Role of AED in managing sexual violence cases

1. Role of AED in managing sexual violence cases Dr Paulin Ng FRCSEd, FHKAM (Emergency Medicine) Senior Medical Officer Tuen Mun Hospital

2. Sexual Violence (性暴力) • Indecent Assault (IA) • Sexual Assault (SA)

3. Sexual assault (rape) A man commits rape if he has unlawful sexual intercourse with a woman who at the time of the intercourse does not consent to it; and at that time he knows that she does not consent to the intercourse or he is reckless as to whether she consents to it. # penetration of labia

4. SV cases in TMH (NTWC) Information Source: AEIS

5. Sexual intercourse (rape) cases: 13 (32.5%) in 2005 SA cases in TMH 2005

6. Roles of AED • Treatment of acute injuries • Prevention of pregnancy • +/- Prophylactic Treatment of STD • Psychological rehabilitation • Forensic examination and collection of evidence

7. Management of Sexual Assault case in AED • Principles • Confidentiality • Minimize interview by different professionals • Avoid unnecessary traumatizing procedures • Ensure privacy and comfort • Clear explanation to the patient to minimize stress

8. Resuscitation and stabilisation • ABC • Treatment of acute injuries, e.g. Head injury

9. Patient Flow (1) • Registration

10. Patient Flow (2) • Triage • Category 1-5 • Designated nursing staff of same sex assigned to take care of the patient

11. Role of the designated nursing staff (Nurse coordinator) • Keep the patient company • Explanation of the anticipating procedures and workflow • Liaison work • Psychological support

12. Scenario 1 • Patient approaches AED on her own • Social Worker (case manager) is not present

13. Introduce the available social services • Designated workers of SWD and the Crisis Centre as case manager • Obtain consent and call the 24-hour designated referral line

14. Introduce the available social services • In the meantime, the Nursing Coordinator may enlist assistance of the medical social worker

15. If patient refuses, • The Nursing Coordinator should give reassurance to the victim and address the victim’s concern • Introduce other NGOs e.g. RainLily

16. Scenario 2 • Case manager accompanies the victim to AED • A call to the NO ic of the A&E Dept beforehand may help

17. Role of the designated nursing staff (Nurse coordinator) • Keep the patient company • Explanation of the anticipating procedures and workflow • Liaison work • Psychological support

18. After triage • The wait will depends on how busy the dept is at the time • A quiet place will be arranged by the nurse coordinator while waiting

19. Patient Flow • Evaluation in cubicle with nurse coordinator as chaperone

20. Medical Consultation • Build up rapport • Usually by a female doctor if available • Obtain consent • History taking • Physical examination • +/- collection of evidence

21. History taking • Be tactful and non-judgmental • Detailed history concerning the gynae history and the event will be taken • Prepare the patient psychologically

22. History taking • Gynae history • The event

23. Gynaecology history • Marital status • Last menstrual period • Any contraception • Date of last intercourse • Delivery history

24. The event • Time, location • Type of sexual violence • Details of the event • Number of assailants • Restraint used • Acts committed • Penetration/Ejaculation/?Condom • Loss of Consciousness

25. Other relevant history • Drug history • substance of abuse, alcohol • Drug allergy and current medications • Past medical history • esp. recent surgery/injury around anogenital region

26. Physical examination • General examination • General appearance • Clothes • External injuries • e.g. face, lips, medial thigh, perineum • lacerations • bruises (color) • pattern of abrasions

27. Physical examination • Pelvic examination • External genitalia, perineum • Vaginal examination, collection of specimens (preferably left to Forensic pathologist)

28. For patients suffering from rape • Unstable patients • Admission after initial stabilisation • Examples: significant head injury; vaginal bleeding • Stable patients • Baseline investigations • Offer emergency contraception • Medical follow up services

29. Baseline investigations • Urine for pregnancy test • Blood for • urgent HbsAg/HbsAb • hepatitis C • VDRL or Syphilis(RPR) • HIV (consent) • STD screening after forensic examination (not indicated in most cases)

30. Emergency contraception • Risk of pregnancy • Around 8% for unprotected intercourse • Check urine for pregnancy test • Earlier the better • Up to 5 days: LNG 1.5mg PO stat • >5 days: FU for pregnancy test • Refer SV/gynae clinic for FU

31. PEP for Hep B • Transmission risk (0.318-3.18%) • Check blood for HBsAg/ AntiHB Ab • FU AED 2 days later

32. PEP for HIV • Transmission risk (0.1-3%) • Current QEH special medical service recommendation: not for PEP

33. PEP for STD • Overall risk: 5-10% • Immediate PEP is offered if perpetrator is known to be infective or the victim has S/S of infection • Refer SV/gynae clinic for FU 2 weeks later

34. Medical follow up services • Hepatitis B • AED follow up service within 48 hr • Pregnancy, STD, AIDS • Sexual violence clinic follow up in ~2 weeks’ time

35. Medical follow up services • Sexual violence clinics • 4 designated sexual violence clinics in different clusters • A referral letter is provided with consent • The patient or case manager, as patient advocate, could make an appointment in any one clinic subjected to her wish

36. Psychosocial support • Case manager • Medical Social Worker • RainLily hotline • Other NGO

37. Report to police • Advise patient to report to police • Police will decide on whether or not to refer to forensic pathologist for evidence collection

38. Thank you Question time later