Drs Gary Quick, Theodore Ruff, and Pam Wilson’s “What’s Wrong With This Picture?” case of a woman with splenic laceration resulting from an assault by a male friend (CONSULTANT, May 2002, page 714) seems to have missed the “elephant in the living room.” The description of the hospital course and follow-up provides a comprehensive guide to care for an injured spleen; however, the issue of domestic violence is not addressed. An estimated 5% to 14% of American women are currently in abusive relationships.¹ Domestic violence leads to significant health problems both for those who experience the abuse and for their children.^2-4 Through routine screening and intervention, health care providers can help reduce the incidence of this common and serious problem—and possibly save lives. How best to address domestic violence? Here is an approach:

• First, show support with a nonjudgmental statement such as, “I am glad you told me. You are not alone, help is available.”⁵
• Second, find out about immediate safety. Is it safe for the patient to go home?
• Third, offer information about advocacy services and emergency shelters and/or a follow-up appointment with a social worker or mental health professional.
• Finally, document the incident in the medical record, including photographs of injuries whenever possible. There are many excellent resources for clinicians.^6,7 Information is also available on activities to address domestic violence that involve the entire health care community.^8-11

— Krista Kotz, PhD, MPH
   Orinda, Calif
— Brigid McCaw, MD, MS, MPH
   Oakland, Calif
We thank Drs Kotz and McCaw for highlighting the important issue of domestic violence. Although the focus of our presentation was the diagnosis and nonoperative management of splenic injuries, we perhaps should have indicated in a sentence or two that the domestic violence involved in the case was addressed. However, a detailed discussion of issues that might affect legal actions or patient safety is not appropriate in an article in which the physicians and hospital are specifically identified. More than 2 years ago, the Oklahoma State Health Department designated domestic violence as a reportable incident. This status requires that physicians ask all female patients over the age of 18 years about domestic violence when they present to the emergency department (ED), and that physicians report cases in accordance with the Health Department protocol. Once a patient has been identified as a possible victim of domestic violence, various actions follow, depending on the patient’s circumstances. Names of shelters and other resources or contacts may be secretly slipped to the patient on a commonplace item, such as an emery board, name tag, or key ring. The ED nurse or physician attempts to interview the patient without the presumed perpetrator of violence present. Offers to contact a “safe house” or shelter may be made. Sometimes a case worker is called to the ED. We follow extant protocols for all of our patients in the ED as part of standard patient care. Domestic violence is a blot on our society and must be addressed at every opportunity.
— Gary Quick, MD
   Department of Emergency Medicine
   Oklahoma Heart Hospital
   Oklahoma City
— Theodore Ruff, MD
   General Surgeon
   Midwest Regional Medical Center
   Midwest City, Okla
— Pam Wilson, DO
   Radiologist
   Midwest Regional Medical Center
   Midwest City, Okla