Forensic Examinations CALI Annual Conference 2014 Rancho Mirage, California Cari Caruso RN SANE-A Forensic Nurse Professionals, Inc. Simi Valley, California We are Nurses First We assess our patients for medical, psychological, social, personal, and physiological issues. Biopsychosocial 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 our own entity. Skills of the Forensic Sexual Assault Nurse Examiner Minimum 40 hour S/A Course with 45 hour Preceptorship and Internship Objectivity Unbiased Evaluation Utilize Standards of Care Accurate and Ethical Evaluation of Findings Scope and Standards of Forensic Nursing Evidence Based Practice 1
The Role of Educator in criminal cases The rules are different in civil cases Many SANEs see themselves as part of the prosecution instead of independent, objective health care professionals They may believe they are responsible to: Support the patient s history It is not our role to believe or not to believe the reported history 2
We are always advocates for the patient s health and well being but, as forensic nurses, we are not advocates for the patient s circumstances If the nurse believes that her/his role is to help victims and get the bad guy they are in the wrong place We do not represent the reported victim We must maintain our professional boundaries and not become invested in the patient s history 3
That is not to say we do not treat our patient s with respect and dignity. We treat our patients as we would treat any other type of patient. We deliver compassionate, competent care with professionalism, affection, understanding, hugs. Hoping that all forensic nurses possess the qualities of: Objectivity Knowledge Integrity Ethics Maintains Professional Boundaries Is up to date with current literature, science, and techniques Forensic Nurses are neutral, unbiased medical professionals who have additional specialized education for interacting with reported victims and suspects which may result in impending legal proceedings. 4
If the nurse has conducted the forensic examination on the reported victim or suspect we will likely be on the witness list for the prosecutor. It is possible that we could be called by the defense Do SANEs believe that the defense attorney is the enemy? 5
The forensic nurse may be contacted by an investigator There is no reason a nurse should refuse to speak with anyone, if the forensic nurse is truly objective. We may want to consult with our legal entity, first. Few SANEs do defense work The Forensic Examination Should be: Thorough Individualized Complete Accurate Objective 6
Acute v Non-acute Exams The possibility of Biological Evidence n Acute exams: From the time of the event up to 120 hours n Non-acute: no biological evidence but possible injury, interview, and photography n Children: programs may differ from 24 to 48 to 72 to 96 hours + Age Levels Adult/Adolescent Programs Puberty and up 12 and over Child programs Under 12 years of age But up to 18 years It is what it is!!! 7
Points of Interest The SANE n Can not determine consent v nonconsent (adolescent/adult) n Cannot substantiate sexual force n Is only hearing one side of the history n Does not ask suspects about the event; only reported victims are interviewed n Must be objective and accurately document the findings or lack thereof The Examiner May n Fail to recognize normal and normal variants n Fail to consider preexisting findings (LCI) n Fail to utilize differential diagnosis n May have tunnel vision and believe all that is seen is related to the alleged sexual assault n Fail to recognize medical conditions/infections n Worry that their findings won t support (v) history n Misinterpret or overstate findings n Not be up to date on current literature Factors to consider n Age of patient; (v) (s) n How long after alleged event was the exam? n Acute v Non-acute n One event or multiple over time? n Patients do not behave as they do on TV or Lifetime movies. n A variety of demeanors will be encountered n When was LCI (last consensual sex)? n May not be able to differentiate findings. n Appropriate collection methods & techniques 8
The completed forensic report form will stay in the patient forensic file with copies to go to LE and the crime lab. There may be additional paperwork. If the case is going to trial ALL the paperwork and photographs should be obtained. There may be more materials than were initially presented. Ask for any and all materials created To Review n Forensic Report & Photographs n Examiner s/expert s CV n Victim & Suspect statements n Police Reports n Witness statements n Crime lab/dna results n Coroner s reports n Proceedings transcripts n Phone records, weather, etc. The Forensic Evidentiary Exam AKA: the SANE Exam Includes: n Head to toe assessment with body map n Reference Samples (blood card/buccal swabs) n Body Photography (with & without ruler) when appropriate n Specimen collection: Nail/hand swabs, bite marks, suction marks, touch DNA, n Wood s Lamp/ALS, etc. n Genital exam, specimen collection photography n Documentation n Drying & packaging of evidence n Chain of Custody 9
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 Speculum Anoscope Wood s Lamp/ALS* Wood s Lamp n Ultraviolet light n Around 365 nm (210-400) n Fluoresces many substances indiscriminately ALS n Alternate light source-high intensity n Around 475 nm n Orange goggles n 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. 10
Alternate Light Source n Fluoresces many substances not specific to body fluids: semen or saliva n Creams, lotions, soda, acne, make-up, fabrics, soap, debris, thread, fabric n Food stains, paint, dried substances, etc. My most dispensable tool I don t use it routinely anymore Wood s Lamp Jimi Hendrix Poster ALS 11
n Colposcope n Digital Photography n Some programs are now, all digital with special software n Should be at least 15 to 20 genital photos in a normal exam. 12
Body Findings may have nothing to do with genital and anal findings 13
Notes: n Most sexual assaults involve little, if any, physical bodily injury, to the reported victim. n Sexual assaults are most common among people who know each other n Very few patients need to go through an emergency department n There may or may not be genital injuries in a sexual assault; there may be injuries in consensual sexual contact n Body injuries are most common in Interpersonal & Domestic Violence situations n Sexual assault by a stranger is the rarest type n Brief Encounter 14
Terms to Avoid: Rough/Vigorous Sex n What is it? n Subjective n Can t be defined n If you try The answer might be n Don t go there Keeping up to date: n Slaughter, 1992, 1996 n Masters and Johnson, Human Sexual Response, 1966 Keep up with current literature Evidence Based Practice Best Techniques Standards of Care Sometimes Forensic Report Forms have Built in bias? 15
Editorial Comments Exam consistent with history Findings could also be consistent with something other than the history: i.e. consent/medical/ etc. List your assault related findings Evidence of sexual assault Sexual assault by history A N A T O M Y Primary areas of genital injury n n n n n Fossa Navicularis Posterior Fourchette Hymen Labia Minora Anus Common injuries: n Tears, abrasions, bruising n Findings can occur with consensual as well as with nonconsensual intercourse 6 o clock is ALWAYS 6 o clock 16
Toluidine Blue Dye n A highlighting tool n 1% Dye solution purple/blue that stains the active nuclei of cells. n Intact skin has inactive nuclei n Injured tissue has exposed nuclei so dye will uptake n Apply dye, wait a minute, decolorize with 1% acetic acid solution Did you eat the chocolate? Me? 17
The Suspect Exam Suspect Exams n Did the suspect have an exam by a forensic nurse examiner? n Suspect may not have to consent for the exam, if in custody (consult jurisdictional laws) n Should not be interviewed, by the SANE, regarding the event n May ask if they are aware of the time frame in order to ask certain questions n Never out of the presence of LE Routine suspect specimens n Fingernail/hand swabs n Penis: Shaft & Glans n Scrotum n Pubic hair brushings (if pubic hair) n Blood card for exemplar or Buccal Swabs n Circumoral swabs n Photography n Urine n Blood for Toxicology, when appropriate n Clothing if it the original clothing 18
Other suspect collections May swab: n Scratches n Abrasions n Touch DNA areas n Any other area that the nurse examiner deems significant n Is DNA where it should be? n Remember that (v) DNA may be on him It should never be the intent of the reviewer to attack the examiner BUT n If the examiner documents poorly n Incorrectly identifies anatomy n Shows bias in her/his report n Misinterprets findings n Employs outdated techniques n Fails to collect appropriate evidence n Fails to take enough photographs n Editorializes n Cites old literature n Cites Human Sexual Response 19
Focusing n What specific issues are to be contested? n Would it be best to have an objective expert review the materials? n Your expert may stay a consultant. n Your expert might testify Double edged sword n Are there things that have been testified to, that need rebuttal? n Will the opposing examiner say the right things? i.e. that they can t tell the difference between consensual and nonconsensual events, can t substantiate force n Choose battles well We are but a cog in the wheel Experts can cancel each other out In Closing 20
n Most adult/adolescent cases are consent v non-consent n Nurse examiners should know that some (v) who present to them are not completely forthcoming n Nurse examiners can not tell you whether something is consensual or nonconsensual n Consistent with, will be the common verbiage n Whatever may be consistent with a history of nonconsensual sex will likely also be consistent with consensual sex. Forensic Nurse Professionals 4225 Valley Fair Street, Suite 105 Simi Valley, California 93063 805 522-9939 fnpi@sbcglobal.net www.fnpi.net Forensic Services * Consulting * Education 21