SANE and S.A.F.E. Program at NMCP Portsmouth

1. SANE and S.A.F.E. Program at NMCP Portsmouth

2. DISCLAIMER THIS PRESENTATION CONTAINS GRAPHIC IMAGES AND INFORMATION THAT MAY BE DISTURBING OR TRIGGERING FOR SOME.

3. Objectives • Distinguish between SANE and SAFE • Trace the forensic, medical, and psychosocial aspects of a sexual assault exam • Case presentation: USS Vella Gulf

4. Things to consider • One in nine women will be the victim of an actual or attempted sexual assault in her lifetime • In the military community, this statistic is ONE IN FOUR • Between 2004 and 2006 reported assaults in the military rose 70%

5. SANE SANE-A SAFE

6. WHAT IS DOES IT ALL MEAN???

7. WHAT IS THE DIFFERENCE BETWEEN “EDUCATED” AND “TRAINED”? • EDUCATED: • Took a class, watched a DVD • Read the instructions in the box • Someone “told” you how do the exam • TRAINED: • Worked under the clinical supervision of an expert SANE-A certified RN to perform the mechanics of the exam

8. What is the benefit to have a SAFE/SANE program? • Specially trained examiners make a profound impact on in the quality of care provided to sexual assault patients. • The ability to offer prompt, compassionate, and comprehensive forensic evidence collection. • Preservation of the patient’s dignity and reduction of the psychological trauma. • Enhanced evidence collection translates to more effective investigations and better judicial outcomes.

9. Joint Commission • Has recognized that personnel in hospitals and other healthcare facilities are often the first individuals to interact with victims of violence or abuse. • In 2004, guidelines were established that set the stage for all hospitals to develop plans to manage these patients, including a clear plan for managing victims of sexual assault.

10. The Exam • History • Lab collection • Medical • Forensic • Assault history • Physical inspection • Evidence collection • ALS inspection • Toludine Blue Dye • Photography • Discharge instructions • Referral/follow up Comprehensive exam: 4-6 hrs typical Can be 12-13 hrs, depending on the constellation of injuries

11. History • Any recent anal-genital injuries, surgeries, diagnostic procedures or medical treatment that may affect the interpretation of current physical findings? • Any sexual event (consensual or not) in the preceding five days • Any pre-existing injuries, not assault related? • Post assault activities: hygiene, consuming food or drink, clothing changes • Think like a defense attorney, and document like a RN.

12. Assault History • The account of the assault given by the victim will guide the exam to some extent • Chronological + 5 senses • See, hear, feel, smell, taste? • Methods employed by assailant • Force or coercion • Sexual acts: specifics • What went where? • Drug Facilitated Sexual Assault (DFSA) Considerations: • Ingestion of alcohol or drugs • Voluntary or involuntary? • Lapse of memory or Loss of consciousness? • THERE IS A DIFFERENCE!!!

13. Excited utterances • A hearsay exception • A statement made in response to a shocking event or condition • The statement must be made spontaneously by the person while still under the stress of the event or condition • A statement made under stress is likely to be trustworthy; and unlikely to be premeditated falsehoods • Document it! • THIS IS PART OF WHAT ALLOWS YOU TO TESTIFY IN COURT AS TO WHAT WAS SAID IN THE EXAM ROOM, in addition to statements made by the patient for the purpose of medical treatment • Statements made for the purpose of the business record.

14. Drug Facilitated Sexual Assault • Definition of DFSA: Use of a chemical agent to procure or facilitate sexual contact • The Drug Induced Rape Crime and Prevention Act of 1996 addresses DFSA • 20 years in prison for distributing a controlled substance with the intent to commit a crime of violence • If substance is given without the victims knowledge • Most common drug used: *A L C O H O L*

15. Drug Facilitated Sexual Assault • Voluntary ingestion of drug/alcohol DOES NOT equal consent to any and all sexual acts • Nor does is negate the responsibility from the assailant! • GHB, ketamine, benzodiazepines and sleeping agents also common

16. Evidence Collection in DFSA • Urine • Limited interpretation, but has longer detection times: collected within 120 hours of ingestion of agent • Blood • Pharmacological interpretation, but has shorter detection time. Collect within 72 hours of suspected ingestion. Gray tubes x2 • Hair Analysis - ?? • Much longer detection window and easy to collect • Harder to work with then body fluids, levels are low usually, and contamination is a big issue • Still questionable evidence

17. Physical inspectionand evidence collection • Go hand-in-hand • Collect clothing • Oral samples, fingernail scrapings, debris collection and hair combings • Document on note AND body diagram, and photograph visible findings • BE SYSTEMATIC !!

18. HOW FAR OUT POST ASSAULT CAN WE NOW COLLECT?? • MAJORITY OF PROGRAMS WORLDWIDE: • OFFER FULL COLLECTION BETWEEN 72 HRS AND UP TO 5 DAYS • NMCP: • WE OFFER FULL COLLECTION UP TO 6 WEEKS POST ASSAULT • ENHANCED Y-STR TESTING CAN DETECT DNA UP TO 6 WEEKS POST ASSAULT!!

19. Swab Collection • Swab any area indicated by the patient to have evidentiary value • Dried stains should be sampled with a moistened CTA • Wet stains swabbed with a dry swab • Label all swab boxes with location that they were collected from and document this on the body diagram We HATE swab dryers at NMCP. Consider the “Pixie Stix” effect!!! C R O S S – C O N T A M I N A T I O N

20. Alternate Light Source Inspection • Fluoresces semen, saliva, and body fluids, as well as clothing fibers • Include all fluoresced areas in documentation • Swab all fluoresced areas WOODS LAMP

21. Genital Examination • A good understanding of common injuries in forced and consensual sex is essential • Lack of injury DOES NOT indicate that sex was consensual • Most common injury sites: • FEMALES • Posterior forchette • Fossa navicularis • Labia minora and hymen • MALES • Anus • Coronal ridge • Scrotum

22. Evidence collection in Female Genital Examination • Vaginal pool • Endocervical • STI Cultures • Wet mount slides (if credentialed) • Anoscopic exam, if indicated and credentialed • Colposcopy can be used for magnification, if desired. Provides binocular vision with a magnification from 5-30 times and the ability to take photographs. • The same can be accomplished with camera & macro lens. STD/STI TESTING: TO DO OR NOT TO DO? “I don’t want the patient to look bad on the stand.”

23. Toludine Blue Dye • Can be used to highlight interruptions to the skin surface that are seen during examination • Dye intake is interpreted as positive for finding; it does NOT however “prove” rape. • No uptake or diffuse uptake is negative for finding BEFORE THE TB DYE AFTER THE TB DYE

24. Evidentiary Photography • Federal Rules of Evidence Rule 403 : implies that a judge will not admit photographs to the courtroom as evidence if the composition is poor, such as photographs with extraneous objects or unnecessary explicit images. Photographs that do not give an accurate representation of the evidence for other reasons will also not be allowed as evidence.

25. Evidentiary Photography • Take pictures BEFORE medical intervention or cleaning • Rule of fives • Far • Mid • Close • Color • Size

26. Photography:POWERFUL TO JURIES • “This picture is a true and accurate representation of what you saw and treated, at this day and this time” • Color, proportion, and clarity of images are paramount

27. CONSTELLATION OF INJURY

28. What is exigent evidence? • Because obtaining consent is not always possible, medical workers should be able to recognize a situation that involves “exigent evidence”. • This describes a situation that can be used to justify taking pictures without obtaining consent when valuable information and evidence must be obtained immediately, or run the risk of being lost. • “Exigent evidence” is often used in child abuse cases, or when a patient must urgently go to the operating room. • CRITICAL/UNSTABLE? • PHOTOGRAPH WITHOUT CONSENT

29. Discharge Medications • Most commonly acquired STDs in sexual assault are Chlamydia, Gonorrhea and Trichomoniasis • Consider and weigh HIV risk • Risk is the perception of the patient • Consider Hep B status and treat appropriately • Standard STD Prophylaxis is: • Ceftriaxone OR Cipro • Azithromycin OR Doxycycline • Metroniadazole • Tetanus status

30. Pregnancy Prophylaxis • 1 pill method: • Only if pt has negative Pregnancy, and presents within 120 hrs of exposure • 2 pill method: • Take first dose as soon as possible after unprotected intercourse • Second dose 12 hours later. • The sooner it’s used the more effective it is. • Consider anti-emetics

31. Arrange Follow up Care • Patients should have an appointment to follow up with PCM or exam provider in 2 weeks. • Follow up labs • Referral to counseling services • Possible follow up exam for injuries, serial photography • Cervical injury? • Penile penetration: UNCOMMON • Object penetration: COMMON • Follow up exam with photography within 48 hrs.

32. Rape Trauma Syndrome • Acute phase: characterized by disorganization. Immediately after the assault to several weeks. • Reorganization phase. These are attempts to return to pre-assault status. Usually starts several weeks after attack. • Expressed vs. Controlled style of coping

33. Judicial Concerns • The U.S. Justice Department estimates that only 26% of rapes are reported to law enforcement. • Only 2% of rapists are convicted or imprisoned • Hard to prosecute • Stigma of coming forward • Unacknowledged victims • DFSA • Self Blame • 78% of rape victims know their assailants

34. SAFE providers in the courtroom • SANEs and SAFEs can be called as expert witnesses • Different then “factual witnesses” • By virtue of their training, education or experience, have a particular knowledge not shared by the general public • Expert witnesses can give their opinion where lay witnesses (factual witnesses) cannot.

35. NMCP SAFE PROGRAM Examiners (MD, RN, IDC) Assistants (E6 – E3) Program launch Aug 2011 24/7 coverage Pager: 988-9546

36. 4 TIERS of SAFE CARE:

37. NMCP resources • Forensic Healthcare Coordinator • Michelle Ortiz, RN, MSN, FNE, SANE-A • 953-0089 office • Paged via ED • michelle.ortiz@med.navy.mil • www.iafn.org • www.safeta.org • www.ACFEI.org QUESTIONS???