Abuse and Maltreatment

Table of Contents

Aliases

Maltreatment of vulnerable populations

Definitions

  1. Abuse/Maltreatment: Any act or series of acts of commission or omission by a caregiver or person in a position of power over the patient that results in harm, potential for harm, or threat of harm to a patient
  2. Child Maltreatment/Abuse: Child maltreatment includes any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. An act of commission (child abuse) is the physical, sexual or emotional maltreatment or neglect of a child or children. An act of omission (child neglect) includes, but is not limited to, failure to provide for the child’s needs (e.g. physical, emotional, medical/dental, and educational neglect) and failure to supervise (e.g. inadequate supervision or safety precautions, lack of appropriate car seat use, and exposure to violent or dangerous environments)
  3. Human Trafficking: when people are abducted or coerced into service and often transported across international borders. Signs may include, but are not limited to: patient with branding/tattoos and environmental clues such as padlocks and/or doorknobs removed on interior doors, and intact windows that are boarded up

Patient Care Goals

  1. Recognize any act or series of acts of commission or omission by a caregiver or person in a position of power over the patient that results in harm, potential for harm, or threat of harm to a patient
  2. Take appropriate steps to protect the safety of the responders as well as bystanders
  3. Get the patient out of immediate danger
  4. Assess any patient injuries that may be the result of acute or chronic events
  5. Attempt to preserve evidence whenever possible; however, the overriding concern should be providing appropriate emergency care to the patient

Patient Presentation

  1. Clues to abuse or maltreatment can vary with age group of the patient and type of abuse
  2. Not all abuse or maltreatment is physical
  3. EMS role is to:
    1. Document concerns
    2. Assess potentially serious injuries
    3. Disclose concerns to appropriate authorities
    4. Initiate help to get the patient into a safe situation
    5. Not to investigate or intervene beyond the steps above
    6. Leave further intervention to law enforcement personnel

Inclusion/Exclusion Criteria

Absolute inclusion/exclusion criteria are not possible in this area. Rather, clues consistent with different types of abuse/maltreatment should be sought:

  1. Potential clues to abuse/maltreatment from caregivers or general environment:
    1. Caregiver apathy about patient’s current situation
    2. Caregiver overreaction to questions about situation
    3. Inconsistent histories from caregivers or bystanders regarding what happened
    4. Information provided by caregivers or patient that is not consistent with injury patterns
    5. Injuries not appropriate for patient’s age or physical abilities (e.g. infants with injuries usually associated with ambulatory children, elders who have limited mobility with injury mechanisms inconsistent with their capabilities)
    6. Caregiver not allowing adult patient to speak for them self, or who appears controlling – pay special attention to patients who cannot communicate due to young age or language and/or cultural barriers
    7. Inadequate safety precautions or facilities where the patient lives and/or evidence of security measures that appear to confine the patient inappropriately
  2. Potential clues to abuse or maltreatment that can be obtained from the patient:
  3. Multiple bruises in various stages of healing
  4. Age-inappropriate behavior (e.g. adults who are submissive or fearful, children who act in a sexually inappropriate way)
  5. Pattern burns, bruises, or scars suggestive of specific weaponry used
  6. Evidence of medical neglect for injuries or infections
  7. Unexplained trauma to genitourinary systems or frequent infections to this system
  8. Evidence of malnourishment and/or serious dental problems
  9. Have a high index of suspicion for abuse in children presenting with a Brief Resolved Unexplained Event (BRUE) [see BRUE guideline]

Patient Management

Assessment

  1. Start with a primary survey and identify any potentially life-threatening issues
  2. Document thorough secondary survey to identify clues of for potential abuse/maltreatment:
    1. Inability to communicate due to developmental age, language and/or cultural barrier
    2. Multiple bruises in various stages of healing
    3. Age- inappropriate behavior (e.g. adults who are submissive or fearful, children who act in a sexually inappropriate way)
    4. Pattern burns, bruises, or scars suggestive of specific weaponry used
    5. Evidence of medical neglect for injuries or infections
    6. Unexplained trauma to genitourinary systems or frequent infections to this system
    7. Evidence of malnourishment and/or serious dental problems
  3. Assess physical issues and avoid extensive investigation of the specifics of abuse or maltreatment, but document any statements made spontaneously by patient
    1. Avoid asking directed questions of a child

Treatment and Interventions

  1. Address life-threatening issues
  2. Remove the patient to a safe place even if no medical indication for transport
  3. Report concerns about potential abuse/maltreatment to law enforcement immediately, in accordance with state law, about:
    1. Caregivers impeding your ability to assess/transport patient
    2. Caregivers refusing care for the patient
  4. For patients transported, report concerns to hospital and/or law enforcement personnel per mandatory reporting laws

Notes – Abuse and Maltreatment