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1 THE ABUSED PATIENT March 2010 CE Condell Medical Center EMS System Prepared by: Steve Holtz, FF/PM Libertyville FD Reviewed/revised by: Sharon Hopkins,

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Presentation on theme: "1 THE ABUSED PATIENT March 2010 CE Condell Medical Center EMS System Prepared by: Steve Holtz, FF/PM Libertyville FD Reviewed/revised by: Sharon Hopkins,"— Presentation transcript:

1 1 THE ABUSED PATIENT March 2010 CE Condell Medical Center EMS System Prepared by: Steve Holtz, FF/PM Libertyville FD Reviewed/revised by: Sharon Hopkins, RN

2 2 OBJECTIVES Upon successful completion of this module, the EMS provider will be able to: define abuse, assault, battery, and neglect. identify reporting requirements for EMS. identify physical indicators of abuse and neglect. identify behavioral indicators of abuse and neglect. identify examples of caregiver neglect. identify physical and behavioral indicators of sexual abuse.

3 3 OBJECTIVES Cont ’ d discuss the assessment and management of the abused or neglected patient based on Region X SOP’s. identify necessary documentation and reporting for abused and assaulted patients. identify mandatory reporting requirements associated with abuse situations. identify community resources that are able to assist victims of abuse and assault. participate in questions throughout the power point. successfully complete the post quiz with a score of 80% or better.

4 4 DEFINITIONS Abuse: to treat in a harmful, injurious, or offensive way Assault: an attempt or offer to do violence to another, with or without battery Battery: an unlawful attack upon another person by beating or wounding, or by touching in an offensive manner Neglect: to be remiss in the care or treatment of

5 5 MANDATED REPORTING EMS personnel are mandatory reporters of suspected child abuse/neglect – Suspicions of child abuse/neglect MUST be reported to DCFS – Reports must be filed, even if hospital will also be reporting the incident – need a verbal report and a written report – Includes both living & deceased children encountered by EMS personnel

6 6 CHILD ABUSE Types: – Physical – Emotional – Sexual – Neglect

7 7 Characteristics of Abused Children  Crying, often hopelessly, during treatment or not crying at all Avoiding parents or showing little concern for their absence Unusually wary or fearful of physical contact Apprehensive &/or constantly on the alert for danger

8 8 Characteristics of Abused Children  Prone to sudden behavioral changes Absence of nearly all emotions Neediness, constantly requesting favors, food, or things Use your instincts & knowledge of age- appropriate behavior

9 9 CHILD ABUSE Common conditions mistaken for abuse: – Car seat burns – Chicken pox (cigarette burns) – Hematological disorders that cause easy bruising – Staphylococcal scalded skin syndrome

10 10 CHILD ABUSE Identification of abused child: – Burns & Scalds abusive burns often have distinctive patterns to indicate implement or source used Burns tend to be in certain common locations – soles of feet, palms of hands, back or buttocks Lack of splash burns because child is not allowed to try to escape

11 11 IDENTIFYING ABUSED CHILD Fractures Sites include skull, nose, facial structures, & upper extremities Twisting & jerking fractures result from grabbing a child by an extremity while neck injuries occur from shaking a child Ribs are soft & pliable in children so if you encounter a child with rib fractures, maintain a high index of suspicion

12 12 IDENTIFYING ABUSED CHILD Head Injuries – Injuries from abuse tend to progress from extremities & trunk to head – Common abuse head injuries include scalp wounds, skull fractures, subdural or subgaleal hematomas & repeated contusions

13 13 CHILD ABUSE – Shaken Baby Syndrome Occurs when a parent/caregiver becomes frustrated with a crying infant & all other attempts to quiet baby have failed The shaking can cause permanent damage subdural hematomas diffuse swelling may also result in injuries to neck & spine or retinal hemorrhages If baby is shaken hard enough or repeatedly, death can occur from injuries

14 14 IDENTIFYING ABUSED CHILD Abdominal Injuries – Although they represent a small number of injuries caused by abuse, they are usually very serious – Blunt force can result in trauma to liver, spleen or mesentery – You should look for pain, swelling, & vomiting as well as hemodynamic compromise

15 15 CHILD ABUSE Signs of neglect – Malnutrition – Severe diaper rash – Diarrhea &/or dehydration – Hair loss – Untreated medical or dental conditions – Inappropriate, dirty, torn clothing – Tired & listless attitude – Near constant demands for physical contact or attention

16 16 CHILD ABUSE Signs of emotional abuse – Parents/caregivers simply ignore child, showing indifference to child’s needs & failing to provide stimulation – Parents/caregivers reject, humiliate, or criticize the child

17 17 CHILD ABUSE Signs of emotional abuse – Child may be isolated & deprived of normal human contact or nurturing – Child may be terrorized or bullied through verbal assaults & threats creating feelings of fear & anxiety

18 18 CHILD ABUSE Signs of emotional abuse: – Parent/caregiver may encourage destructive or antisocial behavior – Child may be over-pressured by unrealistic expectations of success

19 19 REGION X SOP – SUSPECTED CHILD ABUSE Routine pediatric care Note environment, child’s interactions with parents, discrepancies in history obtained, any signs of obvious injury Treat obvious injuries per SOP If refusal to transport, remain at a scene and contact police and request child placed in protective custody Transport Report suspicions to ED staff, carefully document Notify DCFS 24/7

20 20 Mandatory Reporting Child Abuse Must call DCFS immediately by phone (800-252-2873) Must follow verbal report with written form within 48 hours of the initial report State Central Register Illinois Department of Children and Family Services 406 East Monroe St Springfield, IL 62701-1498

21 21 Suspected Child Abuse/Neglect Report

22 22

23 23 REVIEW QUESTION In cases of child abuse, the most likely abusers are (pick one): a. Babysitters b. Siblings c. Strangers d. One or both parents e. Friends charged w/child’s care

24 24 REVIEW QUESTION All of the following are characteristics of abused children EXCEPT: a. Sudden behavioral changes b. Neediness c. Absence of nearly all emotions d. Unusual wariness e. Concern over a parent’s absence

25 25 REVIEW QUESTION One of the signs of intentional child abuse is: a. Staphylococcal scalded skin b. Hematological disorders c. Multiple splatter marks d. Multiple bruises e. Absence of splash burns

26 26 REVIEW QUESTION Children rarely exhibit accidental fractures to the (pick one): a. Head b. Ribs c. Legs d. Arms e. Hands or feet

27 27 REVIEW QUESTION Which type of injury claims the largest number of lives among abused children? a. Malnutrition b. Head injuries c. Burns d. Chest injury e. Abdominal injuries

28 28 ELDER ABUSE Types: – Domestic = physical or emotional violence or neglect when an elder is being cared for in a home-based setting Includes financial abuse – Institutional = physical or emotional violence or neglect when an elder is being cared for by a person paid to provide care

29 29 CHARACTERISTICS OF ABUSED ELDERS Abuse most frequently occurs among people dependent on others for their care, especially if they are mentally or physically challenged In these cases, elders tend to be abused repeatedly by relatives who believe the elder will not or cannot ask for help

30 30 CHARACTERISTICS OF ABUSED ELDERS In the case of neglect, abused elders tend to live alone They may be mentally competent but fear asking for help because relatives complained about providing care or threatened to place them in a nursing home They may be reluctant to give information about their abuses for fear of retaliation

31 31 MANDATED REPORTING EMS personnel are mandatory reporters of suspected elder abuse/neglect – Suspicions of elder abuse/neglect MUST be reported to the Elder Abuse Hotline M-F 0830 – 1700 – 800-252-8966 All other times – 800-279-0400

32 32 REGION X SOP – SUSPECTED ELDER ABUSE Routine Medical Care or Trauma Care Def – “Abuse” – any physical injury, sexual abuse or mental injury inflicted on a person age 60 or older, other than by accidental means Def – “Neglect” – failure to provide adequate medical or personal care or maintenance, which failure results in physical or mental injury to a person or in the deterioration of a person’s physical or mental condition

33 33 SUSPECTED ELDER ABUSE SOP cont’d Abuse and/or neglect of elderly patients may occur in the non-institutional or nursing home setting. It is mandated by the State of Illinois to report suspected abuse cases to the Abuse Hot line (800) 252-8966 (Monday-Friday 0830 – 1700) (800) 279-0400 (All other times) Prehospital provider must accurately and completely document any physical findings on the run report form and relay such findings to the ED staff upon transfer to the hospital

34 34 SCENARIO You are called to the local senior citizen housing center for an elderly male with trouble breathing. Upon your arrival you find a 67 y/o male in a messy apartment sitting upright in a chair with rapid respiratory rate & wheezing Patient can only speak in short sentences & states he’s having trouble catching his breath SpO2 is 92% & you apply NRB at 15L

35 35 SCENARIO What is your initial priority for providing care? After initial assessment, what assessment information should be obtained next? Why is the condition of the apartment significant?

36 36 SCENARIO Vitals = RR 28 with wheezing upon exhalation; BP 160/100; HR 100; skin pink, warm & moist; pupils PERL; cap refill <2 seconds Patient has a shoe box full of meds & when asked about taking them seems confused & states he doesn’t remember what he took today. States he lives alone so there is no one to help him with his meds.

37 37 SCENARIO Based on assessment, would you expect patient’s condition to worsen? What additional assessment should be done en route to hospital? How often should vitals be taken? What information about patient’s living situation seems significant enough to provide hospital staff?

38 38 REVEW QUESTION Many victims of abuse hesitate or fail to report the problem because of: a. fear of reprisal b. lack of knowledge c. fear of humiliation d. lack of financial resources e. all of the above

39 39 REVEW QUESTION All of the following are risks that could lead to elder abuse EXCEPT: a. stress on middle-aged caregivers b. decreased life expectancies c. physical & mental impairments d. limited resources for long-term care e. decreased productivity in later years

40 40 REVIEW QUESTION Which of the following are 2 main types of elder abuse? a. Neglect & domestic b. Emotional & financial c. Domestic & institutional d. Mental & institutional e. Financial & domestic

41 41 REVIEW QUESTION The majority of perpetrators of domestic elder abuse tend to be: a. paid caregivers b. siblings c. their adult children d. spouses e. friends or neighbors

42 42 REVIEW QUESTION Physical or emotional violence or neglect of an elder being cared for by a person hired to provide care is referred to as: a. partner abuse b. sexual assault c. rape d. institutional elder abuse e. JCAHO

43 43 REVIEW QUESTION Physical or emotional violence or neglect when an elder is being cared for in a home- based setting is referred to as: a. domestic elder abuse b. SANE c. chain of evidence d. battery e. isolation

44 SEXUAL ASSAULT Definition sexual assault – To knowingly cause another person to engage in unwanted sexual act by force or threat; a statutory crime Definition rape – The crime of forcing a woman to submit to sexual intercourse against her will Rape is referred to as a sexual assault

45 45 SEXUAL ASSAULT Characteristics of sexual assault/rape victims: – Nightmares – Restlessness – Withdrawal tendencies – Hostility – Phobias related to offender Regressive behavior, such as bed wetting Truancy Promiscuity, in older children & teens Drug & alcohol abuse

46 46 SEXUAL ASSAULT EMS responsibilities: – Provide a safe environment – Psychosocial care (ie – privacy, same-sex caregiver) – Use open-ended questions to reestablish a sense of control – Remain non-judgmental; encourage patient to report the crime explaining importance of preserving evidence

47 47 SEXUAL ASSAULT Evidence preservation: – Clothing should only be removed if necessary & all items should be turned over to the proper authorities Store clothing in paper bags – In the case of rape, patient should not urinate, defecate, douche, bathe, eat, drink, or smoke – Carefully & objectively document all findings

48 48 REGION X SOP As a rule, victims should not be questioned in the field Approach victim calmly & professionally Respect the victim’s modesty Explain all procedures before beginning Avoid touching pt other than taking VS or examining physical injuries DO NOT examine genitalia unless life threatening hemorrhage

49 49 SOP cont’d Allow victim to be treated by same gender if at all possible Preserve physical evidence Handle clothing as little as possible Do not use plastic bags for blood stained articles Bag each item separately in paper bags Do not allow victim to comb hair, bathe, or change clothes

50 50 SOP cont’d Do not clean wounds if at all possible Provide emotional support with a non-judgmental attitude Note: Physical trauma, such as bruising, lacerations and fractures are often associated with sexual assault and may be life-threatening

51 51 SCENARIO You are called to the scene for a 36 y/o female victim of an alleged assault. Upon your arrival, you find a woman at the side of the road partially clothed. She is crying & nearly incoherent. You learn that a male assailant abducted patient at gunpoint & sexually assaulted her. He then threw patient from moving vehicle & fled.

52 52 SCENARIO What should be your first priority when entering the scene? How would you go about obtaining information with this patient? What do you do with items considered evidence?

53 53 SCENARIO Vitals are all within normal limits Blood is noted around patient’s perineum What should you do about bleeding in the perineal area? What interventions should you perform? What items would be considered evidence?

54 54 REVIEW QUESTION The group most likely to be victims of sexual assault or rape are adolescent females under age 18. –T–True –F–False

55 55 REVIEW QUESTION The victims of rape most commonly describer their assailant as a stranger. –T–True –F–False

56 56 REVIEW QUESTION When talking to a rape victim, you can help the patient regain a sense of self-control by asking _____ questions. a. open-ended b. closed-ended c. indirect d. non-personal e. leading

57 57 REVIEW QUESTION In managing a rape case, honor the patient’s request to bathe or shower. –T–True –F–False

58 58 REVIEW QUESTION Unwanted oral, genital, or manual sexual contact is termed: a. partner abuse b. sexual assault c. aggression d. battered e. child abuse

59 59 REVIEW QUESTION Penile penetration of the genitalia without consent of the victim is termed: a. partner abuse b. harassment c. rape d. battery e. child abuse

60 60 PARTNER ABUSE Risk factors for an abusive family situation: Male is unemployed Male uses illegal drugs at least once a year Partners have different backgrounds Family income is below poverty level Partners are unmarried

61 61 PARTNER ABUSE Risk factors for an abusive family situation: Either partner is violent toward children at home. Male did not graduate from high-school Male is unemployed or has blue-collar job Male is between 18 & 30 Male saw his father hit his mother

62 62 PARTNER ABUSE Characteristics of abused partners: – Pregnancy = 45% of women suffer some form of battery during pregnancy – Substance abuse = abused partners often seek the numbing effect of alcohol &/or drugs – Emotional disorders = abused partners frequently exhibit depression, evasiveness, anxiety or suicidal behavior

63 63 PARTNER ABUSE Characteristics of abused partners: – Victim may try to protect his/her attacker; remain alert to subtle signs that patient is being less than honest – Victim may provide verbal clues: “we’ve been having some problems lately” “I always seem to be causing some kind of trouble”

64 64 PARTNER ABUSE Reasons for Not Reporting Abuse: Fear of reprisal Fear of humiliation Denial Lack of knowledge Lack of independent financial resources

65 65 PARTNER ABUSE Direct questioning usually works best; convey awareness of situation Avoid judgmental questions &/or statements Before leaving scene, inform patient to take all necessary precautions – Fastest way out – Where patient will go – Who patient will call, etc.

66 66 SOP DOMESTIC VIOLENCE Definition – the MOST common form of violence and the least reported. An act of attacking, threatening, harassing, or interfering with the personal liberty of any family or household member by any other family or household member, excluding any reasonable discipline of a minor by a parent or guardian of the minor. It is required by the Illinois Criminal Code to notify the police in all cases of domestic violence because it is a criminal offense.

67 67 SOP cont ’ d Be non-judgmental and non-threatening Respect and take the patient seriously Maintain privacy The patient should be interviewed and examined alone (away from family/others) Questions should be asked when household members are not within hearing distance The patient must be asked directly if their injuries are a result of a beating Have a high index of suspicion; battered persons rarely admit the source of their injury

68 68 SOP cont ’ d Aside from typical injuries (trauma to head, neck, face, arms or back) look for: Suicide attempts Depression Substance abuse Hysterics Multiple vague somatic complaints Anxiety Miscarriage Maintain a helping approach and be as non-threatening as possible

69 69 SOP cont ’ d Respect and take the patient seriously NOTE: If victim signs a refusal, inform the patient that EMS personnel are mandated by the State to report all cases of domestic violence to the local police. Explain that it is not required that the patient speak to the police and/or files a complaint. Document this conversation on the run report form. Leave your local community informational brochure with the patient, as mandated by law.

70 70 REVIEW QUESTION Partner abuse is defined as physical or emotional violence from a man or woman toward a coworker. –T–True –F–False

71 71 REVIEW QUESTION Many victims of abuse hesitate or fail to report the problem because of a: a. fear of reprisal. b. lack of knowledge. c. fear of humiliation. d. lack of financial resources. e. all of the above

72 72 REVIEW QUESTION Forty-five percent (45%) of pregnant women suffer some form of battery during pregnancy. –T–True –F–False

73 73 REVIEW QUESTION In assessing the battered patient, all of the following are appropriate actions EXCEPT: a. direct questioning. b. asking the victim why she/he doesn’t leave. c. rehearsing with the patient the quickest way to leave the home. d. nonjudgmental questioning. e. reminding patient that assault is a crime.

74 74 REVIEW QUESTION Patients who have been physically struck by another means they have been battered. –T–True –F–False

75 75 DOCUMENTATION Be timely Be objective – If you did not witness the event, then state who supplied the history (ie: “Patient states…”) Be descriptive – List color of bruises – indicates age of bruise – Write length of lacerations (avoid “small”, “large”) Be accurate – These cases often go to court

76 76 REVIEW QUESTION The most widespread & best known form of abuse involves the abuse of: a. women by men. b. children by their mothers. c. children by their fathers. d. elders by their children. e. same-sex partners.

77 77 MANDATORY REPORTING Suspected child abuse – DCFS 24/7 – 800-252-2873 Domestic violence – Contact the police department of the town in which the incident occurred Elder abuse – M-F 0830 – 1700 – 800 252-8966 – All other times – 800 – 279-0400

78 78 BROCHURES For Domestic Violence If patient is transported, the ED will provide brochures If patient requests to sign a release, EMS to offer the patient a brochure – A Safe Place – Breaking the silence – Breaking the Cycle – Business line – 847-731-7165

79 79 COMMUNITY RESOURCES A Safe Place – Lake County Crisis Center – 847-249-4450 LaCasa – Lake county council Against Sexual Assault – 847-872-7799 Lake County State ’ s Attorney Office – Lake County Domestic Violence Council – 847-377-3000 National Teen Dating Abuse Hotline – 866-331-9474 Order of Protection Assistance – 847-360-6471

80 80 THAT’S IT… QUESTIONS, COMMENTS, FEELINGS? For more training on Child Abuse please visit

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