Physical Exam in Survivors of Torture Laurie Bay, MD Jeremy Hess, MD, MPH Overview • History taking • Approach to exam • Findings – General – Related to specific methods of torture • Documentation History Taking • Obtain complete medical history – Include injuries and scars present before torture. – Document any previous medical conditions, especially those exacerbated by torture or subsequent detention. History Taking • Obtain complete torture history – Ask open-ended questions, allow patient to tell in narrative fashion (make notes). – After narrative is finished ask specifics of torture • Description of devices used • Body positions and methods of restraint • Descriptions of acute and chronic wounds • Any medical treatment during or after torture • Symptoms experienced now that patient relates to their torture History Taking • Ask about acute symptoms after torture – Bleeding, bruising, swelling, open wounds, infection, lacerations, fractures, pain, burns, chemical injuries – Ask about any skin changes or problems the patient can identify that are due to these specific wounds. – Ask how long wounds took to heal, if they were infected, and if treatment was received and what type History Taking • Ask about chronic symptoms – Many are psychosomatic, but some may be due to specific injuries • Headache • Back pain • Sexual dysfunction • GI symptoms • Muscle pain Approaching the Exam • Many times physicians will have been involved in previous torture • Ask patient (if possible) which gender doctor he would prefer • If opposite gender, ensure chaperone present (if possible and patient doesn’t object) • Approach subject by telling patient exactly what you are going to do and asking permission • Tell patient directly that they are in charge and if they want to stop or delay any portion of the examination they can do so at any time. • Ensure privacy and presence of translator (if needed and patient does not object) Exam Findings • Most of what is seen in US is chronic sequelae of torture • Skin and musculoskeletal examinations most important. • Huge topic – read Examining Asylum Seekers from PHR for details (also available free on web) Exam Findings • Be detailed – look at entire body and at every place patient states they were injured (document as you go along) • Explain every test before you do it • Check vital signs, heart, lung, and abdominal exams and document findings (usually normal, rare for patient to have access to sophisticated exam techniques like CT) Specific Findings: Binding • Ligatures: look for linear marks around wrists or ankles due to prolonged application. • Torturers in many countries have learned to use soft restraints to reduce scarring Specific Findings: Beatings • Acutely see bruising in pattern of object used • Chronically see scarring: keloid formation, hypo or hyperpigmentation • Document findings suggestive of deliberate cause: asymmetrical scars, scars on areas not usually scarred, diffuse spread of scarring Specific Findings: Burning • Will produce scars in shape of object used – Cigarettes – Pokers – Electrodes Specific Findings: Electric Shock • Electrodes attached commonly to hands, feet, nipples, mouth, genitals • All areas in between contract tetanically and may cause damage like fractures or dislocations • Scars from electrodes often small: 1-3mm diameter hyperpigmented lesions Specific Findings: Falanga • Also called bastinado and falaka: beating of the soles of the feet • Chronic problems: sequelae of compartment syndrome, crushed footpads with difficulty walking, rigid scarring, rupture of plantar aponeurosis – Squeezing tarsal bones or flexing great toe causes pain – In normal feet will feel flexing of plantar aponeurosis at around 20 degrees, higher values may indicate rupture Specific Findings: Suspension • Injuries are musculoskeletal and neurologic: decreased range of motion and weakness, ligamental tears and joint instability, sensory loss Specific Findings: Sexual Torture • Begins with forced nudity and extends to forced sexual acts, often threat of loss of status and breaking of cultural taboos • Acutely, the same as a rape exam • Rare to find chronic visible wounds given extensive healing ability of genitalia. • May need CT scan to document forced sterilization or surgery • Difficult examination with extensive support needed for patient Other Methods • Many methods may leave no findings Documentation • Tell patient you will be making notes, obtain their permission • In affidavit use medical terms (may explain them in parentheses) • Use terms such as “consistent with,” “highly consistent with,” and “pathognomonic for” -- remember you aren’t saying what happened, you are stating that their signs and symptoms are consistent with the history they give Body Diagrams A Picture Speaks a Thousand Words Recommendations • You can recommend treatment but not provide it. If you provide treatment your relationship changes and you are an advocate, not an expert. • Be impartial no matter how you feel. • Show empathy but don’t take your patient’s side (“That sounds difficult,” not “It’s horrible that they did this to you.”) • Stanley Brodsky’s Testifying in Court: Guidelines and Maxims for the Expert Witness.
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