Domestic Violence

1. Domestic Violence Region 8 EMS September 2011

2. Learning Objectives Cognitive • Describe the various types of domestic violence and common clues of a domestic abuse situation. • Discuss scene safety concerns for the EMS responder. • Discuss the role of EMS at the scene of a domestic violence call, including the treatment and emotional support of the patient.

3. Learning Objectives Psychomotor • Demonstrate the proper technique for assessing a patient involved in a domestic violence incident. • Perform the proper treatment for a patient involved in a domestic violence incident, including psychological care.

4. Anxiety Child abuse Coercive Depression Domestic Partner Elder abuse Incest Incidence Intervention Key Vocabulary

5. Intervention Post-traumatic stress Rape Situational Awareness Substance abuse Threats Victimization Key Vocabulary (continued)

6. Domestic Violence Definition • The victimization of a person by an abuser who is related or has some significant relationship with the abused • A pattern of coercive behaviors used to establish and maintain power and control • Violent incidents that build on previous episodes and often increase in severity over time

7. Common Myths • Domestic violence is not a problem in my community • Domestic violence only happens to poor women and women of color • Some people deserve to be hit • Alcohol, drug abuse, stress and mental illness cause domestic violence • Domestic violence is a personal problem between a husband and wife • If it were that bad she would just leave

8. Violence Wheel

9. Scene Size-up • Ensure safety before entering. • Most uncertain and complex calls • Never know who the victim is • Never know who the assailant is • Rules change • Thorough scene assessment is imperative. • Assume anything is possible. • Remove yourself from the situation any time you feel threatened.

10. Safety During the Call • Police secures the scene • Conflicting parties separated • Carefully monitor scene by someone else • If abuser has left, he/she may return • No one should come between you and your means of egress • You and partner should stay together

11. Occurrence • Touches all socioeconomic backgrounds and includes abuse against men, women, same-sex couples, children, and the elderly

12. Provider Responsibility • Know state and local laws for reporting. • Be aware that your presence changes the dynamics of the situation. • Maintain an unbiased approach. • Treat as a potential crime scene.

13. Provider Responsibility • Identify potential behaviors that point to Domestic Abuse. • Patient is fearful of a household member. • Patient exhibits increased anxiety when person is near. • Patient is reluctant to respond. • Accounts of the incident conflict. • History is inconsistent with the injury or illness.

14. Potential Behaviors • Presents with multiple vague complaints • Complains of trauma without anatomic “evidence of injury” • Injuries in various stages of healing • Household member angry or indifferent toward patient • Hesitation to permit patient’s transport to hospital • Prevents the patient from interacting privately or speaking openly

15. Abuser History • Personal problems • Financially or emotionally dependent • Problems with alcohol and or drugs • May be continuing a pattern of abuse • Suffering from an emotional disorder • Physiological brain disorder

16. Signs of Abuser Instability • Excessive emotional attention • Physical crowding • Nervous behavior or glances • Target glances • Ignoring questions and statements • Repetitious questioning • Ceasing all movement

17. Assessment • Ensure safety for you, your partner, and the patient. • Follow Standard Precautions. • Perform ABCs. • Perform a quick assessment. • Ask good, objective questions. • Perform a secondary assessment. • Initiate correct treatment.

18. Assessment (continued) • Understand injury patterns. • Face & neck: 33% • Arms: 16% • Head: 14.5% • Back & buttocks: 12% • Look for defensive injuries. • Bruises or fractures to the forearm • Pregnancy • Increased abdominal injuries

19. Assessment (continued) • Sexual Assault • Injuries on victim’s breasts or genitals • Bruising patterns • Red/Reddish-blue: less than 24 hours • Dark purple/Dark blue: 1 to 4 days • Greenish/Yellow-green: 5 to 7 days • Normal tint/Disappearing: 1 to 3 weeks

21. Response of Victim • Most will not offer many details . • Victims “put up a wall” • Fear • Embarrassment • Low self-esteem • Feeling that they “deserved it” • Strong feelings for the perpetrator

22. Treatment • Gain patient’s trust. • Treat injuries to level of training. • Provide emotional support. • If possible, have gender-specific responder provide care.

23. Questions • Question in private and safe environment. • Don’t push if the patient does not want to talk. • May reveal the true nature of the situation • Clues to possible hidden injuries • Explain to patient that questions are routine and will help you provide the best care.

24. Documentation • Accurate, detailed, and complete assessment provides the foundation for the documentation. • Everything you see, hear, touch, or smell should be objectively documented. • Descriptive detail of injuries needs to be included. • Document the behavior of others. • Case may end up in criminal or civil court.

25. Transportation • If possible, transport to a specialized facility that can further support patient. • Social services for elder abuse • Pediatric specialties • Rape and sexual assault specialists

27. Taser Injuries

30. Who to Call • U.S. National Domestic Violence Hotline 1-800-799-7233

31. Key Points • Maintain a high level of safety and situational awareness. • You are not a judge and jury; remain objective. • Assess objectively, looking for key injury patterns. • Gain the patient’s trust. • Ask appropriate questions.

32. Key Points (continued) • Support the victim emotionally. • Treat injuries to level of training. • Document objectively and include appropriate detail. • Be prepared for event to end up in court. • Transport patient to specialized facility.

33. Summary • Domestic violence knows no boundaries. EMS can provide the bridge between a victim getting help or not getting help. As a provider and patient advocate, you need to be on guard at all times and to listen to your instincts. Simultaneously, have a high level of situational awareness and be prepared for the unexpected.

34. EKG of the Month Commotio Cordis

35. Commotio Cordis • Sudden cardiac death that occurs in young people during sports participation • Typically involves young, predominately male, athletes in whom sudden, blunt trauma to the anterior chest results in immediate cardiac arrest and sudden death from v-fib. • In most instances, the person was struck by a projectile estimated to be travelling 30-50 mph at most.

38. Drug of the Month Atropine Actions: • Competes with acetylcholine at the site of the muscarinic receptor. • Increases SA and AV node conduction. Indications: • Systematic bradycardia or PEA • Nerve agent exposure, organophosphate poisoning Contraindications: • Acute MI, myasthnia gravis, GI obstruction, known sensitivity to atropine Adverse reactions: • Decreased secretions, blurred vision, pupil dilation, tachycardia Doses: • Let’s look in the SOPs….

39. Applications • Local protocols --- • Recent --- case review Skill of the Month--- • Restraint Application

40. Stroke Update Region VIII EMS Systems - October 2011

41. Acknowledgement • The content for this month borrows heavily from the August 2011 Northwest Community EMS System Continuing Education: Stroke, August 2011 presentation written by Susan Wood, RN, EMT-P and Jen Dyer, RN, BS. We thank Connie Mattera at Northwest Community EMS System for sharing their content with us. • Content also obtained from the Internet Stroke Center, Washington University in St Louis, School of Medicine, and the American Heart Association/American stroke Association website resources.

42. Objectives • Review brain anatomy and physiology, including vascular supply • Review the differences between ischemic/thrombotic and hemorrhagic disruptions in cranial blood flow • Review signs and symptoms of stroke and highlight differences in special populations • Review Region 8 Standard Operating Procedures for stroke • Discuss status of Illinois Stroke Center legislation and its impact on prehospital care • Briefly highlight in-hospital continuity of care for stroke patients

44. Stroke, aka Brain Attack • A sudden, catastrophic event • Focal neurologic impairment • Most often caused by occlusion or rupture of an artery that supplies a specific region of the brain • Brain Attack

45. A little history • More than 2,400 years ago the father of medicine, Hippocrates, recognized and described brain attack or stroke • In ancient times brain attack was called apoplexy, a general term that physicians applied to anyone suddenly struck down with paralysis • Johann Jacob Wepfer was the first to identify postmortem signs of bleeding in the brains of patients who died of apoplexy

46. Statistics • In the US, almost 800,000 people suffer new or recurrent strokes each year (ASA, 2009), 55% die or survive disabled • 3rd leading cause of death in developed nations (behind heart disease and cancer) • $68.9 billion cost of treatment and disability (2009) • Death / Disability rates higher in African-Americans • 60% of strokes happen to males • Strokes in females are more likely to be fatal

47. A & P Review - Lobes Three main components of the brain • Cerebrum • Largest, most developmentally advanced • Higher functions • Cerebellum • Balance, movement, coordination • Brainstem • Final pathway between cerebral structures and the spinal cord • Automatic functions (respiration, heart rate, blood pressure, wakefulness)

48. A & P Review - Layers • Gray matter • aka cerebral cortex • 20 mm thick (3/4”) • Contains centers of cognition, personality and complicated movements • White matter • Network of fibers that enable the regions of the brain to communicate with each other

49. A & P Review – Control Centers

50. Anterior Cerebral Artery Middle Cerebral Artery Posterior Cerebral Artery Lenticulostriate Arteries