When a sexual assault occurs within the Regional Health Command Europe footprint, no matter where the patient is, a team of specially trained medical professionals are available to ensure that person gets the care they need, and want.

Sexual Assault Medical Forensic Examiners are experienced medical providers- registered nurses, nurse practitioners, Certified Nurse Midwives, physician assistants and doctors- with at least two years of clinical experience and additional training in performing sexual assault forensic exams.

A SAFE is an examination of a sexual assault patient. It includes gathering medical history; conducting a full head-to-toe physical assessment and examination; documenting findings; collecting evidence; coordinating follow-on treatment; and providing necessary medical treatment.

Florence Hare, Landstuhl Regional Medical Center Emergency Room Sexual Assault Medical Director and the Sexual Assault Medical Management Office program manager, said "these are experienced providers, but we add to their skill set by helping them to understand the trauma of sexual assault, the impact of the trauma on the patient, how to mitigate that trauma and then how to medically evaluate and assess that patient -- specific to the sexual assault, but also in a broader scope."

The idea, Hare said, is that the patient won't have to relive their trauma by having to tell their story to multiple people.

"In order to reduce the re-victimization or the re-traumatization of the patient having to deal with yet another stranger, to do forensic evidence collection, we teach these health care providers how to do that," Hare said.

Throughout RHCE, there are currently 26 SAMFEs providing support to nine countries throughout Europe. And since SAMFEs aren't permanently stationed in all of these countries, support is provided through a mobile team.

Taking the care to the patient

When a sexual assault occurs in a remote location, such as Powidz, Poland, where there may be no SAMFE on the ground, the victim advocate or medical provider will reach back to the LRMC Emergency Department who will then activate the mobile team.

Once the SAMFE has been notified, their first step is to make contact with the patient, Hare said.

"There is a lot of patient education about the exam process," Hare said. "It is our job to help them make informed decisions -- before we have even talked in detail about what happened."

If the patient decides to have an exam done -- whether reporting restricted or unrestricted -- the SAMFE will get a brief understanding of what happened.

"They get some details of what happened so that they can make recommendations to the patient for what they should or should not do while they wait for the SAMFE to arrive," Hare said.

Because SAMFEs fly commercial to these outlying locations, it can sometimes take upwards of 18 hours to get to the patient so the SAMFE will work with the provider and patient so they are able to collect needed evidence for the SAFE Kit, but also keep the patient comfortable.

"So if it will be 18 hours before we can get to them -- the patient is going to want to eat," Hare explained. "So we might talk to the provider on the ground and have them do an oral swab -- now the patient can eat."

Another example Hare gave - if a patient insists on taking a shower while waiting, they need to understand what that means so they can make an educated decision -- and the SAMFE also makes sure they know what to do with their clothes.

"That first communication with the patient is critical," Hare said, "and when there is a delay like that it is constant two-way communication. This means the provider is able to contact the SAMFE for further guidance or whatever they may need. And when the SAMFE is out of contact on a flight the provider is able to reach back to the alternate SAMFE back at LRMC and there will always be a voice at the other end."

Conducting the exam

SAFEs can take anywhere from 6-8 hours, according to Hare.

"These are long exams, because we need to take the time to make sure they understand the process and we have to move at their pace --the patient is in control," she said.

Katherine Henry, Registered Nurse at Grafenwoehr Army Health clinic and SAMFE, said every exam is different.

"The exam is very specific to each person," Henry said. "We start with getting their background information, how they want to report, restricted or unrestricted, and then we talk about what happened - which is important, because it helps to guide the medical forensic exam."

Depending on what happened, an exam could include a pelvic exam and photographing injuries in addition to collecting samples to be included in the SAFE kit.

The SAFE kit is considered evidence and therefore must maintain a chain of custody. If the patient chooses unrestricted reporting, the SAFE kit will go to law enforcement.

If the report is restricted, the SAFE kit and evidence are stored in a central location by law enforcement. The current requirement for storage is that it must be maintained for five years. No names are used and a unique identification number is assigned for future retrieval should the patient change the reporting option to unrestricted.

Supporting the patient

Regardless of where the patient is, or how they decide to report the assault, the SAMFE is there to help them understand the process and feel like they are making their own decisions, Hare said.

Supporting the patient also means supporting their decision to not have an exam. A SAMFE may be called to help the VA explain the process to the patient, but ultimately that patient can decide to forego the exam.

"This is a medical exam," Hare explained, "this process of launching and working with a SAMFE or not accepting the forensic exam but being seen by the sexual assault medical management office for ongoing medical care and surveillance --one isn't mutually exclusive to the other. So even if they don't do the exam, we are going to follow up with them to make sure they get the care they need. And we monitor them over the next three to six months to make sure they didn't get any infections or they are getting help from behavioral health if they choose. No matter how they report they are eligible for all of that."

It takes a special person

"It really takes a special personality," Hare said of SAMFEs. "Not everyone is cut out for it."
She said one of the key traits a SAMFE needs is patience and to be really good at patient empowerment.

"They've got to be able to give patients back that power and control and decision making, even though the SAMFE may feel that what the patient wants is counterintuitive to what they should be doing, they can't let the patient see that."

To become an Army SAMFE, medical providers attend a two-week course at Joint Base San Antonio, Texas.

Henry, who recently completed that training, said it is an intense two weeks. Starting with learning the "ins and outs of sexual assault, and the role of the entire care team that is involved. It isn't just about performing the exam, it also includes the VA, legal counsel, CID, MPs. It is a whole team of individuals who come together for the victim."

The second week of the training is the clinical portion.

"It is hands on -- in order to complete the course, we have to complete two live exams," Henry said.

Hare, who once served as the AMEDD Center and School Inter-Service Sexual Assault Medical Forensic Examiner Course Program Director, said that not everyone gets into the SAMFE training, "every graduate must be able to function in the SAMFE role upon completion of the course. This is not a training that can be taken and then not utilized."

"It takes a person who is really looking at the patient from the perspective of the patient and the trauma with the end-goal being, 'it is the patient's choice,'" Hare said. "They also have to be able to not take on the patient's trauma. They can't be so empathetic that they become sympathetic and take on that trauma. So there is a balance."

Henry agreed saying that this type of exam can be difficult, and it isn't for everyone. But she hopes she can make this extremely difficult situation a little easier for the patient.

"My goal is to be that person they feel comfortable talking to - to be that person they feel comfortable letting do this type of exam," Henry said. "I can't stop sexual assault from happening, but I can be there to provide support to a victim afterwards and ensure they are taken care of."