1 THE ABUSED PATIENT March 2010 CE - PowerPoint Presentation

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THE ABUSED PATIENT

March 2010 CECondell Medical Center EMS System

Prepared by: Steve Holtz, FF/PM Libertyville FD

Reviewed/revised by:

Sharon Hopkins, RNSlide2

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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. Slide3

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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.Slide4

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DEFINITIONS

Abuse: to treat in a harmful, injurious, or offensive wayAssault: an attempt or offer to do violence to another, with or without batteryBattery: 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 ofSlide5

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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 DCFSReports 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 personnelSlide6

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CHILD ABUSETypes:

PhysicalEmotionalSexualNeglectSlide7

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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 absenceUnusually wary or fearful of physical contactApprehensive &/or constantly on the alert for dangerSlide8

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Characteristics of Abused Children

Prone to sudden behavioral changes

Absence of nearly all emotionsNeediness, constantly requesting favors, food, or thingsUse your instincts & knowledge of age-appropriate behaviorSlide9

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CHILD ABUSE

Common conditions mistaken for abuse:Car seat burnsChicken pox (cigarette burns)Hematological disorders that cause easy bruisingStaphylococcal scalded skin syndromeSlide10

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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 buttocksLack of splash burns because child is not allowed to try to escapeSlide11

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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 childRibs are soft & pliable in children so if you encounter a child with rib fractures, maintain a high index of suspicionSlide12

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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 contusionsSlide13

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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 injuriesSlide14

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IDENTIFYING ABUSED CHILD

Abdominal Injuries

Although they represent a small number of injuries caused by abuse, they are usually very seriousBlunt force can result in trauma to liver, spleen or mesentery

You should look for pain, swelling, & vomiting as well as hemodynamic compromiseSlide15

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CHILD ABUSE

Signs of neglectMalnutrition

Severe diaper rashDiarrhea &/or dehydration

Hair lossUntreated medical or dental conditionsInappropriate, dirty, torn clothing

Tired & listless attitude

Near constant demands for physical contact or attentionSlide16

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CHILD ABUSE

Signs of emotional abuseParents/caregivers simply ignore child, showing indifference to child’s needs & failing to provide stimulationParents/caregivers reject, humiliate, or criticize the childSlide17

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CHILD ABUSE

Signs of emotional abuseChild may be isolated & deprived of normal human contact or nurturingChild may be terrorized or bullied through verbal assaults & threats creating feelings of fear & anxietySlide18

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CHILD ABUSE

Signs of emotional abuse:

Parent/caregiver may encourage destructive or antisocial behaviorChild may be over-pressured by unrealistic expectations of successSlide19

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REGION X SOP – SUSPECTED CHILD ABUSERoutine pediatric care

Note environment, child’s interactions with parents, discrepancies in history obtained, any signs of obvious injuryTreat obvious injuries per SOPIf refusal to transport, remain at a scene and contact police and request child placed in protective custodyTransport

Report suspicions to ED staff, carefully documentNotify DCFS 24/7Slide20

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Mandatory Reporting Child AbuseMust 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 StSpringfield, IL 62701-1498Slide21

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Suspected Child Abuse/Neglect ReportSlide22

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REVIEW QUESTION

In cases of child abuse, the most likely abusers are (pick one):a. Babysittersb. Siblings

c. Strangersd. One or both parentse. Friends charged w/child’s careSlide24

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REVIEW QUESTION

All of the following are characteristics of abused children EXCEPT:a. Sudden behavioral changesb. Needinessc. Absence of nearly all emotions

d. Unusual warinesse. Concern over a parent’s absenceSlide25

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REVIEW QUESTION

One of the signs of intentional child abuse is:a. Staphylococcal scalded skinb. Hematological disorders

c. Multiple splatter marksd. Multiple bruisese. Absence of splash burnsSlide26

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REVIEW QUESTION

Children rarely exhibit accidental fractures to the (pick one):a. Headb. Ribsc. Legs

d. Armse. Hands or feetSlide27

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REVIEW QUESTION

Which type of injury claims the largest number of lives among abused children?a. Malnutritionb. Head injuriesc. Burns

d. Chest injurye. Abdominal injuriesSlide28

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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 abuseInstitutional = physical or emotional violence or neglect when an elder is being cared for by a person paid to provide careSlide29

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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 helpSlide30

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CHARACTERISTICS OF ABUSED ELDERS

In the case of neglect, abused elders tend to live aloneThey 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 retaliationSlide31

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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 – 800-252-8966All other times – 800-279-0400Slide32

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REGION X SOP – SUSPECTED ELDER ABUSERoutine 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 meansDef – “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 conditionSlide33

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SUSPECTED ELDER ABUSE SOP cont’dAbuse 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 hospitalSlide34

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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 & wheezingPatient can only speak in short sentences & states he’s having trouble catching his breath

SpO2 is 92% & you apply NRB at 15LSlide35

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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?Slide36

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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. Slide37

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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?Slide38

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REVEW QUESTIONMany victims of abuse hesitate or fail to report the problem because of:

a. fear of reprisalb. lack of knowledgec. fear of humiliation

d. lack of financial resourcese. all of the aboveSlide39

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REVEW QUESTION

All of the following are risks that could lead to elder abuse EXCEPT:a. stress on middle-aged caregiversb. decreased life expectancies

c. physical & mental impairmentsd. limited resources for long-term caree. decreased productivity in later yearsSlide40

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REVIEW QUESTION

Which of the following are 2 main types of elder abuse?a. Neglect & domesticb. Emotional & financialc. Domestic & institutional

d. Mental & institutionale. Financial & domesticSlide41

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REVIEW QUESTION

The majority of perpetrators of domestic elder abuse tend to be:a. paid caregiversb. siblingsc. their adult children

d. spousese. friends or neighborsSlide42

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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 abuseb. sexual assault

c. raped. institutional elder abuse

e. JCAHOSlide43

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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 abuseb. SANE

c. chain of evidenced. battery

e. isolationSlide44

SEXUAL ASSAULT

Definition sexual assaultTo knowingly cause another person to engage in unwanted sexual act by force or threat; a statutory crimeDefinition rapeThe crime of forcing a woman to submit to sexual intercourse against her willRape is referred to as a sexual assaultSlide45

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SEXUAL ASSAULT

Characteristics of sexual assault/rape victims:

NightmaresRestlessness

Withdrawal tendenciesHostilityPhobias related to offender

Regressive behavior, such as bed wetting

Truancy

Promiscuity, in older children & teens

Drug & alcohol abuseSlide46

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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 controlRemain non-judgmental; encourage patient to report the crime explaining importance of preserving evidenceSlide47

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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 bagsIn the case of rape, patient should not urinate, defecate, douche, bathe, eat, drink, or smoke

Carefully & objectively document all findingsSlide48

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REGION X SOPAs a rule, victims should not be questioned in the field

Approach victim calmly & professionallyRespect the victim’s modestyExplain all procedures before beginningAvoid touching pt other than taking VS or examining physical injuriesDO NOT examine genitalia unless life threatening hemorrhageSlide49

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SOP cont’dAllow victim to be treated by same gender if at all possible

Preserve physical evidenceHandle clothing as little as possibleDo not use plastic bags for blood stained articlesBag each item separately in paper bagsDo not allow victim to comb hair, bathe, or change clothesSlide50

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SOP cont’dDo not clean wounds if at all possible

Provide emotional support with a non-judgmental attitudeNote: Physical trauma, such as bruising, lacerations and fractures are often associated with sexual assault and may be life-threateningSlide51

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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.Slide52

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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?Slide53

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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?Slide54

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REVIEW QUESTION

The group most likely to be victims of sexual assault or rape are adolescent females under age 18.TrueFalseSlide55

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REVIEW QUESTION

The victims of rape most commonly describer their assailant as a stranger.TrueFalseSlide56

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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-endedc. indirect

d. non-personale. leadingSlide57

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REVIEW QUESTION

In managing a rape case, honor the patient’s request to bathe or shower.TrueFalseSlide58

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REVIEW QUESTION

Unwanted oral, genital, or manual sexual contact is termed:a. partner abuseb. sexual assaultc. aggression

d. batterede. child abuseSlide59

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REVIEW QUESTION

Penile penetration of the genitalia without consent of the victim is termed:a. partner abuseb. harassmentc. rape

d. batterye. child abuseSlide60

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PARTNER ABUSE

Risk factors for an abusive family situation:

Male is unemployedMale uses illegal drugs at least once a year

Partners have different backgroundsFamily income is below poverty level

Partners are unmarriedSlide61

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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-schoolMale is unemployed or has blue-collar job

Male is between 18 & 30

Male saw his father hit his motherSlide62

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PARTNER ABUSE

Characteristics of abused partners:Pregnancy

= 45% of women suffer some form of battery during pregnancySubstance abuse = abused partners often seek the numbing effect of alcohol &/or drugs

Emotional disorders = abused partners frequently exhibit depression, evasiveness, anxiety or suicidal behaviorSlide63

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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 honestVictim may provide verbal clues:

“we’ve been having some problems lately” “I always seem to be causing some kind of trouble”Slide64

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PARTNER ABUSEReasons for Not Reporting Abuse:

Fear of reprisalFear of humiliation

DenialLack of knowledge

Lack of independent financial resourcesSlide65

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PARTNER ABUSE

Direct questioning usually works best; convey awareness of situation

Avoid judgmental questions &/or statementsBefore leaving scene, inform patient to take all necessary precautionsFastest way out

Where patient will goWho patient will call, etc.Slide66

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SOP DOMESTIC VIOLENCEDefinition – 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.Slide67

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SOP cont’d

Be non-judgmental and non-threateningRespect and take the patient seriouslyMaintain privacyThe patient should be interviewed and examined alone (away from family/others)

Questions should be asked when household members are not within hearing distanceThe 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 injurySlide68

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SOP cont’d

Aside from typical injuries (trauma to head, neck, face, arms or back) look for:Suicide attemptsDepressionSubstance abuseHysterics

Multiple vague somatic complaintsAnxietyMiscarriage

Maintain a helping approach and be as non-threatening as possibleSlide69

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SOP cont’d

Respect and take the patient seriouslyNOTE: 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.Slide70

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REVIEW QUESTION

Partner abuse is defined as physical or emotional violence from a man or woman toward a coworker.TrueFalseSlide71

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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 aboveSlide72

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REVIEW QUESTION

Forty-five percent (45%) of pregnant women suffer some form of battery during pregnancy.TrueFalseSlide73

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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.Slide74

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REVIEW QUESTION

Patients who have been physically struck by another means they have been battered.TrueFalseSlide75

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DOCUMENTATION

Be timelyBe objectiveIf you did not witness the event, then state who supplied the history (ie: “Patient states…”)Be descriptiveList color of bruises – indicates age of bruiseWrite length of lacerations (avoid “small”, “large”)

Be accurateThese cases often go to courtSlide76

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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.Slide77

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MANDATORY REPORTINGSuspected child abuse

DCFS 24/7 – 800-252-2873Domestic violenceContact the police department of the town in which the incident occurredElder abuseM-F 0830 – 1700 – 800 252-8966All other times – 800 – 279-0400Slide78

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BROCHURES For Domestic ViolenceIf patient is transported, the ED will provide brochures

If patient requests to sign a release, EMS to offer the patient a brochureA Safe PlaceBreaking the silenceBreaking the CycleBusiness line – 847-731-7165Slide79

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COMMUNITY RESOURCES

A Safe Place – Lake County Crisis Center847-249-4450LaCasa – Lake county council Against Sexual Assault

847-872-7799Lake County State’s Attorney Office

– Lake County Domestic Violence Council847-377-3000

National Teen Dating Abuse Hotline

866-331-9474

Order of Protection Assistance

847-360-6471Slide80

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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