abuse and assault ccfp em core lecture march 26, 2015 dr. jo-ann talbot department of emergency...

Abuse and Abuse and AssaultAssault

CCFP EM Core LectureCCFP EM Core Lecture

March 26, 2015March 26, 2015

Dr. Jo-Ann TalbotDr. Jo-Ann Talbot

Department of Emergency MedicineDepartment of Emergency Medicine

Dalhousie UniversityDalhousie University

Saint John Regional HospitalSaint John Regional Hospital

Learning ObjectivesLearning Objectives

1.1. Define abuse and assaultDefine abuse and assault

2.2. Discuss the extension of abuse to all agesDiscuss the extension of abuse to all ages

3.3. Sexual assault in adults and in childrenSexual assault in adults and in children

4.4. Risk factors for abuse, red flagsRisk factors for abuse, red flags

5.5. Principle of the chain of evidencePrinciple of the chain of evidence

6.6. Consent for blood ethanol testing for legal Consent for blood ethanol testing for legal purposespurposes

7.7. The role of the medical expert witnessThe role of the medical expert witness

8.8. Preparation for provision of evidence in Preparation for provision of evidence in courtcourt

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Abuse and AssaultAbuse and Assault

Definition of abuse :Definition of abuse : Maltreatment of another individualMaltreatment of another individual A pattern of coercive controlA pattern of coercive control

Definition of Assault :Definition of Assault : Any act or threatened act of violenceAny act or threatened act of violence

Case 1 Case 1

4 month old with fever, cough, runny 4 month old with fever, cough, runny nose, for past 3 daysnose, for past 3 days

Increased irritability, decreased po Increased irritability, decreased po intake, no vomiting or diarrheaintake, no vomiting or diarrhea

Bruise noted on right ear which Bruise noted on right ear which mom states is from banging his head mom states is from banging his head on the crib and he bruises easilyon the crib and he bruises easily

DiscussionDiscussion

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Bruising in ChildrenBruising in Children

Bruising is often overlooked because Bruising is often overlooked because it is usually clinically insignificant, it is usually clinically insignificant, and requires no immediate and requires no immediate treatment.treatment.

Are there patterns of bruising that Are there patterns of bruising that raise a suspicion of child abuse?raise a suspicion of child abuse?

DiscussDiscuss

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Bruising in childrenBruising in children

Systematic review in 2005 by Maguire et Systematic review in 2005 by Maguire et alal

Patterns of bruising suggestive of Patterns of bruising suggestive of abuseabuse

23 observational studies23 observational studies

7 looked at bruising in normal children7 looked at bruising in normal children

14 looked at abused children (13 case 14 looked at abused children (13 case series, 1 cross sectional)series, 1 cross sectional)

2 looked at both abuse and non abuse2 looked at both abuse and non abuse8

Bruising in childrenBruising in children

Bruising must be assessed in the context of medical, social, and developmental history explanation given patterns of non-abusive bruising

Maguire, Mann, Sibert and Kemp. Are there patterns of Maguire, Mann, Sibert and Kemp. Are there patterns of bruising in childhood which are diagnostic or bruising in childhood which are diagnostic or

suggestive of abuse? A systematic review Arch Dis suggestive of abuse? A systematic review Arch Dis Child. 2005;90:182-86.Child. 2005;90:182-86.

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Bruising in ChildrenBruising in Children

ConclusionsConclusions Bruising in infants who are not moving Bruising in infants who are not moving

independently is rare less than 1%.independently is rare less than 1%. In infants starting to mobilize 17% have In infants starting to mobilize 17% have

bruisesbruises In walking toddler 54% In walking toddler 54% Most preschool and school age children Most preschool and school age children

have bruiseshave bruisesMaguire et al Arch Dis Child 2005Maguire et al Arch Dis Child 2005

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Bruising suggestive of Bruising suggestive of physical abusephysical abuse

Bruises in children not independently Bruises in children not independently mobilemobile

Bruising in babiesBruising in babies Bruises away from bony prominencesBruises away from bony prominences Bruises to face, trunk arms, ears and handsBruises to face, trunk arms, ears and hands Multiple bruises in clustersMultiple bruises in clusters Multiple bruises of uniform shapeMultiple bruises of uniform shape Bruises that carry imprint of implementBruises that carry imprint of implement

Maguire et al Arch Dis Child 2005Maguire et al Arch Dis Child 2005

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BruisesBruises

Bruising characteristics discriminating Bruising characteristics discriminating physical child abuse from accidental physical child abuse from accidental trauma. trauma.

Pierce, Kaczor, Aldridge et al. Pediatrics. Pierce, Kaczor, Aldridge et al. Pediatrics. 2010;125:67-74.2010;125:67-74.

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BruisesBruises

Objective to develop a bruising CDR.Objective to develop a bruising CDR. Case control study of children 0 to 48 Case control study of children 0 to 48

months old admitted to PICU for months old admitted to PICU for trauma, retrospective as all participants trauma, retrospective as all participants identified through the trauma registryidentified through the trauma registry

42 cases physical abuse 42 cases physical abuse 53 controls children admitted with 53 controls children admitted with

accidental trauma over the same time accidental trauma over the same time periodperiod

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BruisesBruises

Conclusions Pierce et al Conclusions Pierce et al Number of bruisesNumber of bruises

Abuse cases median of 6, as many as 25Abuse cases median of 6, as many as 25 Accidental controls median of 1, all had ≤ 4Accidental controls median of 1, all had ≤ 4

Regions predictive of abuseRegions predictive of abuse Ear, neck, hand, right arm, chest, buttocks and Ear, neck, hand, right arm, chest, buttocks and

torsotorso All genitourinary and hip bruising were found in All genitourinary and hip bruising were found in

abuse cases but too few for significanceabuse cases but too few for significance Bruising in child less than 4 months old rareBruising in child less than 4 months old rare

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BruisesBruises

Sugar N, Taylor JA, Feldman KY. Bruises Sugar N, Taylor JA, Feldman KY. Bruises in infants and toddlers: in infants and toddlers: those who donthose who don’’t t cruise rarely bruisecruise rarely bruise. Arch Ped Adol Med. . Arch Ped Adol Med. 1999;153(4):399-4031999;153(4):399-403

Landmark study of 1000 children less than 36 Landmark study of 1000 children less than 36 months old well child care visits at clinicmonths old well child care visits at clinic

Bruises on pre-cruisers rareBruises on pre-cruisers rare Bruises on the hands and buttocks were not Bruises on the hands and buttocks were not

observed at any ageobserved at any age

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Bruising Blunt ObjectBruising Blunt Object

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Bruise PatternsBruise Patterns

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Case 2Case 2

18 month old female with pain in 18 month old female with pain in right leg, refusing to walk, father right leg, refusing to walk, father states that she was playing on picnic states that she was playing on picnic table, fell offtable, fell off

Injury happened about 20 minutes Injury happened about 20 minutes prior to presentationprior to presentation

DiscussionDiscussion XrayXray

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Spiral Fracture Tibia Spiral Fracture Tibia (Toddler(Toddler’’s)s)

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Fractures in ChildrenFractures in Children

Fractures are very common in Fractures are very common in children 60% of boys and 40% of children 60% of boys and 40% of girls will have a fracture by their girls will have a fracture by their 1515thth birthday. Children who are birthday. Children who are abused represent a very small abused represent a very small number of childhood fractures.number of childhood fractures.

Are there characteristics of fractures Are there characteristics of fractures that may represent abuse?that may represent abuse?

DiscussDiscuss27

FracturesFractures

Kemp, Dunstan, Harrison et al from Kemp, Dunstan, Harrison et al from Cardiff, Wales, published a Cardiff, Wales, published a systematic review in BMJ 2008 on systematic review in BMJ 2008 on patterns of fractures in child abusepatterns of fractures in child abuse

Questioned what features Questioned what features differentiate fractures sustained differentiate fractures sustained from abuse from those sustained from abuse from those sustained from other causes.from other causes.

Included 32 studiesIncluded 32 studies28

FracturesFractures

Kemp et al conclusions Kemp et al conclusions Most common abuse fractures were in Most common abuse fractures were in

infants and toddlers infants and toddlers 80% of all fractures from abuse were 80% of all fractures from abuse were

seen in < 18 month old childrenseen in < 18 month old children Multiple fractures were more common in Multiple fractures were more common in

abuseabuse After excluding major trauma rib After excluding major trauma rib

fractures had the highest probability of fractures had the highest probability of abuseabuse

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FracturesFractures

Fractures due to abuse in childrenFractures due to abuse in children Age < 18 months 1 in 9 fractures Age < 18 months 1 in 9 fractures Age 19 months and 5 yrs 1 in 250 Age 19 months and 5 yrs 1 in 250

fractures fractures Age > 5 years old noneAge > 5 years old none

When infants and toddlers present When infants and toddlers present with a fracture consider abusewith a fracture consider abuse

No fracture on its own can distinguish No fracture on its own can distinguish abuse from non abusive causes abuse from non abusive causes

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FracturesFractures

Metaphyseal fractures (bucket Metaphyseal fractures (bucket handle) thought to be strong handle) thought to be strong predictors of abuse. This systematic predictors of abuse. This systematic review did not find any evidence to review did not find any evidence to support or refute this hypothesis.support or refute this hypothesis.

The most comprehensive studies on The most comprehensive studies on metaphyseal fractures were metaphyseal fractures were descriptions of radiologic findings of descriptions of radiologic findings of metaphyseal lesions in case series of metaphyseal lesions in case series of a group of fatally abused children. a group of fatally abused children.

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FracturesFractures Kleinman PK, Marks SC Jr. A regional approach to Kleinman PK, Marks SC Jr. A regional approach to

the classic metaphyseal lesion in abused infants: the the classic metaphyseal lesion in abused infants: the proximal humerus. AJR Am J Roentgenol proximal humerus. AJR Am J Roentgenol 1996;167:1399-403. 1996;167:1399-403.

Kleinman PK, Marks SC Jr. A regional approach to Kleinman PK, Marks SC Jr. A regional approach to classic metaphyseal lesions in abused infants: the classic metaphyseal lesions in abused infants: the distal tibia. AJR Am J Roentgenol 1996;166:1207-12. distal tibia. AJR Am J Roentgenol 1996;166:1207-12.

Kleinman PK, Marks SC Jr. A regional approach to Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the the classic metaphyseal lesion in abused infants: the distal femur. AJR Am J Roentgenol 1998;170:43-7. distal femur. AJR Am J Roentgenol 1998;170:43-7.

Kleinman PK, Marks SC Jr. A regional approach to Kleinman PK, Marks SC Jr. A regional approach to the classic metaphyseal lesion in abused infants: the the classic metaphyseal lesion in abused infants: the proximal tibia. AJR Am J Roentgenol 1996;166:421-6. proximal tibia. AJR Am J Roentgenol 1996;166:421-6.

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Metaphyseal Fracture Metaphyseal Fracture ShoulderShoulder

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Metaphyseal Fracture Metaphyseal Fracture ElbowElbow

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Metaphyseal Fracture Metaphyseal Fracture Distal FemurDistal Femur

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Metaphyseal FractureS Metaphyseal FractureS TibiaTibia

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Rib FracturesRib Fractures

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Fractures Old and NewFractures Old and New

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Fracture callus in Fracture callus in Radius, UlnaRadius, Ulna

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Case 3Case 3

2 year old female with burn to 2 year old female with burn to buttocks from exposure to hot bath buttocks from exposure to hot bath waterwater

See image See image DiscussDiscuss

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BurnsBurns

James-Ellison, Barnes, Maddocks et al. Social James-Ellison, Barnes, Maddocks et al. Social health outcomes following thermal injuries: a health outcomes following thermal injuries: a retrospective matched co-hort study. Arch retrospective matched co-hort study. Arch Dis Child. 2009 Sep;94(9): 663-7 Dis Child. 2009 Sep;94(9): 663-7

Swansea WalesSwansea Wales Retrospective Cohort studyRetrospective Cohort study 145 children age of 3 years admitted for 145 children age of 3 years admitted for

burnsburns Matched against controls for age, sex, Matched against controls for age, sex,

enumeration district.enumeration district.

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BurnsBurns

Followed until age of sixFollowed until age of six Results: 89% of burns were deemed Results: 89% of burns were deemed

accidental and 2.8 % non accidental at accidental and 2.8 % non accidental at initial eventinitial event

By 6By 6thth birthday burn cases were more birthday burn cases were more likely to be referred to social services likely to be referred to social services with 9.7% of cases vs 1.4% of controls with 9.7% of cases vs 1.4% of controls having been abused or neglected. 32% of having been abused or neglected. 32% of cases vs 18% of controls were defined as cases vs 18% of controls were defined as in need (Social services referral)in need (Social services referral)

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BurnsBurns

Children with a burn requiring Children with a burn requiring admission appear to be at higher admission appear to be at higher risk of further abuse or neglect risk of further abuse or neglect compared with controls.compared with controls.

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Case 4Case 4

5 year old girl presents with itching 5 year old girl presents with itching and foul discharge in the vaginal and foul discharge in the vaginal area for past two days. No dysuria or area for past two days. No dysuria or hematuria. hematuria.

How do you approach the history How do you approach the history and physical exam in this child?and physical exam in this child?

DiscussDiscuss

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Child Sexual AbuseChild Sexual Abuse

85% Child sexual abuse cases 85% Child sexual abuse cases presenting to ED are for:presenting to ED are for: disclosure of the abuse disclosure of the abuse or because of other GU tract symptomsor because of other GU tract symptoms

Behavioral DisturbancesBehavioral Disturbances Excessive masturbation, genital fondling, Excessive masturbation, genital fondling,

regression, nightmares, encopresis, or regression, nightmares, encopresis, or other sexually oriented or provocative other sexually oriented or provocative behaviorbehavior

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Child Sexual AbuseChild Sexual Abuse

How do we manage a case of How do we manage a case of suspected pediatric sexual abuse ?suspected pediatric sexual abuse ?

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Child Sexual AbuseChild Sexual Abuse Question child directly about what Question child directly about what

happenedhappened

Write EXACTLY what they sayWrite EXACTLY what they say Document the degree of sexual Document the degree of sexual

developmentdevelopment

The genital exam should be confined to a The genital exam should be confined to a careful inspection of the genitalia and careful inspection of the genitalia and perianal areaperianal area

Use frog-leg position and document labia Use frog-leg position and document labia and hymen conditionand hymen condition

Child Sexual AbuseChild Sexual Abuse Watch for signs of STDWatch for signs of STD’’ss

Once the diagnosis is suspected Once the diagnosis is suspected consult pediatric sexual assault teamconsult pediatric sexual assault team

Consult social servicesConsult social services

Ensure child has safe environmentEnsure child has safe environment

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Red flags for abuseRed flags for abuse

History inconsistent with nature or extent of History inconsistent with nature or extent of injuriesinjuries

Story changesStory changes Caregiver and child discrepancies in historyCaregiver and child discrepancies in history Injuries in siblingsInjuries in siblings Unusual parental behaviourUnusual parental behaviour Intoxicated caregivers, or use of street drugsIntoxicated caregivers, or use of street drugs Boyfriend in the home not related to the childBoyfriend in the home not related to the child

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Red flags for abuseRed flags for abuse

BruisesBruises Number, age, pattern, region of bodyNumber, age, pattern, region of body

FracturesFractures Number, plausible explanation, prompt Number, plausible explanation, prompt

medical attentionmedical attention BurnsBurns Sexual assaultSexual assault NeglectNeglect

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ManagementManagement

Treat injuriesTreat injuries Further work up may include Further work up may include

skeletal surveyskeletal survey Head CT if altered LOCHead CT if altered LOC Trauma blood workTrauma blood work Ultrasound if abdominal pain or Ultrasound if abdominal pain or

vomitingvomiting

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ManagementManagement

Document well, write the childDocument well, write the child’’s s responses verbatim on the chart as they responses verbatim on the chart as they may be admissible as evidencemay be admissible as evidence

Contact hospital child protection team or Contact hospital child protection team or Family ServicesFamily Services

Be firm but non judgmental with parents, Be firm but non judgmental with parents, they may be innocent and concernedthey may be innocent and concerned

DO NOT be fearful of legal battle if you DO NOT be fearful of legal battle if you are wrong. BE fearful of misdemeanor are wrong. BE fearful of misdemeanor charge potential of failure to report a charge potential of failure to report a case.case.

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Adult Sexual AssaultAdult Sexual Assault

Clinical Definition: Clinical Definition:

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Female rape ExaminationFemale rape Examination

Assault history:Assault history: Who ? How many ?Who ? How many ? What happened ? Physical assault too ?What happened ? Physical assault too ? When ?When ? Where ?Where ? Douche, shower, or change clothes ?Douche, shower, or change clothes ?

Medical History:Medical History: LMPLMP Birth control methodBirth control method Last intercourseLast intercourse Allergies and prior medical historyAllergies and prior medical history

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Adult Sexual AssaultAdult Sexual Assault Document bruises, lacerations, or other signs of Document bruises, lacerations, or other signs of

trauma. Pay special attention for trauma. Pay special attention for ““submissive submissive injuriesinjuries””

Pelvic exam Pelvic exam Use a rape kitUse a rape kit Or make smears from the vagina and cervix and Or make smears from the vagina and cervix and

allow to air dry. Make a wet mount and look for allow to air dry. Make a wet mount and look for spermsperm

Take 10 ml of sterile water and do vaginal aspirateTake 10 ml of sterile water and do vaginal aspirate GC and chlamydia swabsGC and chlamydia swabs

Pre moistened rectal or buccal swab for sperm Pre moistened rectal or buccal swab for sperm

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Treatment of Sexual Treatment of Sexual Assault Assault

Treat injuriesTreat injuries Consider Td prophylaxisConsider Td prophylaxis Pregnancy test and repeat in 10 dayPregnancy test and repeat in 10 day

Plan BPlan B Blood Tests:Blood Tests:

HIV- baseline and repeat in 6 monthsHIV- baseline and repeat in 6 months HbsAg, core antibody (anti-HBc), and surface HbsAg, core antibody (anti-HBc), and surface

antibody (anti-HBs) and repeat at 3 monthsantibody (anti-HBs) and repeat at 3 months Consider HepC in high risk and repeat at 6 Consider HepC in high risk and repeat at 6

months if drawnmonths if drawn Swabs for GC, chlamydia, and trichomonasSwabs for GC, chlamydia, and trichomonas Follow up counseling established, follow up Follow up counseling established, follow up

medical caremedical care

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Sexual AssaultSexual Assault Sexually Transmitted Disease ProphylaxisSexually Transmitted Disease Prophylaxis

HIV transmission rates for unprotected sexHIV transmission rates for unprotected sex Receptive anal 1-30/1000Receptive anal 1-30/1000 Receptive vaginal 1-2/1000Receptive vaginal 1-2/1000 Insertive vaginal 1/1000Insertive vaginal 1/1000 Insertive anal 3-9/1000Insertive anal 3-9/1000

HIV - prophylaxis offered based on case by case basisHIV - prophylaxis offered based on case by case basis Hepatitis B - if antibody level low, then start Hepatitis B - if antibody level low, then start

vaccination series. Consider passive immunization in vaccination series. Consider passive immunization in high risk patient. Needs follow-up.high risk patient. Needs follow-up.

Syphilis – benzathine penicillin 18 mil units im (high Syphilis – benzathine penicillin 18 mil units im (high risk)risk)

Chlamydia – Azithromycin 1 g po (all patients)Chlamydia – Azithromycin 1 g po (all patients) Gonorrhoea – Ceftriaxone 250mg im or Cefixime Gonorrhoea – Ceftriaxone 250mg im or Cefixime

400mg400mg

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Intimate Partner Intimate Partner ViolenceViolence

Treatment of victims of intimate partner Treatment of victims of intimate partner violence is the same as for other victims violence is the same as for other victims of sexual and physical assaultof sexual and physical assault

Need to address ongoing safety of the Need to address ongoing safety of the patientpatient

ScreeningScreening Identifies women exposed to violenceIdentifies women exposed to violence Most women do not find screening Most women do not find screening

problematicproblematic It is unclear whether screening leads to It is unclear whether screening leads to

appropriate referral or use of service that appropriate referral or use of service that will benefit the victimwill benefit the victim


Wathen, Jamieson, MacMillan et al. Who Wathen, Jamieson, MacMillan et al. Who is identified by screening for intimate is identified by screening for intimate partner violence? Womenpartner violence? Women’’s Health Issues. s Health Issues. 2008;18:423-322008;18:423-32

5,607 women recruited from 12 primary 5,607 women recruited from 12 primary care, 11 acute care and 3 specialty care care, 11 acute care and 3 specialty care sites in Ontariosites in Ontario

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The screened group completed both a The screened group completed both a brief IPV screening tool (WAST-Woman brief IPV screening tool (WAST-Woman Abuse Screening Tool 8 items) before Abuse Screening Tool 8 items) before their clinical visit and CAS (Composite their clinical visit and CAS (Composite Abuse Scale 30 items) after the visitAbuse Scale 30 items) after the visit

Non screened group completed both Non screened group completed both the WAST and CAS after the clinic visitthe WAST and CAS after the clinic visit

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Screening (WAST) identified 22.1% Screening (WAST) identified 22.1% of women as experiencing past year of women as experiencing past year abuse, in contrast to the criterion abuse, in contrast to the criterion standard (CAS) which identified standard (CAS) which identified 14.4%14.4%

Implications of over identifying Implications of over identifying women as having been exposed to women as having been exposed to IPVIPV

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Red Flags for IPVRed Flags for IPV

Partner with drug or alcohol problem Partner with drug or alcohol problem Patient with alcohol problemPatient with alcohol problem Women age < 30 Women age < 30 Lower income Lower income Never or currently married, Never or currently married, DepressionDepression SomatizationSomatization No relationship to pregnancyNo relationship to pregnancy

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MacMillan, Wathen, Jamieson et al. Screening for MacMillan, Wathen, Jamieson et al. Screening for intimate partner violence in Health Care settings. intimate partner violence in Health Care settings. A randomized trial. JAMA. 2009;302(5): 493-501A randomized trial. JAMA. 2009;302(5): 493-501

6743 women aged 18-64 years seen in 11 6743 women aged 18-64 years seen in 11 emergency departments, 12 family practices and emergency departments, 12 family practices and 3 obs/gyne clinics in Ontario3 obs/gyne clinics in Ontario

There was no difference in screened and non There was no difference in screened and non screened women in the use of referral services, screened women in the use of referral services, in increased or decreased violence, in depression, in increased or decreased violence, in depression, PTSD, Alcohol or drug use, or quality of lifePTSD, Alcohol or drug use, or quality of life

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Domestic Violence Domestic Violence Treatment Treatment

Treat injuryTreat injury Assess risk for suicide or homicide.Assess risk for suicide or homicide. If dischargeIf discharge: :

How safe is home?How safe is home? Is there pattern of escalating violence? Is there pattern of escalating violence? Was batterer arrested? Do they know where Was batterer arrested? Do they know where

he is now? Does he have access to weapons? he is now? Does he have access to weapons? Does she have somewhere safe to go? Would Does she have somewhere safe to go? Would

she feel safer in a battered womanshe feel safer in a battered woman’’s shelters shelter If she wishes to go home, have a plan if If she wishes to go home, have a plan if

the violence erupts again.the violence erupts again.

Domestic Violence Domestic Violence Treatment Treatment

REFFERAL WomanREFFERAL Woman’’s shelter, Legal Aid, s shelter, Legal Aid, and Social Services. and Social Services.

Children involved, consult to Family Children involved, consult to Family Services child protection servicesServices child protection services

Documentation of events and statements Documentation of events and statements are critical are critical Potential legal charges: Restraining orders, Potential legal charges: Restraining orders,

assault child custody, separation, and divorce.assault child custody, separation, and divorce.

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Knife woundsKnife wounds

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Bruise patternBruise pattern

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Wound patternWound pattern

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Principle of the chain of Principle of the chain of evidenceevidence

All evidence collected must be All evidence collected must be appropriately labeled and placed in appropriately labeled and placed in secure area secure area

Collected items must be delivered to Collected items must be delivered to the police without anyone else the police without anyone else having access to the contentshaving access to the contents

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Legal DocumentationLegal Documentation What cases go to courtWhat cases go to court

Sexual assaultsSexual assaults Physical assaultsPhysical assaults Child protection casesChild protection cases Alcohol related driving arrests/ Alcohol related driving arrests/

MVCMVC’’ss

Legal DocumentationLegal Documentation Document wellDocument well

Draw and explain in detail the appearance of Draw and explain in detail the appearance of findingsfindings

Include lab and xray findings in your Include lab and xray findings in your documentation. documentation.

If well documented, may not have to attend If well documented, may not have to attend court.court.

In cases of disclosureIn cases of disclosure the person to whom the disclosure was first the person to whom the disclosure was first

made gets the subpoenamade gets the subpoena

DWI cases are the most common casesDWI cases are the most common cases77

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Ethanol Blood TestEthanol Blood Test

New driving while impaired (DWI) laws New driving while impaired (DWI) laws introduced by the conservative governmentintroduced by the conservative government’’s s Tackling Violent Crime Act in 2008Tackling Violent Crime Act in 2008

DWI cases require either a refusal of a DWI cases require either a refusal of a breath test or a positive breath test with breath test or a positive breath test with documented alcohol leveldocumented alcohol level

Need to obtain consent from the patient Need to obtain consent from the patient before drawing blood for the police. Let before drawing blood for the police. Let police get consent first, then you (saves police get consent first, then you (saves time)time)

Ethanol Blood TestEthanol Blood Test Clean the skin with iodine and avoid Clean the skin with iodine and avoid

alcohol swabs. alcohol swabs. Draw blood in the presence of the Draw blood in the presence of the

officer and initialed by both the officer and initialed by both the officer and medical staff. officer and medical staff.

You may designate this duty to a You may designate this duty to a nurse if they are willing. nurse if they are willing.

The sample is sealed and in the The sample is sealed and in the hands of the police officer to take to hands of the police officer to take to the crime lab for testing. the crime lab for testing.

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Ethanol Blood TestEthanol Blood Test Timing of samples becomes important Timing of samples becomes important

4 hour degradation table (zero order 4 hour degradation table (zero order kinetics) as a standing acceptancekinetics) as a standing acceptance

Collection time beyond 4 hrs requires Collection time beyond 4 hrs requires expert testimony of a toxicologist to expert testimony of a toxicologist to establish a reasonably accurate establish a reasonably accurate alcohol level at the time in questionalcohol level at the time in question

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Role of the Medical Role of the Medical Expert WitnessExpert Witness

Request to testify as a witness on any medical Request to testify as a witness on any medical grounds, most often declared an expert witnessgrounds, most often declared an expert witness

Credibility as an expertCredibility as an expert Very important to the choose your words Very important to the choose your words

wisely and to comment only on what you are wisely and to comment only on what you are sure ofsure of

Any mistakes or statements in error may be Any mistakes or statements in error may be grounds for dismissal of the casegrounds for dismissal of the case

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Preparation for CourtPreparation for Court

Your best preparation is a well Your best preparation is a well documented patient interactiondocumented patient interaction

Most subpoenas come long after the Most subpoenas come long after the patient has been seen in the Emergency patient has been seen in the Emergency DepartmentDepartment

Pull your records and review all your Pull your records and review all your datadata

Make briefing notes to refer to in courtMake briefing notes to refer to in court Take a copy of the chart with youTake a copy of the chart with you

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Learning ObjectivesLearning Objectives

1.1. Define abuse and assaultDefine abuse and assault

2.2. Discuss the extension of abuse to all agesDiscuss the extension of abuse to all ages

3.3. Sexual assault in adults and in childrenSexual assault in adults and in children

4.4. Risk factors for abuse, red flagsRisk factors for abuse, red flags

5.5. Principle of the chain of evidencePrinciple of the chain of evidence

6.6. Consent for blood ethanol testing for legal Consent for blood ethanol testing for legal purposespurposes

7.7. The role of the medical expert witnessThe role of the medical expert witness

8.8. Preparation for provision of evidence in Preparation for provision of evidence in courtcourt

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abuse and assault ccfp em core lecture march 26, 2015 dr. jo-ann talbot department of emergency...

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