If you haven't already, Forensic Nursing: Sexual Assault Nurse Examiner – Part 1 and answer the survey on your interest in forensic nursing. Have you ever thought about it? Why or why not?
Lacy has been a forensic nurse for about four years now, working one-two weekends each month. Her position is divided between interviewing sexual assault victims who come to the ER and processing bodies in the morgue. When she's not collecting evidence, she's unzipping body bags and logging personal possessions (I'll talk more about her work in the morgue in part three). I wanted to know the details of how she actually interviews a patient. Lacy said she is typically called to the ER to conduct the interview. After introducing herself, she usually starts talking to a patient, "The physician notified us that you have been the victim of a sexual assault. We are here to help you, here is what we can offer. If you are interested, there is an interview. We want to hear your story, but you can stop at any time. Nothing is set in stone.”
I was surprised to find out that victims of sexual assault have many choices when they come to the ER – they don't have to be interviewed or talk to the police or have evidence collected. She said, "The best part of my job is being able to give the person some power and control back by letting them know what their options are.” She went on to say, "We enter the room as an advocate. There doesn't have to be law enforcement, no rape kit, no exam. We go in and present options. The victim can choose to be interviewed with no rape kit or law enforcement, they can have the kit, but it can be anonymous. They can be treated for their injuries, for STDs, prophylaxis for pregnancy and then go home. They have all the power. They can even leave and return later to have the kit done.”
She went on to say, "The most satisfying experience is giving people choices – giving them control – there's no set rule, you don't have to do anything. There is a window of time for evidence. We have five days to collect the kit, but they are thinking of making it longer. I always tell them, 'don't wait 2 weeks. If you've showered, we can lose the evidence'. Sometimes people come back later in a couple days, when things get worse, the bruises start showing up worse, the swelling gets worse. It's a hard decision to make in the moment – especially if it's [your attacker is] someone you know.”
Lacy said only about 25% of sexual assault survivors opt to do the kit which really surprised me. "I've worked as a forensic nurse for almost four years and in that time I've only done seven interviews (rape kits). People don't want to take the time to do it. It can take a long time to collect all the evidence. I once took photos of extensive bruising for five hours.” She said that depending on the mental health of the patient, the interviews can be prolonged. "Many of our victims have mental illness...such a vulnerable population...and they can be difficult to interview. I had one woman who kept talking about something that happened two weeks ago. I had to redirect her back to the present. That can be painful for the victim and you don't want to push too hard.”
Lacy told me that in the ER, they don't have to wait for the patient to be treated for their injuries, "Obviously, if it's life threatening, that takes priority, but we can start talking with them and then take a break while they go for an xray. We come back. We notify advocacy agencies whether the patient wants us to or not because they often bring supplies like extra clothing, resources, funding from the state that will pay for ER costs, help with getting a restraining or protective order and so on.”
The National Organization for Victims Assistance is a good place to start if you are unsure of what resources are available in your community.
As well as RAINN (Rape, Abuse & Incest National Network), the nation's largest anti-sexual violence organization.
Search HERE to find resources in your community.
How To Start Collecting Evidence
"We always do a urine. The ER knows, don't offer any food or let them pee- it can wash away the evidence, so we do need a urine for a pregnancy test and to test for STDs. If they want the kit, we start the interview process. Where were you, do you know the perpetrator? What do they look like? Collect the narrative, write it down. We transcribe it but don't record it. The interview is entered into the electronic record, but the staff nurses can't see the record, only the forensic nurses can see the story or history or photos. Law enforcement can subpoena that information if they need it. That's what it's there for. The patient signs consent for all of it. We also ask if we can use the photos for learning purposes. They usually say yes.
"Then we do a head to toe exam and photograph any injuries. Forehead, ears – wherever there are markings on down the body. We might do a photo comparison of a torn up arm with the normal arm. We do the photos in sets of three. The first shows which side of the body we are working on, then closer up, then the 3rd with a ruler.”
I asked Lacy what the most surprising thing has been in her investigations. She mentioned the training she received on strangulation. In one study I read, strangulation occurred in 23% of assault cases. Lacy said, "A lot of assessment goes with strangulation, edema, markings, measuring ligature marks, spots behind the ears, petechiae that arise in the eyes. In evaluation, we ask about strangulation, 'did you lose consciousness, urinate or defecate on yourself?’ That can indicate the intensity of strangulation.
If the patient wants evidence collected Lacy said, "We use a rape kit that looks like a shoe box. It contains 15 packets, the underwear goes in the kit, swabs for different things – the DNA of the victim for comparison, scraping of mouth, privates, fingernails, gunshot residue. We have them pull about 50 strands of their own hair – we collect blood and urine if drugs were involved. Every envelope is sealed with evidence tape with initials over the seal. If it's anonymous, we send it to the police station where they keep it for a year – in case the victim wants it tested. They are doing a better job of giving the victims the tracking number so they can track it and call about it. It's so important to get a lawyer to expedite the process. If law enforcement is there, we can release the kit to the chain of custody – they may wait in the hallway, or we call the detective when we are finished – they come get it.
"We also get training on testifying in court. They teach you what questions they will ask you. It's so important to be thorough since we can be called as an expert witness."
What Is A SANE Nurse?
I am so grateful to Lacy for talking with me, and I am grateful for the nurses who do this work. I was thinking of becoming a SANE nurse, but after this interview, I'm not sure I could handle it. She is one strong woman. If you are interested, go to the International Association of Forensic Nurses website for everything you need to know, resources and more.
NOTE: Many details have been changed to protect Lacy and the community in which she works.
Thanks for reading!
Forensic Nursing (FN)
Forensic Nursing: Sexual Assault Nurse Examiner – Part 1
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