What Every Health Provider Needs to Know about Drowning (Hoffman, 11/3/2021)

 Thank you to Dr. Ben Hoffman who gave a profoundly moving talk on Drowning Prevention in Children. What an honor to host the national expert on accident prevention!

A recording of the excellent presentation is HERE. 

I consider this presentation a MUST for all of us that care for children. This is PRACTICE CHANGING.

Here are our notes:

Drowning is the leading cause of unintentional injuries in children 1-18 from data collected between 2009-2018-- that’s over 9,000 children. 

• Imagine 9 school buses of children-- 72 kiddos in each bus-- that die every year from drowning.
• Drowning is the single leading cause of death in children ages 1-4, and the 2^nd leading cause in children 15-19.
• We must remember the BIPOC community who suffer disproportionately from incidents of drowning.
• we can trace this reality back to systemic racism and lack of access to pools, swimming lessons, etc.

 PREVENTION: the AAP has created both a toolkit https://www.aap.org/drowning and a policy (attached) to help providers educate family’s on drowning prevention. The toolkit has both general information and patient handouts and posters for your office.

https://www.aap.org/drowning

The bottom line: LAYERS OF PROTECTION to prevent drownings, and we should focus particularly on new parents of children <4, teens, BIPOC families, and children with disabilities and epilepsy.

                *infants: never leave unsupervised – even a second- in water.

                *toddlers: their curiosity is dangerous. Never leave a toddler unsupervised around any water. They can get into tubs, toilets, wading pools. Lock or empty these when not in use.

                *swimming lessons: no evidence that they protect infants, but there IS evidence that they work for children 1-4 yrs old and shows a significant reduction in drownings.

                *water competence: we should teach our families that learning to swim is a life skill. Many BIPOC parents were never taught to swim so consider the water dangerous.

                *erect barriers: particularly pools – 70% of pool drownings are when it’s not “swim time”. Pool fences that have 4 sides with a locking gate reduce drownings by 50%.

                *supervision: constant, close and capable supervision-at arm’s length if a child can’t swim competently. Don’t rely on lifeguards – children still drown in their presence.

*life jackets: only coast guard approved life jackets are appropriate (and a must when our families visit the Russian River or the Sonoma Coast). Never rely on anything inflatable. The coast guard approved life jackets are more expensive than the inflatables.

*advocacy: some cities have life jacket loaner programs. Dr Hoffman will be glad to speak to anyone who is interested in starting a program locally (for example Spring Lake loans them with boat rentals).

Beyond Intimate Partner Violence Screening (Agudelo, 10/20/21)

Many thanks to Dr. Lucia Agudelo for her Grand Rounds presentation this week titled Beyond Intimate Partner Violence (IPV) Screening. Dr. Agudelo, who did professional work in this field before entering medical school, shared the high prevalence of IPV in the US, presented us with new framework of how to approach IPV conversations with our patients, and encouraged us to rethink our goal when we screen for IPV--from one of disclosure to one of support.

I do encourage you to watch a recording of Dr. Agudelo's presentation, available HERE.

For those of you who prefer a written summary. . 

IPV is a pattern of assaultive and coercive behaviors that can include physical injury, psychological abuse, sexual assault, progressive isolation, intimidation and threats. It is aimed at establishing power and control of one partner over the other.

https://www.theduluthmodel.org/wheels/

In the US, an average of 20 people experience IPV every minute, which equates to more than 20 million abuse victims annually.

~1 in 5 women and 1in 7 men report having experienced severe physical violence from an intimate partner in their lifetime

~1 in 5 women and 1 in 12 men have experienced contact sexual violence by an intimate partner

IPV has wide ranging effects on physical and mental health and can exacerbate a huge range of medical problems-- everything from asthma and diabetes to depression/anxiety to unplanned pregnancy to menopause symptoms, to GI disorders and fibromyalgia. 

Dr. Agudelo reminded us to consider IPV on our ddx when we are seeing patients with uncontrolled chronic conditions that don't seem to be able to get under control with standard therapies. This may include someone with high blood pressures or difficult to control blood sugars or even chronic pain. For more information on this, check out the 2019 NEJM article on IPV

https://www.nejm.org/doi/full/10.1056/NEJMra1807166

IPV has unsurprising wide ranging impacts on children, including physical injuries and child abuse, fear, depression and anxiety, sleep disturbances, eating disorders, and even impact on early brain development.

Dr. Agudelo introduced us to an evidence-based intervention to address domestic and sexual abuse in health settings called CUES. This methodology has been designed and created to offer support to men and women who are experiencing violence and connect them with help and support if they need/want it.

https://www.futureswithoutviolence.org/wp-content/uploads/CUES-graphic-Final.pdf

C: CONFIDENTIALITY

• know your state's reporting requirements
• always see patients alone for a part of every visit so you can bring up safety
• use professional interpretation (not family/friends) if you cannot speak the patient's language

UE: UNIVERSAL EDUCATION AND EMPOWERMENT

• give patient TWO Safety cards (see graphic)
• "I am giving these cards to all my patients to be sure they know how relationships can impact health"
• Make sure you let the patient know you are a SAFE person to talk to
• Giving cards to EVERYONE (and not just those you suspect are at risk) makes it more likely that people who need the information will get the information

S: SUPPORT

• though disclosure is not the primary goal, you need to be ready to support someone if/when they do disclose
• be ready to make warm handoff to local support agencies with experience with IPV
• offer care plans that take IPV into account

Here is another assessment once IPV has been identified to determine if a person is at high risk of homicide or severe injury from an intimate partner: Danger assessment, available at https://www.dangerassessment.org/

https://www.dangerassessment.org/

Reporting requirements

In California, healthcare providers must file a mandatory report to law enforcement (OES-920) if they see a patient with a current physical injury that is known to be due to assaultive or abusive contact

There is no guidance on mandatory reporting from telephone visits.

If you suspect child abuse and/or neglect, you should report to CPS. If you suspect elder abuse/neglect, you should report to APS. 

Local resources:

YWCA 24/7 Support line (shelter, counseling, etc) 707-546-1234

Family Justice Center (counseling, legal aid) 707-565-8255

SR Courthouse (restraining orders) 707-521-6630

Verity (survivors of sexual assault) 707-545-7270

WOMAN Inc (Bay Area shelter census) 415-864-4722

CLAW (LGBTQ) 415-777-5500

Additional resources:

National Domestic Violence Hotline 800-799-7233

https://www.futureswithoutviolence.org/

Dr. Agudelo finished the presentation by encouraging us to hold our institutions of employment accountable to visible and concrete IPV safety-- including posters on the walls and signs in clinic rooms and bathrooms that denote safety and offer resources, the availability of safety cards and/or safety plans, easy access to resources (numbers, internet sites) for those who may be experiencing IPV and need help.  How doe the clinic or hospital where you work ensure that patients know their rights and that this is a safe place?