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

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. Part 1 of 3:
Background & Challenges

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. 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. 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. 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. “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. Part 2 of 3:
Patient’s Responses

9. Case Study:
Jennifer Collins*
*see pages 64-67

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. 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. 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. 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. 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. How will the Primary Care
Paramedics help Jennifer?

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. Part 3 of 3:
EMS Provider Responses

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. 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. 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. “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. 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. 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. 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. 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. 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. 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. 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. 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. Other Considerations
for EMS Providers

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. 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. “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)