NEGLECT

EMS is CalledEMS is Called

September mid-afternoon wrapping up a September mid-afternoon wrapping up a refusal when a person comes walks up refusal when a person comes walks up to the rig and states that there are two to the rig and states that there are two very young children playing in the park very young children playing in the park for the last several hours with only for the last several hours with only diapers on…alone.diapers on…alone.

What action is indicated for EMS?What action is indicated for EMS?

Narrative:Amb/Eng were called to the scene Amb/Eng were called to the scene to check on 2 small kids outside. Upon to check on 2 small kids outside. Upon

arrival, found children sitting outside by a arrival, found children sitting outside by a playground. Each one has a blanket but playground. Each one has a blanket but

are only clothed in diapers.are only clothed in diapers.

Eng searched to find mom sleeping on couch Eng searched to find mom sleeping on couch w/ another small child. Child doesn’t w/ another small child. Child doesn’t appear to be in distress; appears ok. appear to be in distress; appears ok. OLMC contacted w/orders to transport OLMC contacted w/orders to transport everyone.everyone.

Called DCFS.Called DCFS.

What changes could make What changes could make

this documentation better?this documentation better?

Amb/Eng were called to the scene to Amb/Eng were called to the scene to check on 2 small kids outside. check on 2 small kids outside.

Upon arrival, found children sitting Upon arrival, found children sitting outside by a playground. Each one outside by a playground. Each one has a blanket but are only clothed has a blanket but are only clothed

in diapers.in diapers.

Requested to evaluate two small children under the age of 5 years old found outside without adult supervision in gangway of courtyard by park approx. 30 yards from 2 lane road (traffic speed 45 mph) This day outside temperature of 64 and cloudy; children without any clothing other than a soiled diaper and blanket; skin cool to the touch. Bystander states that the children have been outside for approx. 2 1/2hours without adults present. Children not able to tell us where they live as they were scared and crying, but requested something to eat. Stated, “they were hungry.” Placed inside ambulance and given blankets for warmth.

Eng searched to find mom sleeping on Eng searched to find mom sleeping on couch w/ another small child. Child couch w/ another small child. Child doesn’t appear to be in distress; doesn’t appear to be in distress; appears ok. OLMC contacted appears ok. OLMC contacted w/orders to transport everyone.w/orders to transport everyone.

Called DCFS.Called DCFS.

Search found mother asleep on the couch in second floor apartment 50 yards away, unaware that children were not inside. Found a third child, 4 months old, on floor next to couch next to electrical outlet and glass table with multiple used ashtrays and dirty dishes and silverware (including fork and knife) on table in a soiled diaper. During discussion, mother calm; not upset that the children were alone unattended. She stated, “Thanks for letting me know. I’m going to take a shower and will go and get them.” 4 month old child assessed and calm, goes to EMS personnel without fear. Not making eye contact or moves toward mother, moves all extremities well, no bruising to extremities noted, some yellow green bruising/discoloration behind right ear. OLMC requested that all children be brought into ED for a medical evaluation. Another ambulance called for transport of the third child due to not enough restraint devices. Mother accompanied the 4 month old in ambulance. Asked EMS personnel if we thought the ED could give her some milk for the baby when we arrived.DCFS contacted and spoke with call taker: John Smith ID#12345 at 1358. Written documentation completed/submitted.

Kudos to…Kudos to…This was a real call in which the crew did a This was a real call in which the crew did a

great job, not only in the treatment but also great job, not only in the treatment but also the documentation was done well!the documentation was done well!

PearlsPearls DO NOTDO NOT include subjective opinions,

feelings or conclusionsNO assumptions

Describe using facts

Include unsafe or unsanitary conditions

List individuals present or absent

Document ONLYONLY what was done

Take the timeTake the timeIf the pt suspect of If the pt suspect of

abuse has abuse has multiple bruises multiple bruises on numerous on numerous places on body places on body in different in different stages of stages of healing, take healing, take time to document time to document each one each one carefullycarefully

Example:Example:

Bruise noted to cheek, chin, Bruise noted to cheek, chin, forehead approx size of forehead approx size of quarter yellow/green in quarter yellow/green in

discolorationdiscoloration

Bruise on back of R leg in Bruise on back of R leg in elongated shape approx elongated shape approx

6 in, red in color 6 in, red in color w/abrasion notedw/abrasion noted

Subjective to objectiveSubjective to objective

Called for a 3 month male who was crawling on floor and fell down

three steps. Crying inconsolably with L arm fracture.

Subjective to objectiveSubjective to objective

Called for the child with trauma. Upon arrival, mother stated that the 3 month old was crawling on living room floor and crawled out of patio door down three steps. Upon EMS evaluation, pt found outside on cement patio floor approx. 10 feet away from sliding patio door that does not have screen door. Pt. crying, noted deformity to L humeral area of arm. + distal pulse. You can go on to describe the inside of the house in the area where the mother stated the child was crawling, especially any hazards that might be present…dog, glass table, ashtray, etc.

Subjective to objectiveSubjective to objective

Called for a 5 month old female who was abused by her mother’s

drunk boyfriend. Pt found in custody of police with obvious

signs of physical abuse.

Subjective to objectiveSubjective to objective

Called by aunt, who was picking up the infant from the mother’s boyfriend when she stated “he was drunk.” EMS noted an adult 26 yo male on scene with slurred speech, staggering gait and unaware of where child was located in house or what the child was doing. Child found in care of aunt with police. Physical assessment reveals (document detailed injury assessment findings).

Subjective to objectiveSubjective to objective

Dispatched for a 5 F with vaginal bleeding. Pt crying therefore exam deferred; however EMS notes strap

marks to legs.

Subjective to objectiveSubjective to objective

Dispatched for a 5F with vaginal bleeding. Upon EMS arrival, pt in custody of police and crying and clinging onto female police officer. Child’s underwear was noted to have bright red blood stains approx. 1 inch in diameter in three locations. R and L leg with reddened elongated circumferential marks on upper thigh approx. ¾ inch wide. Additional markings on B inner thighs in the shape of a belt buckle. Clothes torn, etc…

How would you describe these injuries in the narrative?

Looped cord injury:Elongated line of demarcation noted horizontally on pts L arm in three different areas. Deep red abrasion type circumferential

markings noted over L upper arm and one on left lower arm.

Hand print:Reddened area over pts left face extending to L upper eyelid with areas of white demarcation in the shape

of a handprint.

Cigarette Burns:

Multiple areas to face, arms and torso of circle shaped reddened areas approx. 2cm in diameter in different stages of healing. 3 areas to face with blisters and deep red in color. Additional brownish colored bruising to R

shoulder.

Both buttocks up to waist line and into folds of buttocks with multiple bruises are seen. Most of bruising appears to be yellowish green in color with additional dark purple and red discoloration noted to R buttock.

 REMEMBER, your contact with the initial scene must be documented, as it preserves in writing details that the crime scene investigators may not see later on

Domestic Violence

Often there is a preconceived idea regarding victims of domestic violence (DV)

The frequent call to “that address” is familiar to EMS

The question often is, “why don’t they just leave?”

“Why should EMS get involved when the victim doesn’t help themselves?”

DV

Victims are often women (98%)

DV is the single largest cause of injury to women in the US between ages 15-44

DV is grossly underreported to police

20% rape

25% physical assault

50% stalking

IF the victim is male=reporting is even less

As healthcare providers, we are often the As healthcare providers, we are often the first person that victim may confide infirst person that victim may confide in

Unfortunately, if index of suspicion isn’t Unfortunately, if index of suspicion isn’t high, DV will go unrecognizedhigh, DV will go unrecognized

As high as 30% of all women who enter As high as 30% of all women who enter the ED are victims of abusethe ED are victims of abuse

Personnel MUST ask the questions…in Personnel MUST ask the questions…in the right waythe right way

Judgment can lie in the fact that they Judgment can lie in the fact that they are adults capable of making own are adults capable of making own decisionsdecisions

Those decisions are often not Those decisions are often not understood or misunderstood by understood or misunderstood by many; including prehospital many; including prehospital providersproviders

There are cycles & patterns in There are cycles & patterns in violenceviolence

Many layers of complexityMany layers of complexity

Financial considerationsFinancial considerations

Lack of resourcesLack of resources

EmbarrassmentEmbarrassment

Health issues Health issues

DependentsDependents

IsolationIsolation

Each Each phase phase varies in varies in duration duration and and intensityintensity