Why Examine the Suspect?

I've heard it so many times. "We examine the victim but not the suspect." Really? My brain whirls and I have to try to understand this idotic notion. It's almost as simple as an equation If A+B=C, then C-A must=B.
But in the forensic sexual assault world, apparently examining A (the alleged victim) is good enough.

Please, forensic examiners, and persons of common logic, if you examine the victim then fight for examining the suspect as well. Law enforcement has no place in the examination of, and collection of , forensic evidence of the suspect.

In cases of crime, we are supposed to assume that the accused is innocent until proven guilty, but the rampant advocacy of alleged sexual assault victims does not do this. They often immediately begin calling the suspect the "perp" or perpetrator, and the thought is that law enforcement and/or medical will not pay to have the forensic kit done so why do it?

I shake my head in shame that people ever think such a thing. If there was a crime committed, or alleged, then ALL of the crime scene must be examined including the individuals present at the crime. And it is much more than a simple DNA swab. The examiner must do a head to toe exam on the suspect just as one was done on the alleged victim. You never know what you'll find, or what you don't find. And that information has a huge bearing on the case. The Judge and Jury deserve to have ALL of the details. Tox screen levels, trace evidence, photographic evidence, etc.

Let's just say it. There is NO reason that the accused or the suspect in a sexual assault case (or in any crime where there is clinical forensic evidence) should not get a forensic exam. (The assumption being that the victim has made a report and requests an exam.) A suspect exam is needed to pair with the accuser's exam and the rest of the evidence from the place the crime allegedly took place as well as from witnesses. When we fail to do a suspect exam we do a disservice to the justice system. Plain and simple.

So you won't get your exam paid for by VAWA. Find another group who WILL pay for it. The other thing I often hear is, "Well, I'm the only examiner and can't examine both the alleged victim AND the suspect." Concerns over cross contamination and objectivity are cited as reasons why. I say this is bullshit. If an examiner needs to perform an exam, there are perfectly acceptable ways to do this.

In the case of cross contamination and only one examiner, the examiner completes the alleged victim first, showers and change clothes and the suspect exam is done in a completely different room or a room that was wiped down thoroughly before the exam was done. In terms of objectivity, a SAFE/SANE examiner is a medicolegal professional who is ethically bound not to pick sides of a case. We are experts. There should be no loyalty to an alleged victim or a suspect. Our job is to collect forensic evidence, regardless, and when the case goes to trial our role is to help the courtroom understand the results on a scientific evidence based case. It is really that simple.

So, next time you wonder whether your facility should be doing suspect exams, stop asking the question because the answer is "yes". If you do alleged victim exams, then you should do suspect exams as well. The suspect may be innocent, or the alleged victim may have been sexually assaulted/raped, but no one will have the information to decide completely if you don't give them all of the evidence available. Suspect full exam, including photographs of injuries, tox kit, BAL level, STD testing, the full works . . . is important. Look at your protocols and if they do not include suspect exams, change them so they do.

One of the greatest issues I have with many programs in general is the desire to fall back and say "we can't because...." It's important to always change the perspective to: "If we had to, HOW could we do it?" The second question opens up a number of possibilities. Possibilities that can really make a difference for the judge and jury deciding the case.

Think carefully about this. Remember that much of the outcome depends on you, in that evidence needs to be collected correctly, expert-witness testimony needs to be done in a non-biased, professional and ethical manner, and the court will only have the evidence that is collected in order to decide the case (aside from witness testimony). The lives of individuals are at stake. A victim may lose the opportunity for justice, or an innocent man/woman may go to prison for several years and have their name placed on a sex offender registry for the rest of their lives. We owe it to the courtroom to give them as much evidence as we can, so they can make the best decision they can.

*Disclaimer: The statements above do not reflect the opinions or attitudes of the DoD or the US Navy or any other government entity, but are solely those of the author.

SAFE CARE in the Military: Providing Adequate Sexual Assault Forensic Exams

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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*Disclaimer: This blog is solely the opinions and experiences expressed by the author and in no way reflects the opinions, policies or beliefs of the U.S. Government, the DoD or United States Navy.

The 19th Scientific Assembly: Forensic Nursing in the 21st Century 2011

From 19-22 October 2011, approximately 476 forensic nurses and physicians met at the Hyatt Regency Montreal Hotel in Montreal/Quebec Canada.

This trip really began, for me, after landing around 10:30PM at the Montréal-Pierre Elliott Trudeau International Airport in Montreal. I was taken in a taxi, by "Mahmud" (originally from Lebanon, but who had come here as a reporter 37 years ago, and has one daughter who has borne 4 grandchildren...) to my hotel at the Travelodge across from the Hyatt. The Travelodge was half the cost of the Hyatt, and this conference was already beyond my budget.

The following are lectures/presentations I've attended the past few days:

Wednesday:

• Assessing Drug Ingestions: Toxidromes and Toxicology
• Do Come Over, Someone Has Killed Father (The Crime Scene Discussion of Lizzie Borden)
• The Coroner's Inquest: The Impact of Death Investigation on Prevention
• Motor Vehicle Collision Investigation and Reconstruction: Role of the Forensic Nurse

Thursday:

• Implementing a Clinical Forensic Nursing Program: Beyond the Obvious
• Bridging the Gap to Excellence. A Holistic Approach to Forensic-Medical Care in Military Treatment Facilities
• GHB Addiction
• Forensic Nurses Performing QI Studies in Forensic, Criminal Justice, and Investigative Settings

Friday:

The morning keynote address by Helene Berman, RN, PhD was titled "Context Matters: Trajectories of Violence in the Lives of Girls".

Dr Berman's presentation was sobering in terms of considering how our North American culture continues to affect violence in our society. Movies, T.V. shows, Video Games inundate us with violence, desensitize us and depict acts of violence toward young girls, teens and older women. In her talk today, she discussed "gendered socialization", and how our culture needs to pay attention to the problem of violence in our communities. Her talk highlighted what most of us are already aware of, but brought the issue to the forefront.  As she closed, she discussed the roles we, as forensic professionals, need to pay attention to methods of violence prevention in our society.  What remains crystal clear, however, is that there is no distinct path, no easy road, to changing North American culture. There is no quick fix, no single answer, in order to solve this problem. The goal among all forensic nurses should be to become more involved in government/legislation, and work within local communities to educate communities concerning violence.  The multilevel strategies we use to get there will hopefully not only leave long-lasting footprints for years to come, but blaze a pathway for a better world in the future.

Sessions I attended:

• Scene Investigations: Evidence Recognition, Protection and Documentation.
• Blending Forensic Nursing and Army Public Health Nursing to Aid in Eradicating Interpersonal Violence
• Confronting Youth Gangs as a Forensic Nurse
• (My own presentation): Interpersonal Safety of U.S. Military Women in the Deployed Environment of Afghanistan: A Grounded Theory Approach

Overall Musings:

All in all, the conference has been both exhausting and invigorating. The time spent rising early in the morning coupled with jet lag and a few beers the night before, along with long hours sitting and listening to interesting presentations...still has taken a toll on my body. But the connections, the meeting of old friends and new, the stories and backgrounds of such wonderful professionals is enough to galvanize any said 'under-achiever' into action.

'Under-achiever' was a phrase I've heard often at the conference, although I think that anyone who's convened at this professional forum is far from an 'under-achiever'.  Whether ADN/LPN, RN, NP or PhD/MD, each person is here to absorb information, share information, and each one is actively seeking ways to make valuable contributions to their communities in terms or violence prevention and/or response. Instead of professing (even jokingly) to be underachievers compared to our peers, let us each smile and simply congratulate each other on our activities and recognize those around us for their great efforts. Each of us makes our own contributions, whether seemingly great or small in society...and we never know the impact the slightest action may make. So be humble, all, and also know your self worth, and continue to make the world a better place one fingerprint, one footprint, one bit of trace evidence at at time.

~Cin

*****

*Disclaimer: This blog is solely the opinions and experiences expressed by the author and in no way reflects the opinions, policies or beliefs of the U.S. Government, the DoD or United States Navy.