Medical Forensic Response to Sexual Assault, Child Abuse, and other Forms of Interpersonal Violence: EMS Barbara Haner, MN, ARNP Providence Intervention Center for Assault and Abuse Objectives Recognize red flags that may indicate child sexual and/or physical abuse
Recognize common offender behaviors associated with child sexual abuse Implement treatment response consistent with mandatory reporting laws and district policy Statistics 1 in 4 girls, 1 in 6 boys will be assaulted before they graduate from high school In Snohomish County, this means that of the over 70,000 girls and boys currently in
middle and high school approximately 8000 girls and 6000 boys will be assaulted before they graduate Less than 4% of teens will report Statistics Continued FBI stats indicate a 1-2% false report rate (other studies indicate 15%) 80-90% of children are assaulted by a known family member or friend (trusted family friend/ S.O. of mother 56%, family
members 36%, strangers 8%) Non-familial abduction of children under 10 years usually results in fatality within 3 hours Medical Forensic Response to Sexual Assault Variation of what your county response is (SANE, SART, SAFE) May be a Team or individual RNs that have been trained. May be regular ED
RN. May have a CAC (Child Advocacy Center) with scheduled assessments with colposcopic examination Advocacy Services Every County has a designated SA (sexual assault) response center 24-hour crisis line response May have emergency room response
Information and support Medical Advocacy Will respond to your call Information and referral Case Management Sexual Assault Advocates RCW 70.125.060 makes provisions for victims to have a sexual assault advocate available to them throughout the
investigative and legal process Why Arent Child Sexual Assaults Reported Fear of retaliation (esp with teens) He loves me Fear of negativity or personal disclosure associated with legal proceedings or CPS involvement Cultural stigmatization (shame, guilt, SEX) Childs lack of competency and/or capacity Lack of knowledge based language
Willingness to believe the offender over their child Co-Dependent behavior by caregiver Emotional Housing Financial Why Go to the ED
Increased likelihood of reporting Safe place to stash the victim You dont know what you dont know You never get the entire story the first time Medical care Limited time frame for forensics, ECP, Toxicology, ETOH Advocacy support Documentation of history, injuries
Third party reporting Every victim of interpersonal violence should receive a medical exam Assume that any possible child abuse includes sexual assault Offender Epidemiology
Listen to the original facts Dont be swayed by the delivery Usually no disclosure until he hurts someone They want to give you a plausible reason to make you go away They are master manipulators
Grooming behavior Singles out type/age of victim Gifts, secrets, special time/activities Their behavior is often predictable White knight saves the day (day care, housing, financial) Encourages mom to work while he provides day care What happens during evening activities Common Injuries
Only 20% of confirmed SA will have visible medical findings. Usually fondling then masturbating. Pre-pubescent Vestibule: erythema, superficial tears in skin. May have ejaculate in belly button and folds of skin. Post pubescent Based on history of sexual activity
Very few serious or life threatening injuries Forensics Based on Locards Principle of Transference Includes
History Presentation Injuries (medical findings) Biological Debris Trace Hair Fibers
Forensic Considerations Even if victim has showered/bathed and changed clothes there is good chance of DNA Bring soiled clothes, blankets, hay bales, car seats, sanitary pads, condoms, tampons, diaphragms, diapers, sheets Encourage victim to not eat, drink, defecate, douche, oral hygiene prior to examination Save toilet tissue Never place in plastic always use paper bags
first Chain of Custody Documentation Child Specific Forensic Considerations In cases involving pre-verbal children, often the only chance for prosecution is the discovery of physical evidence Most child SA does not include penetration, thus usually no evidence of injury
Most law enforcement and medical personnel are focused on the safety issue and forget the forensic portion Child Forensic Considerations Bring bedding, crib toys, soiled diaper pail, any clothing Bring anything that the child may have come into contact with or may have laying on during or since the abuse Diapers, wipes
Urine Hair Drug Endangered Children (DEC) All children removed from a lab should receive immediate medical assessment regardless of lack of signs and symptoms Usually decontamination occurs in the field Limited time frame for testing (Meth clears in hours) Standard testing will occur to check for blood
disorders, liver damage, hair samples for long term exposure, toxicology screens Children may be drug endangered without being exposed to manufacturing Drug Facilitated Sexual Assault Alcohol is most common drug (very important to determine in teens) Tranquilizers and pain medication Veterinary Drugs Over the counter meds
Rohypnol and GHB not common in this area The use of drugs to facilitate increases the degree of assault charged EMS Response Multidisciplinary approach
Collaboration Preservation Observation Documentation Coordinated County Protocols 2000 county protocols were mandated by the Legislative body and are to be reviewed every 2 years
Collaboration Immediate coordinated investigation Law Enforcement CPS Medical Examiner Victim Support Services Emergency Department Specialized medical care Department of Health Preservation
Preserve Life Render Aid Preserve/secure Scene 1 path of entrance/exit Disturb physical objects as little as possible Dont use any household objects
Dont open doors/windows except as required Contact police Preserve Information Who When
Where How Observation Be conscious of the environment
Odors Damage Housekeeping Temperature/power/water Windows/doors Food Presenting and on-going demeanor of those present History provided
What initial aid was done Photos if possible Documentation Make detailed notes as soon as possible Discrepancies often make the case Who said what What did the child say, verbatim if possible All possible evidence of injuries Make a Timeline if possible
When was the child normal last Initial symptoms tell me about how the baby has been over the last 48-72 hours Who has been with the child during this time Why did you call the aid car Who is everybody, whos missing Medical Exception to Hearsay Crawford Supreme Court Decision Must include what you said or asked Verbatim in quotes what the child said
What is Your Districts Policy What can you do if someone signs a waiver and you want to take the child 4 year old female ,physically and sexually abused by moms new husband Long history of meth use and manufacturing Whatcom Co. SA Services DV/SAS
1407 Commercial; Bellingham, 98225 24 hour Hot line: 360-715-1563 1-888-715-1563 Office line: 360-671-5714 xx PICAA Contacts
Barbara Haner (Medical): 425-297-5770 Medical Appointments: 425-297-5776 Consult with the NE : 425-258-9031 Gayle Ossenkop (Manager): 425-2975780 24 hour Advocacy Crisis Line 425-252-4800
Information governance steps out of the silos that are often present in organizations to create an integrated, comprehensive approach to the management of data and information. This quote from CIO Magazine . describes governance even more succinctly: "Management is the...
Part of the problem is that "silo-busting is exceptional in academia - one is expected to specialize: there is a lot of turf warfare" (Jared Diamond, author of Guns, Germs and Steel, on yesterday's FT, p. ... unemployment benefits as...
Figure 1. Overview of methods A. Banding a bird using banding pliers B. Mist net (6 m x 2 m) used to catch individual birds C. Blood smear stained with Giemsa stain D. Map of Wilkes-Barre, PA and surrounding areas...
Using Data to Determine Outcomes. Screening using ECGs is occurring. Over 430,566 children screened by PHW members in past 10 years. Can we do it better and if so, how do we standardize and improve what is being done currently?
Carrier Use of SIP Aparna Vemuri Voice Engineering Architect Level 3 Communications Eric Zimmerer Director of Product Management ipVerse Inc. Network Architecture SIP with additions = Softswitch to Softswitch Open Standards (SIP BCP-T) Isolate legacy signaling and Maintain backward compatibility...