Today's News

Saturday, March 3, 2001

Doctors should be on alert for signs of abuse

Broken bones and fractures can indicate physical abuse, and doctors sensitive to the issue may end up saving a patient from worse injuries. This was the message of a panel at a symposium Wednesday on physical abuse as a cause of injury.

Victims of abuse showing up with orthopaedic injuries include children and adults, said Mininder S. Kocher, MD, a pediatric orthopaedic surgeon at Children's Hospital in Boston, and one of the symposium speakers.

"They key to management is recognition," he said. Don't just treat the fracture, it isn't the issue. The issue is why did it happen."

Other panel members included Debra A. Zillmer, MD, orthepaedic surgeon at Gundersen Lutheran Medical Center, in La Crosse, Wis.; Susan Hadley, MPH, health care consultant and founder of "WomanKind," a Minneapolis-based program educating health care staff on family abuse; and Ariella Hyman, JD, staff attorney with Bay Area Legal Aid in San Francisco.

While there isn't one predominate kind of injury in children that signals abuse, there are some red flags, Dr. Kocher said.

These include metaphyseal corner fractures, posterolateral rib fractures, and multiple fractures in various stages of healing. "Injuries not common in accidents," he said.

If abuse is suspected in a child, orthopaedists should work closely with other doctors and hospital staff, from social workers to pediatricians, Dr. Kocher said.

They should be familiar with legal reporting requirements, and community resources dealing with child abuse, from social services to legal advice. "The management of child abuse really involves a team approach."

Victims of adult domestic or family physical abuse are unlikely to talk openly about the problem, including to doctors treating their injuries, panelists said. The overwhelming majority of victims are women, but about 10 percent are men.

Even when patients don't open up, just knowing a doctor cares or is willing to listen might prompt a victim to get help outside the clinic or later, Hadley said. "You've passed a message to that patient that you get it, and this is a safe place to return."

A few steps might help patients feel safe with a doctor, panelists said. "Sometimes it's right there in front of you and you have to ask the right questions," Dr. Zillmer said.

Start with careful screening, she said.

Signs that might trigger a problem include overt bruises; a history of repeat visits to emergency rooms; explanations that don't match injuries; a depressed, fearful or anxious manner; or always letting a spouse or partner answer questions. "All female trauma and chronic pain patients should be evaluated," Dr. Zillmer said.

Doctors should be caring, nonjudgmental, and make it clear to patients they don't deserve to be abused and they are not responsible for how they've been treated, Dr. Zillmer said. "Your words, even a few words, can actually have a powerful affect."

Patients should be interviewed privately, away from other family members.

Medical offices should be stocked with posters and brochures with referral numbers for abuse victims, places where patients can sneak a look and quickly scribble a number, she said.

Doctors too, should know the resources in their community, places to refer patients for help, or designate a hospital or clinic staff person as an abuse expert. "A resource person available to spend time with a patient," Dr. Zillmer said.

Attorney Hyman used the acronym RADAR as a guide for doctors concerned about abuse, standing for: routinely inquire; provide assurances; document; assess a patient's safety; provide resources and referrals.

In particular, patients often need help with the legal issues around abuse, and many don't feel comfortable talking to police, she said.

"Refer your patient to someone in the community who can help them navigate the community justice system."

Careful medical documentation of suspected abuse is critical because it might end up as evidence in court, Hyman said. She recommends taking pictures, preserving evidence, noting discrepancies between injuries and explanations of injuries and including descriptions, dates and locations of violence, using patient's words when possible.

Doctors also need help navigating the family abuse legal system, panelists said.

Legal reporting requirements are extremely complicated and vary from state to state. Doctors should contact their state medical associations or social workers at their hospital to learn their specific reporting requirements.

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Last modified 03/March/2001 by IS