Chapter 46 Abuse and Neglect

1. Chapter 46Abuse and Neglect

2. Objectives Define battering Describe characteristics of abusive relationships Outline findings that indicate a battered patient Describe prehospital considerations during care of a battered patient Identify types of elder abuse

3. Objectives Discuss legal aspects of elder abuse Describe abused children and their abusers Outline examination of the abused child Describe characteristics of sexual assault Outline patient care for the patient who has been sexually assaulted

4. Case Study Police call you to a park to care for a young woman who states that she was sexually assaulted by several men, beaten, and then thrown from a car into the woods. She is sobbing convulsively, and asking, “Why me?” You note multiple abrasions to her forehead. Her torn shirt falls away as you begin your exam.

5. Discussion Should you ask her for a detailed account of the incident? What should you do with her blouse? How should you proceed with your physical examination of her? What are your priorities in her care? Describe legal aspects of her care.

6. Incidence, Morbidity/Mortality Abuse of spouse, elderly, children greater than most estimate Only 10% of women report battering >1 million children suffer from abuse or neglect May die of abuse or assault May suffer mental or physical injuries

7. Risk Factors Men and women who beat one another most likely beat their children Children of abusive homes more likely to become spouse or child batterers and abusers of elderly parents

8. Prevention Strategies Early detection Social services support Altering life styles

9. Domestic Violence Three phase cycle Phase1: arguing and verbal abuse Phase 2: physical and sexual abuse Phase 3: denial and apologies “Honeymoon phase” Intervention in phase 2 or 3 Without intervention cycle repeats Usually increases in frequency and severity

10. Cycle of Violence

11. Types of Abuse and Neglect Physical abuse Sexual abuse Emotional abuse Financial/material exploitation Neglect

12. Battering Form of domestic violence Establish control and fear through violence and other forms of abuse

13. Battered Women Reasons for not reporting Personal fear Fear for children Believe offender’s behavior will change Lack of financial and/or emotional support Woman thinks she caused violent behavior Belief that battering is “part of marriage” Must be endured to keep family together

14. Battered Men Usually, batterer is male Battering not limited to women Men report physical violence by intimate less than women because of: Humiliation Guilt Fear to admit loss of control Societal issues

15. Characteristics of Persons in Abusive Relationships Need for love and affection Low self–esteem Alcohol or other drug dependence Difficulty in finances, job security, and legal issues History of physical, emotional, or sexual abuse Believe abuse demonstrates discipline Fear of being “out of control” Uncontrolled temper, extreme jealousy, insecurity

16. Characteristics of Persons in Abusive Relationships Can’t set and enforce personal boundaries Unrealistic expectations of relationship Difficulty in expressing anger Loyalty to abuser takes precedence over emotional or physical safety Repeated attempts to leave relationship Clinical depression Suicidal ideation or attempts

17. Identifying the Battered Patient May be difficult Description of injuries may be incorrect, inaccurate, and protective of attacker Injuries often involve extremities Often contusions and lacerations of face, head, neck, breast, and abdomen

18. Identifying the Battered Patient Other clues Delay between injury and seeking treatment Repeated use of EMS Injuries during pregnancy Substance abuse Frequent suicide gestures

19. Scene Safety Scene and personal safety critical If it is known domestic violence, PD should be summoned EMS shouldn’t enter scene until secure

20. Care of the Victim Physical injuries cared for according to standard practice protocols Attention to emotional needs of victim Abuser often unwilling to allow victim to give a history or to be alone with EMS Question patient privately if possible

21. The Patient Interview Nonjudgmental attitude Avoid saying, “How awful” or “Why don’t you leave?” Supportive attitude Listen Provide support and encouragement Return control to patient if possible Encourage him or her to gain control of life Encourage patient to identify what he or she wants and needs of children

22. The Patient Interview Provide access to community resources Battered spouse programs Victim-witness assistance programs Discuss safety precautions Help patient identify way out, where to go, who to call Provide list or card of community resources Include shelter and hotline numbers

23. Legal Considerations It is a crime to physically assault another person Misdemeanor or a felony depending on: State law Amount of injury inflicted Devices used during the assault

24. Legal Considerations Often attacker arrested but released on his or her own recognizance If early release from custody likely, make patient aware of this Encourage personal safety precautions

25. Legal Considerations Most states do not have mandatory reporting for acts of domestic violence Be aware of reporting requirements in your state EMS personnel should advise medical direction of suspicions and observations of possible violence

26. Elder Abuse Prevalent medical and social problem in U.S. Factors that contribute to elder abuse

27. Elder Abuse Types of elder abuse Physical abuse Psychological abuse Financial or material abuse Neglect (both passive and active) Classified by where it occurs Domestic settings Institutions

28. Legal Considerations 50 states have elder abuse statutes In most states, reporting of suspected elder abuse mandatory If abuse or neglect is suspected: Carefully document findings Advise medical direction Follow local procedures

29. Child Abuse - Neglect Most common form of child abuse Failure to provide physical care Medical care Nutrition Shelter Clothing Failure to provide emotional care Indifference Disregard Characteristics of abusers

30. Child Abusers Often… Demonstrate immature behavior Show personal preoccupation Have little perception of how child feels Are critical of child Do not touch or look at child Are unconcerned about child’s injury Show no guilt or remorse Blame child for injury or illness

31. Characteristics of Abused Child Carefully observe: Child < 6 y/o who is excessively passive Child > 6 y/o who is excessively aggressive

32. Characteristics of Abused Child Carefully observe children who: Don’t mind if parents leave room Cry nonstop during treatment or rarely cry Do not look at parents for reassurance Are wary of physical contact Are extremely apprehensive Appear constantly on alert for danger Constantly seek favors, food, or things

33. The Physical Examination Childhood injuries common Most accidental - not from abuse Distinguishing between intentional and unintentional injury can be challenging Clues obtained by: Observing child and relationship with parent or caregiver Matching history of event to injury

34. Injuries Associated with Abuse

35. Legal Considerations When possible, physical examination of a suspected child abuse victim should be performed with another colleague Concise and legible report Pertinent findings well documented

36. Common Types of Injuries Soft tissue injuries Patterned injuries Fractures Head injuries Abdominal injuries

37. Sexual Assault Sexual assault is committed more frequently than other forms of abuse Can result in mental or physical injury and death States have different interpretations of sexual assault

38. Legal Considerations Take steps to preserve evidence Do not allow patient to urinate or defecate (if possible), douche, or bathe Do not remove evidence from any part of body that had sexual contact

39. Legal Considerations Notify police as soon as possible Be aware of “chain of evidence” Follow reporting requirements Consult with medical direction and follow established protocols

40. Common Injuries That Result From Sexual Assault Abrasions, bruises on upper limbs, head, and neck Forcible signs of restraint Rope burns, mouth injuries Petechiae of face and conjunctiva from choking Broken teeth, swollen jaw or cheekbone, eye injuries from being punched or slapped in face Muscle soreness or stiffness in shoulder, neck, knee, hip, back From restraint in postures that allow sexual penetration

41. Psychosocial Aspects of Care Sexual assault creates physical and psychological disorganization Victims may behave in a variety of ways Don’t question in detail about incident Limit history to elements necessary to provide emergency medical care

42. Psychosocial Aspects of Care Contact with victim should include: Nonjudgmental and supportive attitude Empathetic and sensitive comments Quiet speech Slow movements Considerate gestures Move to a safe and quiet environment

43. Psychosocial Aspects of Care If possible, same gender paramedic should provide medical care Or chaperone should be present Do not leave patient alone Ask permission to call friend, family, or rape crisis advocate Notify hospital of victim concerns

44. The Child Victim Children vulnerable to sexual assault Often have frequent contact with assailant Often occurs in trusted person’s home Most involve male assailant and female victim

45. The Child Victim Indication of sexual assault Abrupt behavior changes Sleep difficulties, nightmares Withdrawal from friends and family Low self–esteem or desire to be invisible Phobias related to offender Hostility Self-destructive behaviors Mood swings, depression, anxiety Regression e.g., bed wetting Truancy Eating disorders Alcohol or other drug use

46. Legal Considerations If sexual assault is confirmed or suspected Follow applicable laws Laws affect confidentiality of children Be aware of regulations in your community In some states, minors may seek care and be treated for sexual assault without parental consent

47. Conclusion Partner, elder, and child abuse are growing problems n the United States. Paramedics must be knowledgeable regarding identification of victims, special aspects of care, scene safety, and documentation requirements.

48. Questions?