EMS professionals and advocates of domestic violence victims in Utah are working to find the appropriate role and training for EMTs encountering abuse victims in the field.
EMTs are often the first responders to violent domestic incidents that involve injuries, so they're in an important position to help victims. Domestic violence includes not only physical violence but also verbal and psychological abuse.
"First responders, be it officers or paramedics, are actually the first face the victim sees and are going to shape how the whole process goes for the victim," says victim-advocate Brooke St. John. As the victim services supervisor for the South Salt Lake Police Department, St. John trains emergency department (ED) nurses to spot signs of domestic violence.
According to St. John, a poor experience with a first responder could cause a victim to shut down and not seek help. She's in favor of expanding mandatory domestic violence training from police to EMS providers.
Utah’s Office on Domestic and Sexual Violence provides training for health-care providers but not EMTs or paramedics, says the office’s Director, Ned Searle. Establishing training is one of Searle’s goals; however, one hurdle his office faces is that all their training is voluntary.
Currently, a formal protocol isn't in place for EMTs to follow when they encounter domestic violence victims in the field, says Jason Nicholl, the paramedic representative to the state's EMS Committee. Nicholl, who's also the lead instructor at University of Utah's paramedic program, tells his students that in the absence of protocol, they should do what's best for their patient.
"Having something that would give us a formal avenue to follow would make things a lot easier because we're there. We're the ones who see it," says Nicholl. "We're the ones who see bruising, who see the behavior, who see the violence and have to respond to it immediately."
EMTs, if trained properly, could be of greater assistance to domestic violence victims. However, they need to keep their focus on providing medical assistance and not stray into areas covered by law enforcement, says Nicholl.
In his 15 years as a paramedic, Nicholl has assisted domestic violence victims by alerting police officers, hospital staff and even hospital pastors because those are the people who have the time, skills and resources to follow up with victims.
Dennis Bang, who oversees training for the Utah Bureau of Emergency Medical Services, agrees. He says that he teaches his instructors and students that they shouldn't act as counselors. Instead, EMS providers should refer abuse victims to victim-advocate organizations.
Bang, a former law enforcement officer also says more could always be done on the EMS side, but he points out that Utah is ahead of other states in addressing the problem. Much of the current training material for abuse is geared toward situations involving children or the elderly, Nicholl says.
"Most of the paramedic texts have entire sections devoted toward neglect and abuse. They focus on child abuse and elder abuse," says Nicholl. "There is very little that is taught in that gap between child abuse and elder abuse."
Under Utah law, health-care personnel, including EMS providers, must report any assaults they treat to law enforcement. However, victims of domestic violence often mask the origin of their injuries and aren't forthcoming to first responders, says St. John.
A Utah Department of Health survey of EDs released this past year found that getting patients to discuss the abuse is the largest obstacle to identifying abuse as the source of the injury. In fact, 96% of the ED staff reported that patients don't want to discuss it, and 57% said their patients denied that their injury was caused by abuse.
Any training program would need to include how to recognize the signs and situations of domestic violence, says Nicholl. EMTs need to be able to recognize discrepancies between injuries and the patient's story of how the injuries occurred, says Dr. Kathleen Franchek-Roa, DO, MD, a University of Utah pediatrician who's researching domestic violence. Because EMTs are in the home, they have extra insight to the injury and where it occurred. They could also assist in alerting patients to what resources are available.
"I don't expect it to be all on the paramedic, but I think [they could initially say], 'What has happened to you? Is it okay? Lots of women we see are suffering like you. We have resources for you,'" says Franchek-Roa, who's also a member of the Utah Domestic Violence Council's health-care subcommittee.
Utah's 2010 domestic and sexual violence report shows that most injuries associated with domestic abuse are minor. Serious injures range from severe lacerations to broken bones and teeth loss. When EMTs suspect domestic violence is involved, they should take a closer look for injures associated with strangulation, says Franchek-Roa.
Once statewide training is developed, actually implementing it into the coursework could be a challenge.
"The competition for training hours is extremely tight," says Nicholl, pointing out that finding class time for everything from teaching new stroke guidelines to meeting required course hours for other injuries and conditions is already an uphill battle. "Finding [time for] something like therapeutic communications, recognitions of abuse, those sorts of things, unfortunately, they take the back seat when they really shouldn't because we see more see more of that than we do of the people who need a test tube or a surgical airway."