THE ABUSED PATIENT March 2010 CE Condell Medical Center EMS System

1. THE ABUSED PATIENTMarch 2010 CECondell Medical Center EMS System Prepared by: Steve Holtz, FF/PM Libertyville FD Reviewed/revised by: Sharon Hopkins, RN

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. 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. 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. 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. CHILD ABUSE • Types: • Physical • Emotional • Sexual • Neglect

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Suspected Child Abuse/Neglect Report

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

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

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. 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. 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. 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. 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