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
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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.
2
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.
3
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
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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
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CHILD ABUSE
• Types:
– Physical
– Emotional
– Sexual
– Neglect
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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
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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 ageappropriate behavior
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CHILD ABUSE
• Common conditions mistaken for abuse:
– Car seat burns
– Chicken pox (cigarette burns)
– Hematological disorders that cause easy
bruising
– Staphylococcal
skin
scalded
syndrome
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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
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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
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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
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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
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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
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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
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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
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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
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CHILD ABUSE
• Signs of emotional abuse:
– Parent/caregiver may encourage destructive
or antisocial behavior
– Child may be over-pressured by unrealistic
expectations of success
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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
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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
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Suspected Child Abuse/Neglect
Report
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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
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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
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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
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REVIEW QUESTION
• Children rarely exhibit accidental fractures
to the (pick one):
a. Head
b. Ribs
c. Legs
d. Arms
e. Hands or feet
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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
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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
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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
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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
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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
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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
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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
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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
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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?
35
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.
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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?
37
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
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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
39
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
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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
41
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
42
REVIEW QUESTION
• Physical or emotional violence or neglect
when an elder is being cared for in a homebased setting is referred to as:
a. domestic elder abuse
b. SANE
c. chain of evidence
d. battery
e. isolation
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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
SEXUAL ASSAULT
Characteristics of sexual assault/rape victims:
– Nightmares
• Regressive behavior,
such as bed wetting
– Restlessness
• Truancy
– Withdrawal
tendencies
• Promiscuity, in older
children & teens
– Hostility
• Drug & alcohol abuse
– Phobias related to
offender
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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
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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
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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
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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
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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
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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.
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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?
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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?
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REVIEW QUESTION
• The group most likely to be victims of
sexual assault or rape are adolescent
females under age 18.
– True
– False
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REVIEW QUESTION
• The victims of rape most commonly
describer their assailant as a stranger.
– True
– False
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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
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REVIEW QUESTION
• In managing a rape case, honor the
patient’s request to bathe or shower.
– True
– False
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REVIEW QUESTION
• Unwanted oral, genital, or manual sexual
contact is termed:
a. partner abuse
b. sexual assault
c. aggression
d. battered
e. child abuse
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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
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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
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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
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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
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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”
63
PARTNER ABUSE
• Reasons for Not Reporting Abuse:
Fear of reprisal
Fear of humiliation
Denial
Lack of knowledge
Lack of independent
financial resources
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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.
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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.
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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
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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
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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.
69
REVIEW QUESTION
• Partner abuse is defined as physical or
emotional violence from a man or woman
toward a coworker.
– True
– False
70
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
71
REVIEW QUESTION
• Forty-five percent (45%) of pregnant
women suffer some form of battery during
pregnancy.
– True
– False
72
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.
73
REVIEW QUESTION
• Patients who have been physically struck
by another means they have been battered.
– True
– False
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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
75
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.
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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
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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
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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
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THAT’S IT…
QUESTIONS, COMMENTS, FEELINGS?
For more training on Child Abuse please visit
https://www.dcfstraining.org/manrep/index.jsp
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