The Sexual Assault Exam
Why is it even done in the ER? I don't get it.
OK, you've been sexually assaulted. I'm sorry to hear that (really). I'll be happy to examine you and make sure you are OK. I'll give you pain medicine for your bruises and sedatives to calm your nerves. I'll suture your lacerations, if any. I'll give you prophylactic antibiotics to lessen your risk of contracting a sexually transmitted disease. I'll give you prophylactic hormones so that you are less likely to become impregnated by your attacker. I'll comfort you with kind, soft-spoken words of sympathy as best I can. I'll give you the telephone numbers of Gynecologists and counselors to follow up with after your emergency room visit. If subpoenaed, I'll even go to court to testify that what I have written in your medical record regarding your history and physical examination is true to the best of my knowledge.
But it's not reasonable to expect me to collect physical evidence from every orifice and crevice of your body or to wade through a lengthy protocol-driven forensic checklist. Or to fill out the seemingly endless pages of forms and anatomical diagrams found in such a "rape kit."
In my opinion, it is my job to stabilize and treat your emergency medical condition. Collection of evidence and detailed completion of medically-unnecessary forms (while sicker patients wait unseen) in order to support an often doubtful and frequently unpursued court case is something altogether different.
I think such examinations are best performed in specialized facilities....not the typical ER. If your ER doesn't have a SANE program, and I suggest that most (if not all) of them shouldn't, then why not refer otherwise uninjured patients to another facility that does offer such a program?
Tell me why I'm wrong.
OK, you've been sexually assaulted. I'm sorry to hear that (really). I'll be happy to examine you and make sure you are OK. I'll give you pain medicine for your bruises and sedatives to calm your nerves. I'll suture your lacerations, if any. I'll give you prophylactic antibiotics to lessen your risk of contracting a sexually transmitted disease. I'll give you prophylactic hormones so that you are less likely to become impregnated by your attacker. I'll comfort you with kind, soft-spoken words of sympathy as best I can. I'll give you the telephone numbers of Gynecologists and counselors to follow up with after your emergency room visit. If subpoenaed, I'll even go to court to testify that what I have written in your medical record regarding your history and physical examination is true to the best of my knowledge.
But it's not reasonable to expect me to collect physical evidence from every orifice and crevice of your body or to wade through a lengthy protocol-driven forensic checklist. Or to fill out the seemingly endless pages of forms and anatomical diagrams found in such a "rape kit."
In my opinion, it is my job to stabilize and treat your emergency medical condition. Collection of evidence and detailed completion of medically-unnecessary forms (while sicker patients wait unseen) in order to support an often doubtful and frequently unpursued court case is something altogether different.
I think such examinations are best performed in specialized facilities....not the typical ER. If your ER doesn't have a SANE program, and I suggest that most (if not all) of them shouldn't, then why not refer otherwise uninjured patients to another facility that does offer such a program?
Tell me why I'm wrong.
Labels: ER, rants, rape kit, sexual assault
posted by scalpel at 8:12 AM
33 Comments:
Because they have already been traumatized. If it were you, would you want to be trucked around town to be examined by several people after you have already been the victim of a violent sexual crime because the ER doc doesn't think he/she is responsible for evidence collection?
Being someone who can handle a lot and has been through a lot; were it me, I surely would have mental breakdown because I would feel as if no one was helping me.
essentially i agree with you. i do see c's point, but if the system doesn't work, why is it the er doc's fault?
the way i see it is you get the sleepers and the non sleepers. like surgeons er docs are non sleepers. forensic docs are sleepers. sleepers generally want to leave this sort of thing to the non sleepers. the question is actually about the gynaes who as far as i can tell are also non sleepers.
Actually, you are right. How would you propose doing it though ? Having a clinic that specialized only in treating rape cases ?
Or simply a full time nurse and police officer at the hospital whose job was that primarily when a case (person) came in ?
It is a specialized thing. Emotional as well as physical trauma. The ER isn't necesarily the place for both...
p.s. I was date-raped when I was 18 and the guy said he would kill me if I told anyone, and I was young and naiive enough to be intimidated and just bleed at home...
This is a wonderful example of such a facility:
Click
Our ED has RNs and PAs who have been trained as SANE examiners; if no examiner is scheduled that night/day, one is called to come in. The victim goes into one of our GYN rooms (very private, but the victim is never left alone), and all of the evidence is collected there. Social services, etc etc come to see the victim there. Admittedly, it does tie up one of our four GYN rooms for hours, but it seems to be a viable way to address this problem
Scalpel, not every city has one of those clinics. Then what?
I agree that rape cases should be handled by those who are specially trained to perform the rape kit with gentle kindness. I've seen a number of rape cases that were treated by ED docs whose compassion deserted them with the flood of patients. In those cases, those poor women were violated all over again.
Non-Medical Professional point of view:
As a lay person, and a female, I thing GuitargirlRN's arrangement sounds very reasonable. I completely understand the ER point of view of "treat 'em and street 'em," however the ER and staff are there to help in a time of medical crisis (ideally). Rape is a medical crisis and I am sorry that some ER docs are not pleased with collecting evidence, but if you don't and no one else is available to do so, who will?
Another point is that of occupying a room. Why is a rape exam any less important than, let's say a yeast infection? Obviously, it isn't and rape is also often time not life threatening (physically), however that is not a reason to think of a rape victim as less than ER worthy.
Again, not a medical professional, just a lady that knows what it feels like to be ignored in a time of medical crisis and have to scream at the top of my lungs to receive reasonable, adequate and necessary treatment.
I'm not saying these patients aren't worthy, or that evidence collection isn't a noble or valuable thing to do. But I can guarantee you that the quality, type, and detail of evidence collection that can be done in a busy emergency department (even one with SANE nurses) isn't even in the same galaxy as the type of examination that can be performed in a facility such as the one I linked.
Performing those exams in the ER is inappropriate for us and suboptimal for the patient. I'm not trained in evidence collection or legally-appropriate interview techniques, nor do I want to be.
I'd rather leave that to the experts.
Scalpel, I completely agree with that assessment.
Something I meant to mention earlier (legally speaking)in your defense. By having an untrained person (ER doc, nurse, etc.) collect the evidence, any potential, future prosecution will be jeopardized. Any half-assed defense attorney would argue evidence contamination, tampering, etc., and therefore cause either reasonable doubt in the minds of a jury, or worse, the exclusion of evidence. Then it just becomes a he said, she said game. Which, generally, is a loss for the prosecution.
So from the legal point of view, your feels are correct.
However, I still don't feel it is right or in the best interest (non-legally speaking) to have the patient be required to go to yet another facility.
The issue of rape victims and evidence collection, I am sure is a frequently debated topic in Medical Land. In an ideal world, with adequate resources, every ER medical facility would have trained sexual abuse/rape staff. Until that time, I am not sure what the right answer is.
One of the hosptitals in our county has a forensic nurse 24/7, and we encourage any victims of rape to go there (although we certainly don't turn them away if they want to stay). Usually the patient is escorted to the facility in the company of police officers, so they are not responsible for finding their own way there. The PD is usually great about sending at least one female officer for this, so that the patient is not accompanied by 2 men. Every few months or so the forensic nurse comes to talk to us about what to do until they go to the other facility (i.e. NO clean catch urine specimens...no showering or cleaning, etc). I've never had to collect evidence for rape, and it would certainly scare the crap out of me as I am not trained to do this. I'm so thankful that we have a facility like this in our county.
Meghan
ER Nurse
The optimal arrangement is to have the police agencies take them to the police with a SART program and not to any old ER. That way they can have their exam done by someone skilled in evidence collection so that the evidence will hold up in court. In a private quiet environment, not a noisy, chaotic environment where there is no privacy. With a female nurse specially trained in the care of the rape victim, not having a vag exam by a male physician. Not that a male physician isn't perfectly skilled but a traumatized woman usually prefers to be in the care of other women. If it were me I would find it much less traumatic to be taken to such a place then to undergo a rape exam in the ER.
You're not wrong at all.
Just as everyone should have a family physician (who should be able to make a living wage), every diabetic should be compliant with diet and exercise to keep their A1Cs under 7%, and everyone should stop smoking, exercise regularly and get enough sleep.
I like your world, Scalpel. Too bad I have to live in the real one.
The way it works for us is SANE nurses are their own thing, its own separate agency. They're not paid by the hospital as hospital employees in other words. SANE nurses carry a beeper and cover a very large area of ERs. There's always one on-call, and one arrives within 45 minutes-hour if beeped. Oftentimes they arrive soon after the patient is registered.
If there is a call for a rape, the on-call nurse comes in (sometimes driving an hour each way to get there, depending on what hospital) and does everything, including giving the STD meds and Plan B or whatever. There are also "houses" in other counties that do the rape exams, rather than ERs. Some of our nurses are trained in SANE, and do that for extra money.
If you're being asked to do the rape exams, that's bunk and you should say Nurse K said so. Whoever is in charge of your ER stuff should try to contract with one of these mobile SANE agencies. You can't turn a rape patient away, so there needs to be someone available to do the exam and you need to be available to treat everyone else.
I see it as a law enforcement responsibility, not mine. We used to have SANEs, but they all stopped doing these exams because it wasn't financially worth their while, and it sucked getting called in the middle of the night to come deal with someone who was probably not raped on their way home from the symphony, let's just say. When an unpleasant task isn't required or properly compensated, it tends to dwindle in popularity until it eventually isn't done at all except in extreme circumstances.
So now such patients are often told that we can evaluate and treat them for any medical injuries, but if they want to have evidence collected in order to support a legal case then they would be better off going to the county hospital.
Your treatment can potentially contaminate the evidence collection process, so it makes no sense for them to be sent somewhere else.
As a citizen, and with regard to the case a witness, you are part of the law enforcement process in this country. Your participation is essential.
i don't know why you are wrong and i would add that the ER is for medical and surgical emergencies and that, as horrible as it is, a sexual assault is rarely either one of these. therefore, as you are engaged in the thirty minute evidence collection kit and chain of custody issues you are not available for codes or MIs. that being said, i can't even get a surgeon to examine a hot belly without a CT scan so i'm not hopeful that your idea can be widely employed. who's going to fund it?
i have a more controversial comment/question to make and here it is. scalpel, what percentage of sexual assault patients convince you by their story that they were actually assualted?
my experience that about 2 in 10 tell me a story that makes me want to go find the asshole and shoot him in the head. the other 8 tell this story...
"well, i was out with friends and got really drunk and woke up with no panties on and i think i might have been raped..." i certainly don't know what to do with these patients especially when the exam is entirely normal.
Bullseye, 911 doc. Or else it's a Kate Faber story.
Another question is why is this condition treated differently than any other assault? We don't have a "hit over the head with a beer bottle" kit or a "shanked in the belly" kit to take hair and fingernail scrapings. I don't collect evidence on gunshot wound patients, either. Once when I actually pulled out a bullet to give to a homicide detective, he wasn't too happy with me.
We treat their injuries and then let the cops talk to them. If the patient wants to pursue charges, and the officers want to collect evidence, great.
Because of the difficulty in proving it, and the necessity of someone qualified to gather evidence such as semen.
Vaginal swabs are no big deal....we're already down there anyway. Ditto for the digital rectal exam +/- swab, if indicated.
The rest of the evidence collection and legal documentation should be left to the police, like with any other crime.
In residency and now, we have on-call SANE nurses who take care of the whole thing. I don't have any contact with the patient unless the SANE nurse feels there is a medical issue other than the sexual assult that demands attention, i.e. a blow to the head with LOC or whatever.
In residency, at the tertiary care center, we accepted transfers all the time from the community for such an exam.
Your post is an eye-opener to me for how nice of a setup I currently have. I think rummaging through that kit and going through the exam while hearing the department fall apart around me would make me lose my mind.
Scalpel, this isn't your job anymore than managing a vent, drawing blood, or giving meds. Yes of course you're able and qualified to do it but there are folks who train to learn these specialized tasks to free you up to handle the things that no one else can.
You have got to get your SANE nurses back or establish a relationship with an ER who has them.
Typically the evidentary exam is funded by the law enforcement agency ordering the exam which makes me curious why you no longer have a SANE or SART program. I am also suprised that the DA for your county tolerates such a non-system of evidence collection, especially if they are aware of your attitude towards sexual assault victims. Having the ED MD or Resident do evidence collection along with juggling all their other patients is no system. In my County the University Hospital does the exams and has dedicated midlevels that are pulled off thier Fast Track duties to perform the exams and all required treatment. If the victim shows up at another hospital they get a basic medical screening exam that does not involve any type of gyn exam and are transported by Police to the University Medical Center for the evidentary exam. Other surrounding counties have law enforcement based on-call SART examiners to respond directly to the facility.
Nurses have lives too. I asked a couple of them who used to do the SANE exams why they don't anymore, and they said the money they were paid for doing it wasn't worth being on call or getting out of bed in the middle of the night to drive to the hospital.
It is actually the responsibility of your county to fund this. Our SART program got dumped because the hospital couldn't afford call but they threatened to take the county to court so they caved and ponied up the money necessary to fund the program including the on call wages, a flat fee for each exam for the SART nurse. Continuing education for the experienced staff and training new SART nurses as well as purchase and maintenance of the equipment. You may want to suggest this to your hospital admit and most victims advocacy groups will assist your hospital in those efforts
I wish ER docs did do these exams. I have rarely been treated with compassion and kindness from RNs, many of whom appear to believe that their profession has a monopoly on these traits. Give the responsibility to female doctors - I have found these to be the most caring and compassionate (and less arrogant than NPs) in the healthcare world!
I know this was posted a while ago, I just happened to read it now. Second what c. wrote, the first comment. You've heard of PTSD, and of retraumatization? You should know what it implies, especially concerning the "do no harm" principle. Finding the most competent and experienced doc in the system is not necessarily what the victim needs, most likely quite the contrary. And btw, female docs aren't necessarily any better than male.
If a patient wants to see a doc for this care, then they should be able to see a doc. It's like when I go to a primary care clinic and get thrown off on a nurse practitioner just cause I'm young and healthy. If I want to see a doctor, I should be able to see a doctor. I don't care what any study says about quality of care, I want to see who I feel comfortable seeing. When I went to the local ER, it was see a SANE or nothing at all. I chose to go somewhere else.
I understand that nurses have lives and that the pay sucks when working for SANE.
I get that the ER is busy and that the docs have higher priority cases.
But often it is hard enough for us to get a victim of rape to seek medical treatment let alone press charges. How many times have I banged my head being called to a case the day AFTER the rape and ofcourse the victim has showered about 20 times and cleaned their clothes? Ugh way too many.
I worked on average 75-80 hour weeks (I know I know that is nothing for you docs...I know this and appreciate all that ya do...(really)...) for about 19K a year as a crisis counselor and rape advocate. I would get paged at all hours of the night by the cops go to the scene or the cop shop and if the victim was seeking medical treatment or pressing charges then yeah to the ER.
In the city I worked in the rape exam was done by a doc but the paperwork etc was done by someone else. Most times I was in the room unless the victim did not want me there.
Some doctors complained about the 30 minutes and some didn't. But like I said they didn't do the paper work so yeah I agree with that part of things no ER doctor should have to spend hours on the paper work, or interviewing the victim etc...
When a person has been raped they so don't want to be there in the ER facing a rape kit. I can't imagine them having to go to several places in order to complete the process.
The city I now live in has about 8 hospitals 2 of which have programs and staff to handle the rape and sexual assault cases. If the victim has no major physical trauma requiring the closest ER then the cops take them to one of those two hospitals.
I've been on cases where the victim was near death and on cases where it comes down to "he said/she said" and later the woman taking back the accusation of rape.
But most cases are not so black and white most fall in that gray area.
In an ideal world ER docs and nurses would not have to deal with the rape exams. I agree.
But in an ideal world rapes wouldn't happen either.
I am a SANE Nurse. I am specially trained in medico-forensic examination. I work on-call and enter 11 different ERs to provide this valuable service for patients. Most ER staff do not have the time or the training to do this. If the crime scene is contaminated or a key piece of eveidence is overlooked or mishandled there is no chance of conviction. Also I provide post sexual assault treatment of STIs and pregnancy as well as referrals for follow up care.
This is an old post true, but I wanted to comment... I was raped in 2005... I went to the hospital where the person doing the "kit" was the on call OB who said he needed to "hurry this up because he was waiting to deliver a baby". Then came in two male cops where one pulls out a notebook and proceeds by saying "So... you're claiming you were raped huh... Why don't you tell me why you THINK it's a rape..." Lovely mother fuckers... NOT. I'm ALL for what you're proposing...
I am sorry about what happened to you. I'm a SANE RN and I still see officers ask questions of the victim in the way that you are describing. I think areas with SVUs have more sensitivity training. It is hard for cops to take off that "hat". They often approach a victim as if they are the criminal because they don't really trust anyone untill you provide evidence.
Pardon my putting in my two-cents' worth here, but first let me say that I have never in my life read anything as insensitive and self-centered as your little rant, Dear Dr, Scalpel. While I appreciate the challenges faced by an ER doctor, that in no way entitles you to show your little white-clad posterior over the time it takes to perform an essential integrated health care exam. No, you are not a forensic examiner, nor a law enforcement professional, nor apparently even a very nice person; however, if it is what the patient needs, IT IS YOUR RESPONSIBILITY TO PROVIDE IT OR AT THE VERY LEAST, SEE THAT SOMEONE ELSE MORE QUALIFIED (NOT TO MENTION COMPASSIONATE) DOES IT! When rape occurs, dear Dr. I'm-so-overworked, it occurs not just physically, but psychologically and emotionally as well. For this reason alone, it is necessary to be as sensitive as possible to the victim's needs. If this means committing a doctor to a 30-minute or more time period with one patient, then that's what should be done. If your hospital is reluctant to do so, then why don't YOU, yes You, instead of having a little snit, speak to those in charge about putting a more efficient system in place? You might even offer to help design such a system as an advisor with actual ER experience in the situation. Um, what's the phrase I'm looking for - ah, yes: Be part of the solution, not the problem!
Respectfully submitted for your edification,
Lisa D. Wallace
Concerned Citizen
Wow. I would never want to encounter you in the ER if I were ever injured. I am appalled at your attitude regarding what is and what is not expected of you. So sorry if you feel it is beneath you to collect "specimens from every orifice".
It is apparent that you didn't go into medicine with the intent of truly caring for people.
How very sad.
I am a SANE and a ER nurse. I agree that they should not be done in the ER. In the area that I live, if someone does not have injuries than we send to the center for support. Sane are on call 24 hours, and we spend 4 hours collecting the evidence for the victim and the police department.
There is no reason that the exam needs to be done in the ER. sexual assault victims are on a lower acuity level. So why not take them to a place where we have all of the support services, access to the judges for protection orders, medication administration, and safe place to stay. In the ER, it is loud, longer wait, have to tell the story to the triage nurse, doctor, police. In the assault center, interview is done by the nurse, who turns it over to the police. their story only has to be told once.
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