Transcript PowerPoint 프레젠테이션

증례
36세 여자가 “살려주세요”라고 외치며 들어온다.
1시간 전에 자던 중에 갑자기 남편이 야구 방망이로 자신
을 죽이려고 했다는 것이다.
Social Emergencies
(Violence and Other Issues)
연세대학교 의과대학 응급의학교실
조광현
목적
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폭력이란?
폭력을 어떻게 선별하고, 기록하며, 보고하는가?
치료와 의뢰를 어떻게 할 것인가?
안전에 대한 평가는 어떻게 하는가?
피해자와 관련된 윤리적 문제점들은 무엇인가?
무엇을 알아야 하는가?
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가정폭력이 여성의 폭력관련손상에 가장 많은 요인이다.
폭력이 응급의학과 방문의 원인이 되거나 흔한 요인 중
에 하나이다.
폭력이 응급실에서 제대로 발견되지 않는다.
초기 발견이 미래의 장애나 죽음을 예방할 수 있다.
의료진의 역할은 발견, 치료, 기록, 의뢰다.
성공은 학대에 대해 질문을 하는 것이다.
떠나는 것은 치명적일 수 있다.
Domestic Violence
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
Social problem with disastrous health
consequences
Definition
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The use of a pattern of assaultive and coercive behaviors,
including physical, sexual, and psychological attacks, as
well as economic coercion, which adult or adolescent
use against their intimate partner
Epidemiology
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2-4 million battered women
20-25% of all adult women
32% will be battered again within 6 month
34% witnessed man beating his wife
2000 die
31% female homicide
Men kill in response to women’s attempt to leave the
abusive relationship
증례
여자는 우측 가슴과 사타구니 부위가 아프다고 하였
다. 매우 흥분되어 울고 있었으며 우측 가슴과 사타
구니 부위에 멍이 들고 부어 있었으며 양측 무릎에
얕은 상처가 있었다.
Emergency Department Presentation
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Traumatic injury, depression, anxiety,
hyperventilation, substance abuse, suicide attempts,
STD, complications of pregnancy, headache,
chronic pain syndrome
Exacerbation of illness (withhold medication)
Barriers to Diagnosis
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Misconceptions
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Patient withholds information; Fear of opening
“Pandora’s box”; Lack of physician training; Fear of
offending patient; Time constraint; Does not know what
to do about it; Believe intervention will not work
nontraumatic complaint
Routine screening for domestic violence
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Ask directly (privately)
Consequences of Failure to Diagnose
Domestic Violence
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Multiple visits
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23% had 6-10 visits, 20% had more than 11 visits
Inappropriate use of psychoactive drugs or
psychiatric hospitalization
Substance abuse or depression, disability or death
Adversely affect the children of victims
증례
The Battered Women
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Who is she?
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Why does she stay?
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Any women
The only true risk factor is being female
Afraid of escalating the violence
Systematically cut off from family and friends
Still love their partner
Why doesn’t she tell
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Fear - not confidential, retribution, believe the physician
does not care
Men Who Batter
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Any men
Higher levels of personality dysfunction
Use power to control the behavior of their partner
and children
Use denial and minimalization, blame others as
justifications for their actions
Alcohol - associated with intensity of violent
behavior
The Effect of Domestic Violence on Children
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30-54% of reported cases of spousal abuse also
report child abuse
1/4-1/2 are hurt accidentally when they try to
intervene
behavioral difficulties - depression or PTSD
high-risk behaviors - drug use, promiscuity,
criminal behavior
repetition of violence
Making the Diagnosis of Domestic Violence
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History and physical examination
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Pregnancy
central pattern of injury
injuries suggesting a defensive posture
certain characteristic injuries
injury inconsistent with the patient’s explanation
multiple injuries in various stages of healing
substantial delay between the time of injury and the
presentation for treatment
frequent visits for vague complaints without evidence of
physiologic abnormality
suicide attempts
multiple prior visits
partner’s behavior
Making the Diagnosis of Domestic Violence
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Routine screening for domestic violence
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Ask directly about the presence of violence in the
patient’s life
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In private, in a sensitive, nonjudgmental way
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Verbal or written questionnaire
Treatment Goals
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Safety of the woman and children
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Assess potential for suicide or homicide
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Psychiatric consultation
Safety assessment
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Domestic violence expert
Essential Information for Battered Women
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She needs to know she is not alone
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She needs to know there is help available for her
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She does not deserve to be beaten
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Refer to domestic violence expert
Preparing the Emergency Department for
Optimal Response
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Optimal
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Services beyond the confines of the emergency department
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Battered women’s shelter, police, legal community, and other
social services
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Domestic violence committee
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Uniform institute-wide response
Protocol
Medicolegal Considerations
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Careful documentation in the medical record
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Photographs of visible injuries
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Obtain consent and document time and date of the
photograph
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Hand-drawn body map detailing areas of
tenderness or hematomas
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Safety plan
Sexual Assault
Female and Male Sexual Assault
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Violent crime
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Motivated by
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Need for power and control
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Anger
Physician’s role
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Patient’s physical and psychologic well-being
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If patient wants to prosecute, provide police with
corroborating medical evidence
Epidemiology
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5% of all violent crime
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one in five will be raped in life time
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20% adult, 12% of adolescent women experience sexual
abuse
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most underreported violent crime (10%)
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male sexual assault (2-4% of all rape)
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facial, extremity injuries are most common
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gynecologic injuries: 7%
Clinical Feature
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Female
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Professional and caring
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Assault - who; What happened; When; Where; Douche,
shower,or change of cloth?
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Medical - last menstrual period; Birth control method;
Last consensual intercourse; Allergies and prior medical
history; Prior sexual assault?
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Physical and evidentiary examination
담당의사의 역할과 책임
1.
2.
3.
4.
5.
6.
7.
8.
구급처치 및 생명을 위협하는 손상에 대한 진단과
치료
성폭력 피해 상황 및 부인과 병력에 대한 문진
피해부위 파악 및 기록과 치료
각종 배양 검사 실시 및 성병 예방
임신 예방
법적 증거물채취 및 기록
진단 치료 후의 상담
추적 관찰
Diagnosis
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Legal determination
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Any degree of carnal knowledge
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nonconsent-unless the victim is a minor, intoxicated, or
mentally incompetent
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Compulsion or fear of great harm
증거물 흐름도
Forensic Laboratory Evaluation
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Sperm survivability
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Acid phosphatase
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Glycoprotein p30
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Genetic typing
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ABO, peptidase A, phosphoglucomutase(PGM), DNA
Treatment
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Physical injuries management by standards of care
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Attend to psychological need of patient
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Pregnancy prophylaxis
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Negative test before postcoital contraception
Sexually transmitted disease prophylaxis
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Gonorrhea, chlamydia, HBV, HIV counseling and testing
Follow-up Care
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Admission indication 1-2%
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24h emergency department counseling
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Multidisciplinary sexual assault response team
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Coordinated, sensitive care
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Medical, legal, psychological
Written instructions - victims recall very little of
their ED care
Child Abuse
증례
5세의 남자아이가 침대에서 놀다 떨어졌다고 하면
서 부모가 데리고 왔다. 아이는 왼쪽 가슴을 매우 아
파하였고 식은 땀을 흘리며 창백해 보였다. 아이 생체
징후는 혈압 100/80 mmHg, 맥박 103회/분, 호흡수
22회/분, 체온 섭씨 37.8도 였다.
아동학대 신고접수 현
황
(1997 ~ 2000.10)
자료-한국복지재단
아동학대 유형별
현황
(1997 ~ 2000.10)
자료-한국복지재단
Child Abuse and Neglect
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Child maltreatment
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Harm to a child because of
abnormal child-rearing
practice
Physical, sexual, emotional
abuse, parental substance
abuse, physical, nutritional,
emotional neglect,
supervisional neglect,
Munchausen syndrome by
proxy
Knowledge of normal child
development
정서적
한국보건사회연구원 실태조사 - 1998
-꼴도 보기 싫다, 병신 이라는 욕설
(72.9%)
- 학교 그만두고 집안 일이나 해라
(53.7%)
- 집에서 쫓겨난 경험 (51.4%)
- 우리집에서 너만 없었으면 좋겠다
(47.8%)
- 나가 죽어라 또는 갖다 버리겠다
(44.9%)
Child Neglect
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Physical, emotional
Failure to thrive
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intercurrent infections:
monilial diaper dermatitis,
AGE
Malnutrition, poor hygiene
Psychosocial dwarf
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Short stature, bizarre
voracious appetite,
disturbed home situation
방
임
한국보건사회연구원 실태조사 - 1998
- 숙제를 해가는지 관심이 없음
(63.2%)
- 어두워질 때까지 혼자 집을 봄
(62.3%)
- 학교 준비물을 챙겨 주지 않음
(61.8%)
Munchausen Syndrome by Proxy
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Uncommon
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Parent induces or fabricates an illness in a child in
order to secure a prolonged contact with health
care provider
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Move from hospital to hospital in search of
diagnosis
Sexual Abuse
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Unrelated complaint
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Disclose their abuse in time
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Assailant is known in over 90%
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History and physical
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Ask directly
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Genital exam: careful inspection
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STD
Child protective service, law enforcement
Physical Abuse
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Spectrum of injuries is
wide
2/3 under 3 year old,
1/3 under 6 month old
Inconsistent history
Physical exam
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Multiple bruised areas
Burns
Shaken baby, shaken
impact syndrome
신체적
한국보건사회연구원 실태조사 - 1998
- 손.회초리로 손바닥, 종아리를 맞음
(92.6%)
- 빗자루나 굵은 몽둥이로 맞음
(80.0%)
- 얼굴이나 뺨 등을 맞음 (72.5%)
- 던진 물건으로 맞음 (51.4%)
- 칼이나 흉기로 위협 당함 (27.5%)
- 다락방이나 장롱 등에 갇힘 (24.3%)
- 팔,다리가 묶임 (21.4%)
증례
흉부 엑스선 촬영에서 좌측 늑골 5-8번까지 골절이
있었으며 혈흉이 의심되었다.
아이의 부모는 모두 서로 전 결혼에서 이혼 후 다시
결혼하였으며 전 결혼에서 서로의 아이들을 데리고
와서 양육하고 있었다.
부모의 말에 의하면 아이들이 서로 장난이 심해 한
아이가 다른 아이를 침대 위에서 놀다가 뛰어내리면
서 차가지고 일어난 일이라고 한다.
Management
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Medical management guided by physical findings
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Report to police or child protection agency
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Physicians are protected by the law from legal
retaliation
Violence
(Public Health Emergency)
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Denies the health of the person
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Diminishes the whole human process
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Violent act and repercussions
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Ripple effect affects everyone
Violence As a Public Health Problem
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Effect of violent act on large population
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Direct effect: victims, witnesses, family members
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Indirect effect: home, workplace, community
Focus on prevention
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Strongest argument of public health approach to violence
control
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Concentrated and coordinated effort for multidimensional
and multifactorial problem
Surveillance and epidemiologic analysis
Violence As a Public Health Problem
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Coordinated and sustained intervention
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Scientific evaluation of the effectiveness of these
interventions
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Hallmark
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Identify high-risk group, design and implement strategic
preventive policies, continue education
Surveillance
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Design and implement surveillance system
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Examine police records, court documents, EMS run
sheets, ED and hospital records
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Real-time online surveillance mechanism
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Timely intervention
Prevention
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Most potential public health approach
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Primary - prevent occurrence
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Secondary - stop ASAP
• Most violence preventive measures
• Law enforcement
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Tertiary - mitigating the effects, reducing repercussions
Can We Succeed
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Violence is complex and long-term problem
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Poverty, drug, alcohol abuse, racism, family
instability, teen pregnancy, overcrowding, school
failure
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Lack of consensus on the real problem and the
approach
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Societal barriers - movies, television, video games,
music, internet
Geriatric Emergency Medicine
Need for Education
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Lack of educational materials
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69% of EP insufficient CME
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53% lack of training in residency
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40% of residency directors - training inadequate
• Ann Emerg Med 1992;21:796-801
• Ann Emerg Med 1992;21:825-829
Evaluation of Older Adults Compared to
Younger Adults
Patterns of ED Resource Use
ED Use By Elderly Persons
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1990 - 15% of ED visits by elderly
Admission to hospital - 5 times
• 32% admitted
ICU Admission - 5 times
• 7% admitted to ICU
Ambulance Service - 4 times
• 30% use ambulance
Comprehensive ED Care - 6 times
• 46% comprehensive care
Ann Emerg Med 1992;21:819-824.
Increase in Elderly
Population (1920 to 2050)
Elder Abuse
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Estimated 1 -2 million victims each year in
the U.S.
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Less than 10% are reported
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27% have elder abuse protocols
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How does this model of care contrast to our approach to
child abuse?
Geriatric Emergency Care Model
ED Environment
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Uncomfortable for older persons
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High volume, high stress
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Anxious, worried patients
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Little privacy
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Limited ED provider time
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Beds, lighting, noise
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Modifications can make a difference
Attitudes and Ageism
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Negative View of Aging
• language
• frail, disabled elderly
• nursing home patients
• distorted view of elderly persons
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Aging - deterioration to be avoided and feared
Attitudes and Ageism
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Aging - state of life
• joys, pains, experiences
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Active, productive, heterogeneous
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Misperceptions
• falls, incontinence, confusion
• thrombolytics
Laboratory Assessment of the Elderly
Laboratory Parameters Unchanged*
Hemoglobin and hematocrit
White blood cell count
Platelet count
Electrolytes (sodium, potassium, chloride, bicarbonate)
Blood urea nitrogen
Liver function tests (transaminases, bilirubin, prothrombin time)
Free thyroxine index
Thyroid-stimulating hormone
Calcium
Phosphorus
Laboratory Assessment of the Elderly
Common Abnormal Laboratory Parameters†
Sedimentation rate
Glucose
Creatinine
Albumin
Alkaline phosphatase
Prostate specific antigen
Urinalysis
Chest radiographs
Electrocardiogram
Serum iron and iron-binding capacity
From Kane RL, Ouslander JG, Abrass IB, Essentials of Clinical Geriatrics. 3rd ed. New York,
NY: McGraw-Hill, Inc;1994:60-61.
*Aging changes do not occur in these parameters; abnormal values should prompt further
evaluation.
†Indudes normal aging and other age-related changes.
Differential Diagnosis
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Does this symptom complex represent myocardial ischemia?
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Does this represent acute cerebral vascular disease?
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Does this represent an infectious process (sepsis)?
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Does this represent an acute abdominal condition?
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Are the symptoms related to the patient’s medications?
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Are the symptoms an exacerbation of a pre-existing disease?
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Do the symptoms fit a new disease process?
ED Assessment of Elderly Patients
ED Mental Status Exam
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High incidence of impairment
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Delirium/Dementia missed in ED
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Reliability of history
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Symptom of medical emergency
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Reversible causes
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Discharge planning
Delirium - acute confusional state
Dementia - impairment in memory and intellectual
function
Missed Delirium in ED Patients
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Screen of 385 patients 65 years or older
Modified CAM Scale
10% of patients met criteria for delirium
ED noted mental status change in only 17% of patients
38% of patients with delirium were discharged from ED with s/p
fall most common diagnosis
14% of patients with delirium died within 3 months compared
to 8% without delirium
Lewis, et al. Am J Emerg Med 1995;13:142-145.
Cognitive Impairments in Elderly Patients
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Cognitive screen done in 547 patients (65 or older)
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No known history of dementia
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34% had moderate or severe impairments not previously
diagnosed
Gersib LW, et al. Ann Emerg Med 1994:23;813.
Alteration in Mental Status in ED
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Adults 70 years or older screened
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40% had altered mental status
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10% had delirium
Naughton, et al. Ann Emerg Med 1995
Case Finding
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252 elderly patients screened
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79% had ADL or IADL deficits
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54% lacked flu vaccination
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36% symptoms of depression
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60% evaluated at follow-up treatment plan initiated
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ED may play a key role in assessing elderly persons
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49% had hazards in their home environment
Gerson, et al. Acad Emerg Med 1995.
Summary Points
1. The elderly person has a unique physiology, pattern and
incidence of disease and psychosocial needs.
2. The optimal emergency care of elderly patients will require a
more comprehensive model of care.
3. The new model of care takes into account the elderly person’s
functional, cognitive, emotional status in assessing the patient
complaint and discharge planning.
4. Cognitive impairments are frequently detected in elderly patients
seeking emergency care. Formal mental status testing will help
assess cognitive impairments and determine the need for further
work up in an emergency department setting.
Summary Points
Continued
5. Assessment of functional activities is important in evaluation
and disposition of elderly patients in the emergency
department.
6. Principles of geriatric emergency medicine have been defined.
Issues such as complexity of the chief complaint, atypical
disease presentation, confounding effects of comorbid
diseases, polypharmacy, cognitive impairment, altered normal
values in some diagnostic tests, decreased functional reserve,
the need for psychosocial support and assessment of
functional status are key factors in optimizing the emergency
care of the elderly.
Key Principles

Always consider and rule-out the worst possible disease based
on the patient’s age, sex, and presenting complaint.

“The eye does not see and the hand does not feel what the
mind does not think of.”
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Appreciate the value of time: reexamine…
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“When in doubt, don’t let them out.”
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Arrange early follow-up

Trust your gut feeling