They come to emergency rooms wearing designer sunglasses to hide black eyes. Their stories seldom vary. "I fell down the stairs," or "I ran into a door."
The clerks at the front desk are not fooled.
"When you see these people so frequently you get to know that falling on steps you don't get beaten so severely as these people get beaten," explained an emergency room unit manager at a Bethesda hospital.
They are victims of "domestic violence," adults abused by other adults -- husbands, wives, lovers, parents. To emergency room staff, they are a well-known paradox: a group of patients for whom shelters and hot lines exist, but who usually go home with no more than a bandage and an ice pack, because they refuse to admit the problem.
"The battered child gets follow-up. The battered spouse rarely gets any," said Dr. Sol Edelestein, director of Emergency Services at George Washington University Hospital. Edelstein, who testified last week before a House subcommitte considering a bill to aid domestic violence victims, said there are no official statistics on the number of abused adults.
Estimates vary from two or three patients a month at some emergency rooms, to two or three "documented" cases a week at Fairfax Hospital, according to Dr. Lawrence Bruther, a staff physician there. And all physicians agree there are many more undocumented cases.
Doctors and nurses said that the problem afflicts all ages and socioeconomic groups. Even one congressman's wife seen last year at George Washington was a suspected victim of abuse, according to hospital officials.
More affluent patients, however, often are the most evasive and unwilling to accept help because of fear of exposure, noted Jean O. Dunham, supervisor of the Alexandria Hospital emergency department.
Women also are afraid to tell the truth out of fear of further beatings, fear for their children, or because they cannot afford to leave home or get legal assistance, hospital workers said.
Jeanne Marquis, nursing unit co-ordinator at George Washington, said she tries to train her nurses to recognize signs of domestic violence.
"They all give you clues," she said. When asked how they were injured, such patients tell an inconsistent story. They avoid eye contact. When questioned rapidly they seem confused about the facts.
When she sees these signs, Marquis said she confronts the patient directly.
"I'll say, "This looks very much like you've been hit,'" Then, she said, most patients break down and tell the true story.
While physicians and nurses are required by law to report suspected child abuse, there is no requirement that hospitals report cases of "adult abuse," and hospital staff members who try to pursue a suspected abuse case have no special protection against lawsuits.
Given this situation, many health professionals are reluctant to press suspected abuse victims on the cause of their injury. Yet unless they can persuade victims to identify themselves, they cannot refer them to the community services that already exist for such victims of domestic violence.
Sometimes, little can be done even for patients who admit they have been abused.
Lauren Datcher, head nurse at Washington Hospital Center's emergency room, recalled a severely injured patient who finally admitted that her husband had abused her repeatedly at gunpoint. She agreed to press charges only when told she might lose her eye. At that point, her husband entered emergency room and pulled a gun on the staff.
Datcher said the man was arrested for possessing an unregistered firearm. After his release, however, his wife went back to him.
Usually, once a patient asks for help, some resources are available. Dunham said she keeps a supply of women's clothers in the Alexandria emergency room for women "kicked out in their nightgowns," and all the hospitals keep telephone numbers of local shelters and crisis centers.
They may refer a patient to hospital social workers. However, social workers are on duty in the daytime, and Marquis said most victims of domestic violence appear in emergency rooms between 10 in the evening and 3 in the morning.
Besides helping a man or woman get out of a violent situation, counselors can offer suggestions about how to "defuse" an argument that could lead to violence, said Susan Luff, mental health liasion nurse for the George Washington emergency room. And they can inform patients about how to apply for benefits and legal aid in preparation for leaving home, said Florence Slepian, head of social services at Fairfax.
Slepian said she sees one or two abused patients a week who have been referred from the emergency room, including some "who come in four or five times a year to the emergency room but never take legal action."
Edelstein deplored the lack of data on the prevalence of domestic violence and the inability of emergency staffs to follow up on what happens to these patients. He said a search of the medical literature had turned up only one attempt to quantify cases -- 1975 British study.
"my ignorance and my Colleagues' ignorance really says something," he said.
None of the nine emergency rooms surveyed kept literature for battered persons on display, although a new pamplet -- "Washington Guide for Battered Women" -- is available from the Task Force on Abused Women of the Women's Legal Defense Fund.
Staff members said intervention should reach families before they come to the hospital. Dunham suggested distributing literature in supermarkets, drugstores and schools.
"It doesn't have to come through the emergency room," said Marquis. "It's too late by then." CAPTION: Picture, A woman who was beaten by her boyfriend.