SAN FRANCISCO — The 3-year-old girl looked as if she were wearing red socks when Dr. Constance Battle saw her at the hospital. Both the child's feet were evenly burned, with the damaged skin ending at a distinct line above the ankle.
The baby sitter, who had brought the girl to the emergency room, said her young charge was prone to misbehaving and in this instance had stepped into scalding water in the bathtub before the sitter could check the temperature.
Some physicians would have accepted that explanation without question.
But before beginning treatment for the burn, Battle silently observed that the normal way of stepping into a tub is one foot first. If the water is too hot, the foot would be hastily withdrawn. Because both feet were injured, the young patient clearly had been lowered into the hot water by an adult--either accidentally or intentionally, she concluded.
Battle, medical director of the Hospital for Sick Children in Washington, was one of a number of physicians and lay professionals at a recent meeting of the American Medical Women's Assn. in San Francisco who urged that all physicians begin to look for injuries that appear inconsistent with the stories that patients, parents and caretakers tell. Such vigilance is necessary, they said, because violence has become a medical problem on a par with the No. 1 killer in the country, cardiovascular disease.
Explaining why women doctors were the ones to declare abuse, assault and battering as topics within the realm of medicine, a neurologist with the Brentwood Veterans Administration Medical Center, Dr. Michael Mahler, commented, "Women tend to be more exposed to that problem (violence) personally. With male doctors, that personal connection doesn't seem to be as strong; there's always a sense that we're dealing with someone else's problem."
Mahler attended the meetings with his wife, Dr. Victoria Paterno, a Santa Monica pediatrician.
About 350 women physicians in attendance learned a new way of regarding any patient with a traumatic injury, regardless of the doctor's specialty. It's an approach that presupposes the possibility of abuse.
"You have to be alert, whether you're in psychiatry or pediatrics," said Battle, newly elected president of the 9,000-member American Medical Women's Assn. "Radiologists have to be alert to bones that might be broken by someone else. Dermatologists have to look for patterns on the skin that might signal abuse. Internists and family-practice people who are treating the elderly need to be aware (of the possibility of violence)."
Dr. Jeanne Arnold, in family practice in Utica, N.Y., suggested that doctors routinely elicit a family history from every patient--asking questions such as, "Who in the family gives you trouble?"--as a way of ferreting out family violence.
The task need not be time-consuming, she said: "In five minutes, I can do a family history and find out whether a patient is at risk for family violence, or whether there's alcoholism or incest in the family."
A woman was admitted to the emergency room of her hospital in Utica several weeks ago, Arnold said, after she had been assaulted by her hammer-wielding husband. Neurosurgeons were able to repair the damage to the woman's skull. But when the victim was well enough to go home to her husband, he lost his temper once again, and killed her.
Using Arnold's method, the victim's family physician would have identified the patient as at risk and sought help for her, and the death might have been averted.
Mapping the Targets
Arnold introduced the group to the "injury map," a tool physicians can use to determine whether trauma to the body may have resulted from assault, even when the victim denies abuse. The image projected on the screen at the front of the conference room showed the head and neck to be the most common targets of punches and blows. The next most frequent points of attack are the upper torso, chest and thorax. Victims are less frequently beaten on the abdomen.
"We need to have a high level of suspicion (when examining patients)," Arnold said. Lingering psychosomatic complaints--tension headaches, vague abdominal pain--can really be symptoms of past or current abuse, she said. (Arnold urged doctors not to give tranquilizers when battering is suspected because a sedated victim may become despondent and attempt suicide.)
When a man reports he's been lacerated by a tree branch, but seems to have the pattern of five fingernails across his face, or when a woman says she tripped off a curb but has bruises on her neck, Arnold said doctors need to ask: "Has anyone been hurting you?"
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