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. EMS Response to Domestic Violence

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

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. EMS Response to Domestic Violence

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 EMS Response to Domestic Violence

5. Power and Control Wheel Courtesy Domestic Abuse Intervention Project Duluth, MN

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 EMS Response to Domestic Violence

7. 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 EMS Response If dispatched as a domestic assault: Are police on scene? EMS Response to Domestic Violence

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 EMS Response to Domestic Violence

9. Scene Safety Assessment • Presence and condition of children and pets • Evidence of: • Struggle • Weapons • Substance abuse • Attempts to conceal information Upon approach, and entry look for: EMS Response to Domestic Violence

10. 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 Scene Safety Assessment (cont.) Be particularly careful if: EMS Response to Domestic Violence

11. Scene Safety Assessment (cont.) • Don’t hesitate to return to ambulance to discuss options, notify police, or contact Medical Control. • Consider using cell phone vs. radio. EMS Response to Domestic Violence

12. Identify yourself as EMS providers Use team approach (never split the team) Be aware of surroundings Attempt to sequester patient Scene Safety Strategies If decision is to proceed: EMS Response to Domestic Violence

13. Avoid treating patient in bedroom or kitchen Limit number of people present Let occupants lead Don’t be afraid to use the ambulance Scene Safety Strategies If decision is to proceed: EMS Response to Domestic Violence

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. EMS Response to Domestic Violence

16. Is fearful or anxious around partner Is reluctant to answer questions, provides conflicting information Has delayed seeking medical help Behavioral Cues Observe if patient: EMS Response to Domestic Violence

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 EMS Response to Domestic Violence

18. Has injuries during pregnancy Has multiple, vague complaints Provides inconsistent medical history Assessment Cues Observe if patient: EMS Response to Domestic Violence

19. Resulting from defensive action In shape of objects On areas normally hidden On other victims (children, elderly, pets) Trauma Assessment Look for injuries: EMS Response to Domestic Violence

20. 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 Medical Assessment Potential medical complaints: EMS Response to Domestic Violence

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

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

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. EMS Response to Domestic Violence

24. Ask About Abuse Keep in mind: • Ask patients in confidential settings • Be non-judgmental • Encourage & support EMS Response to Domestic Violence

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… EMS Response to Domestic Violence

26. Ask direct questions (cont.) • Getting a disclosure is not the objective: • Asking the question and offering resource information is the objective. EMS Response to Domestic Violence

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 EMS Response to Domestic Violence

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. EMS Response to Domestic Violence

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 EMS Response to Domestic Violence

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 EMS Response to Domestic Violence

31. 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? EMS Response to Domestic Violence

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. Things to say when making a referral: EMS Response to Domestic Violence

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. EMS Response to Domestic Violence

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 EMS Response to Domestic Violence

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! EMS Response to Domestic Violence

37. Thank you EMS Response to Domestic Violence

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?