What is the best course of action for a bruised female patient in the ER who reports a fall, but shows signs of potential domestic violence with an intimidating relative present?

Provide Treatment and Support While Ensuring Patient Safety

The correct action is to provide treatment and support (option 2) while simultaneously ensuring the patient's safety through private assessment for intimate partner violence (IPV), as emergency physicians have an explicit ethical duty to diagnose, treat, and properly refer suspected victims of abuse. 1

Immediate Actions Required

Separate the Patient from the Potentially Abusive Relative

• Interview the patient alone in a private setting, as the presence of an angry, intimidating relative who causes the patient to suddenly change her story and want to leave is a red flag for IPV 1
• Use a clinical pretext to separate them (e.g., "We need to perform a physical examination" or "We need to ask some private medical questions") 1
• Ensure adequate security personnel are available to maintain a safe environment for both patient and staff 1

Conduct Private IPV Screening

• Ask direct, specific questions about abuse when alone with the patient: "Are you safe at home?" "Has anyone hurt you or threatened you?" "Are you afraid of your partner/relative?" 1
• Document the inconsistency between her initial fall story and the presence of multiple bruises, the intimidating behavior of the relative, and her sudden desire to leave 1
• Assess for patterns of injury inconsistent with the stated mechanism (falls from stairs typically don't cause multiple bruises in various stages of healing) 1

Treatment and Documentation

Medical Care

• Provide necessary medical treatment for all injuries identified, regardless of whether she discloses abuse 1
• Perform a thorough head-to-toe examination documenting all injuries with precise descriptions, measurements, and photographs if possible (with consent) 1
• This documentation may be critical for future legal proceedings even if she's not ready to report now 1

Safety Planning

• Provide resources even if she denies abuse: Give her written information about domestic violence hotlines, shelters, and safety planning that she can conceal (e.g., disguised as general health information) 1
• Explain that help is available whenever she's ready, and that she can return to the ED at any time 1

Mandatory Reporting Considerations

• Report to appropriate authorities as required or permitted by local law - many jurisdictions mandate reporting of suspected IPV, particularly when there are visible injuries 1
• The ethical duty to report domestic violence supersedes patient autonomy when there is reasonable suspicion of ongoing danger 1

Why Other Options Are Incorrect

Option 1 (Ethics Committee) is Wrong

• Ethics committees are consulted for complex ethical dilemmas requiring deliberation, not acute safety situations requiring immediate intervention 1
• This would cause dangerous delays in addressing an urgent safety concern 1

Option 3 (Respect Choice/Do Nothing) is Wrong

• This directly violates the emergency physician's ethical duty to diagnose, treat, and refer suspected abuse victims 1
• Doing nothing when IPV is suspected enables continued violence and potentially escalating harm, including homicide risk 1
• The patient's "choice" to leave may be coerced by the presence and intimidation of the abuser 1
• Vulnerable populations require evaluation for domestic violence signs, especially when behavioral changes occur in the presence of a potentially abusive person 1

Option 4 (Explain to Both) is Wrong

• Never discuss IPV suspicions in the presence of the suspected abuser, as this dramatically increases danger to the victim 1
• This approach could trigger immediate retaliation and prevent the patient from ever disclosing abuse 1

Common Pitfalls to Avoid

• Never accept "I fell" at face value when the injury pattern is inconsistent or an intimidating relative is present 1
• Don't be deterred by the patient's initial denial - victims often deny abuse multiple times before disclosing, especially when the abuser is nearby 1
• Don't assume that because she wants to leave, you have no further obligation - provide treatment, documentation, resources, and reporting as indicated 1
• Recognize that the patient's sudden change in demeanor when the angry relative arrived is a critical diagnostic clue for IPV 1