Intimate Partner Violence in Emergency Medical Services: A Literature Review

By Elodie Krawczyk

Introduction

Intimate partner violence (IPV) is a silent killer, an endemic that lies blindingly before an unknowing public. IPV, a classification within domestic violence, refers to behaviors that cause harm of any kind between individuals in a romantic relationship.¹

Presenting in numerous forms, IPV is notoriously difficult to identify as it may be any combination of psychological, physical, sexual, spiritual, and financial abuse.^2,9,22 However, it is imperative that emergency medical service (EMS) responders are equipped to identify and support patients suffering from IPV.³

In the United States alone, the Centers for Disease Control and Prevention (CDC) indicates that one in three women and one in four men are victims of physical partner abuse during their lifetimes.³

Common misconceptions exist that call into question the legitimacy of other forms of IPV, severely harming the 61 million women and 53 million men who have suffered psychological aggression at the hands of their partners.³

he scope of this problem is not nearly fully grasped and will never be if it remains underreported and its victims unsupported.

Oftentimes, EMS providers are the first and many times only healthcare providers that IPV victims encounter.⁴ Prehospital care providers are responsible for aiding the entire population. Disaster preparedness, for example, has shifted to a “whole community” approach after Hurricane Katrina, rather than merely being ready to help the healthy, average American adult.

Just as there were significantly more patients with access and functional needs encountered during disaster relief efforts than expected, intimate partner violence is a devastatingly prevalent phenomenon that providers must face whether they are ready for it or not. Unfortunately, EMS providers receive little to no training on IPV and are thus poorly prepared to serve the needs of a large portion of their communities.

Intimate partner violence has innumerable repercussions for the victim, family members and the community. Victims experience both physical and psychological effects that have the possibility of being lifelong challenges. Many victims present with at least one psychiatric condition as a result of IPV, such as Major Depressive Disorder, Post-Traumatic Stress Disorder, and substance use disorders.²⁵

Physically, IPV can manifest in many ways. In the immediate, bruises, welts, burns, lacerations and other injuries may appear. Over time, gastrointestinal, cardiovascular, neurological, and musculoskeletal symptoms may present chronically.²⁶ Unfortunately, the effects of IPV are not limited to physical and psychosocial manifestations.

The monetary cost of intimate partner violence is unfathomable. In 1995, when considering only female victims in the United States, IPV costs totaled $5.8 billion annually.² The CDC factored in the price of mental and physical healthcare, as well as the loss of income from missed work shifts and lacking productivity at home.

As large as that figure may be, it is, unfortunately, grossly low. Inflation raises that number to approximately $11.9 billion in 2024. Additionally, victims of all demographics must be considered in the calculation, not solely women. Regardless, the financial impact of IPV is beyond devastating and leaves many victims unable to afford necessary care.

To answer the question of how intimate partner violence is represented in EMS education and, more crucially, to determine if it is sufficiently presented, this paper examines a plethora of scholarly sources.

Utilizing multiple EMS textbooks for IPV-related content and analyzing various studies on the prehospital sector internationally published in emergency care journals, the key elements of each population, year of publication, and implications are synthesized with one another to form a conclusion regarding the state of IPV education in the EMS system.

According to the National EMS Education Standards (NEMSES),⁶ in alignment with the National Registry of Emergency Medical Technicians (NREMT) certification examination, content is taught and delivered in a three-tiered level of depth and breadth: simple, foundational, and complex. Identifying signs of intimate partner violence is currently being taught at the simple depth, simple breadth step.⁶

However, the sheer prevalence of IPV alone is enough to demand increased comprehension by EMS providers; at minimum, it must be taught at a foundational level, if not complex. This literature review shows that many prehospital care providers are not learning about IPV even at the simple breadth and depth level; improvements in EMS education standards surrounding IPV are long overdue.

Body

The selection of textbooks and supplemental educational material is a crucial component of any course design. The same course taught by the same professor can vary dramatically if different textbooks are used. The same applies to Emergency Medical Technician (EMT) development courses. In the United States, these classes are often geared toward preparing students for the National Registry exam.

A widely used textbook in EMT courses across the United States is Daniel Limmer and Michael O’Keefe’s Emergency Care.⁷ Published in 2020, the 14th edition is an up-to-date text designed to prepare students for the most recent NREMT examination and practical experience.

Its discussion of IPV is concise, emphasizing the importance of EMS providers as potentially being the “only medical care this victim will have access to” and the high likelihood of responding to the same address on multiple occasions.⁷

The content included is accurate and beneficial to students; unfortunately, it simply skims the surface and fails to adequately educate future providers. When discussing matters, the text often fails to explain the reasoning behind the instructions. It instructs providers to “document objectively and state facts, not opinions,”⁷ but does not explain the serious repercussions of failing to comply with this advice. Libel, or defamation in writing, is a crime. Not only might it result in legal trouble for the provider, but it can negatively impact the victim of IPV by empowering the abuser.

Many perpetrators of abuse reverse the truth, claiming to be the victim; if libel occurs, the abuser legitimately becomes a victim in this manner, unfairly prejudicing the already slanted system against the victim. Indicating the reasoning behind certain pieces of instruction often increases the likelihood of compliance when its importance is more fully understood.

Another component incompletely touched upon in the 14th edition of Emergency Care is the art of proper interaction with victims of intimate partner violence. Near the end of the section, the authors instruct providers “not to be judgmental or accusatory;”⁷ however, there is no elucidation upon what those terms mean and how that might look in context.

Left to one’s discretion, comments may seem appropriate to one provider but be considered inappropriate by another’s standards. Because words can have such a lasting impression on human beings, careful selection is imperative to avoid unintentional offence or further harm. The text empowers providers to be cognizant of their comments but fails to provide any guidance beyond that.

Over time, professionals have crafted lists for general use of what to say and what to avoid to ensure the most positive outcome; incorporating a short guide into EMS education could make all the difference for a victim.

The previous edition of Emergency Care, published in 2015, contains nothing on the matter of intimate partner violence.⁸ Less than a decade old, this textbook is still used in classrooms, meaning there are cohorts who are not exposed to the concept of encountering intimate partner violence on calls, much less educated on best practices in those situations.

Suffice it to say, neither edition of Emergency Care offers students a simple breadth, simple depth look into intimate partner violence in the prehospital care sector.^7-8

On the other hand, another popular textbook is the 11th edition of Prehospital Emergency Care by Joseph Mistovich and Keith Karren.⁹ Published seven years ago, it provides three pages of content covering demographics, terminology, the cycle of violence and approaches to IPV scenes and victims.

The text contains thorough information, such as detailing the different types of domestic violence, including “spiritual” abuse. Unfortunately, as in-depth as the section goes, it also omits some important points or even unintentionally misleads the readers.

The “Assessment Findings of Domestic Abuse” subsection details how victims may look tattered with “injuries in various stages of healing.”⁹ All of this is entirely true and ought to be mentioned, but it leans heavily into the stereotype of IPV victims, overlooking a large number of victims who do not fit that model.¹⁰

There are numerous victims who, based solely on physical appearance, do not seem abused. In some cases, victims may seem notably presentable, with a pristine outward presentation of both self and home.¹¹

The text accurately points out that men can be victims but that the majority are female.⁹ However, by directing the attention almost entirely onto female victims, solely using female pronouns when referencing a victim and male pronouns when referencing an abuser, the perceived “unidirectional” perpetuation of violence towards women from men falsely posits this preconceived image of what a victim looks like, negatively “influence[ing] attitudes toward ‘non-typical’ victim and perpetrator groups.”¹⁰

In turn, it greatly impacts victims’ decision-making processes regarding help sought.¹⁰ Misappropriation of individuals as victims or perpetrators by EMS providers has lasting repercussions, potentially having a life-or-death impact.

In Prehospital Emergency Care, the authors discuss potential telling signs of intimate partner violence discovered during interactions with the victim.⁹ Although the victim can, intentionally or otherwise, reveal a great deal about the situation, it is also imperative that responders assess the entire scene for indications.

Additionally, observations of or interactions with other individuals on the scene can also tell a great deal. The textbook fails to discuss some common attributes found in perpetrators. Abusers often appear to the community as friendly, family-centered, and philanthropic, whereas in the privacy of their home, behind closed doors, their behavior shifts dramatically.^9,11

Subsequently, the presence of intimate partner violence is furthermore revealed by the demeanor of any children or pets; in a home with IPV, there will likely be a gravitation towards one parent over another, with a submissive attitude toward the latter.¹² Utilizing all contextual clues increases the likelihood of helping the victim escape the cycle of violence. Additionally, it keeps the responders out of harm by proactively assuming shielding steps to ward off any violence from the suspected abuser.

Altogether, the 11th edition of Prehospital Emergency Care contains a simple breadth, simple depth coverage of intimate partner violence, but it is evident that a more profound understanding is necessary.⁹

Extending from Basic Life Support (BLS) to Advanced Life Support (ALS) care, Essentials of Paramedic Care second edition, published in 2010, also contains three pages on intimate partner violence.¹³ This textbook, more so than the previous ones, lacks an appreciation of the scope of the problem and appears to fall into the trap of misconceptions surrounding the phenomenon.

Not only does it fail to provide a comprehensive dive into the types of IPV, associated factors at play, and the multiplicity of victims, but the text attempts to lift blame from the perpetrator. Certain factors can increase the risk of violence in an individual already predisposed to abuse.

Still, the authors state, “lacking any alternative” after substance use, “partners may turn to physical and/or verbal violence.”¹³ The loss of control experienced due to stifled inhibitions is undoubtedly activating. However, abuse is never unavoidable.^3,14 Saying otherwise alleviates a partial sum of guilt from the perpetrator, invalidating the victim’s pain and lessening the odds that help is sought.

It is paramount that EMS providers understand the implications of such statements and do not fall privy to mindsets rooted in misconceptions.

Essentials of Paramedic Care offers a shallow dive into the profile of a perpetrator of intimate partner violence. Many abusers possess “overly aggressive personalities,” meaning it is common for them to experience terrifying mood swings, “flying into sudden and unpredictable rages.”¹³

The volatility of their emotional state is one reason that EMS responders must do everything in their power to accurately and continually assess scene safety.²² In order, a provider’s priority should be the safety of self, crew and others. Unfortunately, the textbook contains no information concerning scene safety when IPV is implicated.

That said, the text rightly raises to mind that abuse can happen in any relationship, including same-sex, and will present similarly as it does otherwise.¹³ That is important to note when evaluating a scene and considering an abuser’s profile. Just as anyone can be a victim, anyone can also be a perpetrator. Failing to acknowledge that will disadvantage the community and could possibly blind a provider to a dangerous scene and result in injury for the victim and themself.

An important piece of information was excluded from consideration in regards to a perpetrator’s character: despite possessing a furtive demeanor, abusers are often deemed friendly and sociable by the community.^9,11 Consequently, it may be challenging for people to believe that the individual is indeed abusive, leading to further strain on the victim.

The regrettable reality is that, in cases when the abuser is taken into police custody, they “may soon be released on [their] own recognizance, sometimes within a matter of hours.”¹³

Understandably, a patient may be reluctant to involve law enforcement if they are aware of this probability. In the 1980s in the United States, forced prosecution of domestic violence perpetrators ended up inflicting more harm than it helped.¹⁷

Not only did it fail to reduce the recidivism rate of offenders, it fettered the victims and left them feeling let down by the system meant to offer deliverance from that horrible pain.¹⁷ This unsuccessful trial actually offers an answer for EMS providers on how to help IPV victims. It beautifully exemplifies that, due to a broken system, other support avenues are required instead.

As victims’ first and sole advocate, the responsibility of educating oneself on available opportunities falls on EMS providers to then convey to patients.

A review of multiple prehospital care textbooks demonstrates a need for increased education in EMS providers regarding intimate partner violence. Although the gravity of the situation demands it be taught at a higher level, the increased education will only be effective if the baseline content is adequately covered first.

A study was conducted that had prehospital care providers answer a series of questions before and after a three-hour IPV seminar, attempting to uncover statistics on the prevalence of certain misconceptions amongst prehospital care providers. Before the training, 50% of the participants believed that the victim was responsible for the abuse. That number dropped 39 percent after the course; however, 11% of EMS providers still blamed the victim after the training.¹⁸

The three-hour instructional initiative was many of the participants’ first exposure to IPV in the classroom setting. The results of this study demonstrate two crucial points. First, there is a critical need for baseline training in EMS providers based on the misconceptions measured prior to any instruction. Second, it also shows that more intensive training is needed, beyond that at a simple depth, simple breadth.

Continuous, multifaceted educational avenues would increase the retention rate of content and deepen providers’ level of knowledge, thereby bettering patient care.

EMS providers are commonly the first and only healthcare professionals that victims of intimate partner violence see; prehospital care providers are also regarded by the general public as the most appropriate resource for victims, second only to law enforcement officials.⁴

However, as previously discussed, police involvement is inappropriate or not desired in some IPV situations.¹⁷ Therefore, the responsibility of being IPV-informed rests even more significantly upon EMS providers. Currently, a substantial number of EMS providers internationally cannot identify the warning indicators of IPV presence.⁴

Screening assessments are one tool that has the potential to act as a catalyst for victim identification in all fields, including the prehospital care sector.²³ Two examples include the Domestic Violence Scene Assessment Screen (DVSAS) and the Abuse Assessment Screen (AAS).²⁰

Through a series of questions, providers receive a small picture of the situation.²⁰ They are not, however, to act as the sole means for identification. Rather, they are one component that can serve as a starting place on calls.

After conducting research into each, The Centers for Disease Control and Prevention (CDC) has validated a number of various screening tools for use in healthcare settings.²¹ Although the list is not exhaustive, it contains 34 distinct screening assessments for intimate partner violence.

With mixed lengths, they all target a slightly different population and aspect of IPV and are geared for various subsets of healthcare professionals.²¹ Some being more versatile for numerous situations, with others being rather niche, there are multiple CDC-approved screening assessments for intimate partner violence that EMS systems could incorporate into practice to increase the likelihood of IPV identification.

For competent implementation and provider-patient sensitivity, the providers must be educated on both IPV and the proper application of appropriate screening tools.

When IPV is suspected or identified, it is imperative that providers are well-versed in the various resources available to victims beyond police involvement. A study conducted with 260 paramedic students in Australia sought to determine the population’s actual knowledge, perceived knowledge, and perceived preparation when the time inevitably comes to encounter victims of intimate partner violence.¹⁹

On a scale of one to seven, the average amount of knowledge participants felt they had was 2.4, or a “very little” sum, and the average level of perceived preparedness for IPV on the same scale was 2.8, equating to “minimal” readiness.¹⁹ With no additional interventions, these paramedic students will enter the workforce unequipped to adequately cope with the plight of intimate partner violence.

The results further reinforce and emphasize the dire need for increased education of IPV in EMS providers. Need for additional support provisions for the providers’ use during these calls is also demonstrated through this study.

A resource index or conversation guideline could offer preliminary avenues for the provider when offering support to victims; that said, their efficacy is dependent on their utilization, which is entirely reliant upon a provider’s proactive nature and ability to identify the signs of intimate partner violence.

Although the importance of learning the material in textbooks and lectures must not be palliated, it alone is not enough. Supplementing the educational experience with IPV-corresponding patient scenarios will allow students to apply the content taught in simulated real-world situations.

Not only does it reinforce what was previously learned, but it also brings the subject matter full circle and emphasizes its vitality to quality patient care. In EMS education, scenario-based training is fundamental; why should that be any different for a widespread problem such as IPV?

Just as students run scenarios involving cardiac arrest, motor vehicle accidents, and suicidal ideation, “‘learning-centered’” simulations for IPV have shown to be significantly beneficial in preparing providers and boosting confidence in the care offered.¹⁶

A study conducted in 2020 by Craig et al. sought to determine how beneficial, if at all, emergency medical care scenarios for intimate partner violence situations could be.¹⁶ By taking local South African IPV statistics and writing the patient-actor scripts to mirror realistic surroundings, provider confidence and accuracy in responding to these calls were documented throughout.

The study discusses the effectiveness of “expensive mannequins” for the intended skills learnt from these exercises.¹⁶ In many EMS courses, mannequins, sometimes high-fidelity, are frequently employed to safely allow students to practice skills before performing them in the field.

It is hypothesized that the inanimate models lack a “level of feedback and fidelity through which [students] can convey their empathy and history-taking skills;”¹⁶ rather, a scripted simulation may prove more useful.

In conjunction with peer-based training, the results affirmatively answered the research question, promulgating that scenario-based training notably boosts providers’ responsiveness to IPV.¹⁶ By incorporating patient scenarios involving IPV into EMS educational programs, providers will be better equipped to and will have practiced applying learned content in real-world, often stressful, situations.

Future Direction

Further research must be conducted in this area to better understand the specific implications of this lapse in education. In the United States, EMS regulations are determined at the state level; when conducting surveys, providers’ primary area of practice should be recorded.

Then, analyses can be performed to determine the quantity and quality of IPV education and provider confidence with IPV in particular states and regions in the nation. Trends seen in the data can then be used to create specific action plans for each area for maximum efficacy.

In addition to a demographics section, survey questions must target individual beliefs surrounding IPV prevalence, presentation, and solutions. To best isolate misconceptions, the utilization of a Likert scale would be recommended.²⁷ For validity reasons, including rephrased duplicates of a handful of the key questions would be a sound way to ensure consistency in response.

Education on intimate partner violence in the prehospital sector must start from day one. As such, content regarding IPV needs to be incorporated into EMT and paramedic training courses. The textbook must include IPV content, or reading material on the subject should be provided.

Additionally, it must be presented in a lecture format where the students can ask questions and the instructor can share location-specific resources. Although IPV education must start from the beginning, simply including it in new provider training leaves the approximately one million currently certified EMS providers in the US alone without additional education.¹⁵

One way to address this gap would be to create and mandate a continuing education (CE) course in each licensing region. All EMS providers would have to take it within its two-year span. The CE must be structured to include interactive modules if online to ensure maximum interaction with the content.

That said, it would be an excellent way to, at minimum, expose the entirety of the EMS workforce to the basics of IPV in prehospital settings. From that point forward, through new provider education, first responders would not only understand it on a simple level but at a complex depth and breadth.

When developing educational content, whether for a textbook, lecture, or CE course, collaboration with local and national intimate partner violence centers will ensure the authenticity and importance of the information shared.

IPV specialists can assist with trauma-informed phrasing, providing relevant and up-to-date statistics, and connecting the community to additional resources for a variety of needs that the victims may require assistance meeting.

EMS systems must support the providers in their academic endeavors if positive improvements wish to be sustained; one such way to assist both the providers and the community in battling intimate partner violence is by creating a localized compendium of resources.

The clinical guideline ought to provide clear instructions for providers to follow should they be needed. A study conducted in Australia in 2018 tested the efficacy of a carefully constructed clinical guideline for paramedics regarding IPV calls.⁵ It included clinical indications, screening questions, standardized trauma-informed phrases, and an index of relevant resources for referral.

Next to the resources, the indications for utilization and multiple ways to contact each were provided. In addition to including all of the above, the comprehensive document also provides a guideline for proper documentation methods to avoid legal missteps.⁵

The guideline was created in partnership with local law enforcement, IPV specialists, and EMS responders, and was not implemented until full consensus was achieved.⁵

The criterion was largely successful because representatives from all different subject areas were consulted, meaning expertise from numerous individuals was combined until everyone agreed that there were no issues or immediate room for improvement.

Research is further lacking when it comes to non-traditional relationships. Intimate partner violence occurs to people of all demographics, including those in the LGBTQ+ community. Providers ought to not only be able to provide resources but also be familiar with patient-specific resources as applicable.

To spread awareness of and increase engagement in the EMS community with intimate partner violence education, conferences around the nation and worldwide should host speakers on the subject matter.

There, multiple EMS systems will inevitably be familiarized with the issue, and the setting of such conferences fosters an open dialogue for collaboration and improvement through observational and interpersonal learning.

A challenge faced by many systems when any form of abuse or violence is involved is the utilization of proper vocabulary. Systems possess varying definitions from region to region, many with legal repercussions strung along, making it difficult to educate individuals on a large scale.

Given that the EMS system works in tandem with but is not tied to the legal system, the National Association of Emergency Medical Technicians (NAEMT), in collaboration with the NREMT, should implement standardized terminology and guidelines in the national education standards for EMS providers to learn and abide by.

As is recommended when developing a course on the subject matter to provide the best outcomes, any provisions ought to be created in conjunction with intimate partner violence specialists who can provide guidance on best phrasing, handling of sensitive conversations, and more.⁵ Additionally, they may be able to recommend safety strategies for protecting providers while responding to calls involving IPV.

For example, partners might want to consider establishing an agreed-upon signal should they feel a situation warrants extra precaution or retreat. At the least, systems nationwide should implement some form of safety action response that will increase the safety of the responders.

Increasing education levels of intimate partner violence in EMS providers must become an immediate priority in all systems. Employing the various methods of written content, lecture presentations, and interactive animate patient simulations will undoubtedly increase provider comprehension, knowledge, and appreciation of the situation.

That said, EMS instructors cannot effectively educate students if they themselves are insufficiently cognizant of the challenges facing responders. Therefore, it is critical that educators spend time interacting with the subject matter themselves. Regional or national intimate partner violence awareness organizations should be enlisted by EMS systems and the National Registry of EMTs to offer materials to train the trainers. This endeavor need only follow the aforementioned

suggestions for IPV education in the EMS provider population. From there, instructors can incorporate the content into their respective courses as best fit. As previously discussed, each region has its own specific needs concerning IPV education, with certain misconceptions predominating more than others; therefore, educators are empowered to uniquely address their students’ needs while providing consistent information to all.

Considering that most of the educational resources are based on its respective testing, the NREMT exam ought to include IPV-related questions in the test question bank. Through the implementation of IPV examination, standardization of the content will be promoted and textbook publishers will be compelled to include the subject matter, as will EMS class instructors.

Even one question with IPV on the NREMT exam will require individuals to confront the issue, prompting further study, research, and advocacy. Its inclusion also communicates the importance of IPV awareness.

When considering the deficits of EMS education in light of the possibilities for improvement, EMS providers have a genuine potential to greatly improve outcomes for patients suffering from intimate partner violence.

About the Author

Elodie Krawczyk is in the emergency medicine undergraduate program at the University of Pittsburgh. She is a volunteer EMT in Prince George’s County, Maryland, pursuing her paramedic certification after working as an emergency department technician at Georgetown University Hospital in Washington, DC.

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