S.A.N.E. Sexual Assault Nurse Examiner
RN + CSI = SANE
The nurse examiner sat in the witness stand as the jury listened intently while she went over every detail during the rape trial. She explained the purpose of a Wood’s Lamp — an ultraviolet light used to detect bodily fluids — and reviewed how the evidence was documented, labeled and sealed before being signed over to law enforcement. There’s plenty that goes into the four-hour evidentiary examination, and this case was no different.
Testifying in court is just part of the job of a Sexual Assault Nurse Examiner (SANE), who has a dynamic and cutting-edge nursing position. Nurses make ideal forensic examiners because they are excellent at thorough documentation. It is inherent in their work. They also, obviously, have experience examining patients. >>
“Yes, it is sexual assault,” said Malinda Wheeler, RN, FNP, SANE-A, SANE-P, Founder and Director of Forensic Nurse Specialists. “But the victims come in with injuries everywhere on their body, and it’s the attention to detail where nurses are exceptional.” That, and the psychosocial element. An untrained examiner in the Emergency Department (ED) may not know how to care for the victim appropriately.
The California Office of Criminal Justice statistics show in 2008 there were 2,173 forcible rapes in Los Angeles County, 494 in San Bernardino County, and 430 in Orange County. Yet, according to the US Department of Justice, it is estimated that only a little more than half of sexual assaults are actually reported. The goal of the nurse examiner is to make it easier for a victim to come forward.
“SANEs are able to deliver comprehensive, compassionate care in a clinical situation focusing on the patient in a holistic manner, rather than just collecting pieces of a kit,” explained Kim Day, RN, SANE-A, SANE-P, SAFE Technical Assistant Coordinator with IAFN. “The trained educated examiner understands the dynamics of sexual violence, how that will impact the patient in the long run, and is able to tailor their nursing process around that.”
SANEs have been around since the 1970s, but the specialty became offered as a certification through the International Association of Forensic Nurses (IAFN) in 2002. According to the IAFN, all states now have SANEs working as members of a Sexual Assault Response Team (SART). If a sexual assault is reported, especially within 72 hours of the assault, and the victim consents to an examination, then SART is called upon.
SART is a coordinated, multidisciplinary approach to the evidentiary examination of a sexual assault victim. It begins when law enforcement notifies the SANE and a volunteer from a rape crisis center. All parties meet in a private location outside of the ED. This completely removes the victim from the triage wait, which would likely take hours.
This is just the first step toward a more a victim-supportive approach. Furthermore, instead of having the ED staff perform the exam (which may be preceded by a frantic search for a “rape kit” in the supply room), it is done by a nurse who is specifically trained and experienced. The victim is asked to give a detailed account of what happened once, with both the SANE and law enforcement present. This not only prevents the victim from having to repeat themselves, but promotes a coordinated forensic response.
Forensic Nurse Specialists is a private company that provides sexual assault evidentiary examinations 24 hours a day. They have seven SART programs in Orange and Los Angeles Counties, with examination facilities located in Anaheim, Long Beach, Pomona, San Pedro, Torrance and Whittier. The remainder of Los Angeles and San Bernardino Counties has SART coverage through other groups of nurses.
Forensic Nurse Specialists do a whopping 80-100 evidentiary exams a month. They currently have a full team of 12 nurses with three nurses on-call at a time to ensure a one-hour response time to all locations.
THE EXAM AND EVIDENCE
The nurse examiner immediately engages with the victim to explain the SART process and begins to preserve important evidence. These are just some of the exam components:
• Evaluate injuries and treat them as needed.
• Collect standard examination components (e.g. blood, saliva, urine, hair, fingernail scrapings, hair combings).
• Screen the body for areas that fluoresce under the Wood’s Lamp.
• Collect swabs (e.g. vaginal, cervical, or on the body based on history given).
• Examine the genital area with use of toluidine dye to view injuries.
• Photograph injuries.
• Use a microscope to check for semen, if applicable.
• Document – everything.
• Collaborate with SART members to support psychological needs of victim and ensure adequate follow-up.
The SANE takes photographs during the genital examination using SLR digital cameras with auto-timers on a tripod instead of using the more traditional colposcope. They have found the photographs to be excellent and do not have to worry about repairing the colposcope when it breaks down. These photographs allow magnification of microscopic trauma that an ordinary exam in the ED may not reveal.
The whole examination takes about four hours, after which the victim may shower, have a snack and change into new donated clothing to wear home. Consultation is given regarding sexually transmitted diseases and pregnancy. All evidence is carefully packaged and processed to maintain the chain of custody. A small number of cases may end up requiring testimony at a later date. The evidence collected by SANEs has contributed to successful convictions.
“When a case is filed, it most often results in a guilty plea,” Wheeler explained. “When there is a suspect, good evidence, a victim who remembers the assault or evidence they were drugged, there is enough evidence to hold the person responsible.”
Wheeler said they are discovering evidence even beyond the standard “magical” 72-hour reporting window, and finding evidence that’s still on the skin, even after showers. They are also exploring the delayed collection of cervical swabs for detection of semen after the assault. “In fertility clinics,” Wheeler said, “they have found sperm cells intact up to two weeks.”
A CAREER CHOICE FOR YOU?
Many SANEs started as emergency nurses or labor and delivery nurses with “really acute clinical assessment skills,” Day explained. “We are realizing that as years are going on, that really a nurse from any background with good physical assessment skills can take the training and be educated in a way that they can take care of the patient.”
In fact, the Forensic Nurse Specialists just recently hired its first new grad. “She had criminal justice experience already and was in an advanced, accelerated RN program,” Wheeler said. “She turned out to be excellent.”
At minimum, SANEs begin their forensic education with a 40-hour training program. From there, they must have supervised practice until they are competent enough to perform examinations on their own. Some SANEs work with children, suspects of sexual assault or even postmortem victims.
Although SANEs work with a team of responders, their job is on-call and very independent.
“I really like the independence, the autonomy for myself as well as my nurses,” Wheeler said. “I know that they enjoy that part.” If you would like to learn more about sexual assault nurse examiners or forensic nursing, attend conferences and do research on sexual assault, trauma, domestic violence and even medical legal death investigations. Check out the International Association of Forensic Nurses' website for information on training, education and certification at www.iafn.org.
Daria Waszak, RN, MSN, LNCC, is a former Sexual Assault Nurse Examiner and freelance writer with a background in clinical and administrative nursing.
This article is from workingnurse.com.