SAFE Exam - Awhonn

Sexual Assault
Forensic Examination
Major Gwen Foster CNM
Travis AFB, CA
Objectives
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Governing Policies
Reporting Rules
Role of Sexual Assault Examiner
SAFE KIT
Sexual Assault Policies
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Department of Defense Directive 6495.01
Department of Defense Directive 6495.02
Army Regulation 600-20, Chapter 8 and
Appendix 1
AFI 36-6001, Sexual Assault Prevention
and Response Program
Reporting Rules
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Restricted (Confidential)
Unrestricted
Role of Sexual Assault Examiner
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Diagnosis and treat within scope of
practice
Head to toe assessment
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ID, collect, preserve and document evidence
and maintain chain of custody
Refer for appropriate treatment and
follow-up
Provide expert testimony in a court of law
Forensic Examination
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PRIMARY ASSESSMENT
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Physical, mental and emotional care
SECONDARY ASSESSMENT
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ID, collect, preserve and document evidence
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Determine if evidence consistent or inconsistent
Forensic Examination (cont.)
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Within 72 hours
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Yields the highest quality evidence
After 72 hours
Significant healing of trauma
 Trace evidence may be lost through natural
processes and or actions of the individual
being examined
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But…
Forensic Examination (cont.)
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Sperm heads - 19
days post-assault
Epithelial cells - 3
weeks post-assault
Evidence Transfer
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Locard’s Principle of Evidence Transfer
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partial transfer of material from one to the other
Minimum of Three Crime Scenes
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Victim
Suspect
Location of crime
Use physical evidence to tie the scenes together
Evidence Transfer
Evidence Transfer (cont.)
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Trace Evidence: small
pieces of evidence
Direct (Primary) Transfer
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Direct contact between
suspect/victim/scene
Indirect (Secondary)
Transfer
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Carried from location to
other locations
Overview of the Exam
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Forensic interview
A sexual assault examination kit
Victim Interviewing
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Ensure safe and supportive environment
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Influences –
quality of the history
 cooperation during the exam
 Patient attitude toward legal proceedings
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Primary/Secondary Assessment
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Head to Toe
Inspect/photograph
 Collect
 Palpate
 Document
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Equipment
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During examination:
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Camera
Colposcope/anoscope
Toluidine Blue
Woods lamp
Swab dryer
After examination:
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Clothing
Medications
Step 1
Authorization
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Victims: Must
agree to exam
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If refuse, encourage
to have medical
exam
Subjects: Not
necessary if taken
under search
authority or
warrant
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AFI 44-102 2.35.2.4.
Step 2
History and Assault Information
VICTIM’s statements
are placed in
quotations
Step 2 (cont.)
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Interview
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History is critical
Guides subsequent examination for forensic
evidence
 Corroborates physical findings
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Use open-ended questions - avoid yes and no
Tell me what happened.
 What happened next?
 Tell me about the bruise on your face.
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Step 2 (cont.)
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Information to include:
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Identifying data
Date and time of assault
Number of attackers, weapons used, exact threats,
restraints
Location of the assault
Position of VICTIM during assault
Sequence of contact and penetration
Step 2 (cont.)
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Information to include:
Vaginal/Anal contact
 Oral contact
 Ejaculation
 Injuries inflicted upon SUBJECT
 Actions following assault
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Step 2 (cont.)
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Pertinent past medical history:
Last Menstrual Period (LMP)
 Last consensual sexual contact (identify
partner)
 Medication use
 Alcohol and drug use by SUBJECT and VICTIM
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Step 3
Clothing/Foreign material
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Seal each bag and label it
One paper bag for each piece of clothing
VICTIM will completely disrobe
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Have a gown ready
Inspect/Photograph
Examine with a Wood lamp
Photodocumentation I
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Camera Photography of trauma
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Macro ability
Use in same plane of injury
Step 3
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(cont.)
Use of Wood lamp
Fluoresces semen stains
 Augment marks and pattern injuries
 Detect saliva and vaginal fluid
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Step 3 Envelopes
Step 4
Debris Collection
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Collect any debris
detected, i.e. clumps in
hair, grass on body, etc.
Collect any swabs taken
from dried secretions
Step 4 (cont.)
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Collect scrapings from
underneath the
victim’s fingernails
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Useful if the victim
fought off the offender
Recommended to
collect even if no
report of having
fought back
Step 5
Pubic Hair Combings
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Combed to collect any
debris
Paper is placed
beneath victim
Step 6
Pulled/cut pubic hairs
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Purpose is to serve as
control
Recommended by
some law
enforcement agencies
Step 7
Vaginal swabs/smears
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Inspect/Photograph
Colposcopy
Toluidine Blue dye
application
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Completed before
speculum insertion
Photodocumentation II
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Colposcope photography
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External genitalia
Injuries
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External
internal
anal
Toluidine Blue dye (injury enhancement)
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Apply last
Repeat injury pictures
Toluidine Blue Dye
Step 8
Rectal swabs/smears
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Anus should be
visualized to ensure
there is no trauma
Step 9
Oral swabs/smears
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Non-invasive
procedure, always
collect
Step 10
Pulled/cut head hairs
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Minimum of 5 fulllength hairs from
each section: center,
front, back, left and
right sides
Step 11
Known Blood Samples
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In addition to
collecting blood for
DNA comparison,
blood may be
collected for
toxicological analysis
Step 12
Anatomical Drawings
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Document location of
all injuries
Narrative descriptions
should corroborate
documentation
Sexually Transmitted Diseases
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Pre-testing is not advised, results may be
admissible in court
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Treatment Protocols
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Vary from program to program
Not 100% effective
Give information on how and when to follow-up
for care and STD testing
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STD cultures are not part of forensic exam
Signs and symptoms to report
STD Prophylaxis
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CDC Recommendation
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Ceftriaxone 125 mg IM in a single dose
PLUS
Metronidazole 2 g orally in a single dose
PLUS
Azithromycin 1 g orally in a single dose
OR
Doxycycline 100 mg orally twice a day for 7
days
Additional Follow-up Issues
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Refer to counseling
HIV and HBV testing are recommended
and are available free of charge at
appropriate locations
All patients should be urged to follow-up
with testing if symptoms develop
Pregnancy Prevention
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This is prevention not pregnancy
termination
Emergency contraception used to prevent
pregnancy following unprotected
intercourse
Emergency Contraception
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Should be given within 72 hours of assault for
effective prophylaxis
Medication given in two doses 12 hours apart
Should be advised to follow up if regular periods
do not resume
Instruct patient to contact ER if any severe side
effects
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Common
Dangerous
Follow up
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Victim should follow up with medical
provider if anything just doesn’t “seem
right”
Follow up information for counseling
services
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SARC/Victim Advocate
Follow up (cont.)
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After patient has left
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Write report
DOCUMENT, DOCUMENT, DOCUMENT
 Do not draw legal conclusions
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Allow specimens to dry
Give evidence to investigator
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Proper chain of custody
Finishing the Examination
Implications
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Patient is the Crime Scene
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“Evaluation must be documented…for possible
use in future legal actions”
“Consequence to patient, accused, hospital
and provider may result from a failure to do
so”
(Smock ,2006)
Questions
References
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http://www.brooksidepress.org/Products/Military_
OBGYN/Textbook/Assault/Assault.htm
http://www.cdc.gov/std/treatment/2006/sexualassault.htm
http://www.safeta.org/
http://www.sapr.mil/
Distress and Pain During Pelvic Examinations:
Effect of Sexual Violence. Obstetrics &
Gynecology. 112(6):1343-1350, December 2008.
Olshaker, J., Jackson, C., Smock, W. Forensic
Emergency Medicine (2nd ed). Lippincott, Williams
& Wilkins. Philadephia, PA 2006.
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