By all appearances, the middle-age woman who arrived last month at an Orange County hospital emergency room with two crushed ribs and a broken wrist had been injured in a routine highway accident.
But a nurse grew suspicious when the woman insisted on leaving the hospital before her husband, who was unhurt in the crash, could take her home.
Sally, not her real name, later recounted being too frightened to tell the nurse that the accident was caused when her husband accelerated on a hairpin turn after threatening to kill them both.
As Sally left the hospital after being treated, the nurse handed her the phone number of a shelter for battered women and a dollar for bus fare to a community center where Sally could call the shelter.
The nurse’s alertness illustrates the crucial role emergency rooms can play in detecting domestic violence and helping victims find safety. But far too often, emergency room personnel fail.
“Many cases are overlooked,” said Dr. Patricia Salber, past president of the California Chapter of the College of Emergency Physicians.
Salber co-authored a statewide survey of hospital emergency rooms, released two weeks ago, that concluded emergency room doctors and nurses often don’t recognize women with injuries caused by husbands or boyfriends.
The American Medical Assn. says victims of domestic violence represent about a third of all women who visit emergency rooms. But the survey, sponsored by the San Francisco-based Family Violence Prevention Fund, stated that emergency rooms actually identify only 5% of the battered women they see.
The problem, said the survey, is partly because medical personnel often don’t know how to draw information from women who usually are too afraid or embarrassed to reveal the cause of their injuries. Only 23% of emergency room directors in the survey said they conducted sessions on domestic violence for their physicians.
Also, the survey found that few emergency rooms have written policies and procedures to identify, evaluate and refer abused women that meet criteria established by a national commission that accredits hospitals.
The same shortcomings exist among Orange County’s approximately 35 hospital emergency rooms, where, according to medical officials, there is no uniformity in training programs to detect domestic violence.
Yet for some emergency room workers, the survey, reinforcing other national studies on the issue, is a wake-up call.
“The situation is much more subtle than we thought,” said Dr. Stewart Brash, medical director of the emergency department at Western Medical Center-Santa Ana. “It is not just the woman with the big black and blue eye who says she has been beat up by her husband.”
“We have to look a little harder and question a little more aggressively,” he said.
Learning to tackle domestic violence, experts say, is the latest challenge in the hospital emergency room, where personnel already have been trained to deal with child and elder abuse.
Dr. Wes Fields, director of the emergency department at Saddleback Memorial Medical Center, said Saddleback, like many hospitals, has “standing policies and procedures for child abuse and elder abuse.” Now Saddleback is writing similar guidelines for victims of domestic violence.
Fields believes that the lag in paying more attention to battered women in emergency rooms in part “reflects gender biases in society and the underrepresentation of women in medicine and in emergency medicine in particular.”
Hospitals do not generally keep statistics on spousal abuse, as they do on child abuse, and most hospitals can only estimate how many battered women they treat.
However, the state Bureau of Criminal Statistics reports that in 1992, law enforcement agencies in Orange County received 13,876 calls related to domestic violence, up from 11,265 in 1988. Also in Orange County last year there were 1,567 arrests connected to spousal abuse, up from 601 arrests four years earlier.
Concern over escalating violence in the home prompted the formation earlier this year of a task force headed by Orange County Superior Court Presiding Judge Donald E. Smallwood. The group is trying to coordinate county resources--including doctors, law enforcement and social services--to tackle the problem.
“The emergency rooms are an essential link,” Smallwood said.
The problem isn’t easy to solve, partly because of the victims themselves.
Professionals who work with battered women say many are reluctant to reveal the true cause of their bruises, so emergency room personnel must be detectives looking for clues.
“A lot isn’t training, it is gut reaction,” said Dr. Peter Anderson, medical director of the emergency room at Fountain Valley Regional Hospital and Medical Center. “If she has a lot of bruises on her face and says she fell in the bathtub, you might be suspicious. How do you get two black eyes in a bathtub?”
Fran Shiffman, executive director of the Women’s Transitional Living Center, which operates a shelter in north Orange County, said a woman with suspicious-looking injuries should be questioned gently in a room apart from her husband.
“Often he is in the waiting room or just outside a curtain and she does not feel safe,” Shiffman said.
Shiffman said that Sally, who was referred to the Transitional Living Center’s shelter by the emergency room nurse, still lives in fear that her husband will find her, even though the address of the shelter is confidential and the doors are locked against intruders 24 hours a day.
Some emergency room directors say they are doing as much as they can for women, despite the obstacles.
“It is very difficult to say that emergency room personnel are not fulfilling their responsibility because the women often don’t tell them the truth,” said Orange County Deputy Dist. Atty. Wendy Lindley, who prosecutes domestic violence cases.
But some emergency room directors know they need to do more.
Brash said he will place posters in his emergency waiting room with telephone numbers that battered women can call for counseling or shelter. He also plans to begin training nurses and physicians to recognize abuse.
Interviewing suspected victims must be done sensitively, he warned. “We have to walk sort of a narrow line. We don’t want to badger them, or the next time they get hurt they will be afraid to come to the hospital.”
Carol Williams, executive director of Interval House Crisis Shelters, which operates two shelters for battered women in Orange County, said she has advised hospital administrators that her organization can provide a safe haven for their patients and training for their emergency room staffs.
Operators of the three local shelter programs for battered women, with space for about 120 women and children, say that even if the shelters are full they will house an endangered woman in a motel or the home of a shelter volunteer.
Shiffman said last year, 25 of the 150 battered women who used the North County shelter were referred from hospital emergency rooms, a figure that she believes is far too low.
“I am not pointing a finger of blame. I know emergency rooms are very hectic and crisis-oriented,” Shiffman said. “However, the emergency room staff needs to be aware because if no one intervenes in domestic violence, it continues and escalates and the injuries get more severe.”
Emergency room directors say that cultural factors play a role among Latino and Asian immigrants in discouraging women from turning in abusive spouses to authorities.
“There is a lot of shame associated with talking about family problems in those cultures,” Shiffman said. “Added to the problem are language barriers in talking with nurses and doctors who are mostly English-speaking.”
Emergency room physicians and nurses say battered women are found in all economic and social strata.
Women who don’t work and depend on their husbands’ salaries may try to keep the abuse a secret for fear of sullying the reputations of their husbands and thus jeopardizing their own financial security, experts say.
“We have a lot of abuse in Irvine. But they are more likely to say it was an accident, because they have a lot more to lose economically,” said county prosecutor Lindley.
Irvine Medical Center officials said they see few battered women in their emergency room, speculating that is because abused wives and girlfriends in that community instead see private family physicians in confidence for their treatment.
Emergency room personnel are frustrated when their attempts to rescue abused women are repelled.
Dr. Peter Czuleger, an emergency room physician at Mission Hospital Regional Medical Center in Mission Viejo, said, “Even though we suspect some things, if a woman sticks to her story that it was a fall down the stairs, there is nothing we can do.”
“It is frustrating,” he added, “when they say, ‘Yes, he does that but I won’t press charges and I will deny it if you call the police.’ ”