1. Physical Exam in Survivors of Torture Laurie Bay, MD Jeremy Hess, MD, MPH

2. Overview History taking Approach to exam Findings –General –Related to specific methods of torture Documentation

3. History Taking Obtain complete medical history –Include injuries and scars present before torture. –Document any previous medical conditions, especially those exacerbated by torture or subsequent detention.

4. History Taking Obtain complete torture history –Ask open-ended questions, allow patient to tell in narrative fashion (make notes). –After narrative is finished ask specifics of torture Description of devices used Body positions and methods of restraint Descriptions of acute and chronic wounds Any medical treatment during or after torture Symptoms experienced now that patient relates to their torture

5. History Taking Ask about acute symptoms after torture –Bleeding, bruising, swelling, open wounds, infection, lacerations, fractures, pain, burns, chemical injuries –Ask about any skin changes or problems the patient can identify that are due to these specific wounds. –Ask how long wounds took to heal, if they were infected, and if treatment was received and what type

6. History Taking Ask about chronic symptoms –Many are psychosomatic, but some may be due to specific injuries Headache Back pain Sexual dysfunction GI symptoms Muscle pain

8. Approaching the Exam Many times physicians will have been involved in previous torture Ask patient (if possible) which gender doctor he would prefer If opposite gender, ensure chaperone present (if possible and patient doesn’t object) Approach subject by telling patient exactly what you are going to do and asking permission Tell patient directly that they are in charge and if they want to stop or delay any portion of the examination they can do so at any time. Ensure privacy and presence of translator (if needed and patient does not object)

9. Exam Findings Most of what is seen in US is chronic sequelae of torture Skin and musculoskeletal examinations most important. Huge topic – read Examining Asylum Seekers from PHR for details (also available free on web)

10. Exam Findings Be detailed – look at entire body and at every place patient states they were injured (document as you go along) Explain every test before you do it Check vital signs, heart, lung, and abdominal exams and document findings (usually normal, rare for patient to have access to sophisticated exam techniques like CT)

11. Specific Findings: Binding Ligatures: look for linear marks around wrists or ankles due to prolonged application. Torturers in many countries have learned to use soft restraints to reduce scarring

12. Specific Findings: Beatings Acutely see bruising in pattern of object used Chronically see scarring: keloid formation, hypo or hyperpigmentation Document findings suggestive of deliberate cause: asymmetrical scars, scars on areas not usually scarred, diffuse spread of scarring

13. Specific Findings: Burning Will produce scars in shape of object used –Cigarettes –Pokers –Electrodes

14. Specific Findings: Electric Shock Electrodes attached commonly to hands, feet, nipples, mouth, genitals All areas in between contract tetanically and may cause damage like fractures or dislocations Scars from electrodes often small: 1-3mm diameter hyperpigmented lesions

15. Specific Findings: Falanga Also called bastinado and falaka: beating of the soles of the feet Chronic problems: sequelae of compartment syndrome, crushed footpads with difficulty walking, rigid scarring, rupture of plantar aponeurosis –Squeezing tarsal bones or flexing great toe causes pain –In normal feet will feel flexing of plantar aponeurosis at around 20 degrees, higher values may indicate rupture

16. Specific Findings: Suspension Injuries are musculoskeletal and neurologic: decreased range of motion and weakness, ligamental tears and joint instability, sensory loss

17. Specific Findings: Sexual Torture Begins with forced nudity and extends to forced sexual acts, often threat of loss of status and breaking of cultural taboos Acutely, the same as a rape exam Rare to find chronic visible wounds given extensive healing ability of genitalia. May need CT scan to document forced sterilization or surgery Difficult examination with extensive support needed for patient

20. Other Methods Many methods may leave no findings

21. Documentation Tell patient you will be making notes, obtain their permission In affidavit use medical terms (may explain them in parentheses) Use terms such as “consistent with,” “highly consistent with,” and “pathognomonic for” -- remember you aren’t saying what happened, you are stating that their signs and symptoms are consistent with the history they give

22. Body Diagrams

23. A Picture Speaks a Thousand Words

24. Recommendations You can recommend treatment but not provide it. If you provide treatment your relationship changes and you are an advocate, not an expert. Be impartial no matter how you feel. Show empathy but don’t take your patient’s side (“That sounds difficult,” not “It’s horrible that they did this to you.”) Stanley Brodsky’s Testifying in Court: Guidelines and Maxims for the Expert Witness.