedure, and we tell them that we ask these questions of all patients so they don’t become defensive," she says. "We ask if they are now in or have ever been in a relationship where they have been abused, and we ask if they would like to talk to someone if their responses are positive."
Men and women are privately asked the same questions because both groups can experience abuse, Munson points out.
While Fairview has staff dedicated to counseling and referring victims of domestic abuse, smaller surgery programs can set up a program without adding staff, says Lisa James, senior program specialist at FUND, an organization that focuses on domestic violence education, prevention, and public policy reform.
Include questions related to domestic violence in all routine preadmission visits, and have a resource folder available for the preadmission nurse, suggests James. The resource folder should have the names of staff members who are identified as domestic violence counselors or liaisons, or names and phone numbers of local community agencies, she says.
Work with local agencies to develop a method of referral and follow-up if the surgery program staff does have a patient who asks for help, she adds.
Your surgery program should train staff about how to ask questions and how to handle referrals and follow-ups. Set up policies that fit your center, suggests James. "Don’t set up an complicated procedure that will be hard to follow and staff if you are a small program."
Take advantage of existing resources offered by local agencies as well as organizations such as FUND, James suggests. "FUND offers examples of policies and guidelines, questions to ask, posters, reference cards, and technical assistance for setting up domestic abuse referral programs," she says.
When developing procedures to respond to reports or evidence of domestic abuse, remember that the safety of the patient is paramount, says Hastings. "There is no hospital stay to protect them, so we need to make sure we don’t send them back into a dangerous situation," she adds.
Ask the patient if he or she feels safe going home, says Zillmer. If the response is negative, suggest some resources that can help the patient find a safe place, she adds.
Physicians or the staff nurses may feel frustrated because they can’t fix the problem for their patient themselves, but they play a critical role, says James. "Even if the patient is referred to someone else for help, the physician or same-day surgery nurse may be the first person to ever give the victim an opportunity to ask for help."
Recommended reading
• Zillmer DA. Domestic violence: The role of the orthopaedic surgeon in identification and treatment. J Am Acad Orthop Surg 2000; 8:91-96.
• Short LM, Johnson D, Osattin A. Recommended components of health care provider training programs on intimate partner violence. Am J Prev Med 1998; 14:283-288.
• Flitcraft A. (ed). Diagnostic and Treatment Guidelines on Domestic Violence. Chicago: American Medical Association; 1992.
For more information about same-day surgery staff’s role in identification of domestic abuse, contact:
• Debra A. Zillmer, MD, Orthopedic Department, Gunderson Lutheran Medical Center, 1836 South Ave., La Crosse, WI 54601. Telephone: (608) 782-7300. E-mail: [email protected].
• Debra P. Hastings, CNOR, MSRN, One Wild Acres Road, Gilford, NH 03246. Telephone: (603) 524-5995. Fax: (603) 524-3549. E-mail: [email protected].
• Sherrie Munson, MSW, Department Manager, WomanKind, Fairview Health System, Fairview University Medical Center, 2450 Riverside Ave., Minneapolis, MN 55454. E-mail: [email protected].
• Lisa James, Senior Program Specialist, Family Violence Prevention Fund, 383 Rhode Island St., Suite 304, San Francisco, CA 94103-5137. Telephone: (415) 252-8900 ext. 27. Fax: (415) 252-8991.
For resource information about setting up a domestic violence identification and referral program, contact:
• Family Violence Prevention Fund, 383 Rhode Island St., Suite 304, San Francisco, CA 94103-5137. Telephone: (888) 792-2873 (Rx-ABUSE) or (415) 252-8900. Fax: (415) 252-8991. Web: www.fvpf.org/health. A number of information packets are free, and FUND also offers training and reference materials for a fee.
• National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Mailstop K65, 4770 Buford Highway N.E., Atlanta, GA 30341-3724. Telephone: (770) 488-1506. Fax: (770) 488-1667. Web: www.cdc.gov/ncipc. A free document titled Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Program for Health Care Providers can be requested by telephone, fax, or e-mail through the Web site.
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