Improving EMS Response to Domestic Violence

1. 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.

2. 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 This training is designed to make you a better EMS provider, but also a better person. DV is everywhere at your job, church, community, in the back of your ambulance and in the crew quarters.This training is designed to make you a better EMS provider, but also a better person. DV is everywhere at your job, church, community, in the back of your ambulance and in the crew quarters.

3. Definition of Domestic Violence Domestic violence: Is a pattern of behavior (physical, sexual, verbal, emotional, financial, spiritual, etc.) used by one person to control another�s 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. Teaching Points: Brainstorm examples of abuse (physical, emotional and sexual) with group. Talk about and address stereotypes about cause of abuse, etc� as they come up in this conversation.Teaching Points: Brainstorm examples of abuse (physical, emotional and sexual) with group. Talk about and address stereotypes about cause of abuse, etc� as they come up in this conversation.

4. 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

5. Power and Control Wheel Provide an example of abuse � someone�s story to help explain the wheel. Offer the additional aspect of this dynamic: � Pity me. I need you.� vs. Threats and Violence When abusers go back and forth between these things, it contributes to the victim�s challenge in figuring out whether there is hope for change�whether the threats and violence are permanent and/or bad enough to outweigh the degree to which the abuser really needs her/him. �I�m sorry I hit you. It is just that I love you so much and get scared that someone will take you away from me. When I heard that you were out with your friends I just lost it. I know you would never hurt me, but every other person I�ve ever loved has betrayed me, and I have a hard time trusting that you are really as wonderful as you are.� Leave the Power and Control Wheel up and do Risk Analysis ExerciseProvide an example of abuse � someone�s story to help explain the wheel. Offer the additional aspect of this dynamic: � Pity me. I need you.� vs. Threats and Violence When abusers go back and forth between these things, it contributes to the victim�s challenge in figuring out whether there is hope for change�whether the threats and violence are permanent and/or bad enough to outweigh the degree to which the abuser really needs her/him. �I�m sorry I hit you. It is just that I love you so much and get scared that someone will take you away from me. When I heard that you were out with your friends I just lost it. I know you would never hurt me, but every other person I�ve ever loved has betrayed me, and I have a hard time trusting that you are really as wonderful as you are.� Leave the Power and Control Wheel up and do Risk Analysis Exercise

6. 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 Children�s Programs Batterer Intervention Programs

7. EMS Response If yes, Stage and advise PD of your arrival Enter only as directed by police If no, Stage and wait until police arrive and scene has been secured Ask about what typically happens in their system. The answer is going to vary across the state, but they know best, so ask!Ask about what typically happens in their system. The answer is going to vary across the state, but they know best, so ask!

8. 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

9. Scene Safety Assessment Presence and condition of children and pets Evidence of: Struggle Weapons Substance abuse Attempts to conceal information

10. Scene Safety Assessment (cont.) 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 & doesn�t need medical care

11. Scene Safety Assessment (cont.)

12. Scene Safety Strategies Identify yourself as EMS providers Use team approach (never split the team) Be aware of surroundings Attempt to sequester patient

13. Scene Safety Strategies Avoid treating patient in bedroom or kitchen Limit number of people present Let occupants lead Don�t be afraid to use the ambulance

14. 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

15. Primary Health Issues Keep in mind that medical issues are first priority.

16. Behavioral Cues Is fearful or anxious around partner Is reluctant to answer questions, provides conflicting information Has delayed seeking medical help

17. Observe if partner or caregiver: Is angry, belligerent or indifferent to patient�s needs Refuses or hesitates to allow transport Focuses on own minor health issues Attempts to control patient�s interaction with EMS

18. Assessment Cues Has injuries during pregnancy Has multiple, vague complaints Provides inconsistent medical history Any injury to a pregnant woman is suspect: Abuse often begins during pregnancy. Abuse directed at chest or abdomen may cause miscarriage, stillbirth, preterm labor. Look for multiple injury sites, abdominal bruises, vaginal bleeding, postpartum sexual assault.Any injury to a pregnant woman is suspect: Abuse often begins during pregnancy. Abuse directed at chest or abdomen may cause miscarriage, stillbirth, preterm labor. Look for multiple injury sites, abdominal bruises, vaginal bleeding, postpartum sexual assault.

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

20. Medical Assessment 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

21. Transport vs. Non-Transport If patient accepts transport: Consider advising hospital security Explain medical consequences Provide support & referral to a DV project

22. Transport vs. Non-Transport If patient declines transport: Be non-judgmental Provide first aid Provide support & referral to a DV project Document well

23. 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. FS- The patient�s clothing may be evidence. If you have had to cut it off to treat injury, turn it over to law enforcement. If an injury shows evidence of a particular object � the impression of a ring, belt � -- advise police so they can look for that object. FS- The patient�s clothing may be evidence. If you have had to cut it off to treat injury, turn it over to law enforcement. If an injury shows evidence of a particular object � the impression of a ring, belt � -- advise police so they can look for that object.

24. Ask About Abuse Keep in mind: Ask patients in confidential settings Be non-judgmental Encourage & support

25. 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 women�s lives, I ask about it routinely�

26. Ask direct questions (cont.) Getting a disclosure is not the objective: Asking the question and offering resource information is the objective. Teaching Points: Why people who are abused might not tell EMS People who are abused may: -fear retribution if the battered learns they have disclosed . -feel protective of the batterer. -have told a physician or other medical professional in the past and received no response or a negative response. -feel that the EMT doesn�t have time to listen or ask questions. People who are abused may believe that: They are the only one. People will not believe them. They are responsible for the abuse. People who are abused may feel. Shame and/or humiliation Fear and/or guilt The victim may be reluctant to accept medical assistance due to fear of retaliation by the abuser.Teaching Points: Why people who are abused might not tell EMS People who are abused may: -fear retribution if the battered learns they have disclosed . -feel protective of the batterer. -have told a physician or other medical professional in the past and received no response or a negative response. -feel that the EMT doesn�t have time to listen or ask questions. People who are abused may believe that: They are the only one. People will not believe them. They are responsible for the abuse. People who are abused may feel. Shame and/or humiliation Fear and/or guilt The victim may be reluctant to accept medical assistance due to fear of retaliation by the abuser.

27. 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 Encourage victim to talk about the abuse Encourage victim to talk about the abuse

28. 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.

29. 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

30. 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 Teaching Points: Good documentation lessens likelihood of needing to go to court and testify. Conversely, bad documentation increases it. Insert run sheet here, with translation. Teaching Points: Good documentation lessens likelihood of needing to go to court and testify. Conversely, bad documentation increases it. Insert run sheet here, with translation.

31. Ask about 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?

32. Review Options, Offer Referrals 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.

33. Review Options, Offer Referrals (cont.) Additional helpful things to say to a victim: I�m concerned for your safety and the safety of your children. You do not deserve to be treated this way. I�m sorry this happened to you. How can I help? Many people experience this. You are not alone.

34. 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, an�ambulance attendant, emergency medical technician�has 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 report�to the department� (Title 22 Chapter 1-A, Subsection 3477). Maine Department of Human Services Central Intake 1-800-452-1999 Teaching points: Remember to keep patient�s confidentiality when discussing your concerns with the partner or family member.Teaching points: Remember to keep patient�s confidentiality when discussing your concerns with the partner or family member.

35. 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.

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

37. Thank you

38. 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?