3.2. BULLYING AND NEGLECT

Related terms

Neglect of vulnerable populations

Definition:

1. 1. Abuse/neglect: any act or omission by caregivers or persons in authority over a patient that results in harm, potential harm, or threat of harm.
      
      Child neglect/abuse: Child neglect is any act or chain of events or omission by a family member/caregiver that results in harm or potential harm. The act of committing (child abuse) is the physical, sexual or emotional abuse of a child or children. Neglect (abuse) includes, but is not limited to, failure to meet a child’s needs (e.g., physical, emotional, medical/dental, and educational) and inadequate supervision (e.g., inadequate supervision or safety measures, lack of appropriate use of child seats in a car, and exposure to violent or unsafe environments).

1. 1. Human trafficking: abduction or forced labor in the service sector and subsequent trafficking abroad. Signs may include, but are not limited to: patients with branding/tattoos and external markers such as padlocks and/or door handles removed on interior doors and entire windows that are boarded up.

The purpose of providing care

1. 1. Identification of any signs of abuse or neglect, actions or omissions by a caregiver or person in authority over a patient that results in harm, potential harm or threat of harm to the patient by the caregiver.

1. 1. Use of appropriate methods to ensure the safety of EMS professionals and ordinary citizens at the scene.

1. 1. Protect the patient from immediate threats.

1. 1. Examine any injuries that have been sustained as a result of acute or prolonged events.

1. 1. Attempting to preserve evidence whenever possible; however, the primary concern should be to provide the patient with appropriate emergency care.

Description of the patient

1. 1. Signs of abuse/neglect may vary depending on the age of the patient and the method of abuse.

1. 1. Not all methods of abuse/neglect are physical.

1. 1. The role of the EMT in this situation is as follows:

a) document suspicions;
b) assess potentially serious injuries;
c) notify the appropriate authorities in case of suspected child abuse/neglect;
d) initiate the patient protection process;
e) not investigate or intervene beyond the above steps;
f) leave further action to law enforcement officials.

Inclusion/exclusion criteria

There are no clear inclusion/exclusion criteria in this situation. Rather, you should look for clues that correspond to different types of

of bullying/maltreatment:

1. Potential evidence of abuse/neglect by caregivers or the environment:

a) apathetic attitude of the caregiver towards the patient’s condition;
b) overreaction of the caregiver to questions about the situation
c) inconsistencies in the testimony of the caregiver or bystanders regarding the event itself;
d) information provided by caregivers or bystanders does not correlate with the nature of the injuries;
e) Injuries that are not age- or physical-capable (e.g., infants with injuries that are typical of older children, elderly patients with limited mobility with
mechanisms of injury incompatible with their capabilities);
f) the caregiver does not allow the adult patient to express himself/herself – special attention is required for patients who are unable to communicate
independently due to childhood age or language and/or cultural barriers;
h) inadequate protective measures or the patient’s place of residence/ or signs of protective measures that restrict the patient’s will.

2. Potential evidence of abuse/ maltreatment can be identified from the patient:

a) multiple bruises with different stages of healing;
b) atypical behavior for the age (for example, adults are full of fear or their behavior is submissive; vulgar behavior in children)
c) traces of burns, bruises or scars indicating the use of specific instruments;
d) signs of negligent medical treatment of injuries or infections;
e) unexplained injuries of the genitourinary system or frequent infectious diseases of this system;
f) evidence of malnutrition and/or serious dental problems.

3. Be highly suspicious of child abuse in children with unexplained events (see Short-term Unexplained Deterioration (STUD) guideline).

Patient management

Assessment

1. Start with an initial assessment and identify any life-threatening conditions.

2. Document the secondary assessment in detail to identify potential signs of abuse/neglect:

a) inability to express oneself due to age, language and/or cultural barriers;
b) multiple bruises with different stages of healing;
c) behavior that is atypical for the age (e.g., adults are full of fear or their behavior is submissive; vulgar behavior in children);
d) traces of burns, bruises or scars indicating the use of specific instruments;
e) signs of medical negligence in relation to injuries or infections;
f) unexplained injuries of the genitourinary system or frequent infectious diseases of this system;
h) evidence of malnutrition and/or serious dental problems.

3. Assess physical injuries and avoid detailed investigation of the causes of neglect or abuse, but document any statements that the patient may spontaneously make. Avoid asking direct questions of children.

Treatment and interventions

1. Assess for life-threatening conditions.

2. Move the patient to a safe place even if there is no medical reason for hospitalization.

3. Immediately report suspected abuse/neglect to law enforcement (as required by law):

a) the caregiver is obstructing the patient’s transportation/examination;
b) the caregiver refuses to provide care to the patient.

4. If you are transporting the patient, provide information about your suspicions to the hospital emergency room and/or law enforcement in accordance with the relevant law.

Patient safety

1. In the absence of medical emergencies, the next priority is to ensure the patient’s safety and move them to a safe environment.
2. Do not confront suspected abusers/neglectful persons. This can create a dangerous situation for the EMT and the patient.

Useful information for training

Key Points

1. Each state has laws that require reporting of crimes such as neglect or bullying. It is important to be aware of these state laws and to know the clear boundaries of information dissemination – to whom and to what extent this information can be provided.
2. Evidence of neglect or bullying may vary depending on the age group and the nature of the bullying. Remember that not all bullying or neglect causes physical harm. It is important to understand that the task of the EMT is to document the suspicion, assess the potential threat to the patient’s life, report the suspicion to the appropriate authorities, and ensure the patient’s safety. EMS workers should not investigate the causes of bullying on their own, nor should they interfere in solving this problem – these actions are clearly reserved for law enforcement officials.
3. It is important to have a high level of suspicion when there are clear signs of life threats to children with CBPS. Among the very serious causes of CBPS, child abuse was the underlying cause in 11% of cases. One retrospective review of studies noted that an EMS call due to clear signs of life-threatening injury (CLI) was associated with more than 5 times the likelihood of a violent head injury being diagnosed as the cause of CLI, clearly confirming that EMS workers should have a high level of suspicion during such calls.
4. Bullying and abuse can happen to patients of all ages.
5. Patients may be unwilling or unable to disclose abuse or mistreatment, so it is the responsibility of EMD staff to assess the situation, document appropriately, and take appropriate action to ensure a safe place for the patient.
6. Document your findings by describing what you see and do not presume possible causes (e.g., “0.5-inch round back burn” as opposed to “cigarette burn”).
7. Providers should be aware of mandatory reporting in their area, especially for adults (domestic violence, elder abuse).

Relevant assessment findings

As indicated above.

Key elements of documentation

Careful documentation of any patient statements and any physical findings about the patient or environment are critical in cases of abuse or neglect.

Criteria for the effectiveness of care

No recommendations.