Improving EMS Response to Domestic Violence

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Improving EMS Response to Domestic Violence

• Adapted from the curriculum created by the New
  Hampshire Bureau of EMS, the National Health
  Initiative on Domestic Violence, and the Family
  Violence Prevention Fund.

EMS Response to Domestic Violence
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What We Want

• Increased sensitivity and understanding of
  domestic violence
• More referrals to domestic violence projects
• Quality information and documentation for the
  criminal justice system

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Definition of Domestic Violence

• Domestic violence
• Is a pattern of behavior (physical, sexual,
  verbal, emotional, financial, spiritual, etc.)
  used by one person to control anothers actions
  and feelings.
• One way to think of these behaviors is as
  tactics, actions which are chosen and planned.
  An abuser is not out of control the abuser is
  trying to control the victim.

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Domestic violence occurs in all types of
relationships and occurs across all demographics

• Dating, living together, or married.
• Current or past relationships.
• Race/ethnicity
• Gay, lesbian, bisexual, transgender or
  heterosexual.
• Income level
• Class
• Education/occupation
• Age elder, adult, and adolescent
• Physical ability

EMS Response to Domestic Violence
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Power and Control Wheel
Courtesy Domestic Abuse Intervention
Project Duluth, MN
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Maine Coalition to End Domestic Violence (MCEDV)

• 9 agencies statewide
• 24-Hour toll-free hotlines
• One-on-one support advocacy
• Support groups
• Emergency shelter or safe house
• Transitional housing
• Legal advocacy and referral
• Information access to public assistance
• Community and School Based Education
• Childrens Programs
• Batterer Intervention Programs

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EMS Response
If dispatched as a domestic assault Are police
on scene?

• If no,
• Stage and wait until police arrive and scene has
  been secured

• If yes,
• Stage and advise PD of your arrival
• Enter only as directed by police

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EMS Response

• Since many DV calls are not identified as such,
  evaluate every call, every patient, and whether
  there is a need for law enforcement involvement.
• Scene Safety Assessment
• Patient Safety Assessment

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Scene Safety Assessment
Upon approach, and entry look for

• Presence and condition of children and pets
• Evidence of
• Struggle
• Weapons
• Substance abuse
• Attempts to conceal information

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Scene Safety Assessment (cont.)
Be particularly careful if

• 911 hang-up or difficulty getting info from
  caller
• History of suspicious calls
• You are met at the door or denied entry by
  someone who says the victim is fine doesnt
  need medical care

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Scene Safety Assessment (cont.)

• Dont hesitate to return to ambulance to discuss
  options, notify police, or contact Medical
  Control.
• Consider using cell phone vs. radio.

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Scene Safety Strategies
If decision is to proceed

• Identify yourself as EMS providers
• Use team approach (never split the team)
• Be aware of surroundings
• Attempt to sequester patient

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Scene Safety Strategies
If decision is to proceed

• Avoid treating patient in bedroom or kitchen
• Limit number of people present
• Let occupants lead
• Dont be afraid to use the ambulance

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Scene Safety Strategies (cont.)

• The abuser may view your presence as a threat.
  Remember to
• Avoid touching or crowding
• Be non-threatening (non-judgmental)
• Stay calm
• Maintain a safe distance

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Primary Health Issues

• Keep in mind that medical issues are first
  priority.

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Behavioral Cues
Observe if patient

• Is fearful or anxious around partner
• Is reluctant to answer questions, provides
  conflicting information
• Has delayed seeking medical help

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Observe if partner or caregiver

• Is angry, belligerent or indifferent to patients
  needs
• Refuses or hesitates to allow transport
• Focuses on own minor health issues
• Attempts to control patients
• interaction with EMS

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Assessment Cues
Observe if patient

• Has injuries during pregnancy
• Has multiple, vague complaints
• Provides inconsistent medical history

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Trauma Assessment
Look for injuries

• Resulting from defensive action
• In shape of objects
• On areas normally hidden
• On other victims (children, elderly, pets)

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Medical Assessment
Potential medical complaints

• Physical symptoms related to stress, anxiety, or
  depression
• Persistent headaches
• Chest, back, pelvic or abdominal pain
• Exacerbated chronic illness (hypertension,
  diabetes, asthma, angina)
• Substance abuse
• Suicidal ideation

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Transport vs. Non-Transport

• If patient accepts transport
• Consider advising hospital security
• Explain medical consequences
• Provide support referral to a DV project

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Transport vs. Non-Transport

• If patient declines transport
• Be non-judgmental
• Provide first aid
• Provide support referral to a DV project
• Document well

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Crime Scene Considerations

• Minimize your effect on potential evidence
• Advise police of injuries discovered during
  assessment of patient
• Have all personnel use same entrance.
• Tell police anything you witnessed (see, smell or
  hear) at the scene.
• Provide police with contact information.

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Ask About Abuse

• Keep in mind
• Ask patients in confidential settings
• Be non-judgmental
• Encourage support

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Ask Direct Questions

• Has anyone at home hit you or tried to injure you
  in any way?
• Do you ever feel unsafe at home?
• In addition to medical condition, I notice you
  have a number of bruises. How were you injured?
• Because violence is so common in many womens
  lives, I ask about it routinely

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Ask direct questions (cont.)

• Getting a disclosure is not the objective
• Asking the question and offering resource
  information is the objective.

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Ask direct questions (cont.)

• If the patient answers yes
• Listen and ask questions non-judgmentally
• Validate their experience
• Document their statements
• If patient answers no, or will not discuss topic
• Be aware of physical, behavioral cues
• Document inconsistencies
• Make referrals discreetly

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Documentation

• Write legibly and use quotation marks
• Record an objective description of the abuse as
  observed and described to you.
• When documenting what victim states, write
  victim stated instead of victim alleged
• Patient statements are not hearsay.
• Record all pertinent physical findings.

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Documentation (cont.)

• Your EMS report may be the only record of
• Inconsistencies in reporting
• Delays in seeking treatment
• Observations of environment
• Statements made by patient and partner

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Documentation (cont.)

• Potential evidence preservation/collection
• Collect evidence such as ripped clothing or
  handful of hair
• Explain options to patient re use of evidence
• Use paper bags for evidence collection
• Describe shape, location of injuries

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Ask about indicators of escalating risk
Indicators of escalating risk

• Increase in the frequency or severity of the
  violence?
• Increasing or new threats of homicide or suicide
  by the partner?
• Gun or other weapon present or accessible?
• Threats to children?
• Abuse of pets?

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Review Options, Offer Referrals

• Things to say when making a referral

• Did you know that there are organizations in the
  community that can help you?
• All their services are free and confidential.
• The local domestic violence projects have 24-hour
  toll-free helplines staffed by people who care.

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Review Options, Offer Referrals (cont.)

• Additional helpful things to say to a victim
• Im concerned for your safety and the safety of
  your children.
• You do not deserve to be treated this way.
• Im sorry this happened to you. How can I help?
• Many people experience this. You are not alone.

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Mandated Reporting

• An EMS provider must immediately report to Child
  Protective Services any child whom you have
  reasonable cause to suspect has been abused or
  will be abused (Title 22 Subchapter II,
  Subsection 4011).
• When, while acting in a professional capacity,
  anambulance attendant, emergency medical
  technicianhas reasonable cause to suspect that
  an incapacitated or dependent adult has been or
  is at substantial risk of abuse, neglect or
  exploitation then the professional shall
  immediately reportto the department (Title 22
  Chapter 1-A, Subsection 3477).
• Maine Department of Human Services
• Central Intake
• 1-800-452-1999

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However

• No one is mandated to report violence of a
  competent adult unless it is a gun shot wound.
• The choice about whether to contact law
  enforcement, a domestic violence project, or
  anyone else belongs to the victim.

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In Summary

• Victims know their situation best and can best
  evaluate their safety and the safety of their
  children.
• An EMS providers role is to offer the patient
  medical treatment, options, support and referral
  information.
• You can make a difference!

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Thank you
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Handouts

• Power Control Wheel
• Myths Why Does Battering Happen?
• Signs to Look for in a Battering Personality
• 6 Things to Say to Victim 8 Actions to Take
• MCEDV Map of Domestic Violence Projects
• EMS Safety at the Scenes of Domestic Violence
• EMS Domestic Violence Indicators or Red Flags
• What to Look For Common Diagnosis/ Clinical
  Indicators
• Documenting Abuse
• How to Access EMT Records and Run Sheets
• Is DV an Issue for EMS?