Understanding the SANE Exam

Transcription

1 Understanding the SANE Exam California Public Defenders Association October 2017 Cari Caruso RN SANE-A Forensic Nurse Professionals, Inc. Simi Valley, California

2 Forensic Sexual Assault Nurse Examiners We are *nurses first* We assess our patients for medical, mental, social, family, and physiological issues. We are the link between nursing and the law But we are not the law and should not see ourselves as working for anyone. We are an independent entity Among other entities.

3 The attributes of the excellent Forensic Sexual Assault Nurse Examiner Objectivity Unbiased Evaluation Knowledge of Standards of Care Accurate and Ethical Evaluation of Findings Scope and Standards of Forensic Nursing Practice Evidence Based Practice

4 The Role of Educator

5 Objectivity If the forensic examiner thinks it is her/his job to help victims and get the bad guy, she/he is in the wrong field.

6 Role of the SANE * Nurse First * ********************************** It is not my role to believe or not believe the patient history It is my role to document what the patient tells me and to photograph and accurately and objectively describe my findings

7 Acute v Non-acute Exams The possibility of Biological Evidence Acute exams: From the time of the event up to hours to 7 days + Non-acute: no biological evidence but possible injury, interview, and photography Children: programs may differ from 24 to 72 to hours to 96 hours

8 Age Levels Adult/Adolescent Programs Puberty and up 12 and over Child programs Under 12 years of age But up to 18 years

9 Points of interest The SANE (or anyone) can not determine consent v non-consent, as a rule Can t substantiate anogenital force The history given to the SANE is only one side of the story Patient health and safety, objectivity, accurate documentation

10 More points *We would not interview a suspect, regarding the event, during the suspect examination *There is no consent for underage persons *

11 Staying Objective

12 Could there have been Misinterpretation or overstatement of findings Failure to keep current; up-to-date literature Failure to recognize normal and normal variants Failure to recognize medical conditions and hygiene issues that can be confused for sexual findings Failure to use differential diagnosis: May have tunnel vision (all that is seen is related to the alleged sexual assault) Failure to consider preexisting findings (LCI) Worry that the findings won t support reporting victim (rv) history

13 Factors to consider How long after reported event was the exam? Patients do not behave as they do on TV or Lifetime movies. There is no such thing as delayed report. people report when they are ready When was LCI (last consensual sex)? Was DNA recovered? (May not be relevant) Get ALL the paperwork and photographs (prosecution may think they have it all but they may not) Is there motivation for a false report?

14 Rough Sex What is it? Subjective Can t be defined If you try The answer might be Don t go there

15 Keeping up to date: Slaughter, 1992, 1996 Masters and Johnson, Human Sexual Response, 1966 Keeping up with current literature Evidence Based Practice Best Practice Standards of Care

16 The Forensic Exam

17 The Forensic Evidentiary Exam AKA: the SANE Exam Includes: Head to toe assessment with body map Reference Samples (blood card/buccal swabs) Body Photography (with & without ruler) when appropriate Specimen collection: SETS of 2 or 4 swabs: Nail/hand swabs, bite marks, Suction marks, touch DNA, Anogenital exam, sample collection, photography Documentation Drying & packaging of evidence

18 The Forensic Evidentiary Exam AKA: the SANE Exam Includes: Evaluation and prophylactic treatment for STI and pregnancy Recommendations for follow-up STI testing Advocacy to arrange counseling

19 Anoscope Speculum

20 Wood s Lamp/ALS* Wood s Lamp Ultraviolet light Around 365 nm ( ) Fluoresces (absorbs) many substances indiscriminately ALS Alternate light source-high intensity Around 475 nm Orange goggles More discriminating *Probably my least useful tool. Fluoresces countless substances. Collection is guided by history or if unknown history, all imaginable points of contact. No fluorescence when the lab finds DNA and rarely are significant body fluid patterns observed.

21 Alternate Light Source Fluoresces many substances not specific to body fluids: semen or saliva Creams, lotions, soda, acne, make-up, fabrics, soap, debris, thread, fabric Food stains, paint, dried substances, etc. My most dispensable tool Not used except for entertainment

22 Jimi Hendrix Poster Wood s Lamp

23 ALS

24 Photography Colposcope Digital Some programs are now, all digital Should be at least 15 to 20 anogenital photos.

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27 Body Findings may have nothing to do with genital and anal findings

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32 Reality A great percentage of reported sexual assaults involve little, if any, physical bodily injury to the victim. Interpersonal violence (DV) more body injury Very few patients need to go through an emergency department Assaults are most common among people who know each other Sexual assault by a stranger is the rarest type Brief Encounter 2002 It is easy to accuse someone of sexual assault

33 Forensic Report Forms may have Built in bias

34 Bias and buzz words Exam consistent with history if not clear that findings could also be consistent with something else: consent/medical List your assault related findings Evidence of sexual assault Sexual assault by history

35 [ ] Exam consistent with history What does this mean? Is it possible that whatever is consistent with the history could equally be consistent with something other than the history? More later

36 Should they really be asking us that? It is not our role be believe or not to believe the story. Our role is to be a nurse first Assess the patient Document the patient s medical and forensic history Collect samples Provide prophylaxis, resources, and referrals

37 Did you eat the chocolate? Me?

38 What if there are no findings? Expectations: Age, history, activity, perception, normal variants, hygiene, medical findings, time between event and exam, Acute v non-acute Prepubertal v pubertal

39 A N A T O M Y

40 Primary areas of genital injury Posterior Fourchette Fossa Navicularis Hymen Labia Minora Anus Common injuries: Tears, abrasions, bruising Findings can occur with consensual as well as with nonconsensual intercourse 6 o clock is ALWAYS 6 o clock

41 Toluidine Blue Dye A highlighting tool 1% Dye solution purple/blue that stains the active nuclei of cells. Intact skin has inactive nuclei Injured tissue has exposed nuclei so dye will uptake Apply dye, wait a minute, decolorize with 1% acetic acid solution

42 The Suspect Exam Did your client have one?

43 Suspect Exams Suspect does not have to consent for the exam if in custody (consult jurisdictional laws) Health and Medical history Should not be interviewed, by the SANE, regarding the event May ask if they are aware of the time frame in order to ask certain questions Never out of the presence of LE

44 Routine suspect specimens Fingernail/hand swabs Penis: Shaft & Glans Scrotum Pubic hair brushings (if pubic hair) (Pubic hair plucking (if pubic hair)) Blood card for exemplar or Buccal Swabs Circumoral swabs Photography Urine Blood for Toxicology Clothing if it is the original clothing

45 Other suspect collections May swab: Scratches Abrasions Touch DNA areas Any other area that the nurse examiner deems significant Is DNA where it should be? Remember that (rv) DNA may be on him

46 The suspect is our patient, too!!

47 It should not be the intent of the consultant to attack the examiner; rather to review and assess the work for accuracy and objectivity Hopefully, it will be a learning experience if the prosecutor relays feedback to the program to be utilized for Peer Review, chart review, case review, and competency

48 However If the examiner documents poorly Incorrectly identifies anatomy/findings Shows bias in her/his report Misinterprets findings Employs outdated techniques Fails to collect appropriate evidence Fails to take enough photographs Editorializes Cites old/invalidated literature Cites Human Sexual Response Lubrication

49 Most adult/adolescent cases are consent v non-consent Nurse examiners should know that some (v) who present to them are not completely forthcoming Nurse examiners can not tell you whether something is consensual or nonconsensual Consistent with, will be the common verbiage Generally, whatever can be consistent with the history could also be consistent with something other than the history.

50 Preparation Do you have the entire file? What issues are in contention? Choose your battles well Would it be best if your expert stayed a consultant? Might your expert testify? Double edged sword Are there significant things that need rebuttal? Will there be any surprises from the opposing examiner?

51 We are but a cog in the wheel The case may not depend on exam findings

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53 If you would like to see some photo examples of anogenital findings, please, stay behind for photos and more discussion.

54 Forensic Nurse Professionals 4225 Valley Fair Street, Suite 105 Simi Valley, California Forensic Services * Consulting * Education