Recognizing victims of domestic violence

Clinicians should trust their intuition when a patient's injuries don't match up with their story.
Clinicians should trust their intuition when a patient's injuries don't match up with their story.

I recently had a patient who presented to the emergency department with the chief complaint of a head injury. The patient explained that she had bruising to her face and a bad headache after she was hit in the eye by a dog bone. This was an unusual story, but she went into vivid detail about how the dog bone hit her, what time it happened, and where the event occurred. She said that the injury was three hours old.

“That bruising looks older,” I thought – but, I'd never dealt with a patient that had been hit by a dog bone before. I continued with the exam, and because the patient was complaining of a severe headache, ordered a CT scan.

I didn't think any more of my patient or her story until later – I came back to tell her that the CT scan was negative and was surprised to find the patient, now accompanied by her very concerned mother and father,  hysterically sobbing. It wasn't until her parents requested information on how to file a police report and asked for domestic violence resources that it became clear what was really going on. My heart dropped; my teenage patient had not been hit by a dog bone, but was a victim of domestic violence. The incident had occurred the night before, and she had actually been punched in the face. 

My patient had me fooled. She had the nursing staff fooled, the support staff fooled, and my attending fooled, too. She had told such a strange story that we didn't question it. After all, the stranger the story in the emergency department, the more likely it is to be true. It amazes me how the patient was able to look each of us in the eye and repeat her story word for word, never changing a detail. 

Emergency department clinicians are constantly dealing with traumatic injuries. It scares me to think about how many of these injuries are the result of unnoticed domestic violence. As clinicians, we need to always be on alert, and never let our intuition waver. When I looked at my patient and thought that her bruising appeared older than her story suggested, I shouldn't have let that thought go. I should have evaluated her and looked for other signs of bodily harm, and I should have gently asked her more questions related to domestic violence. Thankfully, the truth came out and she was provided with the resources that she needed. Because of her, I'm reminded to keep domestic violence in the back of my mind when I examine each and every one of my patients, regardless of their age or gender. If something doesn't make sense, even in the slightest, I'm going to ask deeper questions to try and figure out the real story. With this mindset, I hope to help any victim of domestic violence that comes across my path.

Jillian Knowles, MMS, PA-C, works as an emergency medicine physician assistant in the Philadelphia area.

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