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Domestic & Sexual Violence: A Health & Safety Issue -One Health Region’s Strategy to Reduce Risk Presenter: Linda McCracken RN Sexual Assault Nurse Examiner.

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Presentation on theme: "Domestic & Sexual Violence: A Health & Safety Issue -One Health Region’s Strategy to Reduce Risk Presenter: Linda McCracken RN Sexual Assault Nurse Examiner."— Presentation transcript:

1 Domestic & Sexual Violence: A Health & Safety Issue -One Health Region’s Strategy to Reduce Risk Presenter: Linda McCracken RN Sexual Assault Nurse Examiner AHS-Domestic Violence Program Coordinator

2 2 The Essential Message Overview of associated adverse health conditions, & potentially lethal outcomes related to Domestic & Sexual Violence/Abuse that often go undetected when no one raises “the question” What denotes a medical emergency Opportunities do exist for primary prevention

3 3 What’s in it for you? After this presentation, you’ll have a better understanding of: you’ll have a better understanding of: Injury recognition & chronic illness in the context of abuse What to ask & or look for from a medical standpoint How collaboration can enhance response to this public health issue

4 Relevance *AB shelters find that the health effects of their clients: Are varied Often severe Have gone on for many years without resolution ACWS-Position Statement Responding to the Health Needs of Women & Children involved in Domestic Violence

5 Issues from a medical perspective What are the most common health challenges experienced by clients you see? What concerns you the most? What about their children?

6 Long Term Effects of Stress Cardiovascular system Gastrointestinal system

7 7 Stress & The Immune System Stress and Disease: New Perspectives By Harrison Wein, Ph.D.

8 8 Consistent high level of Cortisol Is Toxic To Brain Development The stress response system in the brain is fully formed at birth but the cerebral cortex is not Babies can experience stress but are highly dependent on caregiver to manage stress Chronic stress can impair the developing brain

9 Genetic Risk Factors Emerging Earlier …and harder to control Key message for Health: Many don’t associate their health problems with abuse and therefore, may not disclose abuse.

10 10 Inseparable! The Mind/Body: Inseparable! Hx of sexual abuse: 2.8 times more likely to have a functional bowel disorder, chronic abdominal pain, Irritable Bowel Syndrome Irritable Bowel Syndrome Talley, N.J., Helgeson S, insmeister AR. Are sexual & physical abuse linked to functional gastrointestinal disorders Gastroenterology 1992; 102:A52 Vulnerable population + cultural beliefs Some believed that the stress in the relationship caused the cancer

11 11 Chronic or recurrent headaches Temporomandibular disorder Musculoskeletal complaints Chronic back pains …but is it always all ‘just in their head’? Or are they related to old injuries, most often recurrent and untreated

12 12 Many injuries of physical abuse are focused on the head & face Evidence of pulled hair Photos used with permission: Domestic Conflict Unit DV Presentation-CPS Injury Patterns Among Female Trauma Patients: Recognizing Intentional Injury Crandall ML, Nathens AB, Rivara FP J Trauma. 2004;57:42-45 The “Shut-up” Blow

13 Mild Traumatic Brain Injury *L.O.C. not required One of the most undiagnosed, prevalent, and serious consequences of IPV “Subtle Concussions”/ Soft Neuro Signs“Subtle Concussions”/ Soft Neuro Signs “chronic headaches” Second Impact Syndrome RiskSecond Impact Syndrome Risk

14 14 Variations of “amnesia” or “seizures.” Despite an expectation that full recovery should occur within 12 weeks of the MTBI (Belanger et al., 2005) a sizable minority continue to experience persistent symptoms (Wood, 2004) and have difficulty with returning to work, school or play. (Bazarian, Blyth, Mookerjee, He, & McDermott, 2010). Cognitive indicators of MTBI, such as, “feeling slowed down” or “mentally foggy” or “difficulty concentrating”

15 Intimate Partner Sexual Violence common expression of domestic violence (esp. during reproductive yrs) likely to be raped may times physical violence also possible Reproductive Coercion

16 16 …In IPSV Genital injuries: vaginal stretching, lacerations (tears) Miscarriages, still births *Anal injuries Pelvic pain Frequent vaginal and urinary tract infections, painful intercourse Recurrent STI’s HIV/AIDSHIV/AIDS Hepatitis BHepatitis B Substance Abuse Public Health Issues “No negotiation of condom use” Jacqueline Campbell

17 What denotes medical urgency in the context of DV Airway Breathing Circulation ‘Disability’ …Level of Consciousness Suicide Ideation

18 18 Strangulation-a Case of Medical Urgency Photo used with permission: Domestic Conflict Unit DV- CPS

19 “It hurts to swallow” **Victims may have no visible injuries -but underlying injuries may kill the victim up to 36 or more hrs later due to de-compensation of the injured structures

20 20 Chrisler & Ferguson, 2006 More than of victims are strangled at least once { the average is 5.3 times per victim } Injuries identified in non-fatal strangulation cases were similar to injuries found in fatal IPV strangulation assaults (Hawley et al, 2001) under-assessed & underappreciated by health care (Sheridan & Nash, 2007)


22 22 If they don’t tell…“Ask” Hoarseness or complete loss of voice Swallowing changes- pain, difficulty, drooling Breathing changes/difficulty, coughing Headache, weakness Passed out ?, loss of memory since assault Nausea or vomiting Mental changes, restlessness, and combativeness Urinary or bowel incontinence during event Seek Medical Attention Immediately !

23 23 Strategies to Reduce Risk Opportunities do exist to incorporate questions about Domestic Violence into routine patient encounters to determine points of intervention with the goal of preventing lethal outcomes

24 24 Nearly one in three women who presented to emergency departments (34.8%) or academic clinics (31.4%) reported severe physical abuse or forced sexual activity in their lifetime One in seven (13.7%) women in the emergency departments reported severe physical abuse in the past year Alice Kramer, RN, MS* Darcy Lorenzon, MS and George Mueller, PhD Aurora Health Care, Milwaukee, Wisconsin Women’s Health Issues 14 (2004) 19–29 One study on “Prevalence” *Accessing Health Care

25 25 ‘+ disclosure’ Top 10 Diagnostic Codes with ‘+ disclosure’ of DV when asked Source: Kelly Nelson, CHIM Health Information Analyst, Health Information Reporting Data Integration, Measurement & Reporting Alberta Health Services - Calgary One Site’s : Emergency Department Data 2008/09 Adjustment disorders Depressive episode, unspecified Examination and observation following alleged rape and seduction Other symptoms and signs involving emotional state Physical abuse Other and unspecified abdominal pain Threatened abortion, unspecified as to episode of care, or not applicable Acute pancreatitis, unspecified Mental and behavioural disorders due to use of alcohol, acute intoxication Mental and behavioural disorders due to use of alcohol, dependence syndrome

26 26 Part of Assessment * at some point during their stay We know that violence and the threat of violence in the home is a concern for many people and can directly affect their health. Abuse can take many forms: physical, emotional, sexual, financial or neglect. We routinely ask all patients and parents about maltreatment or violence in their lives. Is this a concern for you or your child(ren) in any way? Awareness/ planting the seed Education- providing explanation Why we’re asking you Risks to kids when exposed to DV

27 Is it “Screening”? Different from most other health care screening interventions Not unaware Not asymptomatic Violence is not a mere risk factor awaiting identification …getting a ‘yes’ or ‘no’ is not our goal Taken from: Intimate partner Violence Consensus Statement Society of Obstetricians and Gynaecologists of Canada (SOGC) April JOGC 2005 pgs. 365-388

28 28 “not our job to rescue” Supportive not curative Validate their experience Provide OptionsFind out what they wish to do … Provide Options Try to ascertain their level of risk for serious harm “CONNECT” “CONNECT” them with resources

29 29 *CONNECT *Rural Referral Assistance Available Single Point Access Enhanced information and referral For victims, their families &/or the professionals that are concerned “ a shelter without walls” Deb Tomlinson, Project Manager CONNECT * Also Available for Consultation 24/7

30 30 Age/Gender 20-something yr old Female- presented to 2 sites over course of 3 yrs *6 of those visits at same site Date Presented Coded Diagnosis ?Asked & Response June 1.Injury that required surgical intervention and hospital stay 2.Physical abuse 3.Maltreatment by spouse during unspecified activity & place of occurrence 4.Pregnancy State “YES” January 1.UTI 2.Unspec. Abdominal Pain Blank November 1.Panic Disorder Blank October- (visits 2 & 3) 1.Cellulitis Upper Limb + IV Therapy Both visits- Blank October (visit 1) 1.Burns-Wrist & Hand- Fire Blank June 1.# Multi Site- Metacarpals 2.Assault Blank

31 31 …some words of wisdom from a survivor “I really think that it’s the compassion, the asking of the question, the referral which can happen in a matter of minutes, which can be the hinge, the gateway to the way out” Excerpt from “The Voices of Survivor Documentary” “I know it saved my life” words of a patient seen in the Strathmore Emergency Department

32 Closing Comments for Reflection: Client-Centered Evolution of Response What additional resources would help your client address their medical needs in your community? Is there opportunity for a more collaborative response that involves all designations & disciplines? Do “turf issues” get in the way?Do “turf issues” get in the way?

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