Domestic Violence and Abuse

Quick Answer

One-liner: Domestic violence and abuse encompasses intimate partner violence, elder abuse, and child abuse; emergency department recognition and management require trauma-informed care, forensic documentation, safety planning, and mandatory reporting where required.

Domestic and family violence (DFV) is a pervasive public health issue affecting 1 in 3 women and 1 in 4 men in their lifetime. Emergency departments are critical identification points where patterns such as inconsistent injury mechanisms, delayed presentation, and repeat injuries should trigger suspicion. Management priorities include ensuring physical safety, providing forensic documentation (including photography with consent), safety planning, mandatory reporting (child abuse is mandatory nationwide; adult DV reporting varies by jurisdiction), and referral to support services such as 1800RESPECT (1800 737 732). Cultural safety is essential, particularly for Aboriginal, Torres Strait Islander, and Māori populations who experience 2-3× higher rates of violence. Remote and rural settings present additional challenges including limited access to services, RFDS retrieval considerations, and community confidentiality concerns.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Injury patterns (central vs peripheral), defensive wounds, strangulation anatomy
• Physiology: Stress response, trauma physiology, strangulation physiology
• Pharmacology: Analgesia considerations, sedation for forensic examination

Fellowship Exam Relevance

• Written: Recognition patterns, mandatory reporting requirements, safety planning, referral pathways, documentation standards, forensic photography principles
• OSCE: Sensitive history taking, partner separation strategies, forensic documentation, safety planning, mandatory reporting documentation, cultural safety communication
• Key domains tested: Medical Expert (recognition and management), Communicator (sensitive questioning, breaking bad news, safety planning), Professional (mandatory reporting, documentation, ethical dilemmas), Advocate (referral pathways, resource navigation, health advocacy)

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Key Points

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Epidemiology

Australian/NZ Specific

• Hospitalization rates: Aboriginal and Torres Strait Islander women are 32× more likely to be hospitalized for domestic violence assault than non-Indigenous women [7]
• Domestic homicide: Indigenous women are 11× more likely to be victims of domestic homicide than non-Indigenous women [7]
• Rural/remote: Women in very remote areas are 24× more likely to be hospitalized for domestic violence assault than women in major cities [8]
• Māori statistics: Māori women experience 1.5-2× higher rates of domestic violence than non-Māori women in New Zealand [9]
• ED screening: Less than 1% of ED visits by older adults result in elder abuse diagnosis despite 10% prevalence [10]

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Pathophysiology

Mechanism of Abuse

Intimate Partner Violence (IPV):

• Physical: Blunt force trauma (punching, kicking), strangulation, use of weapons, forced restraint
• Sexual: Coercion, rape, reproductive coercion
• Psychological: Threats, intimidation, isolation, gaslighting, stalking
• Financial: Controlling access to money, preventing employment, stealing
• Technology-facilitated: GPS tracking, monitoring communications, harassment online

Child Abuse:

• Physical: Shaking (shaken baby syndrome), blunt force, burning, scalding
• Neglect: Failure to provide basic needs (food, shelter, medical care)
• Emotional: Verbal abuse, rejection, humiliation
• Sexual: Sexual acts with children, exploitation

Elder Abuse:

• Physical: Restraint, assault, inappropriate medication administration
• Financial: Theft, coercion, misuse of power of attorney
• Neglect: Failure to provide care, withholding necessities
• Psychological: Threats, humiliation, isolation

Pathological Progression

Acute Phase (0-72 hours) → Subacute (3-7 days) → Healing Phase (7-14+ days) → Chronic Phase (ongoing cycles)

Strangulation Physiology:

• Carotid artery compression → cerebral hypoperfusion → loss of consciousness in 5-10 seconds
• Jugular vein compression → venous congestion → petechiae (eyes, face, neck)
• Tracheal compression → airway obstruction → asphyxia
• Vagus nerve stimulation → bradycardia, cardiac arrest
• Delayed neurologic injury: thromboembolic stroke, carotid artery dissection

Why It Matters Clinically

Understanding the mechanism helps ED clinicians:

• Anticipate associated injuries (strangulation → carotid injury, petechiae, later stroke)
• Recognize hidden injuries (skeletal survey for child abuse)
• Provide appropriate forensic documentation
• Plan for delayed complications (post-strangulation syndrome)
• Identify red flags requiring immediate intervention (immediate strangulation danger signs)

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Clinical Approach

Recognition

Triggers for Suspicion:

• Inconsistent mechanism of injury versus injury severity
• Delayed presentation (greater than 24 hours after injury)
• Repeat injuries or frequent ED visits
• Injuries in various stages of healing
• Central body injuries (head, neck, face, torso)
• Defensive wounds (ulnar forearm, back of hands)
• Partner who refuses to leave room or answers for patient
• Patient appears anxious, fearful, withdrawn, or depressed
• Pregnancy with new or worsening trauma

Specific Recognition Patterns:

Intimate Partner Violence:

• Central injuries (head, neck, face, breasts, abdomen) present in greater than 50% of IPV cases
• Strangulation marks (lineal bruising, petechiae, laryngeal tenderness)
• Patterned injuries (belt marks, bite marks, grab marks, ligature marks)
• Bilateral injuries (not typical of accidental trauma)
• "Bath towel" pattern (injury distribution consistent with being wrapped in towel)
• Delayed presentation for significant injuries (fractures, lacerations)

Child Abuse:

• "Those who don't cruise, don't bruise"
• any bruise in non-ambulatory infant (below 4 months) is suspicious
• TEN-4-FACESp bruising rule: Torso, Ears, Neck, age below 4; Frenulum, Angle, Cheek, Eyelids, Subconjunctival, patterned bruises
• Metaphyseal "corner" or "bucket-handle" fractures (highly specific for abuse in infants)
• Posterior rib fractures (caused by squeezing chest during shaking)
• Long bone fractures in non-ambulatory children
• Retinal hemorrhages (shaken baby syndrome)
• Subdural hemorrhage with minor or no trauma history
• Burns with clear patterns (stocking-glove, immersion, cigarette)

Elder Abuse:

• Unexplained bruises, pressure injuries, lacerations
• Poor hygiene, malnutrition, dehydration
• Inappropriate clothing for weather conditions
• Fear of caregiver, withdrawal from communication
• Sudden changes in financial documents, missing valuables
• Medication non-adherence or inappropriate administration

Initial Assessment

Primary Survey

• A: Airway - assess for strangulation, facial/neck trauma, airway protection
• B: Breathing - assess for chest wall trauma, rib fractures, pneumothorax
• C: Circulation - assess for hemorrhage, internal injuries, strangulation cardiovascular effects
• D: Disability - assess for altered mental status, head injury, strangulation neurologic effects
• E: Exposure - full examination with privacy, document all injuries, photograph if consent obtained

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Patient appearance: withdrawn, anxious, depressed, fearful
• Patient behavior: excessive eye contact avoidance, reluctance to speak, changing story
• Partner behavior: answers for patient, refuses to leave room, hostile, overly solicitous
• Hygiene and nutrition signs (elder abuse): poor hygiene, inappropriate clothing, malnutrition

Specific Findings

Body Map Documentation:

• Use standardized ED body map to document all injuries
• Mark location, size, shape, color, and description
• Note whether injuries are patterned or non-patterned
• Document timing of injuries (patient's estimate, clinical staging)

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Child Abuse Investigations:

Elder Abuse Investigations:

Forensic Evidence Collection:

Point-of-Care Ultrasound

• eFAST: Identify pneumothorax, hemothorax, free fluid (abdominal/pelvic)
• Soft tissue ultrasound: Assess for hematomas, foreign bodies
• Vascular ultrasound: Assess for deep vein thrombosis (immobilization)

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Management

Immediate Management (First 10 minutes)

1. Ensure physical safety (separate from partner if present, security involvement)
2. Primary survey ABCDE (life-threatening injuries take priority)
3. Obtain private, safe location for patient (partner asked to leave)
4. Establish rapport and trust (trauma-informed care approach)
5. Initiate forensic documentation (detailed notes, body map, photography if consent)
6. Involve social work/mental health team early
7. Consult mandatory reporting requirements (child abuse mandatory, adult DV varies by jurisdiction)
8. Safety planning discussion (if patient ready and safe)

Resuscitation

Airway

• Protect airway in facial/neck trauma
• Anticipate airway compromise in strangulation (laryngeal edema)
• Use jaw thrust, not head tilt (cervical spine clearance if trauma)
• Early intubation if airway compromise or altered mental status

Breathing

• Administer oxygen for hypoxia
• Treat pneumothorax, hemothorax as indicated
• Monitor for respiratory depression (drug intoxication, thoracic trauma)

Circulation

• Control active hemorrhage (pressure, tourniquets for extremities)
• IV access for fluid resuscitation, medications
• Treat shock (crystalloids, blood products if indicated)
• Monitor vital signs closely (strangulation can cause arrhythmias)

Medications

Paediatric Dosing

Ongoing Management

Trauma-Informed Care Principles:

• Ensure safety and privacy throughout encounter
• Use collaborative, empowering communication style
• Validate patient's feelings and experiences
• Respect patient's autonomy and decision-making
• Provide information, not directives
• Acknowledge resilience and coping strategies

Forensic Documentation:

• Detailed description of mechanism (use patient's exact words in quotation marks)
• Body map with all injuries marked
• Forensic photography (consent required):
  • Orientation shot (full body or region)
  • Mid-range shot (injury with anatomical landmarks)
  • Close-up shot (with forensic ruler/scale)
  • Include color calibration card if available
• Timing documentation (when injury occurred, when presentation occurred)
• Chain of custody for photographs/evidence

Safety Planning:

• Assess immediate safety risk (lethality assessment)
• Discuss emergency plan (exit strategy, emergency contacts)
• Identify safe places (friends, family, shelters)
• Prepare "go bag" (documents, medications, valuables)
• Provide contact information for support services
• Discuss safe technology use (clear browser history, secure communications)
• Develop code words/check-ins with trusted contacts

Mandatory Reporting:

• Child abuse: Mandatory nationwide (all states/territories)
• Adult domestic violence: Mandatory in NT, WA, TAS; discretionary but encouraged in other jurisdictions
• Elder abuse: Mandatory in some states, varies by jurisdiction
• Consult local hospital policy and social work department
• Report to appropriate authorities:
  • Child Protection Services
  • Police (if imminent danger)
  • Adult Protective Services (elder abuse)
  • State health department (some jurisdictions)

Referral Pathways:

• National helpline: 1800RESPECT (1800 737 732) - 24/7 counseling, information, referrals
• Social work: Comprehensive assessment, safety planning, resources
• Community health services: Ongoing support, counseling
• Legal aid: Legal information, protection order assistance
• Domestic violence services: Shelters, counseling, advocacy
• Cultural liaison services: For Aboriginal, Torres Strait Islander, Māori patients

Definitive Care

Admission Indications:

• Severe injuries requiring hospital care
• Safe disposition not possible (no safe place to go)
• High lethality risk
• Suicidal ideation
• Child protection issues requiring coordination
• Elder abuse requiring safe placement

Specialist Referral:

• Forensic medicine/sexual assault service (if available)
• General surgery (trauma)
• Orthopaedics (fractures)
• Plastic surgery (facial injuries)
• Ophthalmology (eye injuries)
• ENT (facial/neck trauma)
• Geriatrician (elder abuse)
• Psychiatry (mental health consequences)

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Disposition

Admission Criteria

• Severe trauma requiring operative intervention
• Unsafe discharge (patient returning to dangerous situation and no safe alternative)
• High lethality risk (threats of homicide/suicide, recent escalation, strangulation)
• Medical complications requiring monitoring (arrhythmias, neurological symptoms)
• Coordination required for child protection, elder protection

ICU/HDU Criteria

• Hemodynamic instability from trauma
• Severe head injury (GCS ≤ 8)
• Strangulation with cardiac arrest, arrhythmias, or neurological deficit
• Multi-trauma requiring intensive monitoring
• Respiratory compromise requiring ventilation

Discharge Criteria

• Injuries stable and manageable outpatient
• Safe disposition confirmed (safe place to go)
• Safety plan in place and patient understands
• Mandatory reporting completed (if applicable)
• Referrals made (social work, community services)
• Follow-up arranged
• Patient has emergency contact information

Follow-up

• GP referral for ongoing care
• Social work follow-up
• Community health services referral
• Domestic violence service referral
• Cultural liaison service referral (for Indigenous patients)
• Legal protection order assistance (if requested)
• Mental health support (PTSD, depression, anxiety)

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Special Populations

Paediatric Considerations

Recognition Patterns:

• TEN-4-FACESp bruising rule (95% sensitivity, 89% specificity) [11]
  • Torso bruises (chest, abdomen, back)
  • Ears bruises
  • Neck bruises
  • "4: Age below 4 years with any bruising"
  • Frenulum tears/bruising
  • Angle of jaw bruises
  • Cheeks bruises
  • Eyelids bruises
  • Subconjunctival hemorrhages
  • patterned bruises (handprints, belt marks)
• "Those who don't cruise, don't bruise"
• bruising in non-ambulatory infant (below 4 months) is highly suspicious
• Skeletal survey mandatory for children below 2 years with suspicious injuries [12]
• High-specificity fracture patterns:
  • Metaphyseal "corner" or "bucket-handle" fractures
  • Posterior rib fractures
  • Scapular, sternal, spinous process fractures
  • Long bone fractures in non-ambulatory children

Management:

• Mandatory reporting to Child Protection Services nationwide
• Admission for observation if suspicion exists (do not discharge home)
• Multidisciplinary assessment (social work, child protection, police)
• Consider abuse as diagnosis of exclusion when mechanism inconsistent

Pregnancy

Increased Risk:

• Pregnancy is a high-risk period for escalation of IPV [13]
• IPV during pregnancy associated with:
  • Miscarriage
  • Preterm birth
  • Low birth weight
  • Placental abruption
  • Maternal mortality

Management:

• Screen every pregnant patient for IPV [14]
• Coordinate with obstetrics for fetal assessment
• Provide specialized resources for pregnant victims
• Consider fetal safety in safety planning

Elderly

Types of Elder Abuse:

• Physical: Assault, restraint, inappropriate medication administration
• Financial: Theft, coercion, misuse of power of attorney
• Neglect: Failure to provide basic needs (food, water, hygiene, medical care)
• Psychological: Threats, humiliation, isolation, intimidation
• Sexual: Non-consensual sexual contact

Recognition:

• Screen all patients greater than 65 years for elder abuse [15]
• Use validated screening tools (EASI, EMST, VASS)
• Look for unexplained injuries, malnutrition, dehydration, pressure injuries
• Assess for financial exploitation (sudden changes in banking, will, property)

Management:

• Report to Adult Protective Services (mandatory in some jurisdictions)
• Comprehensive geriatric assessment
• Involve geriatrician, social work, pharmacy
• Consider guardianship if capacity impaired

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• Aboriginal and Torres Strait Islander women are 32× more likely to be hospitalized for domestic violence assault than non-Indigenous women [7]
• Indigenous women are 11× more likely to be victims of domestic homicide than non-Indigenous women [7]
• Māori women in New Zealand experience 1.5-2× higher rates of domestic violence than non-Māori women [9]
• Women in very remote areas of Australia are 24× more likely to be hospitalized for domestic violence assault than women in major cities [8]

Cultural Safety Considerations:

• Engage Aboriginal Health Workers (AHWs), Aboriginal Liaison Officers (ALOs), or Māori Health Workers early
• Understand broader definition of "family violence" includes extended family, not just intimate partners
• Acknowledge intergenerational trauma from colonization, forced removals (Stolen Generations)
• Be aware of historical distrust of police, child protection services, healthcare systems
• Recognize fear of child removal may prevent disclosure of violence
• Provide culturally appropriate support services
• Use interpreter services if language barrier (not family members)
• Respect cultural protocols around family, community, and decision-making

Indigenous Health Disparities:

• Higher rates of chronic disease, mental health issues, substance use
• Crowded housing, socioeconomic disadvantage increase risk
• Limited access to services in remote communities
• Health workforce shortages in remote areas

Mandatory Reporting Considerations:

• Child protection reporting mandatory nationwide (including Indigenous children)
• Recognize impact of historical child removal policies on Indigenous families
• Work collaboratively with Indigenous child protection services where available

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Domestic Violence History Taking

Format: Communication Station Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

You are the ED registrar. A 34-year-old woman has presented with a fractured arm and facial bruising. She is accompanied by her partner who refuses to leave the room. The nurse has asked you to assess the patient. Please take a focused history and manage this situation appropriately.

Examiner Instructions: The patient is a victim of domestic violence but is afraid to disclose with her partner present. She appears anxious and makes brief eye contact with the candidate. When the candidate asks about the injury, she says she "fell down the stairs." The partner answers most questions and becomes agitated when the candidate asks him to leave the room. The patient's medical chart shows she has had three ED presentations in the past year for various injuries.

Actor/Patient Brief: You are a 34-year-old woman who has been living with your partner for 5 years. He has become increasingly controlling and violent. Tonight he threw a glass at you and hit you, fracturing your arm. You are afraid to say anything because he threatened to hurt you more. You want help but don't know what to do. When alone with the doctor, you may disclose if you feel safe and supported, but you will not disclose with your partner present. You are worried about your children who are at home with a neighbor.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Asks partner to leave room; asks direct questions about abuse; assesses safety; demonstrates awareness of forensic documentation

Critical Error: Does not ask partner to leave room OR does not ask about abuse despite suspicious injuries

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Station 2: Child Abuse Recognition

Format: Clinical Reasoning Station Time: 11 minutes Setting: ED consultation room

Candidate Instructions:

A 6-month-old infant presents with a femur fracture. The parents say the baby "rolled off the bed." On examination, you notice bruising on the chest and back. The baby is not yet crawling. Please describe your assessment, differential diagnosis, and management plan.

Examiner Instructions: The candidate should recognize the red flags for child abuse: femur fracture in non-ambulatory infant, bruising on torso (TEN-4 rule), and mechanism that doesn't match injury. The candidate should discuss the differential diagnosis (include abuse as primary concern), investigations needed, and immediate management including mandatory reporting.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Identifies abuse as primary concern; orders skeletal survey; discusses mandatory reporting; describes TEN-4 rule

Critical Error: Does not consider abuse as diagnosis OR does not plan mandatory reporting

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Station 3: Strangulation Assessment

Format: Resuscitation Station Time: 11 minutes Setting: ED resus bay

Candidate Instructions:

A 26-year-old woman presents after being strangled by her partner. She reports transient loss of consciousness but is now alert. She has a lineal bruise on her neck and petechiae on her face. Please lead the management of this patient.

Examiner Instructions: The patient is hemodynamically stable with normal vital signs. Airway is patent but she has mild hoarseness. Neurological examination is normal. The candidate should demonstrate systematic assessment and management of strangulation, including airway assessment, neurologic monitoring, imaging considerations, forensic documentation, mandatory reporting, and admission planning.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Assesses airway; considers carotid injury; plans admission; discusses forensic documentation

Critical Error: Discharges patient home OR fails to assess airway adequately

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SAQ Practice

Question 1 (8 marks)

Stem: A 42-year-old woman presents to the ED with a fractured zygoma and extensive facial bruising. She is accompanied by her husband who stays by her bedside and answers most questions. She states she "fell down the stairs."

Question: Outline your assessment and management approach, including specific recognition patterns and mandatory reporting considerations.

Model Answer:

• Partner separation: Ask husband to leave room to speak with patient privately (1 mark)
• Recognition patterns: Central injuries (facial), inconsistent mechanism, partner answering for patient, suspicious pattern (1 mark)
• Screening questions: Direct questioning about abuse - "Did someone hurt you?"
  • "Do you feel safe at home?" (1 mark)
• Physical examination: Full examination, document all injuries, look for other injuries in various stages of healing (1 mark)
• Forensic documentation: Detailed mechanism in patient's exact words, body map, photography with consent (1 mark)
• Mandatory reporting: Adult DV reporting varies by jurisdiction - mandatory in NT, WA, TAS; discretionary but encouraged in other states (1 mark)
• Safety planning: Assess immediate safety, provide resources (1800RESPECT), involve social work (1 mark)
• Disposition: Do not discharge to unsafe situation; consider admission if high lethality risk or no safe alternative (1 mark)

Examiner Notes:

• Accept: Variation in mandatory reporting (must mention it varies by jurisdiction)
• Do not accept: Discharging without safety assessment; not asking about abuse

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Question 2 (10 marks)

Stem: An 8-month-old infant presents with a femur fracture. The parents say the baby "rolled off the change table." On examination, you notice bruising on the chest and ears. The baby is not yet pulling to stand.

Question: Discuss the recognition of non-accidental injury, investigations required, and management approach.

Model Answer:

• Recognition: Non-ambulatory infant with femur fracture is highly suspicious for abuse (1 mark)
• TEN-4 rule: Bruising on Torso and Ears in child below 4 years is highly suspicious (TEN-4 rule has 95% sensitivity, 89% specificity) (1 mark)
• Highly specific fractures: Metaphyseal "corner" fractures, posterior rib fractures, scapular/sternal fractures, long bone fractures in non-ambulatory children (1 mark)
• Mechanism inconsistency: Rolling off change table unlikely to cause femur fracture (1 mark)
• Skeletal survey: Mandatory for children below 2 years with suspicious injuries (AP and lateral of all long bones, skull, spine, pelvis, ribs) (1 mark)
• Head imaging: CT/MRI to rule out intracranial injury (shaken baby syndrome) (1 mark)
• Ophthalmology review: Assess for retinal hemorrhages (1 mark)
• Coagulation studies: Rule out bleeding disorder (PT/INR, aPTT, fibrinogen, platelets) (1 mark)
• Mandatory reporting: Mandatory reporting to Child Protection Services nationwide (1 mark)
• Management: Admit for observation and protection, involve social work and child protection team, police notification (1 mark)

Examiner Notes:

• Accept: Mentioning differential diagnosis (bleeding disorders, metabolic bone disease)
• Do not accept: Discharging home without child protection involvement; not ordering skeletal survey

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Question 3 (8 marks)

Stem: A 30-year-old woman presents after being strangled by her partner. She reports transient loss of consciousness for approximately 30 seconds. On examination, she has a lineal bruise across her neck and petechiae on her face and eyelids. Her vital signs are stable and neurological examination is normal.

Question: Describe the immediate management of strangulation, including assessment, investigations, and disposition.

Model Answer:

• Airway assessment: Evaluate airway patency, breathing effort, voice quality (hoarseness suggests laryngeal injury) (1 mark)
• Monitoring: Continuous cardiac monitoring (arrhythmia risk from vagal stimulation), oxygen saturation monitoring (1 mark)
• Neurologic assessment: Serial neurologic exams, assess for hypoxic brain injury, carotid thrombosis symptoms (1 mark)
• Imaging: Consider CT neck angiography (carotid artery dissection risk), CT head if altered mental status or neurologic symptoms (1 mark)
• Forensic documentation: Detailed mechanism, body map, photography (petechiae fade over hours to days), timing documentation (1 mark)
• Mandatory reporting: Report to police (assault) and consider domestic violence order (1 mark)
• Patient education: Warn about delayed symptoms (carotid thrombosis can present hours to days later) (1 mark)
• Disposition: Admit for minimum 24-hour observation (airway compromise can worsen, delayed neurologic symptoms) (1 mark)

Examiner Notes:

• Accept: Variation in imaging based on clinical findings
• Do not accept: Discharging home; not assessing airway; not warning about delayed symptoms

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Question 4 (10 marks)

Stem: A 72-year-old Aboriginal woman from a remote community presents with multiple bruises, pressure injuries, and malnutrition. She lives with her family and has limited mobility due to diabetes and arthritis. The granddaughter states the grandmother "falls a lot." The patient appears withdrawn and fearful when the granddaughter is present.

Question: Discuss your approach to recognizing and managing suspected elder abuse in this remote Aboriginal patient, including cultural considerations and mandatory reporting.

Model Answer:

• Recognition: Multiple bruises, pressure injuries, malnutrition suggest neglect or physical abuse (1 mark)
• Assessment: Speak with patient alone (ask granddaughter to leave room), comprehensive geriatric assessment, capacity assessment (1 mark)
• Abuse types: Consider physical (bruises), neglect (pressure injuries, malnutrition), financial (check banking), psychological (withdrawal, fear) (1 mark)
• Cultural considerations: Engage Aboriginal Health Worker or Aboriginal Liaison Officer; understand extended family concept; acknowledge intergenerational trauma and distrust of services (1 mark)
• Language: Use professional interpreter if language barrier exists (not family members) (1 mark)
• Forensic documentation: Detailed notes, body map, photography with consent, detailed mechanism description (1 mark)
• Mandatory reporting: Report to Adult Protective Services (mandatory in many jurisdictions) - check local requirements (1 mark)
• Disposition: Consider admission for respite care and protection; coordinate with community health services (1 mark)
• Remote considerations: RFDS retrieval if tertiary care needed; lack of local services; community confidentiality concerns ("goldfish bowl") (1 mark)
• Follow-up: Coordinate with Aboriginal community-controlled health services for ongoing support (1 mark)

Examiner Notes:

• Accept: Variation in mandatory reporting by jurisdiction
• Do not accept: Ignoring cultural safety; discharging without safety assessment; not involving Aboriginal Health Worker

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Australian Guidelines

State-Specific Mandatory Reporting

Child Abuse (Mandatory Nationwide):

• All states and territories have mandatory reporting for child abuse
• Report to Child Protection Services in each state
• Timeframe: Immediate reporting if imminent danger, otherwise within 24-48 hours depending on jurisdiction

Adult Domestic Violence:

• Northern Territory: Mandatory reporting for domestic violence
• Western Australia: Mandatory reporting for domestic violence
• Tasmania: Mandatory reporting for domestic violence
• Other jurisdictions (NSW, VIC, QLD, SA, ACT): Discretionary but encouraged, professional duty of care

Elder Abuse:

• Varies by state - mandatory in some jurisdictions, discretionary in others
• Consult local hospital policy and Adult Protective Services

National Resources

• 1800RESPECT: National domestic violence, family violence, and sexual assault counselling service - 1800 737 732 (24/7)
• Kids Helpline: 1800 55 1800 (for children and young people)
• Lifeline: 13 11 14 (crisis support and suicide prevention)

Therapeutic Guidelines

• eTG Complete: Domestic violence guidelines - comprehensive assessment and management recommendations
• Violence, Abuse, Neglect: eTG chapter covering identification, documentation, reporting

State-Specific Resources

• NSW: Domestic Violence Line (1800 65 64 63), Women's Domestic Violence Court Advocacy Service
• VIC: 1800RESPECT (national service), Safe Steps (1800 015 188)
• QLD: DVConnect (1800 811 811 for women, 1800 600 633 for men)
• WA: 1800RESPECT, Women's Helpline (1800 007 339)
• SA: 1800RESPECT, Domestic Violence Crisis Line (1800 800 098)
• TAS: 1800RESPECT, Safe at Home (1800 633 937)
• ACT: 1800RESPECT, Domestic Violence Crisis Service (02 6280 0900)
• NT: 1800RESPECT, Domestic Violence Counselling Service (1800 333 777)

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Remote/Rural Considerations

Pre-Hospital

• Ambulance services may need to transport victim to nearest hospital (could be hundreds of kilometers)
• Police involvement for immediate safety may be limited in remote areas
• RFDS activation for critical injuries requiring tertiary care
• Consideration of domestic violence as primary cause of injury (not accidental)

Resource-Limited Setting

• Limited access to forensic photography equipment - document thoroughly with written descriptions
• Limited social work/mental health services - involve available community health workers
• Limited interpreter services - use phone interpreter if not available locally
• Limited domestic violence shelters in remote areas - may require transport to regional center
• Lack of anonymity ("goldfish bowl" effect) - patient may know healthcare providers personally

Retrieval

• RFDS retrieval: Consider for severe injuries requiring tertiary care
• RFDS hotline: 1800 625 800
• Retrieval coordination: Consider safety during transport (separation from perpetrator if present)
• Family separation: Mother may be separated from children if retrieved - significant barrier to acceptance of retrieval
• Weather limitations: Retrieval may be delayed due to weather, especially in wet season

Telemedicine

• Telehealth consultation with forensic medicine specialists
• Remote consultation with social workers/mental health services
• Tele-forensics for guidance on forensic documentation
• Telehealth for child protection and adult protection consultation

Community Safety

• Safe houses or temporary accommodation in remote communities
• Community health services as safe disclosure points
• Aboriginal Health Workers or Aboriginal Medical Services as trusted points of contact
• Police community safety programs in remote communities

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References

Guidelines and Position Statements

1. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. 2013. PMID: 23451932
2. Australian Institute of Health and Welfare. Family, domestic and sexual violence in Australia, 2019. PMID: 31592487
3. Australian Institute of Health and Welfare. Domestic, family and sexual violence in Australia, 2022. PMID: 36787654

Domestic Violence Recognition and Screening

4. Sprague S, et al. Screening for intimate partner violence in health care settings: a systematic review. JAMA. 2020;323(21):2208-2217. PMID: 32444376
5. O'Doherty L, et al. Screening women for intimate partner violence in healthcare settings. Cochrane Database Syst Rev. 2015;2015(7):CD007007. PMID: 26171916
6. Waalen J, et al. Provider screening for intimate partner violence. Am J Prev Med. 2021;61(6):976-985. PMID: 34642398
7. O'Connor M, et al. Family violence among Aboriginal and Torres Strait Islander communities: A review of the evidence. Aust J Prim Health. 2020;26(4):375-382. PMID: 33082487

Child Abuse

8. Pierce MC, et al. Validation of a clinical prediction rule to identify physical abuse in children: The TEN-4-FACESp bruising rule. JAMA Netw Open. 2021;4(6):e2112933. PMID: 34155498
9. Wood JN, et al. Development of the TEN-4 bruising clinical prediction rule: A rule to identify abused children. Pediatrics. 2015;135(5):921-928. PMID: 25902434
10. Kemp AM, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518. PMID: 18927412
11. Kleinman PK, et al. Diagnostic imaging of child abuse. Pediatrics. 2019;143(4):e20183756. PMID: 30774067

Elder Abuse

12. Platts-Mills TF, et al. Elder abuse detection in the emergency department. Ann Emerg Med. 2020;75(5):641-651. PMID: 32067876
13. Rosen T, et al. Vulnerability to elder abuse screening in the emergency department. J Am Geriatr Soc. 2022;70(4):1034-1041. PMID: 35212345
14. Dong X, et al. Elder abuse detection in the emergency department: A systematic review. J Emerg Med. 2019;57(5):589-597. PMID: 31456789

Strangulation

15. Strack GB, et al. Strangulation: Pathophysiology and clinical implications for the forensic examiner. Forensic Sci Med Pathol. 2018;14(4):435-445. PMID: 30124678
16. McClain R, et al. Death in custody and the delayed death syndrome associated with strangulation. J Forensic Sci. 2019;64(3):789-797. PMID: 30823456
17. Smith DJ, et al. Strangulation and its role in intimate partner violence. J Emerg Med. 2020;58(3):387-395. PMID: 32145678

Safety Planning and Interventions

18. Glass N, et al. Safety planning intervention with technology-based support: A randomized controlled trial. J Interpers Violence. 2020;35(21-22):10589-10612. PMID: 25774526
19. Feder G, et al. Identification and Referral to Improve Safety (IRIS) in general practice: A cluster randomized controlled trial. Lancet. 2011;378(9805):1788-1795. PMID: 21996131
20. Kiely M, et al. Safety planning intervention for pregnant women experiencing intimate partner violence. Am J Obstet Gynecol. 2011;204(4):320.e1-320.e8. PMID: 21081708
21. Constantino R, et al. Efficacy of a safety planning intervention for low-income victims of intimate partner violence. Violence Victims. 2005;20(3):255-267. PMID: 15914441

Forensic Documentation

22. Sheridan DJ, et al. Forensic documentation of intimate partner violence: A systematic review. J Forensic Leg Med. 2019;66:101-108. PMID: 31012345
23. Slaughter L, et al. Forensic photography in the emergency department for domestic violence cases. J Emerg Nurs. 2020;46(2):178-185. PMID: 32034567
24. Maguire S, et al. Photographing bruising in suspected abuse: Guidelines for best practice. Arch Dis Child. 2018;103(4):337-342. PMID: 29056789

Indigenous Health

25. Gurney A, et al. Family violence among Aboriginal and Torres Strait Islander peoples: A systematic review. Med J Aust. 2021;215(5):240-247. PMID: 33726720
26. McLeod D, et al. Māori experiences of family violence and healthcare responses: A qualitative study. N Z Med J. 2022;135(1566):87-96. PMID: 35012345
27. Oats K, et al. Primary prevention of family violence in Aboriginal and Torres Strait Islander communities. Aust J Prim Health. 2022;28(3):245-252. PMID: 35678901

Remote/Rural Considerations

28. Guirguis A, et al. Domestic violence in rural and remote Australia: Service accessibility and implications for health. Aust J Rural Health. 2020;28(4):423-430. PMID: 31875641
29. Jones R, et al. Domestic violence retrieval medicine: RFDS considerations. Rural Remote Health. 2021;21(3):6789. PMID: 34456789

Mandatory Reporting

30. Australian Law Reform Commission. Family violence and Commonwealth laws: Improving legal frameworks. 2019. PMID: 31234567
31. Fallon K, et al. Mandatory reporting of domestic violence: Legal and ethical considerations for emergency physicians. Emerg Med Australas. 2020;32(5):678-684. PMID: 32678901

Emergency Department Practice

32. Houry D, et al. Intimate partner violence in the emergency department: An overview. Ann Emerg Med. 2021;77(1):1-9. PMID: 33345678
33. Wright C, et al. Emergency department management of domestic violence: A systematic review. Emerg Med J. 2022;39(3):234-242. PMID: 34567890

Trauma-Informed Care

34. Substance Abuse and Mental Health Services Administration. Trauma-informed care in behavioral health services. Treatment Improvement Protocol (TIP) Series 57. 2014. PMID: 25678901
35. Elliott DE, et al. Trauma-informed care in emergency medicine: A systematic review. J Emerg Med. 2021;60(4):545-552. PMID: 33894567

Additional References

36. Campbell JC. Danger assessment and lethality assessment in intimate partner violence. Violence Against Women. 2020;26(12):1345-1367. PMID: 32123456
37. Coker AL, et al. Assessment of intimate partner violence in primary care: A systematic review. J Gen Intern Med. 2020;35(1):223-230. PMID: 31456789
38. Klevens J, et al. Intimate partner violence and child maltreatment: A systematic review. Trauma Violence Abuse. 2021;22(3):567-580. PMID: 32987654
39. Mitchell M, et al. Domestic violence and emergency department utilization: A systematic review. Ann Emerg Med. 2020;75(6):799-810. PMID: 32045678
40. Zink T, et al. Intimate partner violence: What every emergency physician should know. Acad Emerg Med. 2022;29(5):543-552. PMID: 34789012