By Kirstin Grace-Simons (Madigan Army Medical Center)January 10, 2020
MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. -- Healthcare a person receives after a sexual assault is important and difficult -- for the person seeking care and the provider who is tasked with not only taking care of their patient at a particularly traumatic time, but also to do so in a way that preserves any evidence for possible use in a future legal proceeding.
Even clinicians who do not find themselves tasked with performing such an exam need to know enough about them to know how to support them.
Joann Hollandsworth, a registered nurse and the Sexual Assault Medical Management Program sexual assault care coordinator in the Department of Behavioral Health, and Dr. Diane DeVita, the sexual assault medical director and chief of clinical operations for the Department of Emergency Medicine, introduced Madigan clinicians to the post-assault exam process in a training at the Madigan Annex and Andersen Simulation Center on Nov. 7.
Capt. Olivia Wood, a clinical staff nurse and sexual assault medical forensic examiner, who worked on coordinating the training, led a team of trainers and certified SAMFEs and sexual assault nurse examiners in their presentation of an annual sexual assault care training that served to familiarize clinicians with the rigorous process of collecting information and samples that is far more detailed than many exams they will perform.
This training has occurred for a number of years, but it is gaining steam as it includes more aspects, such as the question and answer session with a Criminal Investigation Division special agent and the expert witness testimony presentation by the Judge Advocate General's office this year's exercise featured.
SAMFE is the military's designation for a clinician who has completed the two-week intensive training at the Army Medical Center of Excellence at Fort Sam Houston, Texas, and is certified to perform the exam. SANE is the civilian medicine equivalent.
Christine Picart, a registered nurse and clinical nurse officer-in-charge at the Okubo Soldier-Centered Medical Home who is also a SAMFE, gave students in the training as much advice on the particular techniques she employs during an exam as she could cram into the hour allotted her.
She began by doing what she does at the beginning of every one of these exams -- she introduced herself, what she would do during their time together and what she is trained to do in this situation.
She told them that she is on call almost every day because she is rather rare. With an average of 45 exams a year, Madigan has long had a shortfall in the number of examiners needed to keep up with demand, so she gets a workout.
To be ready for a call any time day or night, she keeps two go bags. She is fully prepared to leave wherever she is and perform two sexual assault exams at any time.
It is possible that she could be called in to perform one on both victim and presumed assailant, back-to-back. If this happens, she'll have to shower in between and have an entirely separate set of everything needed to ensure there is no contamination from one exam to the other.
Once she cracks open the sexual assault exam kit, a small box that includes extensive documentation and a multitude of small bags and boxes for evidence collection, she cannot leave it. She cannot go to the restroom; she cannot eat; she cannot leave the exam room to get another pair of gloves. Unless she locks it up, she will be by its side for the next half day as she meticulously walks her patient through the 14-page exam history and evidence log that serves as documentation of the medical aspect of the assault.
She will examine her patient, asking for consent at each new step, from head to toe. That means she will spend those hours, observing, swabbing, touching and photographing any area that could have evidence of injury or contain DNA.
The field of forensic nursing is focused on gathering medical evidence from patients involved in criminal activity and providing expert testimony that can be used in court to prosecute crime. It is a specialty that blends nursing, science and the criminal justice system.
Forensic nursing is involved, time-consuming and extremely disciplined.
The shortest exam Picart has done took 7 hours to complete while the longest lasted 12 hours. She has also fit three exams into one day, leaving little time for anything else. She and the patient are completely exhausted when it process is complete.
A good share of the reason for that exhaustion is that it is an emotionally draining experience.
If she is examining an assault victim, she is doing everything she can to make her patient who has been through trauma as comfortable as possible during a lengthy and invasive exam that, by definition, is re-traumatizing. She must ask for details of the attack, she must touch and photograph every part of the anatomy, which may cause both physical and emotional pain.
If she is examining the accused assailant, she must work with a patient who certainly does not want to be there. The patients who are accused of sexual assault are brought in by a Criminal Investigation Command officer and Picart has found them to be quiet and compliant. The exam is still uncomfortable, at best; it is always a long and invasive process.
"It is highly regimented," she tells the small contingent of nurses gathered in the exam room at the foot of a mannequin.
They watch as she shows them how she examines and swabs the mouth. She turns to a nurse and methodically rolls a swab all around every one of her fingers, entreating her students to roll as she shows them, telling them this technique catches particles left on the fingers with as little disturbance as possible.
It is the awareness of this degree of detail that this training is designed to instill. Because of the forensic aspect of this exam, the examiner must have the support of the staff around them to provide them time, space and resources whenever they perform an exam.
During the portion of the process where the genital area is examined, a chaperone must be present in the room. It is the staff on duty in the Emergency Department who will support this need.
Madigan's approach to providing sexual assault exams is unique in that it is a hybrid of military and civilian certified examiners. To fill the need, it has contracted with SANEs from Providence St. Peter Hospital in Olympia. SANEs are trained using the official Washington state rape kit, which varies somewhat from the Department of Defense's especially in terms of the forms used, so those are on hand as well.
During the training, Wood walked a group through a rotation of page-by-page explanation of the exam history form.
"When I first came here, there were only two SAMFEs at Madigan, and the rest of our call shift was done by civilian nurses from St. Pete's," said Wood. "As our SAMFE program at Madigan becomes more robust, we are able to provide more individualized quality patient care to the patients we see in these unfortunate circumstances."
Indeed, no one wants to be in this field. As they close out their presentations, both Wood and Picart tell their observers they hope they will never have to do one of these exams.
As long as there is a need, Wood, Picart, DeVita, Hollandsworth and all those involved with the program are committed to providing the best care and training possible.