Sue felt playful and began tickling John's feet. Enraged, John pushed her away from him, hurling her into the closet. His violent response and the traumatic landing stunned Sue.

She composed herself. “Did he really do that to me?” Sue thought. “If you ever do anything like that to me again, I'll call the police!” she roared.

In response, John snatched a handful of Sue's hair and jerked her to the floor. He rained blows to her head and face, rocketing her glasses across the room. Frenzied, John escalated his attack, flattening her with an elbow to the face.

Fighting for her life, Sue grabbed for John's testicles. Incapacitated for a moment, John's grip relaxed and Sue fled to grab her purse. John then threw a heavy work boot at her, smashing her back, and demanded she leave the house.

This true story shows that in the horrific world of domestic violence, inhabitants subsist on a mean diet of gratuitous violence, pain and numbing isolation.

Domestic violence, defined

Although the O.J. Simpson and Richard Sharpe cases created a media frenzy, many Americans lack accurate knowledge concerning the pervasiveness of domestic violence. They believe these celebrated cases are aberrations, but the facts say otherwise.

According to the Federal Bureau of Investigation, domestic violence remains the most under-reported crime in the United States, with actual incidents estimated to be 10 times higher than reports indicate. Domestic violence continues to be the leading cause of injury to women ages 15 to 44.

Domestic violence encompasses a variety of acts and includes any pattern of assaultive and coercive behaviors, including physical, sexual and psychological attacks, as well as economic coercion. The violence results in fear and physical and psychological harm to victims and their children.

Perpetrators of domestic violence seek to control victims by these tactics, and adults and adolescents of all sexual orientations have been known to use domestic violence.

There are four main types of domestic violence, some of which can occur with or without physical contact:

1. Physical assault can include spitting, scratching, biting, grabbing, shaking, pinching, pushing, restraining, throwing, slapping, punching, choking and burning. Of course, using weapons such as knives, guns and household objects also qualifies. Physical assault may or may not cause visible injuries.

2. Sexual assault includes pressured or coerced sex, the use physical force to obtain sex, or sexual assault accompanied by violence. The perpetrator denies the victim autonomy over his or her body. Victims may resist, which can bring on punishment, or they may comply, hoping the sexual abuse will end.

3. Psychological assault has many faces. Threats of violence and harm can be made with words or by indirect means, such as stalking or displaying weapons. Attacks are often made against pets or property, and children often are used as pawns.

   Emotional abuse consists of repeated verbal attacks or humiliation, with the perpetrator emphasizing the victim's vulnerabilities such as parenting skills or religious beliefs. Isolation is also a major control tactic. Perpetrators will isolate their partners from family or friends to conceal the abuse.

4. Economic coercion finds perpetrators seeking to control their partners by limiting access to money. They are likely to thwart any attempts to gain financial independence, thus maintaining an economic stranglehold on the partner.

One more service

Fire service responsiveness to improving service delivery has generated hazmat teams, technical-rescue teams, dive teams, SWAT medics and bicycle medics. Domestic violence calls are no different.

The proliferation of domestic violence prompted the American College of Emergency Physicians to issue the following policy statement:

“The American College of Emergency Physicians believes domestic violence is a serious public health problem. Consequently, EMS personnel will encounter victims of domestic violence. The interactions at the scene, the potential for harm to the health care provider, and the need for special documentation and communications differ from other out-of-hospital situations.

“ACEP believes that training in the evaluation and management of victims of domestic violence should be incorporated into the initial and continuing education of EMS personnel. This training should include the recognition of victims and their injuries, an understanding of the patterns of abuse and how this affects care, scene safety, preservation of evidence, and documentation requirements.”

During a response to a domestic violence call, on-scene incident commanders should perform four primary duties: ensure personnel safety, remove endangered occupants, mitigate the emergency and protect property.

Admittedly, that could describe almost any other call, but chiefs can tailor their EMS response in the same ways they add other non-fire services to their departments' repertoire. For example, they may want to:

• Network, attend seminars and stay abreast of new developments in the field of domestic violence;
• Access fire service Web sites and gather domestic violence information; and
• Contact departments with domestic violence policies and procedures and incorporate those principles.

One such department is in Las Vegas. Tim Szymanski, public information officer, shares his department's domestic violence response policy: “When responding to a domestic violence call, we stage until Las Vegas Metropolitan Police arrive and advise that the scene is secure.”

That's all well and good, but what if EMS arrives prior to the police? According to Szymanski, no one enters the scene if there's a concern for EMS responders' safety or the possibility of violence.

“EMS personnel in Las Vegas have received some awareness training about domestic violence, but it is handled by the police,” he says. “If we feel that a victim may become violent en route to the hospital, EMS can refuse to transport, let police transport, or have a police officer or deputy marshal accompany them to the hospital.”

First responder curriculum

On the other end of the spectrum is the Seattle-King County Department of Public Health, where Patty Ousley is the director of EMS training. The county dispatches 3,500 first responders and EMTS hailing from 34 fire departments.

Ousley's work as a registered nurse and within the juvenile detention system led her to become an advocate for people who have been victimized. At a 1999 conference she heard about New Mexico's fresh EMS approach to domestic violence calls. When she returned to Washington, Ousley designed and developed Domestic Violence: The EMS Response for King County.

“Since most of domestic violence is not directly reported to the police or the doctor, we decided to work with the firefighters, who are the first to get to the house of the victims,” Ousley says.

The curriculum arms EMS personnel with knowledge and skills for optimal effectiveness, putting participants through various scenarios. In one of these, EMS responders arrive at the home of a female patient complaining of ankle pain. Her husband meets them at the door, preventing them from completing a history and physical exam.

A common reaction is for the responders to become frustrated, but frustration creates a barrier, making accurate assessment and awareness of domestic violence more difficult. The husband's behavior here is a red flag, something EMS personnel must recognize to provide effective treatment, transport and referral for patients.

According to Ousley, about 35,000 firefighters have been trained in how to talk to victims and how to write a report of an incident that can be used in court, even when the victim does not want to complain. “Our system helps the police department build strong cases,” she says.

There are three ironclad rules in domestic violence cases: Document, document, and document. “Documentation is the velvet hammer that nails perpetrators of domestic violence,” says Ousley, so EMTS need to wield a ready and accurate pen.

To achieve that documentation, Ousley recommends EMS personnel talk to the patient in a confidential setting, away from the suspected abuser. This technique helps to overcome the isolation and psychological abuse that have fed off each other and ascribed omnipotence to the batterer.

Responders can express concern and support through statements such as:

• You are not alone.
• You don't deserve to be treated like this.
• You are not to blame.
• You are not crazy.
• What happened to you is a crime.
• Help is available to you.

Red flags

Responders must remain alert to red flags. “It's a feeling one gets in the gut or one that raises the hair on your arms,” says Ousley. Here are some possible signs of domestic violence.

• Patient seems fearful of household member or exhibits increased anxiety when member is near.
• Patient is reluctant to answer questions or provide information about how the injury occurred.
• Patient lives in an isolated, unhealthy or unsafe living environment.
• Patient offers history that is inconsistent with the injury or illness, such as claiming an infant received an orbital fracture from a fall on shag carpet.
• Patient exhibits injuries in various stages of healing, particularly to the back, neck and ribs. Responders detecting injuries in various stages of healing sustained by children must report their findings to police, physician or children's services bureau.
• Household member refuses or hesitates to permit patient's transport to hospital.
• Household member seeks to prevent patient from interacting.
• Police/EMS have responded to the same address previously or repeatedly.

Domestic violence rampages are an increasing public health crisis. Abusers terrorize families and exert malevolent influence to their progeny. Fire chiefs charged with EMS response need to equip, engage and empower their personnel to mitigate domestic violence calls. Doing such harmonizes with the fire service's long-standing mission of preserving life and property — preserving and protecting the helpless and hopeless.

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A 22-year veteran of the Akron (Ohio) Fire Department, Lt. Marc D. Greenwood, EMT-P, also has worked with American Medical Response for 16 years. He has been published in several fire service journals and EMS/health-care magazines. Greenwood can be e-mailed at mgreenwood@ci.akron.oh.us.

What to do on a call

The acronym REST provides responders with a guide to completing an assessment of a domestic violence patient.

• Recognize, by assessing the patient's surroundings and result of examination, a possible domestic violence situation.
• Evaluate and assess the situation for safety and injuries to victim.
• Support the victim with a trusting environment in which to provide treatment.
• Treatment includes medical treatment, referrals and documentation.