I'm in the midst of my emergency medicine rotation right now - my last real clinical rotation of medical school. I didn't save it until the end intentionally, and I was a little worried about how burned out I'd be during a rotation that included night shifts and an unpredictable schedule. This turns out to have been justified. Now that I'm safely on the other side of a cluster of 3PM-midnight and 11PM-7AM shifts, I am feeling better, but the last few weeks have been really rough. The biggest challenge, however, has not been the schedule. The disaster that is my sleep schedule pales in comparison, as the most difficult aspect of this rotation has been the intimate partner violence. Little has made me feel more powerless than the women* who have been bruised and beaten by their partners. They come in to the emergency room because of pain that won't go away, because of unborn babies that have them worried, and because of risks for disease they can't ignore. They leave with medical assessment, reassurance, and treatment for these things, but to be honest, I'm not sure whether they really get what they need. I say I'm not sure, because I'm embarrassed that I've not taken the time to find out whether a social worker sees them, or whether they are given references for shelters or other resources. I've been too overwhelmed by assessments of the pain, ultrasounds of the babies, screening for disease risks, and, most of all, the management of my own emotions, to get much past the emergency care they ask for explicitly.

We talk about intimate partner violence during the pre-clinical years. We talk about the statistics, how many people are harmed by those closest to them in a given year, and we talk about the shelters and resources available locally. I seem to remember a panel discussion featuring survivors of intimate partner violence, and maybe a few healthcare providers who were some sort of experts in this area. We learn that we should ask every patient whether they feel safe at home. And I think most of us do it. I know I tried to include that as a part of the social histories I took during M3 year.  And I don't think a single patient told me "no" in response to that question all year. I'm certain some of them were lying, definitely to me, and maybe to themselves, but I nonetheless really didn't confront this kind of violence directly. I do recall patients I saw in clinic who discussed their past or present violent situations either with me or with a previous provider who had documented it, but it was hard to connect the women I was seeing in clinic with what I knew to be going on at home.

The ER is different, and so much of what we see there has just happened and is written all over the faces of the patients who present there. I get the sense that for people who love emergency medicine, this is a big part of why. There is a rawness to the undifferentiated nature of many of the complaints in the ER that can be exciting; there is an adrenaline rush that goes with being the systematic hero, even when the heroic measures aren't enough. But what do you do when the raw edges were supposed to be soft? And when there are no heroic measures? I'm not sure, and I'm still reeling a bit from having something revealed about the world that I'd really rather not know. What do you do when sometimes it's hard?

*I know that men can also be victims of intimate partner violence, but the patients I've seen have all been women.