Special Report

Figure: intimate partner violence, traumatic brain injuryYour patient presents to the ED with a broken wrist. She says she tripped and landed on it. You take a history, conduct a physical examination, and prepare to send her for x-rays, but she seems agitated and a little confused and doesn't answer your questions directly. She squints at the bright lights of the ED and complains of a headache. Is this woman intoxicated or on drugs? Possibly. But it's equally likely, if not more so, that she has a traumatic brain injury because she was struck in the head, face, or neck by an intimate partner, one time or on multiple occasions. TBIs resulting from intimate partner violence (IPV) are more common than you might expect. “Our work has demonstrated that among women who experience IPV, blows to the head, neck, or face are pervasive (94%). More than 75 percent of these blows were identified as severe enough to cause potential physiological disruption of consciousness and memory, meeting our definition for subconcussive head injury,” said Catherine Fortier, PhD, an assistant professor of psychiatry at Harvard and the deputy director of the VA Translational Research Center for TBI and Stress Disorders (TRACTS). “More than one-third of the women studied experienced a blunt force injury secondary to IPV that was severe enough to meet diagnostic criteria for traumatic brain injury.” Another study of 53 survivors of domestic abuse found that 92 percent of them had received blows to the head, and 40 percent of them had lost consciousness. (Prof Psychol Res Pr. 2002;33[1]:39.) Eve M. Valera, PhD, an associate professor of psychiatry at Harvard Medical School and a leading researcher on traumatic brain injuries among survivors of intimate partner violence, estimated that as many as 1.6 million survivors of intimate partner violence might experience a TBI every year. “This isn't just an occasional occurrence,” said Dr. Valera. “Although we don't have good epidemiological estimates of IPV-related TBI because there hasn't been a study designed to get at that, a range of studies have examined TBI rates among women who have experienced IPV in different settings: in the community, in a shelter, or a mix. The numbers are always high.” Screening for IPV But unlike TBIs that occur as a result of football injuries or on military deployments—which have received a significant amount of media attention in recent years—these brain injuries are easily missed by families, friends, and the medical community. They occur out of sight and behind closed doors, and survivors are often reluctant to report their abuse. “Most of the women who have participated in my research had experienced more than one TBI, but they're often the kind we call ‘mild,’ not necessarily a severe TBI that lands them in the hospital,” Dr. Valera said. “Some injuries do send a survivor of violence to the ED—like a broken bone or if they're bleeding profusely. But if you had a hit to the head and lost consciousness for a bit or didn't lose consciousness but felt nauseous and sick and dizzy, you might avoid going to the ED because you don't realize how important it is and you don't want to upset the partner who injured you. When I was interviewing women about this, I've rarely had someone say, ‘I went because I thought I had a concussion and was worried about that.’” More than eight of 10 survivors of IPV are women, although IPV occurs across the gender spectrum and with both same- and opposite-sex partners. (Emory University School of Medicine: Nia Project. https://bit.ly/3CGAbgK.) For emergency physicians, Dr. Valera suggested two different cues for screening: A woman should be screened for IPV if she presents with head, neck, or facial injuries that are not known to be associated with another etiology (like a car crash). “We need to be doing much better in terms of screening for IPV in the emergency department across the board,” said Audrey Bergin, MPH, the manager of the domestic violence (DOVE) program at Northwest Hospital in Randallstown, MD. “Directly ask about IPV, prefacing the question with, ‘This is something I ask all my patients because intimate partner violence is prevalent.’ People don't like to feel singled out. You can ask questions such as, ‘Are you afraid of or do you feel threatened by a current or former partner?’” A woman should be screened for concussion if she has experienced IPV. “If a patient in the ED reports experiencing IPV, you need to ask questions about loss of consciousness, altered state, headaches, confusion, and dizziness,” Dr. Valera said. “Always entertain the idea that this patient may have sustained a concussion or multiple injuries to the brain.” Signs of Violence Sometimes obvious cues can be missed, said Danielle Toccalino, a PhD candidate in the University of Toronto's Acquired Brain Injury Research Lab. “We commonly see diagnostic codes associated with trauma to the face and head, like a fractured jaw or a broken nose, that would suggest a brain injury is highly likely, but there's nothing in the notes about any kind of assessment to see if there is trauma to the brain,” she said. “The first step to improve management of IPV-related TBIs is simply awareness of both of these things, and the fact that they often go together.” And don't focus on current injuries to the exclusion of possible past TBIs, said Dr. Valera. Survivors often present for something that is not an acute TBI. Screening for a current brain injury is incredibly important, but you should also look back to see if there might have been a TBI in her past. You may also find signs in the patient's behavior. “Key hallmarks of brain injury include inability to focus, challenges regulating emotions, acting irritable or altered, and sensitivity to lighting,” said Ms. Toccalino. “These are things that, if you're not thinking about brain injury, might lead you to chalk them up as a ‘difficult patient’ or assume they are intoxicated.” A Difficult Diagnosis Screening, identification, and diagnosis of TBI can be difficult in the best of situations, and even more so when you're not looking at an acute injury, Ms. Toccalino acknowledged. “The process needs to strike a balance between looking for diagnostic clarity and looking for ways that you can accommodate a possible brain injury in the way you practice and get survivors the support they need.” She noted that certain support programs, in some cases, may only be accessible with a definitive diagnosis such as confirmation of the injury via imaging. “There may be concussion clinics or access to occupational therapy, physical therapy, and speech-language pathology that is only supported by insurance or government health plans if you have a diagnosis,” she said. “But to get a diagnosis, you need imaging or a neuropsychology assessment.” Imaging can be costly without giving them definitive answers because TBI often does not show up on a scan, Ms. Toccalino said. Neuropsychology assessments are also costly and can be quite long, which may put a lot of financial and cognitive stresses on the individual without a lot of benefit. “And to add to the picture, from a legal perspective, getting a diagnosis of TBI may be challenging if you end up going through a custody battle or other legal proceeding where that can be used against you,” she said. How can you set up systems and processes in the ED that can best serve survivors of IPV who have experienced one or more TBIs? “We know that survivors want to be asked,” Ms. Toccalino said. “Many of them want the opportunity and the space to have someone to talk to about what they are going through, but it can't be just one question on a huge checklist of 20 to 30 things to get through.” Building Rapport There are a few things to keep in mind during these patient encounters. Don't make assumptions, for instance, about who is and is not likely to experience IPV. “Although some groups of women are disproportionately affected by IPV, IPV impacts all races, ethnicities, cultures, and socioeconomic levels,” Dr. Fortier said. “COVID-19 has also led to increased prevalence and severity of IPV.” And you should always address a patient's safety first. “Make sure you are asking questions in a quiet, safe space away from the potential abuser,” Ms. Toccalino said. Building rapport with the patient is also important. “Even if you're only together for a short period of time, sit down and show that you're taking time to listen,” Ms. Toccalino said. “Let them know that you are invested and care about their response, and will work through it with them, no matter what that response is.” If possible, have someone on your team or on call who is specifically trained in trauma-informed approaches be present. Be aware of how often they may already have been asked these questions. “They might have heard this already in the ambulance or in ED triage,” Ms. Toccalino cautioned. “Being repeatedly asked a ‘checklist’ question as if no one is paying attention to your answers can be disheartening and retraumatizing.” Instead, you can say, “I know you have been asked already whether you are afraid of someone hurting you or living in an abusive situation, but I want to ask you that question one more time to be sure you have the opportunity to respond completely.” Don't rush—take your time and don't speak too quickly. “Ask what the patient understands, not if they understand,” Ms. Toccalino said. “Ask if they'd like instructions for things like changing bandages in written form, not just verbal.” And make sure you have up-to-date resources to offer. “These will be very specific to your individual area. There's no guarantee that they're going to come back to have a touchpoint with somebody else who may have the right information, so you need to have as much information as you can about the networks in the area you can connect them with,” said Ms. Toccalino. “Wherever possible, and I know this can be challenging in an ED setting without an ongoing relationship with a patient, be aware of what community resources you are referring to and follow up if you can.” Don't be judgmental or tell the person what to do, like “You need to leave now.” “Leaving is actually the most dangerous time,” Ms. Bergin said. “You can give the patient options, but give them control over what they do next. You can tell them, ‘There is a domestic violence program, you can use the phone right here to call their hotline, or we can get you a car to go there.’ Even if they don't respond right now, a few kind words of hope can go a long way. You can plant the seed, but you might not see the fruits right away.” Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.

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