Initial Goal Directed Treatment, Identification and Management of a Patient in the Trauma Bay by the Trauma Center Nurse -WARNING - images can have significant emotional impact-

1. www.sokwanele.com
Initial Goal Directed
Treatment,
Identification and
Management of a
Patient in the
Trauma Bay
Trauma Bay Considerations for
Violence, Abuse and Neglect Patients

2. • The images and
information in this
presentation are a sad
and realistic part of
our life in the ED.
• In this presentation
we will hear, see and
speak about abuse,
neglect and violence
and discuss our roles
in managing these
patients.
Clinical Warning
Clipart.com

3. “When people go to
work, they shouldn't
have to leave their
hearts at home.”
Author: Betty Bender
Excuse yourself if you must, we will understand

4. • Define:
– Child abuse and neglect
– Elder abuse and neglect
– Domestic Violence
• Identify the primary and secondary role of the Nurse in managing the
care of a trauma patient/victim.
• Case based discussion of care models for the patient/victim.
• Discuss and determine actions related to recognition and
preservation of a possible crime and crime scene evidence.
• Review the standards of identifying and reporting suspected cases for
all ED Nurses.
• Define and discuss the resources available to all nurses in supporting
the possible victim of a crime of abuse or neglect.
Objectives

5. Answer:
• The ABCDEs – Patient care is always the essential focus
• Save the life then move on to:
1. Ask “what’s not right with this”
2. Preserve the evidence and report
• When possible preserve evidence from the beginning, if
resources and medical conditions allow
Pop Quiz
Question: What are the initial
critical steps when taking care of
a traumatic injury patient who
you suspect of being a victim of
violence, abuse or neglect?

6. • Systematic patterns of behavior in a relationship
that are used to gain and/or maintain control and
power over another.
– Emotional abuse
• Includes hurting another person's feelings by saying
cruel, unfair comments or by name calling
– Psychological Abuse
• Any threat to do bodily harm to a partner, a child, a
family member, friends, pets, or one's self (suicide).
– Sexual Abuse
• Any non-consenting sexual act or behavior.
– Physical Abuse
• Any forceful or violent physical behavior.
Definition of Abuse
(Adult or Child)
Source: Domestic Abuse Project

7. Child abuse and neglect is defined by Federal and State laws
and can vary state by state.
– The Federal Child Abuse Prevention and Treatment Act (CAPTA)
provides minimum standards that States must incorporate in their
statutes.
– The CAPTA definition of "child abuse and neglect," at a minimum,
refers to:
• "Any recent act or failure to act on the part of a parent or
caretaker, which results in death, serious physical or emotional
harm, sexual abuse, or exploitation, or an act or failure to act
which presents an imminent risk of serious harm"
Child Abuse Defined
Source: The Federal Child Abuse Prevention and Treatment Act (CAPTA)

8. • Broadly defined (and varies state by state)
• There are three basic categories of elder abuse:
– Domestic elder abuse
• By someone who has a special relationship with the elder (a spouse, a
sibling, a child, a friend, or a caregiver), that occur in the elder’s home, or in
the home of a caregiver.
– Institutional elder abuse
• Generally occurs in residential facilities for older persons (e.g., nursing
homes, foster homes, group homes, board and care facilities).
• Perpetrators are persons who have a legal or contractual obligation to
provide elder victims with care and protection (e.g., paid caregivers, staff,
professionals).
– Self-neglect or self-abuse
• “Self care deficit” type issues due to lack of caring about ones own
life, financial concerns, or the focus of caring for a spouse
Definition of
Elder Abuse and Mistreatment
Source: US Centers for Aging

9. • The willful intimidation, assault, battery, sexual assault or
other abusive behavior perpetrated by one family
member, household member, or intimate partner against
another.
– In most state laws addressing domestic violence, the relationship
necessary for a charge of domestic assault or abuse generally includes
a spouse, former spouse, persons currently residing together or those
that have within the previous year, or persons who share a common
child.
– As of 2007, a majority of states provide some level of statutory
protection for victims of dating violence.
Definition of Domestic Violence
Source: National Center for Victims of Crime

10. ABCDE… is Your First Objective
Saving the life
of your patient
is your
primary role!
Then ask yourself:
1.What’s wrong with this story?
2.How can I help preserve evidence?
3.Who do I need to report this to?

11. • Consider preservation of evidence as soon as
you suspect a crime
– Implement it only if it doesn’t slow or jeopardize
care in any way
– Make certain everyone in the room is aware of
the plan to preserve
– Limit the number of people who touch what is
placed in the bag – always wear gloves
– Consider having multiple open paper bags on the
floor when the pt arrives
After the ABCDE…
Preserve the Evidence

12. • Everything goes into paper bags
– This includes sheets the patient was transferred to the
ED on (from the ambulance)
– Nothing goes into plastic
– One bag per item (or item type) is the most practical to
avoid cross contamination of evidence
• Bags should be sealed with tape and labeled with
name (or trauma alias), date, time and initials and
provided to PD as soon as possible
– Seals should not be pt labels (the MRN is considered
PHI)
– If at all possible, do not leave the bags unattended
After the ABCDE…
Preserve the Evidence

13. • Consult the PD if it is suspected that the
hands should be paper bagged (for
evidence collection from the hands later)
– Typically only done if the patient is dead or
stable
– Only with the Trauma Surgeon’s consent
– Never impact care and assessment needs of the
hands
• It gets in the way of assessment, art lines
etc…
• If you need to clean the patient for a
procedure, clean only the required area and
then save the cleaning materials
After the ABCDE…
Preserve the Evidence

14. Child Abuse/NeglectBelfastTelegraph
www.thesun.co.uk

15. • Think First…
• Remember:
–ABCDE…
–Save the life
–Ask: “What’s not
right with this?”
–Preserve and
Report
Case Scenario:

16. • EMS Report – Code Yellow:
– 8y/o male fell down a flight of
stairs
– c/o buttock pain, right forearm
deformity, headache with
possible short +LOC.
– Pt is very calm, constantly asking
if his Mom is there, GCS 15
– Vitals WNL, C-collar, LBB, right
arm splinted +PMS
Case Scenario #1

17. Case Scenario #1
• EMS Report – Code Yellow:
– 8y/o male fell down a flight of
stairs
– c/o buttock pain, right forearm
deformity, headache with
possible short +LOC.
– Pt is very calm, constantly asking
if his Mom is there, GCS 15
– Vitals WNL, C-collar, LBB, right
arm splinted +PMS
Would a 8 year old fall down an
entire flight of stairs”?
Is this normal?

18. Case Scenario #1
• EMS Report – Code Yellow:
– 8y/o male fell down a flight of
stairs
– c/o buttock pain, right forearm
deformity, headache with
possible short +LOC.
– Pt is very calm, constantly asking
if his Mom is there, GCS 15
– Vitals WNL, C-collar, LBB, right
arm splinted +PMS Are these reported injuries
consistent with falling down a flight
of stairs?

19. • EMS Report – Code Yellow:
– 8y/o male fell down a flight of
stairs
– c/o buttock pain, right forearm
deformity, headache with
possible short +LOC.
– Pt is very calm, constantly asking
if his Mom is there, GCS 15
– Vitals WNL, C-collar, LBB, right
arm splinted +PMS
Case Scenario #1
How calm would a 8 year old be, after
being placed in a board and collar, and
now in a trauma bay with people pulling
off clothes, etc…?
Social Development wise… how
many 8 year olds would rather
have Mom over Dad?

20. • Findings in the Trauma Bay:
– 8 year old male
– Airway clear – Name is Oliver
– Multiple head contusions
– Right forearm deformity
– Circumferential contusion (some old some
new) both wrists
– Bilateral knee abrasions with full ROM
– Contusions to anterior/superior chest wall,
spaced at either side of sternum
– Multi layer contusions to the buttock
– No blood at meatus
Case Scenario #1
www.philosophyblog.com.au
http://www.fordarlieroutier.org
http://www.fordarlieroutier.org

21. • Findings in the Trauma Bay:
– 8 year old male
– Airway clear – Name is Oliver
– Multiple head contusions
– Right forearm deformity
– Circumferential contusion (some old some
new) both wrists
– Bilateral knee abrasions with full ROM
– Contusions to anterior/superior chest wall,
spaced at either side of sternum
– Multi layer contusions to the buttock
– No blood at meatus
Case Scenario #1
www.philosophyblog.com.au
http://www.fordarlieroutier.org
http://www.fordarlieroutier.org
Do all these injuries make sense
based on the mechanism of
injury?
If not does it matter why?

22. • What did you do for Oliver in
the Trauma Bay?
– ABCDE…
– What about rectal tone on this patient?
• Would you, what considerations
would you take, if any?
– Emotional Support
– Definitive diagnostics and treatment
– Observe and assess interactions with
staff and family
• What can you do for Oliver after
the Trauma Resuscitation?
– Continue with the above
– Report your concerns/suspicions
• Why?
Case Scenario #1

23. The Latest Data
Child Abuse/NeglectBelfastTelegraph
www.thesun.co.uk

24. • During 2008, an estimated 772,000 children were
determined to be victims of abuse or neglect.
Child Abuse is Everywhere
Source: HHS 2008 Child Maltreatment Annual Reports
•Children in the age group of birth to
one year had the highest rate of
victimization.
•Female 51.3%
•Male 48.3%
•45.1% were Caucasian, 16.6% were
African-American, and 20.8% were
Hispanic.

25. • An estimated 1,740 children died due to child abuse or
neglect
– 71.1% of all victims suffered neglect
– 16.1% of all the victims suffered physical abuse
– 9.1% of all the victims suffered sexual abuse
– 7.3% of all the victims suffered from psychological maltreatment
(A child may have suffered from multiple forms of maltreatment and
was counted once for each maltreatment type.)
2008 Types of Abuse
Source: HHS 2008 Child Maltreatment Annual Reports

26. • Most were parents or relatives
– 80.1% of perpetrators of child maltreatment were parents
• 90.9% were the biological parent of the victim
– 6.5 % were other relatives of the victim
• Perpetrators
– Female 56.2%
– Male 42.6%
– 75.2% younger than age 40
• Of the perpetrators who were child daycare providers, 21.2%
committed sexual abuse.
Who is Abusing Children
Source: HHS 2008 Child Maltreatment Annual Reports

27. • Healthcare workers are legally required to report
suspicion observed in their line of service
– The code limits required reporting to persons acting in their professional
or official capacities.
• However anyone can report
• Does not require a medical professional to report, if not in their line
of service
• The Code does not require clear determination of
fact or “proof”
• Report to the police, immediately if you fear risk of
immediate harm
Virginia Code 63.2-1509
Reporting Child Abuse/Neglect
Source: http://leg1.state.va.us

28. • No legal ramifications for the reporter
– Immune from civil and criminal liability (unless done in
malice)
• No obligation to advise family of the report
• Failure to report within 72 hours of suspicion can result in
fines and license action.
• “A mandated reporter [e.g. Nurse] who has reason to suspect that a
child is an abused or neglected child shall report the matter
immediately to the local department of the county or city wherein the
child resides or wherein the abuse or neglect is believed to have
occurred or to the toll-free child abuse and neglect hotline of the
Department of Social Services.“
Virginia Code 63.2-1509
Reporting Child Abuse/Neglect
Source: http://leg1.state.va.us

29. Virginia Code Citation: Ann. Code § 63.2-100
• No child who in good faith is under treatment solely by spiritual means through
prayer, in accordance with the tenets and practices of a recognized church or
religious denomination, shall for that reason alone be considered to be an abused
or neglected child.
• Further, a decision by parents who have legal authority for the child, or in the absence of
parents with legal authority for the child, any person with legal authority for the child,
who refuses a particular medical treatment for a child with a life-threatening condition
shall not be deemed a refusal to provide necessary care if:
– The decision is made jointly by the parents or other person with legal authority and the
child.
– The child has reached age 14 and is sufficiently mature to have an informed opinion on the
subject of his or her medical treatment.
– The parents or other person with legal authority and the child have considered alternative
treatment options.
– The parents, or other person with legal authority, and the child believe in good faith that
such decision is in the child's best interests.
Religious
Child Abuse/Neglect Exceptions

30. “A mandated reporter shall disclose all information
that is the basis for his or her suspicion of abuse or
neglect of the child and, upon request, shall make
available to the child protective services coordinator
and the local department that is the agency of
jurisdiction any information, records, or reports that
document the basis for the report.”
Reporting and PHI in Virginia
Source: http://leg1.state.va.us

31. • Police
• Child Protective Services (DFS)
• FACT/Child Abuse-SANE?
• ED Social Worker
• Child Life Services (they can assist with comfort)
• Advise your charge nurse and other caregivers as
warranted
Who are you going to call?

32. Questions?
Child Abuse/NeglectBelfastTelegraph
www.thesun.co.uk

33. Elder Abuse
and Neglect

34. • Think First…
• Remember:
–ABCDE…
–Safe the life
–Ask: “What’s not
right with this?”
–Preserve and
Report
Case Scenario

35. Case Scenario #2
• EMS Report – Code Blue
– 64y/o Female impaled knife near
xyphoid unknown depth
– Found by neighbor who hadn’t
seen her in weeks
– Labored breathing, lungs CTA, abd
soft
– VS: HR 158, BP 79/36, RR 32
– Pt refused to leave the house until
her son came home and said it was
OK, till she became unresponsive
– GCS now 5 (E1, V1, M3), EMS
working to intubate
Copyright © NSW Institute of Trauma & Injury Management 2010

36. Case Scenario #2
• EMS Report – Code Blue
– 64y/o Female impaled knife near
xyphoid unknown depth
– Found by neighbor who hadn’t
seen her in weeks
– Labored breathing, lungs CTA, abd
soft
– VS: HR 158, BP 79/36, RR 32
– Pt refused to leave the house until
her son came home and said it was
OK, till she became unresponsive
– GCS now 5 (E1, V1, M3), EMS
working to intubate
Copyright © NSW Institute of Trauma & Injury Management 2010
Lacking a detailed story, what
doesn’t make sense about this
patient case?

37. Discussion – Clues to Consider?
• EMS Report – Code Blue
– 64y/o Female impaled knife near
xyphoid unknown depth
– Found by neighbor who hadn’t
seen her in weeks
– Labored breathing, lungs CTA, abd
soft
– VS: HR 158, BP 79/36, RR 32
– Pt refused to leave the house until
her son came home and said it was
OK, till she became unresponsive
– GCS now 5 (E1, V1, M3), EMS
working to intubate
Copyright © NSW Institute of Trauma & Injury Management 2010
What would you do for this patient in
the Trauma Bay?
What issues should you consider?

38. National Data Statics
Elder Abuse
and Neglect

39. Elder abuse reports on the rise
Source: National Center for Elder Abuse

40. Elder woman are the center of
abuse
Source: National Center for Elder Abuse

41. • Healthcare
workers are
the largest
reporting
group, yet
many go
unreported,
especially
“self neglect”
cases
Healthcare workers are the
largest reporting population
Source: National Center for Elder Abuse

42. • Average Age - 77
– The median age of elder abuse victims was 77.9
– The median age of self-neglecting elders was 77.4
• 66.4% of abused elders are white
– 66.4% were White
– 18.7% were Black
– 10.4% Hispanic
– <1% Native Americans and Asian American/Pacific Islander
Age and Race of Elder Victims
(1996 data)

43. • It is estimated that for every one case of elder abuse,
neglect, exploitation, or self neglect reported to
authorities, about five more go unreported.
– National Elder Abuse Incidence Study. 1998. Washington, DC:
National Center on Elder Abuse at American Public Human Services
Association.
• Current estimates put the overall reporting of financial
exploitation at only 1 in 25 cases, suggesting that there
may be at least 5 million financial abuse victims each year.
– Wasik, John F. 2000. “The Fleecing of America’s Elderly,”
Consumers Digest, March/April.
Total Elder Abuse/Neglect Cases

44. •This act revised the “Mandated reporters” list to
include dentists, pharmacists, certified emergency
medical services personnel, guardians and
conservators
•The Act always included physicians, nurses, mental
health professionals, social workers, and law
enforcement officers.
Virginia Adult Protective
Services Act of 2004
http://www.dss.virginia.gov

45. • Police
• Adult Protective Services (DFS)
• FACT/DV (Domestic Violence) - SANE
• ED Social Worker
• Geriatric Care Nurse (they can assist with comfort)
• Advise your charge nurse and other caregivers as
warranted
Who are you going to call?

46. Questions?
Elder Abuse
and Neglect

47. DomesticViolence
runninginheels.co.uk
http://www.sharenator.com/Male_Do
mestic_Violence/
www.americasupportsyou.com

48. • Think First…
• Remember:
–ABCDE…
–Safe the life
–Ask: “What’s not
right with this?”
–Preserve and
Report
Case Scenario

49. Case Scenario #3
• EMS Report – No Trauma Code
– 34y/o male reports being assaulted, will
not disclose further details, nobody in
custody
– “Blood is everywhere” unable to
determine exact location of injuries (if
any), pt has moved from initial location
so UTA total blood loss, not actively
bleeding from anywhere
– VS: HR 128, BP 155/90, RR 22, PERRLA
GCS 13-14
– Pt wants to AMA, but Police have
“encouraged” pt come for evaluation www.dailymail.co.uk

50. Case Scenario #3
• EMS Report – No Trauma Code
– 34y/o male reports being assaulted, will
not disclose further details, nobody in
custody
– “Blood is everywhere” unable to
determine exact location of injuries (if
any), pt has moved from initial location
so UTD total blood loss, not actively
bleeding from anywhere
– VS: HR 128, BP 155/90, RR 22, PERRLA
GCS 13-14
– Pt wants to AMA, but Police have
“encouraged” pt come for evaluation www.dailymail.co.uk
Lacking a detailed story, what
doesn’t make sense about this
patient case?

51. • Findings in room 12
– Airway and breathing are
good. Pt is oriented to person
and place but confused
– Blood is everywhere but no
active bleeding noted until you
get to “E” and Expose
• You note significant trauma
to the rectum, groin and
lower back – Bleeding
limited at this time
– VS remain stable
Case Scenario #3
Medscape.com
www.dailymail.co.uk

52. • Findings in room 12
– Airway and breathing are
good. Pt is oriented to person
and place but confused
– Blood is everywhere but no
active bleeding noted until you
get to “E” and expose
• You note significant trauma
to the rectum, groin and
lower back – Bleeding
limited at this time
– VS remain stable
Case Scenario #3
Medscape.com
www.dailymail.co.uk
Not knowing all the facts,
what are you immediate
actions?
What are your follow-up
actions related to the
possible criminal aspects?

53. DomesticViolence
National Data Statics
runninginheels.co.uk
http://www.sharenator.com/Male_Do
mestic_Violence/
www.americasupportsyou.com

54. • As few as 5% of domestic violence victims are
identified as such in Emergency Department
records.
– American Journal of Public Health, 1989
• Nearly one-third of American women (31 percent)
report being physically or sexually abused by a
husband or boyfriend at some point in their lives.
– Bureau of Justice Statistics Crime Data Brief: Intimate Partner
Violence, 1993-2001, (2003)
Domestic Violence data

55. • Intimate partner violence made up 20% of all
nonfatal violent crime experienced by women in
2001.
– The risk of injury increases among female rape and
physical assault victims when their assailant is a current or
former intimate partner
• Intimate partners committed 3% of the nonfatal
violence against men in 2001
Domestic Violence data
Source: Bureau of Justice Statistics Crime Data Brief: Intimate Partner
Violence, 1993-2001, at 1 (2003)
Source: www.ncjrs.gov

56. • The prevalence of domestic violence among Gay and
Lesbian couples is approximately 25 - 33%.
• Seven states define domestic violence in a way that
specifically excludes same-sex victims.
• States with sodomy laws (e.g. Virginia) essentially
require same-sex victims to confess to a crime in
order to prove they are in a domestic relationship.
– Virginia’s laws can conflict with each other, offering
unclear legal determination. Actions and prosecutions
vary by local jurisdiction.
Domestic Violence data
Source: Barnes, It's Just a Quarrel', American Bar
Association Journal, February 1998

57. • One in three teenagers has experienced violence in
a dating relationship
• 15 percent of teen girls and boys have reported being
victims of severe dating violence (defined as being
hit, thrown down, or attacked with a weapon).
• 8 percent of 8th and 9th grade students have
reported being victims of sexual dating violence.
Domestic Violence data
Source: National Center for Victims of Crime

58. • Virginia law requires that if law enforcement has
probable cause to believe that a domestic assault has
occurred (this usually means they are able to see
scratches, bruises, or other injuries with their own
eyes), they must arrest the “predominant physical
aggressor” unless special circumstances exist which
would dictate some other course of action
– VA Code 19.2-81.3
• Healthcare workers are required to report under the laws
for Child and Adult abuse, as well as under the
requirements of knowledge of a violent crime taking
place, but there is no direct law requiring reporting of
domestic abuse
Domestic Violence Laws

59. • Fairfax Police
• FACT/SANE – Sexual
• ED Social Worker
• Advise your charge nurse and other caregivers as
warranted
• Refer the possible victim to: Virginia Family
Violence/Sexual Assault Hotline - (800) 838-8238
Who are you going to call?

60. DomesticViolence
Questions?
runninginheels.co.uk
http://www.sharenator.com/Male_Do
mestic_Violence/
www.americasupportsyou.com

61. Discussion:
Clues to Consider in theTrauma
• What would you consider are your priorities in a
Trauma Resuscitation with any abuse or neglect
patient?
– Does this differ from any victim of violence or neglect?
• How would you communicate with family in case of
suspicion?
• What ancillary services might you involve?
• What discussion would you have with the rest of the

62. Who can you call if the event
you’ve seen or participated in
is too much for you, or you just
want to talk?
•Your Peers
•ED Social Worker
•EAP
– 24/7/365
What if it’s too much for you

63. Conclusions
• Remember your ABCDEs always come first.
• Think about what else could be going on.
• Consider the need to report suspicion – not the
need to know for sure.
• Utilize the vast resources IFH and the community
offers to manage these cases.
• Seek the support of your peers and other
professionals.

64. THE
END