CME INVITE - Intimate Partner Violence
Date: 2025-01-17
MULTIDISCIPLINARY ROUNDS
On behalf of Coroner Dr. Louise McNaughton-Filion, this is a CME accredited event and important invite to Multidisciplinary Death Investigation Rounds.
DATE: January 21, 2025
TIME: 4:00pm -5:30pm (EST)
DVDRC/IPV (Domestic Violence Death Review Committee / Intimate Partner Violence)
Presenters: Dr. Elizabeth Urbantke, Indira Stewart and Shalini Konanur
At the end of this session, attendees should be able to:
- Explain the purpose and the mandate of the DVDRC.
- Describe the evolution of the DVDRC, particularly since the inquest into the deaths of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam.
- Evaluate and describe initiatives arising from the DVDRC.
Zoom Link
Follow the link on any computer or phone to access the broadcast through Zoom:
*** See the OPA's Private Facebook Group for Zoom link ***
Obtain CME Credits - Survey Link
After the talk, we invite everyone to participate in completing the survey. Completing the survey is necessary if you plan to obtain CME credits.
*** See the OPA's Private Facebook Group for Survey Monkey link ***
*** This event will be archived. To view the recording, please check our Private Facebook Group for email contact.
Intimate Partner Violence and Paramedicine in Canada: a short report
Prepared for the Ontario Paramedic Association at the request of the Office of the Chief Coroner of Ontario.
- Lead Researcher: Rory A. Marshall, PhD(c), MSc, BA, PCP
- President: Darryl Wilton
- Vice-President of Operations: Katherine Hambleton
- Director of Research: Dr Walter Tavares
Table of Contents
- Professional Biography
- Introduction
- IPV and Paramedicine
- Recommendations for Call Taking and Dispatching
- Recommendations for On-Scene Practice
- Recommendations for Documentation
- The Big 3: Education, Training, and Infrastructure
- Conclusion
- References
1. Professional Biography
Rory A. Marshall is subject matter expert in both intimate partner violence and paramedicine. Marshall is a PhD Candidate in the Faculty of Health and Social Development at the University of British Columbia Okanagan. He completed his MSc in Biomedical Sciences at the University of Saskatchewan and his BA at Vancouver Island University. Marshall hosts an impressive academic record at the intersection of intimate partner violence and paramedicine, yielding multiple international conference presentations, and peer reviewed publications. His community-engaged research hosts a variety of collaborations including emergency medical services across multiple provinces, provincial and regional community health organizations, as well as hospitals to develop meaningful research outputs with implications for clinical practice that benefit survivors of intimate partner violence. Clinically, Marshall practices as a paramedic for Alberta Health Services Emergency Medical Services and British Columbia Emergency Health Services. He also has international clinical experience in Central America and New Zealand. Among other appointments, Marshall is a Senior Fellow for the McNally Project for Paramedic Research, and a Researcher and Clinical Member of the Alliance Against Violence and Adversity. Academically, he is an instructor at the Justice Institute of British Columbia in the School of Paramedicine and Health Sciences, and is an expert peer reviewer for journals including Paramedicine and PLoS One. He also serves as an evidence appraiser for the Dalhousie Prehospital Evidence Based Practice Database.
2. Introduction
Violence is defined by the World Health Organization (WHO) as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”1 A key component of this violence definition is the intent. Intimate partner violence (IPV; i.e., partner abuse, dating violence), a sub-category of domestic violence, is defined as physical, sexual, and/or psychosocial abuse to an individual that is perpetrated by a current or former intimate partner.2 The intent is precisely what distinguishes IPV from other violent types, as IPV perpetrators need to achieve and maintain power and control.1 IPV can affect anyone but impacts are most substantial among women and people from equity deserving groups (i.e., sexual minorities, gender minorities, disabled people, racialized people, and those that occupy a low socioeconomic status).1,3–5
IPV is a personal and public health crisis as global prevalence rates reach upwards of 1 in 3 women being exposed to IPV in their lifetime.4 More recent estimates of physical IPV alone are 1 in 3 within a woman’s lifetime and upwards of 1 in 10 within the past year.6 Owing to the stigma associated with IPV and other complexities adding barriers to identifying IPV, the already devastating incidence rates are likely higher than what is being reported.7,8 IPV, including physical violence, is cyclic, repetitive, and escalating in nature.1 Thus, the risk of homicide perpetrated by an intimate partner is extreme. This lethality is particularly evident when a survivor is attempting to end or leave a partnership.9,10 Non-lethal, physical IPV has been shown to cause a variety of short-term and long-term health consequences.11,12 Further, IPV-caused brain injury (IPV-CBI) is a prevalent (observed in >80% of physical IPV survivors) health consequence in IPV. Importantly, IPV-CBI can originate from direct or indirect trauma, as well as non-fatal strangulation (NFS).13–17 IPV can cause impact to all bodily systems.11,12 IPV-CBI can further exacerbate or mask signs and symptoms from other ailments, and compound challenges faced by survivors when accessing healthcare.18–20 Physiological barriers (ex., cognitive impairment, insomnia), psychological barriers (ex., anxiety, depression, post-traumatic stress disorder), and disadvantageous social determinants of health (ex., gender minority status, visible minority status) can all act as concomitant barriers to the legal, social, and financial requirements of navigating a situation of IPV. Further factoring in the potential for child custody conflicts,21 the immense burden survivors face in attempting to achieve a safe, stable, and prosperous life is nearly impossible to navigate without support.
3. IPV and Paramedicine
Currently, the intersection of paramedicine (i.e., emergency medical services, out-of-hospital care) and IPV in Canada is in a critical, dangerous, and inadequate state. The Paramedic Association of Canada, who govern the educational and vocational competencies for paramedics on a national level, do not include any competencies surrounding IPV.22 Despite having competencies for child abuse, elder abuse, and abuse of persons with disabilities,22 a horrendous failure exists when considering the absence of partner abuse (i.e., IPV) competencies. This is mirrored by a lack of treatment protocols, guidelines, and goals of care for paramedics encountering IPV patients. Certain emergency medical services may have local guidance, but it is unclear if intermittent and varied guidance is effective within a much larger profession. Research, albeit limited, suggests that paramedics are seeing patients experiencing IPV,23 and that those patients are likely underserviced.24 Underservicing patients contributes to the cyclic nature of violence, and corresponding health, social, legal, and financial detriments. Recently, an alleged murder of a veteran paramedic by her former spouse, a former paramedic himself, has fragmented Canadian paramedicine and lead to widespread calls for action within the field.25–27
Globally, guidance exists for managing patients experiencing IPV. The WHO has created guidance for healthcare providers when treating patients experiencing IPV.28 The Listen, Inquire, Validate, Enhance, and Support (LIVES) approach is a foundational framework used to support survivors of IPV.28 Outside of this work, specific resources exist for certain sub-aspects of IPV (ex., IPV-CBI, NFS),29,30 that can also be adapted but are not specific to paramedicine. In Australian paramedicine, a general guideline for paramedic’s responding to women experiencing IPV has been developed, integrating the LIVES approach.31 This guideline, the only published paramedic-specific guideline, centres around the principles recognize, respond, refer, and record.31 Indeed, the current guidance and evidence around care for survivors of IPV is limited. The current guidance and evidence at the intersection of paramedicine and IPV is minimal bordering absent. Literature gaps surrounding Canadian paramedicine and IPV include, but are not limited to, education, training, infrastructure, and policy. Immediate action is needed to rectify the care provided by paramedics to survivors of IPV. Recommendations are based on the best available evidence, which must often be adapted to paramedicine. Inaction is not an option as prolonged stagnation will continue to be harmful, if not lethal for survivors/victims receiving emergency medical services care.
4. Recommendations for Call Taking and Dispatching
Emergency medical call takers (EMCTs) have been integrated into the paramedical response to improve patient care.32 Although challenges exist for EMCTs,33 the ability to impact patient care begins at this first point of contact. As the majority of emergency medical services in Canada call take and dispatch using an iteration of the Medical Priority Dispatch System (MPDS),34 similar information is often gathered nationally during call taking. An electronic patient flagging system35 could be a useful method to analyze and asses of risk of IPV. Although no published literature exists, using addresses and patient-specific information (ex., age, gender, etc.) appears promising to examine location-specific risks of IPV prior to on scene arrival. Various services across Canada use an iterative process of address flagging identity risks for patients and paramedics, commonly for violent or hazardous addresses. Ideally, paramedic IPV address flagging would be inter-agency (ex., police, homecare) and paramedic driven (functional reporting updated following each visit). Furthermore, this process could also be used to adjust call takers' radar for signs of IPV among known addresses and ask additional questions aimed to identify IPV (when appropriate and in alignment with safe patient practices). Improving information gathering at the EMCT level may be of great benefit in calls involving IPV.
With information about known or suspected IPV available to emergency medical dispatchers (EMDs), appropriate resources could be deployed with the appropriate awareness being conveyed to paramedics prior to arrival. The MPDS is well-documented to over- and under-dispatch resources.36,37 EMDs have been shown to identify when situations call for different resources versus those advised by the MPDS.38,39 Structured guidance allowing for clinical judgement should be developed to manage resources allotted to situations of known or suspected IPV addresses. Any decision must err on the side of paramedic and patient safety. Beyond resource allocation, crew safety acknowledgements prior to arrival, and frequent on scene safety checks may be appropriate for situations involving IPV.
5. Recommendations for On-Scene Practice
Paramedics frequently experience unacceptable violence on the frontlines, causing harm and time away from work.40 This, paired with the inherent dissonance between the expectations paramedics have of no violence during emergency calls, in comparison to realities of practice where there is violence during emergency calls, may synergize to further cause detriment to the workforce.41 In situations involving IPV, the risk of violence against paramedics, patients, children, other responding agencies, bystanders, and perpetrators is elevated. Robust safety guidance must begin prior to arrival and be continued throughout each ambulance call. Most violence against paramedics occurs on scene, but often persists throughout the patient interaction.40 Paramedic calls are fluid and dynamic situations. Effective and frequent communication with EMDs and, where appropriate, other agencies (ex., police) is likely to improve the safety of all involved.
Although IPV may be overt in some situations, often it can be hidden. Survivors who have experienced or are experiencing violence commonly develop coping strategies, both beneficial and harmful, to survive.42–44 There is a lack of research linking screening for IPV to improved patient outcomes. However, ignoring IPV is not the answer. Thus, identifying violence is likely a vital step. Many screening tools exist for identifying IPV.45 The sensitivity and specificity vary,45 and no tools have been validated in the prehospital or paramedical settings. The clinically validated Humiliation, Afraid, Rape, Kick (HARK) tool covers all components of IPV and has been used in a variety of settings.46–48 This brief 4-item tool is a promising option for use in paramedicine. However, adaptation of an existing tool or development of a paramedic-specific tool may be most appropriate for the field. A uniform tool, like Face, Arms, Speech, Time-Vision, Aphasia, Neglect (FAST-VAN) for strokes,49 that is well-adopted across the country would be optimal for initial analysis of quality improvement. It should be noted that all screening tools have a degree of error. Paramedics should still be able to advance patient care on suspicions of IPV in the absence of disclosure. There has been a recent push for universal patient education about IPV and healthcare and/or support options.50,51 The Confidentiality, Universal Education + Empowerment, Support (CUES) intervention is an evidence-based method for healthcare providers to discuss IPV in the absence of a disclosure.52 Educating and explaining options to all patients and families can alleviate provider burden from screening and empower patients with options for themselves and others.52 Using the CUES intervention on scene can initiate pathways to care and support (PtCS) in situations of conveyance and non-conveyance.
In situations of IPV, non-conveyance may be the best option for some patients. Patients may also elect non-conveyance contrary to what is advised by paramedics. Non-conveyance must not be a barrier for PtCS. Safety and lethality must be considered as the prevalence of IPV homicide is high.53 The Lethality Screen is an 11-item tool that can be used to assess for the risk of lethality in situations of IPV.54 When children are involved, additional consideration should be given to the children’s safety and lethality risk. Actions should be taken in accordance with existing guidance on known or suspected child abuse or neglect. Beyond safety, community-based programs to support survivors can form PtCS. With the growth of assess, treat, and refer pathways in paramedicine,55 specific and regionally appropriate options could be beneficial for survivors of IPV. Ongoing development of the community paramedic role could also be utilized to serve survivors of IPV.56 Of course, community paramedic safety must be prioritized when working in this setting. There is a literature gap in non-conveyance PtCS in paramedicine, but frontline organizations (ex., women’s shelters) could support pathway development and successful implementation.
In situations of conveyance, additional considerations and accommodations should be assessed. Given the safety and lethality risks, conveying children with the survivor may be appropriate. The adaptable and versatile nature of paramedics and paramedicine should be deployed to achieve principles of care in a manner that is appropriate for each individual situation. In the absence of paramedic-specific all-encompassing guidance, the IPV recognize, respond, refer, and record principles for paramedicine,31 adapted to local context, in conjunction with the general principles of care in situations of IPV,28,57,58 could be used as the best available direction for paramedics to continue care during conveyance. IPV-CBI,29,59,60 and NFS30,61 should be factored into assessment, treatment, and care planning for patients who have experienced IPV.
It should be noted that it would be unreasonable to expect paramedics to develop a comprehensive longitudinal plan for survivors experiencing IPV in the relatively brief duration each patient is with paramedics. The primary role of the paramedic in these situations is recognizing and addressing physiological emergencies or conditions, and then recognizing, educating, and referring survivors to the appropriate experts. Gold standards of care may expand on these primary roles by conducting a more in-depth analysis of the patient, including the IPV situation, and holistic health and wellness needs. If achievable, beginning care and care planning during conveyance should be trauma-informed and consider social determinants of health.56,62,63 Using evidence-based practice (i.e., the combination of the best available science, clinical experience, and individual patient factors)64 could be a strong approach to navigate IPV from a paramedical perspective.
There is a distinct lack of clarity around the legal obligations for paramedics involved IPV service calls.31,65–67 Clear separation between what is to be reported for health purposes and what is to be reported for legal purposes, if any, may aid in clarifying this barrier for paramedics. It is likely overlap would exist, but two separate reporting processes may improve transparency, and function. Further, there is a lack of clarity about what can and should be relayed to staff at receiving facilities. Clear guidance for paramedics about transitions in care and service during conveyance should be outlined.68 Without appropriate transitions in care and service, the PtCS may encounter hinderance upon facility arrival. A consistent and linear process should be clearly distinguished for the patient experience, beginning with paramedics.
6. Recommendations for Documentation
The ambulance care record (ACR) is a pinnacle of patient care in paramedicine. ACRs are produced by paramedics to generate an accurate record of each interaction. The vast majority of ACRs are produced electronically, as paper ACRs increasingly become an outdated practice.69 A variety of time stamps, selectable fields, and free text fields compose electronic ACRs. Typically, a single narrative free text section is used to describe the event (ex., similar to doctors’ notes) with selectable field documentation (ex., vital signs, assessments) supplementing the text. ACRs are commonly used as a proxy to assess clinical care provided by paramedics.70,71 Documenting in the out-of-hospital environment has inherent challenges,72 but functional and appropriate ACRs are vital to patient care, specifically during transitions in care and service.
ACRs, in their current design, are inhibiting the care of survivors of IPV. Currently, there are no standards outlining the required documentation for IPV. Thus, an absent prevailing standard indicates paramedics cannot be at fault for insufficient documentation. Further, ACR programs are not structured for functional and trackable documentation of IPV, creating yet another barrier. Infrastructure and paramedic adjustments are needed to improve the accuracy and measurability of documentation.
The occurrence of IPV must be documented. This could be most effective in a selectable field (searchable and trackable, unlike a narrative text box). Either IPV screening or universal IPV education selectable fields could be beneficial as incorporated ACR fields. Optimal uptake may result from implementing such fields as mandatory for each patient. Documentation should be clear and objective. IPV documentation may encapsulate a truer sample with an option for suspected IPV. A suspected field may be useful in instances of non-disclosure. Paramedic documentation should not declare a situation, but rather report paramedic findings, highlight the need to address this concern, and advance the case to experts in a clearly defined process.
Selectable fields can be used to create patient registries.73 ACRs can also be linked to MPDS dispatches for non-traditional uses.74 This may be appropriate for situations of IPV where a registry could link to EMCT and EMD systems to mitigate safety concerns. The same registry could cross-tabulate with other agencies to be more robust for all service providers (ex., police, home care). Beyond documenting IPV, information about weapons or other threats at an address may be valuable to address safety concerns. Outside of an operational aspect, being able to analyze ACRs for situations involving IPV can be further utilized to assess from a quality improvement perspective. Currently, there is a challenge in conducting quality improvement work largely due to documentation hinderances. During non-conveyance for example, an IPV selectable field could initiate a process of community health (i.e., community PtCS for IPV). This occurs commonly for community referrals for other processes such as homecare or palliative care.75,76 During conveyance, the ACR could link to hospital charting and all subsequent patient charting. Having selectable fields trigger pathways within the hospital (ex., crisis worker consultation, social worker consultation, forensic nurse consultation, legal consultation, etc.) could accommodate PtCS without increasing the administrative burden of healthcare staff.
To accommodate proper documentation, education, training, and infrastructure to support paramedicine must be in place. As the nature of calls involving IPV can be quite traumatic, time to debrief and consideration from critical incident stress management teams could be beneficial. A common complaint among paramedics is the lack of follow-up or feedback regarding patients they have treated. Not closing these loops leaves paramedics vulnerable to a lack of feedback and limited growth. Organizations may want to consider a closed-loop feedback integration that informs paramedics, within the limits of confidentiality, that their efforts contributed to their patients care.
7. The Big 3: Education, Training, and Infrastructure
In general, the intersection of paramedicine and IPV could benefit from robust advancements in three key areas:
- Education
- Training
- Infrastructure
Historic quality improvement efforts have focused on education and training.77 However, targeting only education and training is likely to limit the behaviour change capacity of interventions to produce sustained success.78–82 Robust implementation and application of behaviour change theories, models, and frameworks should be implemented to achieve the desired practice when applied to education, training, and infrastructure.
Education, relevant learning about a topic, on IPV is needed within Canadian paramedicine. Nationally mandated education encompassing IPV, IPV-CBI, and NFS could lead to improvements in paramedic knowledge. Understanding the relationship between IPV and risk factors (ex., gender, age, polyvictimization),10,83,84 social determinants of health,56,63 and lethality54 could bolster the basic comprehension of paramedics to better equip them to encounter patients experiencing IPV. Education may be best delivered in a format that promotes learning and knowledge retention. Content should be evidence-based and developed in consultation with survivors of IPV, experts in IPV, frontline IPV workers, and paramedics. Education may be most beneficial when delivered in conjunction with training.
Training, teaching behaviour to integrate into clinical practice, on how to manage cases involving IPV is needed within Canadian paramedicine. Nationally mandated training encompassing recognition (situational awareness), response, and reporting may benefit survivors of IPV as they attempt to access healthcare and support.31 Specific training around screening,85 universal education,51,52 referral processes,31 transitions in care,68 and documentation31 could bolster paramedic proficiency which has the potential to translate to improvements in clinical practice. Considering the ongoing challenges of the paramedic role,41 appropriate debriefing, coping, and processes to access supports for paramedics may also be a useful component of training. Paramedic training, both during formal programming and in-service training, has a history plagued with poor learning and training delivery. Efforts to educate and train paramedics should consider all components of program delivery including method (ex., online versus in-person), content development (ex., who is developing content, how is it being developed), instructors (ex., experts versus staff on accommodations), and frequency (ex., yearly). Effective education and training are likely to support improved practices surrounding situations involving IPV.
Infrastructure to support best practices for IPV survivors is needed within Canadian paramedicine. Education and training must always be supported by infrastructure. Policy, surrounding areas like data sharing (ex., inter-agency address flagging systems, violence reports), and registry creation (ex., suspected IPV cases in an area), would enable the implementation of procedures for paramedics and other responders to serve survivors of IPV. Functional procedures and guidelines for paramedics could be developed in alignment with policy and realistic expectations during clinical practice. Technological advancements, like ACR developments (ex., fields for IPV, IPV screening tools, lethality assessments), active linkage (ex., ACR connecting to hospital charting and processes or community PtCS), and feedback loops (ex., closed-loop email feedback to paramedics), are likely to also facilitate improved practices, thus facilitating improved care and ideally improved outcomes. Infrastructure to support practice must be constantly and critically revised to enable paramedics to execute desired care. Expectations for paramedics remain high and must be accompanied by the infrastructure to support the desired practice.
8. Conclusion
The facts are clear even if the research is lagging. IPV is a pandemic causing substantial and devastating harm to human health and well-being. Paramedicine is a field housed within healthcare and emergency services that is uniquely positioned to support survivors of IPV by providing access to care, and engaging in harm reduction and prevention. Paramedicine in Canada is failing survivors of IPV. There is a path forward, and although it is not completely elucidated, there can be no more hesitance. People are being assaulted and murdered, and paramedics may have the unique opportunity to intervene and disrupt the cycle of violence. Living without violence is a human right.86 Living without the health consequences of violence is a benefit of having that right ferociously protected. Paramedics have two choices moving forward; whereby inaction will result in further harm and death, action will likely result in improved health and outcomes for survivors of violence. The choice is clear, and the time for action is now.
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