Evaluating IPV in the Fracture Clinic

from left to right - Mo Bhandari, Lesley Gotlib Conn, Aynsley Young, Emil Schemitsch

15 years ago, Emil Schemitsch saw a young business woman in the fracture clinic who had been recently treated for an open tibial fracture. She stated that she had been at a party wearing high heels, then fell over, and fractured her leg. Several years later, a lawyer told him that her leg had actually been hit with a baseball bat by her boyfriend. He had wondered how a fall from high heels could result in an open tibial fracture - it seemed highly improbable, but he had not pursued the true cause at the time in a very busy clinic.

Mohit Bhandari of McMaster University (see article Fall 2010) has been working with Emil on the Intimate Partner Violence (IPV) problem for the past several years. When Mo was a resident at McMaster, he and his wife, who is a social worker, started thinking about this issue. Mo and Emil subsequently connected and published a survey, which found that 87% of Canadian Orthopaedic surgeons believed IPV victims represented fewer than 1% of patients in their clinics. They subsequently published a study in the Journal of Bone & Joint Surgery of 300 women who were interviewed about the incidence of IPV and found that the opposite was true. “There was a 1 in 3 chance of IPV in the past year, especially using the broader definition that includes emotional, sexual, and physical abuse. 9% had been exposed to physical abuse and 2.5% were in the clinic that day for a fracture or dislocation that was directly the result of physical abuse. “The problem is quite a bit bigger than we had assumed. Orthopaedic surgeons are in a good position to look for and recognize this problem. When women present with traumatic injuries, they are often worried primarily about the injury and it is often only in the follow-up visits that the orthopaedic surgeon has the opportunity to ask about and respond to an abuse disclosure.” Mo and Emil have completed an international ten clinic study of 3,000 women that has been published in the Lancet. The prevalence was similar in this much larger number of patients.

Nurse Aynsley Young has done independent work on IPV in the Emergency Department at St. Michael’s Hospital, where she is promoting universal screening for IPV. Emil and Aynsley have developed a screening program in the MSK clinics. There is a tool kit with binders of articles and protocols, a list of questions to ask, and a list of resources for support in the clinic. When he learned about this project, Ori Rotstein said: “This is a great opportunity for knowledge-translation” and connected Leslie Gotlib Conn, a Knowledge Translation Research Manager at St. Michael’s Hospital to join Emil and Aynsley. Through focus groups with residents, the group developed questions to ask, identified barriers, and completed a workshop with new PGY1 orthopaedic residents, supported by a grant from the Dean’s Fund for Education.

The group is modeling their approach on Earl Bogoch’s osteoporosis studies at St Michael’s. “Earl and his colleagues now have an osteoporosis coordinator who makes sure that patients with fractures are on the correct medications for osteoporosis and that they stay on them. The government gave Earl a grant to set up osteoporosis coordinators in fracture clinics across Ontario. The same model is needed for the IPV project. IPV assessment is difficult in the fracture clinic setting: 80- 100 patients in 5 hours in a clinic filled with cast technicians, nurses, and a thin curtain between patient gurnies offers no privacy for the kind of questions that might uncover or illuminate IPV in follow-up visits. It should be possible for the surgeon to ask some simple screening questions and then to say: ‘I’d like you to talk to our social worker’. The patient could then go to a private area and be seen by an IPV coordinator who could spend sufficient time to evaluate the causes and approach to the abuse. In the future, it will be important to do a longitudinal evaluation to see what happens over time to the abused patients and what coordinators and interventions can do. This is a project for the future.”

As past president of the Canadian Orthopaedic Association, Emil is coordinating with the CEO and staff of the association on publicizing and teaching about this problem. The issue has also been described on CBC radio and morning television.

“The old model of a clinic with all 7 wrist fractures in the same room near the cast cart means there is no time for anything but moving on to the next fracture. The outcome is that the patient will return with another fracture in the case of osteoporosis, or may be murdered in the case of IPV. It is appropriate to ask the question: ‘Are you safe?’, but doctors cannot ignore the wishes of patients to avoid the police. ‘If they are called, he’ll kill me, or my kids will be taken’. We need the help and intervention of social workers to help make this problem manageable. There is a social worker connected to the entire MSK program, but there is no dedicated IPV coordinator, like the osteoporosis coordinator. The model is there. ‘We need to apply it in IPV. The challenge is to make IPV screening and referral standard operating procedure.’”

A very active clinician and surgical investigator, Emil recently completed his term as Head of Orthopaedic Surgery at St. Michael’s Hospital. He has over 300 publications, and has held many grants. He has four childrenone playing in the Ontario Hockey League, and one who will soon enter it.

M.M.