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If law enforcement has not been called, call them now. DO NOT ENTER UNTIL POLICE ARRIVE AND SECURE THE SCENE. The personal safety of the EMS provider outweighs the need to respond -- this might be the toughest judgment call you’ll ever have to make. Your adrenaline is pumping, you are ready to respond, to stop the bleeding or save a life but remember: If you’re hurt, you are not helping anybody, and you are adding to the burden of others who now need to respond to you as well as to the original patient. For these reasons and more, exercise caution and heightened awareness when responding to a scene of potential domestic violence. Ask yourself the following when responding to potentially high risk calls:
Should I approach?
Are there obvious dangers in approaching?
Who is the subject I will be dealing with? Is there prior history in responding?
Who am I? What are my limitations, my strengths, my own history?
What help is available?
When is the contact taking place (at night, during the day, in a trailer, etc)?
Once inside, your awareness needs to continue. While the police may have already secured the scene, it is appropriate for you to do the same. Visually frisk everyone for weapons. Determine who is in the residence and where they are. Once identified, spectators should be asked to leave. Don’t allow residents to get between you and an exit route. Don’t let yourself be backed into a corner. Know where your partner is at all times. Don’t get tunnel vision when treating a patient; ensure that your partner is equally aware of what else is going on. Observe the body cues of others in the room, such as clenched fists, flared nostrils, and flushed cheeks. If the scene is otherwise safe but weapons, or potential weapons, are present in the room, you should ask that they be put away. It may help to practice a standard response to this type of situation, so that you will be prepared at the scene. One sample response is “For your safety and mine, I need to ask you to put the weapon away.” You should make a mental note of the type and location of the weapon in case you are asked about it by law enforcement personnel.
EMS personnel need to recognize and be aware that while they were originally called to help. Their presence, along with law enforcement, changes the dynamics of the scene. Specifically, either the victim or perpetrator may turn on you or the police at any time. For example, before EMS or law enforcement arrives the confrontation is between the batterer and the victim. The confrontation is the perpetrator’s attempt to obtain or maintain control over the victim. Once outside help arrives, the two-way tension changes and now involves three or more people.
Once the aggressor or violent husband is arrested, his role is changed and he perceives himself as the victim. By the arrest procedure itself, the police officer now becomes a potential threat to the perpetrator. This change effects the role of the victim, who may decide to side with her husband against the police officer. Why? Victims may go after the police because if they don’t do everything possible to help release their perpetrator they’ll get beat again as soon as he is released. (She isn’t trying to “rescue” her husband, but is trying to stay alive.) This is a primary reason why law enforcement officers are apprehensive to respond and intervene in these types of calls: they are often injured at the scenes of domestic violence calls. Nationally, of all officers who are assaulted in the line of duty, one third occur at domestic violence scenes, and domestic violence calls account for an increase in the number of law enforcement deaths, from 3.1% of all deaths in 1986 to a total of 7.1% of police officer deaths occurring in domestic violence calls in 1995. While EMS may have been called to provide medical care, it is important to recognize the change in dynamics and that the delivery of medical care may be viewed as a threat. The presence of a rescuer -- whether law enforcement making an arrest or EMS providing medical care -- changes the dynamics between the perpetrator and victim. It also must be remembered that women are in the most danger when they try to leave their abuser. Studies show that 75 percent of battered women are beaten after they leave (e.g. at the time of the beating incident, they were either divorced or separated).
Part of the problem in responding to a domestic violence scene is that in all probability, the violence has been occurring for some time. The violence may have escalated over the years, to the point where the victim may be unaware of how lethal it has become. Victims and perpetrators consistently minimize the level of violence experienced. Also, many victims are embarrassed, shocked, or feel responsible and want to minimize the violence out of guilt and shame. The victim may be fearful: a past arrest may not have been effective and violence was inadvertently encouraged.
In addition to the dynamics of the scene, it may be necessary to diffuse aggressive behavior before you can even approach the victim to deliver medical care. Avoid touching or crowding an already hostile person since it may provoke more violent behavior. Be non-threatening. Stay calm. Don’t get too close. Take a balanced stance. Take your time and take nothing for granted. Assume control of the situation SLOWLY. Introduce yourself, speaking directly to the patient. Explain what you’re doing. Ask open-ended questions, allowing them to talk. Restore control to the victim. Do not be judgmental. If you can, separate yourself and the victim from the perpetrator -- an explanation may be that you need to use equipment that is in your ambulance.
Pay attention for early warning signs of a potential attack. Sample behavior and physical posturing include:
conspicuous ignoring of questions and statements by you or police;
repetitious questioning;
looking around nervously;
excessive emotional attention;
ceasing all movement;
physical crowding;
assuming a pre-attack posture;
target glance.
These are clues for EMS personnel to heighten awareness and to ensure your own personal safety.
RECOGNIZING AND TREATING VICTIMS OF DOMESTIC VIOLENCE
The odds are very high that most of us, as emergency care providers, have treated victims of domestic violence during our career. Maybe we had no awareness of what we were responding to. Or just maybe, we had a very real suspicion of domestic violence but didn’t know how to deal with the situation. Should we have expressed our concern? What do we say or do? What if the patient denies being abused, what then? While victims of domestic violence may not offer details on their own initiative, they may discuss it if asked simple, direct questions in a non-judgmental way and in a confidential setting. The patient should be interviewed alone. This cannot be emphasized enough: Question the victim directly about battering only if the suspected abuser is not present. Your ambulance may provide a safe environment for the victim of domestic violence to admit to a problem and ask for assistance. Your ambulance may provide the ideal opportunity for an EMS responder to question the patient and uncover any abuse that is occurring. Ask the patient direct, non-threatening questions in an empathetic manner, emphasizing that certain questions are asked of all trauma patients. You may want to think of sample questions ahead of time so that you will be comfortable and ready when the situation arises. Listed below are some sample direct and non-judgmental approaches. Consider practicing or modifying these statements to see which ones feel appropriate for you:
Because domestic violence is so common in today’s world, I’ve begun to ask about it routinely. Has your partner done this to you?
We often see people with injuries such as yours which are caused by someone they know. Could this be happening to you?
You seem frightened and anxious. Has someone hurt you?
Sometimes when others are over-protective and jealous, they react strongly and use physical force. Has this been happened to you?
Are you afraid of anyone in your household?
Has any household member physically hurt you or threatened to hurt you?
At first, you may find it difficult to ask these questions. You may think them to be intrusive or that you are being nosy. However, these kinds of questions should be part of your patient assessment. It may help to explain that questions of this sort are asked of all injured patients and that these questions are part of your protocols. Practice, and learn which ones work best for you.
The series of questions to ask can be easily remembered with the “SAFE” acronym.
S Do you feel SAFE in your relationship? Should I be concerned for your SAFETY?
Are there situations in your relationship where you have felt
A AFRAID?
What happens when you and your partner disagree or ARGUE?
Are your FRIENDS aware that you have been hurt?
F Do your FAMILY members know about the abuse?
Would FAMILY or FRIENDS be able to help or support you?
Do you have a safe place to go in an EMERGENCY?
E If you needed to leave now, do you have an ESCAPE plan? Would you like to talk with an advocate to develop an EMERGENCY safety plan?
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