Most of you are aware that I'm a huge proponent of performing Sexual Assault Forensic Exams correctly and thoroughly. And nothing bugs me more than to believe the military has failed to provide the best forensic care possible for alleged victims and suspects. Nothing except knowing we can provide even better care by providing quality forensic medical care in all areas of violence prevention and response.
As clinical forensic examiners in the military, I believe we owe it primarily to the courtroom to make sure that the evidence we collect follows proper chain of custody, and that we collect as much evidence as possible so that the judge and jury can make the best decision they can concerning a verdict.
During much of my career, I've heard numerous reasons why forensic exams could not be conducted at small military clinics or military hospitals. One of the major reasons cited was that there were not enough cases for a healthcare provider (MD, NP, PA or RN) to remain competent at performing exams. The more I heard this excuse, the more I became confident this was only an excuse borne out of limited thinking, fear and laziness.
Consider how we train healthcare providers to perform life-saving skills such as basic life support (CPR). In all of my years of training and becoming certified to "save lives" I never once had to save an active cardiac arrest patient to make me competent at BLS/CPR. How, then, did I learn and maintain those skills? Simulation. It's that simple.
Now don't get me wrong here. This is not to say that watching a video on sexual assault exams will suffice in training providers how to perform exams. Simply showing a video does not provide the necessary hands-on practice and understanding needed to perform such a life threatening exam. And it IS a life threatening exam.
"How so?" you might ask. Well, when a case goes to court, there is the alleged victim and there is the suspect. The victim, if s/he is truly a victim, deserves justice and his/her day in court. The suspect, if truly innocent, deserves to be acquitted or if guilty deserves to go to prison. If the suspect is innocent and is sent to prison (sometimes for 12 or more years) that act has affected the rest of his/her life. Even if/when they are released, the felon remains on the sex offender registry list for a lifetime. A LIFETIME.
That is one reason why knowing how to perform the exam properly is so crucial. And it is not only the examination that is critical. The Court Martial (trial) can take up to a year before it is held, and the clinical forensic examiner is not going to remember every detail of that exam after such a long period. Thorough documentation, understanding of the expert witness process and professional ethics are paramount in order to avoid the pitfalls that can come with inexperience.
Back to training and simulation. Practicing how to perform the sexual assault forensic exam using hands on simulation is important, and it is even more important for registered nurses who do not routinely perform genital examinations on men and women. Knowledge of what is normal genitalia and knowledge of what is an abnormal finding is imperative. Knowledge of the process of the exam is essential. By writing up mock case scenarios, gathering the paperwork and equipment, and going through a few mock exams semi-annually or even quarterly, the clinical forensic examiner can maintain a fair level of expertise in sexual assault examination. But they should not do this alone.
SAFE CARE stands for Sexual Assault Forensic Exam Competency and Review Exercises. Under this model, the sexual assault examiner is precepted and deemed competent to perform these examinations by another experienced examiner. Competencies are a check off list of skills needed and/or understood in order to maintain those skills. During mock or simulated exams, an experienced examiner guides the trainee through the mock case, paperwork, victim interview, sexual assault exam (victim or suspect) and has the opportunity to testify in a mock trial. Registered nurses who do not routinely perform genital exams should have clinical time with Nurse Practitioners/Midwives, Physicians Assistants or Physicians in learning how to perform speculum and pelvic exams so that they have a range of understanding concerning what 'normal' genitalia look like.
In the military, many Medical Treatment Facilities (MTF's) in the U.S. have opted for having civilian SANE/SAFE services perform their exams. While these services are generally good, there are enormous pitfalls with this approach.
First, military personnel do not gain the experience they need to perform these exams, so that when they are sent on deployment, or to an overseas base such as Okinawa, Guam or Sigonella, they are ill prepared to care for these patients. If civilian services are the preference for sexual assault exams at a military base, it is better if the MTF works with the civilian services and involves military providers in the civilian examination process. In this way, military providers can learn and maintain skills for when they are needed.
Second, the resources are readily available in the military to perform these services and the military misses a golden opportunity at standardizing their clinical forensic care and setting the bar for providing optimum forensic services to military personnel and their beneficiaries. The military has the ability to follow-up patients through electronic medical records, to refer members to ancillary services such as behavioral health and social services and as a result victims rarely fall through the cracks. When military members are cared for at civilian services, their medical/forensic care is generally not as complete in that follow-up care can easily fall by the way-side.
Third, the military is its own culture. There are cultural norms, expectations and behaviors that exist in the military that are often beyond civilian understanding. A military medical member is more likely to understand the victim and suspect, to be in touch with their environment and situations, to understand their language and their expectations. Civilian services often find it difficult to grasp the deep nuances of military culture.
Forth, there are members in military leadership who believe that physicians/surgeons are better qualified to perform sexual assault exams or to run SAFE units. This is far from the truth. Most surgeons would rather be performing surgery. THAT is where their supreme skills lay, and surgery is where the heart of their practice is. An emergency physician is the least likely candidate to perform sexual assault exams because ER physicians may be needed at a moment's notice for an acute trauma. A sexual assault exam takes anywhere from 3 to 6 hours to complete. . . sometimes longer. A sexual assault exam is a FORENSIC exam, which means it must follow a CHAIN OF CUSTODY and the evidence cannot be left alone for even a second. This means that not only is the ER physician not a likely candidate to perform the exam, but the ER nurse who assists the physician during a trauma is not a likely candidate either. In addition, in the civilian world, it is primarily nurses and nurse practitioners who perform these exams, and gold standards are set by the International Association of Forensic Nurses (IAFN) who, as a professional organization, has members who perform research in these areas and who are constantly building up their professional knowledge base in forensic clinical care.
There is a community of professionals in the military medical world who are BEST suited to perform sexual assault forensic exams. That community is the midlevel providers (NPs, CNMs, PAs). Among these groups, most providers are highly familiar with normal anatomy including genital anatomy. Most do not have ancillary duties such a "Nurse of the Day" watch, with the exception of some CNM's (midwives) who may pull call on the Labor Deck. Among all of the military medical professionals, midlevel providers are best suited to run a SAFE center, and to train future examiners. But this cannot occur unless each MTF takes up the rope and starts their own Clinical Forensic Center of Excellence.
Why a Clinical Forensic Center and not just a SAFE Center? Because the military, like the rest of the world, deals with criminal cases of abuse, child sexual assault, domestic violence, aggravated assault, homicide and suicide. A Clinical Forensic Center can address the medical aspects of all of these cases in a forensic manner and become more sustainable to that point. Such a center could be the pinpoint for forensic epidemiology and can more thoroughly address all areas of violence prevention and response rather than simply focusing on one area.
I've taught many clinical forensic courses to military personnel around the world. From Japan, to Maryland, to California, Kuwait, Afghanistan and Guam. I've served as an expert witness at several court martials for the prosecution and for the defense, and subsequently I've reviewed hundreds of cases and documentation of sexual assault exams. Because of this, I can say with a large degree of certainty that the military would do better to embrace the concept of clinical forensics and involve its medical services in caring for its members and beneficiaries, and training to a standard that equals or exceeds that of the IAFN. With standardization and full fledged development, the military would be able to grasp the full problem of violence as a public health issue and it would save money and potentially decrease all areas of violence and resulting injury by taking an active and epidemiological approach this problem.
Until that time, the first steps must be to embrace simulation practice for forensic sexual assault exams, and ensure that those individuals performing them are competent. Hopefully the time is near where every MTF will have a Clinical Forensic Center of Excellence, but until then we can at least hope for the best quality of forensic care the military can provide.
A wonderful article (which referenced a paper Diana Faugno and I both wrote on simulation and had published in the Journal of Forensic Nursing) discusses the researched benefit of performing simulation when learning how to care for sexual assault patients.
It is titled: SEXUAL ASSAULT FORENSIC EXAMINERS’ TRAINING AND ASSESSMENT USING SIMULATION TECHNOLOGY. The pdf file is readily available to view.
The abstract of article by Diana Faugno and I can be found here:
The SAFE CARE model: Maintaining competency in sexual assault examinations utilizing patient simulation methods. If you have trouble obtaining a copy, please let me know and I'd be happy to assist.
Enjoy and practice well!
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