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Assault Matters: What You Need to Know

2 CPD in Australia | 0.5CD + 0.5G in New Zealand | 1 May 2019

By Esther Euripidou

Assault is the act of inflicting physical harm or unwanted physical contact upon a person and it can vary in severity. Having the confidence to screen for and recognise possible assault and manage assault victims should be part of every optometrist’s scope of practice.

This article describes the cases of two patients who presented to a Sydney practice. It outlines issues that are relevant to optometry, identifying aspects of the victim’s presentation and behaviour that may arise within case management. 

LEARNING OBJECTIVES

When consulting victims and suspected victims of physical assault:

  1. Understand there are varied presentations of assault,
  2. Recognise a victim’s rights,
  3. Know your duty of care,
  4. Realise the importance of empathy, and accurate, detailed record keeping,
  5. Have a plan in place to manage their care, and
  6. Recognise the need, and know the most effective way, to urgently refer on to the nearest eye hospital.

Nightly news stories on television, radio, and social media highlight the fact that violence occurs everywhere – from school playgrounds and community sports venues through to shopping centres, social events, and festivals.

According to the Bureau of Crime statistics, victims of general domestic assault are predominantly female (69.2%) and the offenders male (82%).1 In non-domestic assault, 70.9% of the victims were male.1

Sadly, violence in domestic relationships can become cyclic, and involve increasing brutality. Australian statistics suggest that domestic violence is increasing, with 62 women killed by domestic violence in the 12 months prior to 23 November 2018, eight more than the previous year.2  

Random assault is also on the rise with 90 people killed in single punch – or ‘coward punch’ assaults - since the year 2000.3  Between 2010 and 2015, 79% of reported male perpetrators in male victim assault related eye injuries were “unspecified /unknown”.4 The most commonly assaulted parts of the body are the head and neck region.5  

Eye gouging – the barbaric act of pressing or tearing the eye using the fingers or an instrument6 – has re-emerged in modern society. This injury can vary dramatically in severity and urgent hospital referral is necessary.

Poisoning with eye drops is another form of assault. Visine eye drops mixed into beverages for example, have resulted in domestic violence charges.3 Severe breathing, respiratory failure, nausea, vomiting and seizures are recorded as side-effects for the ingestion of Visine by Poisons Information.

Noxious substances, including ammonia and aerosol insect sprays, have also been used in assault. In these cases, immediate and prolonged irrigation with cold tap water is critical and more important than transferring the patient to hospital.

There are many factors associated with assault that need to be considered, among them the effects of alcohol, drugs and showmanship. When the assault victim is a woman, offenders often claim that they had not intended to kill, or harm the person to such an extent.

Gouge trauma

 

Duty of Care

Kerbing violence can only happen when, as a society, we take a conscious stance to support victims and assist police in finding the perpetrators for assault crimes.

As optometrists, we are in a strong position to do this. We can help victims by recognising incidents of assault, providing first aid, and referring them on for further medical treatment and support. We can also encourage victims of assault to report incidents to the police and take steps to report suspected or known assaults as well, especially when we suspect repeated and escalating incidents.

Case Study One

Jimmy, an older gentleman sits in the waiting room, supporting his head. I see two black eyes beneath a pair of round lenticulated bifocals. His eyelids are swollen and bruised. With his limited English, he explains that he was assaulted the previous night while working as a taxi driver. Having lost his glasses, he was wearing an older pair, which did not provide adequate vision. He needed new glasses as soon as possible. He said his eyes felt sore on movement.

His vision measured R 6/6, L 6/7.5++ acuity. He was aphakic and required a prescription of approximately +9.00 in each eye. I noted cloudiness at the plane of the lens capsule, and central shadows with direct ophthalmoscopy. He declined further tests and spectacles were made urgently. He collected them within a week.

Doctors reported to me that one month later, Jimmy presented to St George Hospital and was diagnosed with a hematoma at the back of the head, requiring drainage.

Two months later, Jimmy’s GP referred him to an eye specialist. The report read, “no obvious injuries to his eyes”.

Four months later he returned to me complaining that since the assault, his vision had deteriorated.

On this visit, I measured R 6/7.5, L 6/7.5-.

I referred him to a second ophthalmologist who reported, “a hazy vitreous; vitreous prolapse may have occurred as a result of the assault”. The ophthalmologist recommended bilateral vitrectomies with secondary posterior chamber intraocular lenses (IOLs). The patient proceeded with the two surgeries, which resulted in acuity of: R 6/6, L 6/7.5++ (unaided); +2.00 readers were required for near.

Jimmy experienced two intraocular pressure (IOP) spikes post surgery and needed to use therapeutic eye drops short term, however he was happy with the end result.

Critical Evidence

Six months after the assault, I was subpoenaed to give evidence for Jimmy’s case in the District Court by the Director of Public Prosecutions. I made a formal statement with a police officer beforehand to explain the details of my medical report.

The officer informed me that my patient’s assault had been far more serious than he’d led me to believe. He had been punched and thrown from a bridge, which rendered him unconscious. Having been treated at St. George Hospital, he had regained consciousness and discharged himself immediately to be with his family.

I was the first health care practitioner he consulted after being treated in hospital, and the first to see him in a conscious state. Therefore, my clinical notes and statement became critical to his court case.

Reflecting on the matter, I questioned all the circumstances. With no English, was Jimmy a new immigrant? Was he licenced to drive the taxi? And why did he refuse comprehensive medical care at the time of assault?

Was he resilient or lacking better judgement?

Case Study Two

In my early career I often had to deal with assault presentations on Saturday mornings. Cases usually involved young men who had been out for the night, had separated from friends and had been attacked in an isolated location.

One Saturday morning I attended to David, who had been assaulted by three men as he walked home from the bus stop after a late shift at work. The men demanded money and/or drugs and when David replied that he had none of either, he was forcibly restrained by one assailant while the other two punched him in the head. 

David’s prescription glasses were broken, and he suffered burst blood vessels in both of his eyes. Punches directed at his mouth uprooted two teeth, which needed extraction.

David ran home as quickly as he could, and his family called the police and ambulance. He was transferred to the Prince of Wales Hospital in Randwick NSW, where he underwent tests and scans to investigate his injuries.

David’s medical report stated that both eyes had sustained traumatic cataract and needed cataract surgery. His left eye had a macula hole.

Vision following surgery was, R 6/9, L 6/60.

His case management was complex and suitable counselling was critical for prompt treatments and care.

Figure 1. Management guide for ocular trauma due to domestic violence or assault11

 

Managing Victims of Assault

The government bodies in Australia and New Zealand recognise that a victim of crime has the right to:

  • Be treated with courtesy and compassion.
  • Have access to medical and counselling services, as well as welfare, health and legal services.7,8

 

When a person has been assaulted, they are likely to be confused, fearful and anxious, which can impact their capacity to report the incident with accuracy and accept necessary treatment. They may feel the need to vent anger, feelings of hurt or mistrust. Indeed, this may be necessary in order to progress to examination.

Regardless of their behaviour, victims of assault need to be treated with courtesy and compassion.8,9 It is important to show them respect and work within their level of comfort. Cultural sensitivities and privacy issues must also be taken into consideration.

On occasion, a victim of assault with limited English will bring a child with them to act as an interpreter. It should be remembered that children are sensitive and exposing them to evidence of assault may be emotionally challenging or even lead to post traumatic stress disorder. Additionally, young children can have difficulty understanding events and can make false or anomalous correlations.10 Cultural differences may also impact their capacity to interpret clearly and/or objectively. If possible, try to protect any children present by organising a phone interpreter.

Medical Assessment

When medically assessing or treating a victim of assault it is important to follow a systematic process that both maximises patient care and prepares you in the event that you are required to give evidence in court. Remember to manage a suspicion of assault as you would an actual assault, because a suspicion may become evident in the future. Even when the offender is not identified, the patient may be able to claim victim’s compensation.

Bloody chemosis ruptured globe

Optic nerve avulsion

Giant retinal tear

 

Take a reliable history, recording details that can be clearly understood by the patient:

  • Quote the patient’s words e.g. “seeing red in my vision”,
  • Store any evidence of the assault or a foreign body (e.g. debris, glass fragments from the eye),
  • Take photographs with patient consent, including the patient’s full face in at least one photo,
  • Accurately record the time of the event, the place, and people present, and
  • Draw a body map to record other injuries.

Conduct a thorough eye examination to assess severity and the level of urgency for referral. This examination will include checking for:

Pupil reactions (abnormal pupil responses are a strong predictor of major ocular injury),12  

Ecchymosis of the eye – a flat, blue or purple patch measuring 1cm or more in diameter, caused when blood leaks from a broken capillary into surrounding tissue under the skin,13 

A ruptured globe/open globe (laceration injury),

Lenticular dislocation, particularly if pseudophakic, (IOL flicker/flutter after eye movement),

  • A pupil that is not round,
  • Haemorrhagic chemosis (360 degrees)/clock hours description/quadrants of redness,
  • Orbital wall fracture indicating a fist injury – double vision can be a sign that the extra ocular muscles are entrapped in the orbital wall fracture,11   
  • Extra ocular motility restriction,
  • Hyphaema,
  • A vitreous bleed,
  • Lid laceration requiring stitching,
  • Vossius ring (pigment circle on anterior lens surface), and /or
  • Retinal detachment.

Balance testing procedures with conversation that builds rapport and makes the patient feel at ease.

Arrange the patient’s transfer to a hospital or appropriate medical centre for care and referral on to a counselling service. Patients fading in and out of consciousness will need to be relocated to a hospital in case of brain injury.

Severe Eye Trauma

In cases of severe eye trauma, it is essential that you urgently refer your patient to the nearest eye hospital. Call the registrar to explain the case and supply your patient with the name of a contact person at the hospital. The patient should be fitted with a clear post-surgical eye shield to protect the wound during transfer.

MRI and CT scans will need to be performed for orbital wall and skull assessment, as well as for internal bleeding (retro-orbital hematomas). A hematoma generally refers to a pocket of blood which has started to clot.

Non-Severe/Blunt Injury

In cases of non-severe or blunt injury, it is important to:

  • Take a visual acuity score (distance, near and binocular),
  • Note pupil reactions and variation between eyes, including any microscopic differences noted with slit lamp evaluation,
  • Check for diplopia in extreme gaze positions,
  • Gauge measurements against the uninjured eye, particularly intraocular pressure,
  • Rate your patient’s level of pain or numbness, and
  • Check their ability to close the eye.

Take note of the patient’s demeanour or anxiety level and record any verbal statements. This is particularly useful for domestic violence cases which require police notification.

Reporting

All assaults, and even suspicion of assault need to be reported. This can be done via the Crime Stoppers website (www.crimestoppers.com.au),15 which aims to build a trusted link between members of the community and law enforcement.

The Crime Stoppers portal is user friendly for culturally and linguistically diverse populations,13 and people can report a crime either anonymously or with full disclosure. It is particularly valuable for encouraging people from some ethnic communities, who may harbour distrust in policing based on experience in their home country, to report domestic violence.

Over the last six years the amount of information received by Crime Stoppers has steadily increased, resulting in a growing number of arrests and charges laid.

Refer your patient on to Crime Stoppers or any of the other listed services for further assistance as and when appropriate:

Police Emergency Services:

(AUS) 000; (NZ) 111

Crime Stoppers: (AUS) 1800 333 000; (NZ) 0800 555 111

Lifeline:

(AUS) 131 114

Victims Services:

(AUS) 1800 633 063

National Disability and Abuse Helpline:

(AUS) 1800 880 052

Domestic Violence Hotline:

(AUS) 1800 656 463

1800 Respect:

(AUS) 1800 737 732

Victims Information Line:

(NZ) 0800 650 654

Child Protection Services:

ACT, NSW, QLD, NT (AUS) 132 111

SA: (AUS) 131 478

TAS: (AUS) 1300 737 639

WA: (AUS) 1800 622 258

VIC: (AUS) 131 278

Reasons for Non-Reporting

Many victims of assault choose not to report their experience to the police, making it difficult to attain a clear picture of how many people are assaulted in Australia, and how many ocular injuries (due to domestic violence or work related eye injuries) are acquired due to assault.

The NSW Police Service attributes non-reporting to:

• Fear of repercussion/reprisal,

• Fear of not being believed,

• A lack of knowledge about services relating to the offence,

• The perception that the incident/injury was not significantly serious,

• Not wanting to be acknowledged as ‘a victim’,

• Not wanting the offender to be punished, and/or

• Feeling too confused, upset, or injured.16

From patient experience, I believe that in the short term, some victims fail to report because they prefer to pretend the incident didn’t happen. They hope that by not reporting, it will be easier to move on with their lives. Often, they validate their decision not to report by consoling themselves that at least it was them – rather than their child – who was assaulted. Or they tell themselves they’re tough enough to get over it. For some, reporting can feel like a burden, particularly if the perpetrator is unknown.

However, unless perpetrators are reported, they will escape detection and continue their pattern of behaviour. And with this in mind, as health professionals we should make a point of counselling patients about the need to report ocular injuries.

Optometrists, ophthalmologists, ambulance officers, hospital staff, and good Samaritans can all become victims. I have found that referring to people who have been assaulted as ‘injured’ as opposed to ‘a victim’ can help reduce any associated stigma, making it easier for them to report the incident.

The Crime of Concealment

Not reporting a known assault may also have legal consequences. Referred to as, ‘the crime of concealment’15 failure to report a known or suspected serious crime to the police carries a penalty of two years imprisonment.

In the words of Crimes Act 1900 (NSW). section 316, “If a person has committed a serious indictable offence and another person who knows or believes that the offence has been committed and that he or she has information which might be of material assistance in securing the apprehension of the offender or the prosecution or conviction of the offender for it fails without reasonable excuse to bring that information to the attention of a member of the Police Force or other appropriate authority, that other person is liable to imprisonment for two years”.17

In other words, every citizen is required by law to bring serious breaches of the law to the attention of the police. If you are aware that a child has been assaulted, you are obliged to protect the child despite any privilege or confidentiality requests in communication by ‘the other’ parent, older sibling, or extended family/whanau in New Zealand.

Further Reading

This article highlights just some of the assault cases that may present in your practice and provides suggestions for their management. Empathy is essential to build patient trust, a thorough examination is vital to protect their vision, and thorough, clear record taking will ensure you are fully prepared should you be required to give evidence in court.

The way in which patients present and their approach to providing information and seeking assistance may be influenced by their cultural background. To gain an understanding of cultural variation patterns, I recommend referring to Domestic violence case studies – Arabic, Aboriginal and Greek at www.baysidewomensshelter.com.au.

Other useful reference material includes:

  1. USA treatment model for assault affecting the eye, American Journal of Clinical Medicine, Winter 2014. Vol.10. Number 1. Ocular Manifestations of Domestic Violence: A case review
  2. Understanding legal rights for victims: www.victimservices.justice.nsw.gov.au
  3. BOCSAR-statistics by locality

 

Thank you to Associate Professor Andrew Chang, Sydney Retina Clinic, for his guidance and for contributing photos for this article. Patient's names have been changed.

   

Esther Euripidou achieved her Bachelor of Optometry Honours in 1987. A clinical optometrist with over 30 years in private practice at various eastern Sydney locations, she is particularly interested in developing strategies to deal with anxious patients.

 

References
1. www.bocsar.nsw.gov.au/documents/BB/bb61.pdf  (BOCSAR is the NSW Bureau of Crime Statistics and Research)
2. www.smh.com.au/national/we-need-to-talk-about-violence-to-men-and-boys-20181122.
3.  www.smh.com.au/90-killed-in-single-punch-assaults since 2000. Viewed 28/11/2018.
4.  www.aihw.gov.au/get media. National Hospital Morbidity Database. Table 2.11 Assault related eye injury cases by perpetrator. Australia 2010-2015.
5.  www.saudijos.org/article asp. Etiology of injuries due to assault in the head and neck region…by I.U. Madueke.
6. https://en.wikipedia.org/wiki/Eye-gouging
7.  www.usatoday.com/story/news/nation…poisons-eye-drops…1188709002 (Sept.4,2018) South Carolina, U.S.A.
8. Domestic Violence is a Crime. Police & Community Booklet (multilingual). Victims’ Rights, page 17.
9. www.victimsinfo.gov.nz/support-and-services/victims-rights
10. www.ncbi.nlm.nih.gov/pmc/articles/PMC 1414752/Post traumatic Stress Disorder in Children.
11. American Journal of Clinical Medicine. Winter 2014. Volume 10. Number One. “Ocular Manifestations of Domestic Violence: A case review”.  Kelkar.A, White, W.A and Kosoko-Lasaki, O.
12. PMID 29782814.” Primary Assessment of the patient with orbital fractures should include pupillary responses and VA changes to detest occult major ocular injuries”. By Chow.J, Parthasarathi, K.
13. www.medicalnewsstudy.com/articles/321943php. Ecchymosis
14. allaboutvision.com/conditions/eye injuries - regarding eye injuries
15. www.crimestoppers.com.au  30/11/2018
16. www.police.nsw.gov.au/crime/bias_crime_categories/why you should report it.
17. Public Space: The Journal of Law and Social Justice (2007) Vol. 1, Art 4, p10-Concealment.

' When medically assessing or treating a victim of assault it is important to follow a systematic process that both maximises patient care and prepares you in the event that you are required to give evidence in court '