BY: DEBRA S. HOLBROOK, RN
A 30-year-old woman leaves work one night and stops at the ATM to get money to buy bread and milk. She is held up at gunpoint by two men, forced into her car and driven out of town to a field where she is brutally raped and beaten.
The men steal her car and leave her naked, but she makes it to a nearby house where a family calls police. Two officers respond and interview the woman, tell her to get cleaned up and they call for an ambulance. Paramedics arrive and interview the woman, clean her wounds and transport her to the closest emergency department. There she waits for hours, half dressed and alone, in a busy waiting room. She tells her story to no fewer than six staff members before finding out that no one on this shift has ever been trained to collect evidence with a "rape kit" or a forensic medical examination. Seven hours after reaching the emergency department, she is discharged. She has received no medicine, no advocacy and no photographs have been taken documenting her injuries. With a sheet wrapped around her for covering, she is placed in a cab and sent to a police station to give her report to a detective.
If this story sounds shocking, then even more appalling is that this scenario takes place today in more than 50 percent of hospitals in America where there is no coordinated response to care for patients who are victims of sexual assault. It is estimated that a rape victim tells her story to approximately 10 people before relating it to forensic personnel who need to hear the details. Although victims are often transported to local emergency departments, medical and nursing staff are seldom trained to collect evidence or use specialized equipment to detect injury invisible to the naked eye. Combine this data with statistics that estimate 1 in 3 women will be sexually assaulted in their lifetime.1 There is startling reason to be concerned about the deficit of care in hospitals across the United States.
STATE-OF-THE-ART CARE
Regional program managers and directors believe Mercy Medical Center, Baltimore, sees more sexual assault patients than any other hospital in their network, which covers the states of Maryland, New Jersey, Delaware, Pennsylvania and Washington D.C.
Founded in 1994, the Sexual Assault Forensic Examiners Program (SAFE) at Mercy Medical Center, serves patients who are victims of such assault in the city of Baltimore and surrounding counties. The mission of this program mirrors the ideals of Catherine McAuley, founder of the Sisters of Mercy: "In the care of the sick, great tenderness above all things." The SAFE Program is under the umbrella of the Forensic Nurse Examiners Program which is composed of 30 nurses who are available 24/7 to care for patients affected by personal crimes of violence. With their help, Mercy offers comprehensive forensic medical care and intervention for cases involving sexual assault and interpersonal violence, including domestic abuse, neglect or maltreatment of elder and vulnerable populations.
The Mercy team treats up to 50 cases of sexual violence each month and knows well that the majority of crimes against women are committed by men that they know. Stranger rapes represent only 10 percent of the total cases seen by Mercy. Patients range in ages from 13 to 94 years of age, and represent all cultures, races and economic classes. Scenarios range from girls being abducted from school bus stops and raped and young girls being raped by family members, to strangers breaking into homes and assaulting women and children and burying their victims under leaves and debris after attempted homicides. No one case is more horrible than another, and all are equally as devastating to those who are assaulted.
SPECIALIZED CARE BY FORENSIC NURSES
Patients brought to Mercy are triaged with collection of a brief statement about their assault and attention from on-site medical providers for any urgent medical needs. A forensic nurse examiner and a law enforcement officer then meet with the patient in a private waiting area. The nurse takes the patient to a private, state-of-the-art exam room for a forensic medical interview. From this interview the nurse is able to note areas of injury and, during a head-to-toe examination, locate and collect biological evidence (body fluids), trace evidence (hair and fibers) and photographic evidence of the assault.
In keeping with the conditions specified in Directive 36 of the Ethical and Religious Directives for Catholic Health Care Services, contraceptive medications are offered to these patients when the use of these medications is indicated medically. Mercy's policy on this matter receives careful ongoing review by qualified physicians and by the hospital's ethics committee. The medications used at Mercy do not disrupt an existing pregnancy (indeed they are not offered if a woman is pregnant), but they are highly effective in preventing a woman from becoming pregnant from the violent crime of rape.
The patient is then offered the opportunity to shower, given fresh clothing (many times her clothing has been collected as evidence), then talks with a skilled patient advocate who assists with follow-up and community safety resources. Thanks to the response team's skilled and caring support, the patient is discharged to the care of law enforcement or family with a stronger sense of empowerment.
OPPORTUNITY FOR ANONYMOUS REPORTING
A 24-year-old woman is raped and beaten by her estranged husband. Before leaving, he threatens to kill her and their children if she reports the crime to police. Terrified, she drives to a local hospital emergency room for medical treatment and medicine to prevent sexually transmitted infection, but insists that the hospital not notify law enforcement. She knows her husband will carry out his threats if she files charges against him.
Forensic nurses find this an all too common scenario, and one with critical implications. Until recently, many forensic programs have been required to obtain a police report number before they can collect evidence of the assault. If the victim changes her mind later about reporting the crime or pressing charges, the chance to collect fresh DNA, trace and photographic evidence is gone.
Now, however, federal law tells states they risk losing federal grant money if they require a victim of sexual assault "to participate in the criminal justice system or cooperate with law enforcement in order to be provided with a forensic medical exam, reimbursement for charges incurred on account of such exam, or both."2
This regulation is partially built on the expectation that patients will be more likely to seek medical treatment when they understand that hospital personnel are not going to magnify a frightening, stressful situation by catapulting the patient into the criminal justice process.
It also gives the patient valuable time to regain decision-making capability that is so often compromised during acute emotional trauma. Patients who later decide to report their assault have benefited tremendously by having evidence collected to corroborate their account of the crime.
PROTECTING IDENTITY
The Baltimore City sexual assault response team met on multiple occasions to design a protocol by which victims can report to the hospital and have an evidence kit collected. The kit contains a series of envelopes for biological and trace evidence including hair combing, oral, genital, anal and miscellaneous swabs and clothing collected by trained forensic nurses who maintain strict rules for procurement and packaging. The kit also contains forensic medical interview/assessment reports, as well as photographic evidence.
Women who do not want to report the crime to law enforcement may sign a consent form allowing the evidence kit to be assembled and assigned a "Jane Doe" number to protect the patient's identity. Mercy Medical Center holds anonymous kits for one year from the date of the patient's hospital visit, preserving the evidence in case the woman later decides to report the assault to the police. This process is also compliant with HIPPA privacy regulations, as the "Jane Doe" patients sign a strict informed consent which tells them how long the kit will be maintained, as well as to whom a police report should be made should they choose to do so.
The federal regulation went into effect in January 2009. Although there is no way to measure how many patients will choose to report sexual assault under the "Jane Doe" structure, Mercy has had seen a 100 percent increase in reports since the anonymous kits were created. However, according to the Maryland Coalition Against Sexual Assault, an estimated 60 percent to 84 percent of sexual assaults go unreported. Clearly, a significant number of victims are not receiving the urgent medical care that they need.
Forensic nurses have the precious opportunity to change lives in keeping with the mission of the Sisters of Mercy by helping these patients become survivors of their assaults through empathy, skilled care and returning the patients' sense of dignity.
NOTES
- George Mason University, Worldwide Sexual Assault Statistics, 2005, http://www.vawnet.org/.
- The Violence Against Women Act Forensic Compliance 2005 Reauthorization, http://www.mcasa.org/index.php?page=vawa-forensic-compliance-project.
DEBRA S. HOLBROOK is coordinator of forensic nursing, Mercy Medical Center, Baltimore.