Like many of you, my job has me up at strange hours. I come home from work in the middle of the night, or I am up before the sun on my way to a shift. I was taught from a young age to be careful walking alone when the streets are empty—head up, headphones off, phone out of sight, dressed a certain way. The calculations to stay safe in public are an ingrained and inescapable reality.
Women and girls are preoccupied with the perceived threat of violence from strangers in public, but we are more likely to be killed or assaulted by an intimate partner or a family member. (FBI Supplementary Homicide Report, 2011; Eval Rev. 2006;30:229.) Working at Highland Hospital, a county hospital in Oakland, CA, I see victims of intimate partner violence (IPV) nearly every shift. With each person, there is so much to juggle as the treating physician—stabilize and treat injuries, offer resources, document meticulously, comply with state-mandated reporting, and identify who is at risk for suffering further violence or even homicide.
EDs are one of the primary institutions where those being abused may visit. We have the opportunity to offer intervention, yet more than two-thirds of acutely injured victims of IPV presenting to emergency departments are not identified. (J Gen Intern Med. 2011;26:894; http://bit.ly/2pk2XSS.)
Identifying the most at-risk patients among the many victims of intimate partner violence is even more challenging. Access to firearms and a history of nonlethal strangling are significant risk factors for domestic violence homicide, but neither strangling nor guns at home will necessarily be revealed in the physical exam or freely volunteered by patients. We physicians will likely miss these key pieces of history if we do not explicitly ask about them. (Am J Public Health. 2003;93:1089; http://bit.ly/2CHlUln; MMWR Morb MortalWkly Rep. 2017;66:741; http://bit.ly/2qTUupD; Ann Intern Med. 2016;165:205; http://bit.ly/2pckjkm.)
A few things guide me in identifying those at high risk of domestic violence homicide, a term we have adopted from the legal system for when someone is murdered by an intimate partner, a spouse, or an ex-partner (Am J Public Health. 2003;93:1089; http://bit.ly/2CHlUln; Partner Abuse. 2012;3:231; http://bit.ly/2QiZuiw; MMWR Morb Mortal Wkly Rep. 2017;66:741; http://bit.ly/2qTUupD):
- An abuser having access to firearms makes domestic violence homicide five times more likely in abusive relationships. (Am J Public Health. 2003;93:1089; http://bit.ly/2CHlUln.)
- A history of being strangled is an independent predictor of domestic violence homicide. (J Emerg Med. 2008;35:329; http://bit.ly/375BiWN.)
- People in abusive relationships are at increased risk of serious injury or death when they leave their partner or abuser.
- Intimate partner violence in the United States cuts across all genders, races, and social classes, but Native American, Alaskan Native, and non-Hispanic black women who are poor face the highest rates of domestic violence homicide. (MMWR Morb Mortal Wkly Rep. 2017;66:741; http://bit.ly/2qTUupD.)
We need more research to identify those most at risk for domestic violence homicide, and we need evidence on effective interventions even more. We know that approximately half of the men and women murdered by intimate partners in the United States are killed using a gun, yet data on the frequency and characteristics of domestic violence-related gun violence, proximal risk factors, and best practices in prevention are sparse. (Am J Public Health Nations Health. 2018;108:967.)
Identifying at-risk victims is challenging enough in this environment. With the limitations of current research and available tools, are we really able to offer evidence-based interventions in the emergency department? I want the best possible care for our patients and to provide options and advice that are backed up by strong evidence.
Some states (including California where I practice) have extreme risk protection orders (ERPO) laws, also referred to as red flag laws, which provide an avenue for temporarily removing guns from environments where their presence may increase the risk of violence or homicide. Common sense would suggest that this is a reasonable option for protecting vulnerable people, but we need evidence about whether ERPO laws are effective in preventing injuries and deaths.
Coming home from a night shift, just before daybreak, (head up, headphones off, phone out of sight), I turn the key and feel a sense of relief in arriving home. It's difficult to acknowledge that the same cannot be said for some of the patients I discharged overnight.
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Dr. Gonsalvesis a senior resident in emergency medicine at Highland General Hospital in Oakland, CA.