Annals of Emergency Medicine
Volume 32, Issue 3 , Pages 363-366, September 1998

Assault-Related Injury: What Do We Know, and What Should We Do About It?☆☆☆

Division of Emergency Medicine Department of Surgery University of Colorado Medical School Denver, CO

Article Outline

Abstract 

[Abbott J: Assault-related injury: What do we know, and what should we do about it? Ann Emerg Med September 1998;32:363-366.]

 

See related article, p 341.

The rhetoric concerning domestic violence (DV) and interpersonal injury has reached a fever pitch in the emergency medicine literature, as well as in the lay press. Violence is a serious national problem in our society and appears to be escalating. In the emergency department we are painfully aware of the tangible consequences of the problem. Some of the statistics are stunning—recent studies have indicated that about 50% of women visitors to EDs have experienced violence at the hands of an intimate at some time in their adult life. 1, 2 Up to half of homicides with female victims are committed by male intimates. 3 Other statistics are more questionable; the often-quoted statistic that 25% to 33% of women present to the ED because of DV-related problems is clearly inflated. 2, 4, 5, 6 Those who are passionate about the subject of violence exhort us to “screen” all patients, recognize patterns of injury, report abuse to the police, arrest the “perps,” and have psychiatrists and social workers counsel the patients. Physicians of a more skeptical mindset cite cases in which the issues surrounding violence were not as clear as we would like. They recall alcohol use by both parties in assaults, fights among girlfriends, men injured by their spouses, and the low incidence of acute injury due to DV in their practices. What’s a physician to do in the face of such a politically charged debate?

Research in the field of DV and interpersonal violence has been problematic. Initial methods of diagnosing DV and describing the epidemiology of violence were primitive at best. We are indebted to Stark et al, 4 who in 1981 were the first to highlight the poor (about 5%) documentation rate of DV in chart review. Unfortunately, their retrospective methods blended medical records of patients with documented DV with those of patients who sustained injuries from an unidentified assailant and even troubling cases in which the stated cause of injury did not adequately account for the trauma documented in the chart. This methodology created enormous potential for chart-review bias by reviewers. In addition, Stark and colleagues never considered the possibility that a victim’s assault-related injury might be caused by somebody other than her intimate partner.

Fanslow et al, in this issue of Annals , present a thoughtful and more precise description of the scope of the more general category of “assault-related injuries.” As with other retrospective chart reviews, their study suffers from the problem of incomplete documentation; an unknown number of patients may have gone unrecognized. Even for the subset of patients with identified assaults, chart diagnosis was potentially subject to selection biases by both the treating physician and the chart reviewer, because criteria for “intentional” injury remain murky. But the Fanslow study represents progress, and it highlights some of the lessons that we have learned over the last 15 years.

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WHAT DO WE KNOW? 

1.Interpersonal violence takes many forms. DV is the most common source of assault-related injury, at least in women. In the Fanslow study, 63% of assaults against women were perpetrated by a partner or former partner. But other family members or acquaintances accounted for more than 30% of identified assaults, so we know that other forms of interpersonal violence also occur. Some studies have suggested that physical violence committed by women against men may be as common as that perpetrated by men against women—although women sustain substantially more injuries than men as a result of such acts. 7, 8, 9 Most striking, as the authors note, is that very little of the violence—the results of which we see in the ED—is perpetrated by unknown assailants. In this study only 6% of identified perpetrators were not known by their female victims.

2.Documentation of assaults is poor. Many records are inadequate with regard to assailant history and the “mechanism” of assault-related injury. In fully 50% of cases in the Fanslow study, the alleged assailant and his or her relationship to the patient was not documented in the medical record. Others have decried the failure of emergency physicians to detect and properly record DV-related visits and assault-related mechanisms. 2, 4, 10 Fanslow’s estimate of the level of documentation is probably inflated because the presence of a recorded perpetrator was one method of identifying a patient eligible for their study. How many assaults and assailants were missed completely?

3.Detection of assault-related injury requires history-taking. The myth exists that victims of DV or assault can be identified by patterns of injury, types of complaints, anatomic location of trauma, or various socioeconomic variables—much as we use these clues to decrease or increase our suspicion of other diseases. But we have learned that patterns of injury or trauma to certain body parts do not predict DV with accuracy of any clinical utility. 5 As Fanslow and colleagues demonstrate, even those injuries more closely associated with assault (contusions, ill-defined signs and symptoms, internal injuries, trauma about the face) were associated with intentional injury in less than half the cases. Practitioner bias may have enhanced the association of contusions and facial injuries as intentional, if those injuries led the practitioners to suspect assault and ask the patient. As we and others have noted, patients with nontraumatic complaints also present to the ED with problems arising from the stresses of DV or other forms of interpersonal violence. 2, 6 Unfortunately, the type of somatic complaint is no more helpful than the pattern of injury; it has never been demonstrated that such complaints as headache, sleeplessness, and abdominal pain have predictive value or clinical utility. Demographic criteria are equally useless; DV is not just a disease of homeless, urban, black, or alcoholic women. 8, 9, 11 Although few would argue that rates of victimization are equal across the demographic spectrum, DV is universal enough that the clinician cannot delicately fail to ask any “subgroup” of patients. Perhaps a structured chart would help us document the alleged perpetrators and mechanisms of assault-related injury. Somehow, some way, we must improve the inadequate passive-voice note seen so commonly: “Hit by bat. Face laceration sutured.”

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WHAT DO WE NEED TO KNOW? 

Although we have learned a great deal about assault-related injuries, there is much that we still do not know:

•What is the epidemiology of assault-related injury in men?

•Are any medical symptoms associated in a clinically useful way with DV?

•How do drugs and alcohol work as cofactors?

•Are mandatory-reporting laws helpful?

•Is there a practical way ED personnel can assess patient safety?

•What kind of interventions help our patients avoid future assaults?

Physicians who take histories, ask questions, and listen to the stories of victims of violence realize that victims live in a complex world that is often different from our own. Violence is clearly a part of the history or current circumstances of many ED patients. Many of these victims are thoughtful people who must make difficult choices that defy the kind of snap decisions that are common in ED practice. They may be so “combat-habituated” that differentiating the victim from the assailant is difficult. The pictures of our patients’ worlds that we glimpse in the ED are not simple ones. When we combine that with our lack of knowledge about how to make a difference, it becomes hard to know where our responsibilities begin and end.

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WHAT IS THE EMERGENCY PHYSICIAN’S RESPONSIBILITY IN CASES OF ASSAULT-RELATED INJURY? 

In a busy ED we can screen for risky health behaviors of many types. We do not, however, have the kind of longitudinal physician-patient relationship needed to build trust and solve complex problems. What, then, is our responsibility in regard to assault-related injury?

•Our most clear responsibility is a legal one. In 45 states, assault-related injury is reportable. 12 As with penetrating trauma caused by stab wounds or gunshot wounds, DV and other interpersonal traumas usually require police notification and filing of a report, even if the victim does not press charges.

•We have a responsibility to take an accurate and complete history of our patients’ problem. Without detection and documentation, we cannot measure the toll of violence any more than we can measure the effect of alcohol on our patients’ problems. We recognize that alcohol intoxication and dependence are contributors to motor vehicle crashes, falls, assaults, and medical illnesses; our understanding of the cause of a patient’s laceration or fracture or abdominal pain would be incomplete without information about drinking. In cases of assault-related injury, the first step is to recognize the cause of the injury and “name” it—for the patient, for ourselves, and for society. How can we improve on studies such as that of Fanslow et al without doing a better job of documenting the problem? Some physicians prefer to write “ alleged assault,” recognizing that we do not have the tools or the complete story to make a legal judgment. But we can and must meet our responsibility to document an adequate history.

Beyond this, our requirements are less clear. Somatic complaints of headache or abdominal pain may also be related to the stress of interpersonal violence. We are certainly more intellectually satisfied to detect this than to be left with “unknown origin of pain” as our discharge diagnosis. Particularly with medical complaints, it may or may not be possible to detect the seemingly unrelated social precipitant of an acute presentation. The sheer busy-ness of the ED and our own interests and abilities may dictate how much time we can take to hear our patients’ stories. To expect to make the diagnosis of a “context” of violence or a history of past violence in our patients as a standard of practice seems to be beyond the scope of what we can require reasonably of ourselves in the ED.

Where does this leave the issue of universal “screening”? Fanslow et al recommend that health care providers routinely screen patients for a history of assault. I and many others authors in the field of DV confess to being less than precise with our use of the term “screening” in relation to assault or DV. To “screen” implies detecting a condition before it has symptoms—as we would with hypertension or diabetes; in these cases, our purpose would be to intervene and prevent the progression of disease. But our patients experiencing violence have symptoms. What we really need is just to take an adequate history.

Right now we lack evidence to support universal screening. Studies in which populations of ED patients are screened have found a 2% to 5% incidence of acute presentations, at least for domestic violence. 2, 5, 6, 8 Fanslow et al reported that 9% of injuries in the ED were the result of assault. The lifetime prevalence of DV, at least in women, reaches 50% in many of the same ED studies. 2, 5, 6, 8 It is unclear, however, whether screening every patient to detect past DV or assault is useful—that is, will it identify a group of patients in whom we can prevent future violence or injury. What do we have to offer in the way of interventions, if and when we detect it? We need better answers.

Assault-related injury is a common cause of trauma seen in the ED—probably more common than you or I know. The presentations may be occult. We must become better at asking injured patients what happened and at developing strategies to help them prevent future episodes of victimization. The best way to start is to take and document an adequate history on every injured patient—male or female.

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References 

  1. Furbee PM, Sikora R, Williams JM, et al.  Comparison of domestic violence screening methods: A pilot study. Ann Emerg Med. 1998;31:495–501
  2. Abbott J, Johnson R, Koziol-McLain J, et al.  Domestic violence against women: Incidence and prevalence in an emergency department population. JAMA. 1995;273:1763–1767
  3. Arbuckle J, Olson L, Howard M, et al.  Safe at home? Domestic violence and other homicides among women in New Mexico. Ann Emerg Med. 1996;27:210–215
  4. Stark E, Flitcraft A, Frazier W. Wife abuse in the medical setting: An introduction for health personnel. Washington DC: Office of Domestic Violence; 1981;
  5. Muelleman RL, Lenaghan PA, Pakieser RA. Battered women: Injury locations and types. Ann Emerg Med. 1996;28:486–492
  6. Olson L, Anctil C, Fullerton L, et al.  Increasing emergency physician recognition of domestic violence. Ann Emerg Med. 1996;27:741–746
  7. Ernst AE, Nick TG, Weiss SJ, et al.  Domestic violence in an inner-city ED. Ann Emerg Med. 1997;30:190–197
  8. Forjuoh SN, Kinnane JM, Coben JH, et al.  Victimization from physical violence in Pennsylvania: Prevalence and health care use. Acad Emerg Med. 1997;4:1052–1658
  9. Centers for Disease Control and Prevention . Physical violence and injuries in intimate relationships—New York, behavioral risk factor surveillance system, 1994. MMWR Morbid Mortal Wkly Rep. 1996;45:765–768
  10. Schwartz RJ, Boisoneau D, Jacobs LM. The quantity of cause-of-injury information documented on the medical record: An appeal for injury prevention. Acad Emerg Med. 1995;2:98–103
  11. Kyriacou DN, McCabe F, Anglin D, et al.  Emergency department—based study of risk factors for acute injury from domestic violence against women. Ann Emerg Med. 1998;31:502–506
  12. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence: Do they promote patient well-being?. JAMA. 1995;273:1781–1787

☆ Reprint no. 47/1/92113

☆☆ Reprints not available from the author.

PII: S0196-0644(98)70015-0

Annals of Emergency Medicine
Volume 32, Issue 3 , Pages 363-366, September 1998

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