electric shock torture by Crossofchanges

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									 Physical Exam in
Survivors of Torture
       Laurie Bay, MD
   Jeremy Hess, MD, MPH
• 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
  – 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
             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
• 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
• Torturers in many
  countries have
  learned to use soft
  restraints to reduce
Specific Findings: Beatings
              • Acutely see bruising in
                pattern of object used
              • Chronically see scarring:
                keloid formation, hypo or
              • 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
  – 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
    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
  – Squeezing tarsal bones or flexing great toe causes
  – In normal feet will feel flexing of plantar aponeurosis
    at around 20 degrees, higher values may indicate
 Specific Findings: Suspension
• Injuries are
  musculoskeletal and
  decreased range of
  motion and
  weakness, ligamental
  tears and joint
  instability, sensory
 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
• Tell patient you will be making notes, obtain their
• 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
• You can recommend treatment but not provide
  it. If you provide treatment your relationship
  changes and you are an advocate, not an
• 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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