Rape Hidden Injuries

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Presentation on Chapter 6 of EMS Street Strategies: Effective Patient Interaction, 2nd Edition, by Stephen M. Soreff and Robert T. Cadigan

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Rape Hidden Injuries

  1. 1. Rape: Hidden Injuries Stephen M. Soreff & Robert T. Cadigan, “Chapter 6,” EMS Street Strategies: Effective Patient Interaction, 2nd Ed. (Delmar Learning: 2003, Clifton Drive, NY) Mark Wooldridge Communications Class Primary Care Paramedic Program CTS Canadian Career College
  2. 2. Part 1 of 3: Background & Challenges
  3. 3. Background: What is rape? The Criminal Code of Canada defines sexual assault according to three levels that include acts such as unwanted sexual touching to violent physical harm to the victim: 1. Sexual assault – section 271 (level 1) involves minor physical injuries or no injuries to the victim. It carries a maximum sentence of 10 years imprisonment. 2. Sexual assault – section 272 (level 2) involves sexual assault with a weapon, threats or causing bodily harm. It carries a maximum sentence of 14 years imprisonment. 3. Aggravated sexual assault – section 273 (level 3) results in wounding, maiming, disfiguring or endangering the life of the victim. The maximum sentence for this offence is life imprisonment.
  4. 4. Statistics... In 2004, about one in ten sexual assaults were reported to police (General Social Survey (GSS) on Victimization): about 512,000 incidents of rape, attempted rape, or sexual assault occurred in 2004, representing a rate of 1,977 incidents per 100,000 population aged 15 and older. police-reported sexual assault counts are notably lower, with about 24,200 sexual offences recorded by police in 2007. (www.statcan.gc.ca)
  5. 5. Relevance: The dynamics of a rape or sexual assault call will be invariably different than that of an accident due to the psychological impact of an intentional trauma inflicted on the patient. “When you respond to a rape or sexual assault, you have a great opportunity to address both the physical and psychological pain. Yet, you will face special challenges in emergency medical care of a sexually assaulted patient.” (63)
  6. 6. Challenges for Primary Care Paramedics: Gaining the patient’s trust Performing an assessment on a patient who is sensitive to any perceived violation of privacy Effectively supporting the patient during treatment Dealing with your own feelings
  7. 7. “You can have tremendous influence on the patient’s decisions and, therefore on the patient’s ultimate recovery from emotional trauma of assault.” (64)
  8. 8. Part 2 of 3: Patient’s Responses
  9. 9. Case Study: Jennifer Collins* *see pages 64-67
  10. 10. Situation & Patient’s Response Jennifer was attacked just Her initial reaction: fight before 10:55 pm, in the back, cry out; then her vestibule of her apartment mind went blank - she felt building, on the evening of faint & wanted to run away September 28 but could not Post-attack she is afraid, Jennifer is ambivalent ashamed, worried the about what she wants: go attacker might come back home or avoid being alone; call her mother but not tell Seeks help from a what happened; comfort neighbour, who calls the from her boyfriend but not police on her behalf to be touched by a man
  11. 11. Situation & Patient’s Response Jennifer sees the arriving She is unsure as to whom she police officers as threats, not needs: it may be difficult for allies her to talk about the experience with the police; repeating the story may cause her to relive the assault EMS providers arrive within a Jennifer responds more to the minute of the police female EMS provider, embracing her; she demonstrates partial amnesia with regard to the attack EMS providers identify Jennifer is caught between themselves, offering help, & wanting help and wanting to police ask for information be left alone
  12. 12. Emotions & Thoughts Behind the Patient’s Behaviour: The thoughts and feelings that follow an assault may trouble the victim for months after and may cause some level of incapacitation. Directly following the assault, the victimʼs thoughts and feelings may include: emotional shock guilt (numbness) depression disbelief disorientation embarrassment powerlessness shame
  13. 13. Perhaps the victim’s greatest fear is that she is powerless. she fears there is no resolution for the fear and the pain if she does not work through the event successfully, the need for flight or comfort may have unhealthy consequences: Flight may result in: Comfort may result in: -actually running from the scene -inability to tolerate being alone -chemical retreat through alcohol -excessive dependence on others or tranquilizers -a need to be perpetually busy (67-68)
  14. 14. Primary Care Providers must remember: “Given the violent, potentially homicidal context of rape, whatever steps a victim took to save her life were all right. “It is important that the victim appreciate that survival is the paramount concern. “Many survivors become critical of their own behaviour and the measures they took to save their lives.” (69)
  15. 15. How will the Primary Care Paramedics help Jennifer?
  16. 16. EMS & Patient Interaction EMS provider suggests that someone Jennifer realizes she has some provide refreshments, and that sitting control. By allowing the patient to quietly might be best for a few know she has - and will continue to minutes. Jennifer asks, “What do I do have - a say in the process, the EMS now?” EMS responds, “What do you provider is encouraging her mean?” independence Jennifer asks, “Do I go to the hospital? EMS makes note of Jenniferʼs Do I talk to the police?” EMS calmly attentiveness, whether her mind discusses her options, describing the wanders, reading her body language experience of a rape crisis center, the for signs that the patient has made a advantages of an assessment in the decision - e.g. growing silent present location, and a thorough assessment at the Emergency EMS confirms Jenniferʼs decision & Department (ED) suggests supports (e.g. counselors for informing friends, family)
  17. 17. Part 3 of 3: EMS Provider Responses
  18. 18. 3 Reasons Why a Rape Victim Should Seek Medical Treatment: “It is necessary to determine if the victim has been physically injured. “It is necessary to ease fears, such as fears about venereal diseases or STIs, unwanted pregnancy, or HIV/AIDS, and to take appropriate measures. “It is essential to collect medical evidence to prosecute the rapist if and when a suspect is caught.” (68)
  19. 19. First, be aware of your own responses. EMS providers, like families, friends, and co-workers of the victim, tend to respond in one of three ways: Supportive Aloof Accusatory -bolsters a damaged sense -generally involves ignoring -directly or subtly blaming of self & promotes recovery or minimizing the situation the victim by suggesting -being emotionally distant & she invited the attack in -involves: some way withdrawn from the patient a) listening -focusing on the physical -the victim becomes the injury rather than the victim of the helpers b) willingness to spend mental or spiritual ones (69-70) time, -reducing close contact with c) being open & the victim accepting when the victim pours her heart -victim may interpret the out withdrawal as disapproval
  20. 20. Intervention Strategies - 1 of 6 Observe The location can yield important patient care information: -in a violent attack, the victim may have suffered injuries from being thrown or pushed against walls, doors, radiators... -suspect blunt injuries as well as direct injuries from hitting or stabbing -pay particular attention to how the victim holds her body, and be aware of the possibility of head trauma (70)
  21. 21. “Jennifer was grabbed by the left arm and thrown against the door before she was raped. Her mood swings and unusual behaviour may suggest head trauma.” (70)
  22. 22. Intervention Strategies - 2 of 6 Interact There are 3 important principles: “1) Meet the victim at the level of her distress. -Do not order her about. -Do not overprotect her. “The treatment process should bring in the victim as a partner to the fullest extent possible so that she is not robbed of further autonomy. Reassure her that there is no danger of a subsequent attack.
  23. 23. Intervention Strategies - 2 of 6 Interact “2) Emphasize your capabilities. “Concentrate on your professional strengths. Your role is to treat and transport the patient. It is not to apprehend a rapist or to collect physical evidence from a crime scene. However, EMS providers should be able to perform their duties without confusing an investigation.
  24. 24. Intervention Strategies - 2 of 6 Interact “3) Allow the woman the time to reach her own decisions, if her injuries do not require immediate treatment. “Unless there are signs of serious physical injury, caring and compassion are more important to a successful outcome than speed.” (70-71)
  25. 25. Intervention Strategies - 3 of 6 Ask To treat the patient successfully, you must know a number of important facts. -be supportive rather than prying or critical -emphasize your concern with two immediate questions: “Where do you hurt?” “How can we help?” -find out what medications the patient has been taking (71)
  26. 26. Intervention Strategies - 3 of 6 Ask To treat the patient successfully, you must know a number of important facts. -“ask the patient if she has bathed, washed, and changed clothing, or urinated after the assault... all of these actions have an impact on evidence collection and will be important to note on your reports as well as on other police reports.” (71)
  27. 27. Intervention Strategies - 4 of 6 Act “Vital signs should be obtained as soon as possible for a baseline measure and to assure that physical functions are stable.” (72) -treat any bleeding, sprains, or fractures; administer oxygen as appropriate -a gynecological examination should only be done in the ED *Familiarize yourself with the rape treatment protocols of your ED, in order to explain them if required, and coordinate your care with that which will be given at the hospital.
  28. 28. Intervention Strategies - 5 of 6 Attend “Be supportive. It is important to be there, rather than focusing on getting the patient somewhere else. It is important that the survivor make her own decisions and regain control over her own life.” (72)
  29. 29. Intervention Strategies - 6 of 6 Document “The key to effective documentation is to report what is necessary for the patientʼs treatment, without revealing personal data unnecessarily. -the victim may be inconsistent, vengeful, suspicious; these are normal reactions to victimization -extensive or vivid quotations are not necessarily helpful here “Your records may become part of a legal investigation, and some findings may be relevant in court.” (72)
  30. 30. Other Considerations for EMS Providers
  31. 31. “After attending a victim of violence, you may share some feelings of vulnerability. There are healthy and unhealthy ways of dealing with these feelings.” (72)
  32. 32. Think about this... EMS providers may become Be aware of your prejudices. cynical. -you may encounter situations in -callousness may result in which the victim is a prostitute or ineffective care a drug user -victims may need to feel secure -a professional response in order to accept a helping demands that these patients relationship receive the same type of approach: nonjudgemental and -remember to see the victim as a respectful thinking, feeling individual - not just another statistic (72)
  33. 33. “The consequences of rape can stay with the survivor for years. What you do in the minutes after the assault can help in the process of healing.” (73)

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