A Guest Post By: Jimmy Futrelle
The EMT Spot would like to welcome Jimmy Futrelle to our guest post roster. Jimmy s a Paramedic hailing from Scurry County Texas. Jimmy has been responding on calls long enough to remember the Lifepack 5 and using D50 as a diagnostic tool. His unique background working for private and public EMS as well as for local law enforcement makes him uniquely qualified to teach on the subject of sexual assault.
This detailed guide to responding to these challenging calls is well worth reading. I sincerely thank him for this contribution.
Responding To Sexual Assault
Sexual assault is possibly the most devastating form of assault perpetrated on another human being. The legal definition of sexual assault is “any genital, anal or oral penetration by a part of the accused’s body or by an object, using force or without the victim’s consent.”
The U.S. Department of Justice’s National Crime Victimization Survey reports that over 500,000 women and approximately 49,000 men report being sexually assaulted each year. It is estimated that 1 in 5 women will victims of rape by the time they are 21 years of age. 61% of reported rape victims are less than 18 years old. 1 in 7 women will be raped by their partners. Only 16% of rapes are ever reported to the police.
Let us not confuse sexual assault with sexual abuse. Sexual abuse is repeated instances of sexual assault occurring over a period of time, generally by a person familiar to the victim. Whereas this crime is no less devastating, we are going to focus on the act of sexual assault.
Assessment and Treatment
When dealing with sexual assault victims, as with any assault, we must assess the physical and mental status of the patient. The psychological trauma af rape can be more severe that the physical injuries sustained. Since intimidation can be a more predominant factor in female assault, physical injuries may be more subtle. On the other hand, in male patients, we tend to see more severe physical injuries. Attempts to assault men are more frequently initiated with a severe physical assault. We, as health care providers, must be aware of these differences and treat the patient appropriately.
There are two assessments we must perform the physical assessment and the psychological assessment. Each is done congruently and treated accordingly.
Your priority is to the patient’s physical status. The ABC’s apply here as they would to any other acutely injured patient. We assess airway, breathing and circulation. Then briefly assess for any problems such as respiratory distress, shock, or any internal or external injury or hemorrhage that may require immediate treatment.
Common injuries seen with sexual assault are as follows:
1.) Abrasions and bruises on the upper limbs head and neck.
2.) Forcible signs of restraint–rope burns on wrist or ankles, mouth injuries sustained during gagging.
4.) Broken teeth, swollen jaw or cheekbone, torn frenulum of the lip or under the tongue, eye injuries from being punched or slapped in the face.
5.) Muscle soreness or stiffness in the shoulders, neck, knee, hip or back from restraint in postures that allow sexual penetration. Pain or bleeding from vagina or rectum, indicating possible tears in the delicate tissue in these areas.
Each or these injuries must be treated appropriately. Oxygenation, control of bleeding, stabilization of fractures, and fluid replacement, where necessary.
Our next priority is to create a safe environment for the patient. Remember that sexual assault is about control, and the victims currently feel as if they no longer have control over anything. It is imperative that no further assessment or treatment be given, without informed consent. The only exception to this rule is if the patient has an altered level of consciousness and/or a life threatening injury is present and implied consent is called for. Be very familiar with the guidelines of implied consent in your system.
Privacy is a big issue here. Move the patient into the ambulance or into a private area for the remainder of the exam. Some considerations for performing a physical exam:
1.) Explain all of your actions to the patient.
2.) Explain what a secondary survey is and why it is necessary.
3.) Avoid whispering things to others such as police, family or other medical professionals, in the presence of the patient. This can lead to feelings of paranoia.
4.) Do not perform procedures (setting up oxygen, or an IV) outside of the patient’s view, without explaining them first.
5.) If the patient wishes to have someone present for emotional support, make the arrangements.
6.) To open up a dialogue with the patient and establish a rapport of trust, begin with questions regarding the patients current use of medications, allergies and past medical history.
Avoid questions about the specific assault, unless the patient chooses to provide you with details. Only ask questions if the answers are necessary for medical treatment of the patient. “Sexual assault is a circumstance of such magnitude that it does not respond during the acute phase to emotional release or catharsis.”
Pertinent questions can include:
1.) Did the patient take any drugs (prescription or otherwise) or consume any alcohol before or after the assault.
2.) Did the patient urinate, defecate, or attempt to clean themselves following the assault.
3.) Did the patient bath, wash their hands or face, brush their teeth, gargle, or change their clothes following the assault.
4.) Has the patient smoked, drunk any fluids, or eaten anything since the assault.
If possible, do not allow the patient to perform any of the above actions. Inform the patient that it could effect the collection of evidence later at the hospital.
If medical treatment is necessary, explain all procedures and insure that the patient understands. The patient’s physical condition is paramount, but we must guide our treatment with some common sense.
If the need for oxygen arises, then try using a nasal cannula if possible. A mask may give the feeling if being suffocated. Avoid invasive procedures when possible, such as IV’s or blood draws. These are painful procedures and should wait till the patient arrives at the hospital. This way, medical and evidence samples of blood can be taken at the same time. These priorities should never jeopardize the patient’s condition.
Transport the patient to a medical facility capable of performing evidence collection. Not all emergency departments can perform this function, so be aware of the standards in your area. If the patient wishes to go to a hospital not capable of evidence collection, advise the patient of this. Offer an alternative facility. Transport the patient quietly and gently. Avoid use of lights or siren when at all possible.
Preserving evidence is vital if criminal charges are pursued. Take necessary steps to preserve evidence in all sexual asault cases. Medical stabilization must be balanced with the need to protect rapidly decaying physical evidence. Emotional support from a friend, family member or rape crisis counselor is preferred, but excessive delays should be avoided. It’s helpful to be familiar with the evidence collection procedures in your area. Patients will quite often ask you about what will be done with them when they arrive at the hospital. Be as informative as you can. Let them know that nothing will be done without their consent. If you do not know the answer to a question, be honest. Do not give false expectations.
Sexual assault is a crime and the location the assault occurred is a crime scene. Be careful what you touch and where you walk. If the police are present, have an officer escort you and be with you while you are inside the crime scene. This gives you a witness to your actions, and helps to secure you from moving or disrupting any evidence vital to the police investigation. If medical treatment is provided to the patient on scene, do not leave any treatment materials on the scene. Keep all wrappers and containers together. The officer in their investigation must explain anything you leave behind.
Wear your gloves. It reduces the chance of you leaving fingerprints, which must be explained later by the police. If an officer is not present when you enter the scene, then let them know what you did, where you walked and what you touched or moved, prior to there arrival. Document these movements in your report. Do not delay treatment or transport to await police. The police can obtain information from you and the victim, just as effectively at the hospital, as they can at the scene.
If any clothing or jewelry is removed from the patient, have the patient place each piece in a separate bag. At the hospital, place your linen and gloves in bags. Particle evidence may have fallen onto the linen or come off on your gloves. Place evidence in paper bags rather than plastic, to avoid moisture build up. Label the bags with time, date, contents and name of person who collected it. Turn all evidence over to the receiving physician or the investigating police officer. It is crucial that the chain of evidence not be broken.
Reporting and Documentation
It is a requirement in all U.S. states to report the sexual assault of a child, or adolescent under the age of 17 or an elderly person above the age of 60. It is not a requirement in all states to report sexual assault in person’s aged 17 through 59. This is the case in the state of Texas. Doing so without the patient’s consent, can be a violation of the patient’s right to privacy and a breech of patient confidentiality.
Where does our obligation to the patient’s right to privacy start and end? This is a question in which the answer varies from state to state, district to district, system to system. You must be familiar with the laws of your state and the requirements of the system in which you operate. Let the patient know up front the requirements placed on you, before initiating a secondary assessment. This gives the patient the right to disclose only the information they wish.
How and what do we document? Everything but our opinions. If criminal charges are pursued, then our documentation of the patient’s condition becomes a vital piece of evidence. We must document a detailed and chronological report of our assessment, findings, treatment and any information obtained about the assault. Detail must be given specifically to the physical exam.
Note any injuries and/or markings in meticulous detail. Describe the size, shape and location of each injury. (e.g., “Five red bruises are noted on the patient’s upper right arm. They are oval shaped and approximately one inch in diameter. Four are located on the lateral side of the arm and one is located on the medial side of the arm”). Document the patient’s mental status, and quote the patient wherever necessary. Do not make judgments or assumptions. Note if any evidence was collected and document the names of the persons receiving the medical report and the evidence.
We should take care to treat victims of sexual assault with the utmost compassion. We are tasked to preserve, protect, treat and comfort, all in a very short period of time. It is important that we allow patients to give informed consent to any and all treatment and assessments we perform. We must provide a safe and comfortable environment for them without distraction. We must preserve all evidence, no matter how insignificant it may seem. We must document all findings, procedures and assessments in meticulous detail. Most of all, we must be as honest with our patient’s as we can. Remember, were the victims first impression of medical assistance. We set the pace. We make the patient’s transition to the sterile hospital setting an easy one or a difficult one.
Strategies for the Treatment and Prevention of Sexual Assault Guide, American Medical Association
H.D. Grant, R.H. Murry, Jr, J.D. Bergeron, Emergency Care, 4th Edition.