Rape Hidden Injuries


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Presentation of Chapter 6 in the book EMS Street Strategies: Effective Patient Interaction, 2nd ed., by Soreff and Cadigan

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  • Above all, rape is a crime of violence, not of passion. It is usually violence toward a woman by a man with the objectives of dominating, inflicting pain, and humiliating her, not reaching orgasm.
  • With only a small proportion of sexual offenses formally documented through law enforcement, the prevalence of sexual assault in Canada has been difficult to quantify.
  • A victim of rape frequently wants one or both of two options: A) FLIGHT: to run and hide, to be invisible, and/or B) COMFORT: someone to give her support and security.
  • 2 other reasons why a victim might be reluctant to report a rape: the rapist might be someone she knows, including a husband or ex-husband, or she might be an undocumented resident In this situation, the Primary Care Paramedic can be instrumental in encouraging the victim to turn to competent professionals such as a rape crisis center, and family - getting the victim to accept treatment and setting the stage for later recovery.
  • Denial, flashbacks, intrusive thoughts, fears of another assault, and nightmares may persist. She may blame herself or others, as she searches for explanations. Physical and emotional intimacy might become difficult.
  • So how can EMS providers help?
  • If the mechanisms of injury seem apparent, these should be noted.
  • One of the first challenges you face in assessing a rape victim is getting permission to assess and treat. In large part, success may reflect the attitude that you bring to the situation. Being overprotective may prevent the patient from initiating the normal process of working through her feelings. This applies to other cases with victims of intentional violence.
  • One of the first challenges you face in assessing a rape victim is getting permission to assess and treat. In large part, success may reflect the attitude that you bring to the situation. Being overprotective may prevent the patient from initiating the normal process of working through her feelings. This applies to other cases with victims of intentional violence.
  • -vigorous questioning can take on the character of another assault -a patient on blood-thinning medication may be susceptible to bleeding problems -do not overlook the possibility that the patient might have been pregnant at the time of the rape, but it may not be advisable to raise this question specifically
  • Your service should have policies and procedures for cooperating with police at scenes of crimes and safeguarding evidence - it is important that you know them.
  • Rape Hidden Injuries

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