Anal sexual trauma case in a 6 year old girl...

[peaceloveandPA]

First, let me state that I am making this post mainly for venting, because I feel like I could vomit at any moment. So sorry if this doesn't make any sense whatsoever....

 

Inpt Psych....

 

Medical Consult for a 6 year-old who complains of "vaginal itching;" also reports from nursing staff of being hypersexual, masturbating so patient is placed in room by herself...

No complaints of urinary symptoms, abdominal pain, constitutional symptoms, vaginal rash, etc. etc.

 

Nurse in to chaperone for exam... Pt responds inappropriately. Hysterically laughing throughout exam, very very resistant. Outer labia is erythematous, (probably from self-manipulation); was not able to assess further because patient is almost impossible to examine.... very very raw excoriations immediately surrounding anus in the shape of a perfect circle, with inner erythema, appearance of superfical lacerations immediately surrounding anus, anal tears. notttttt like constipation, or rash-like. This looks like serious sexual trauma.  But I'm no expert.... Urinalysis negative; urine gc/chlamydia negative. Patient denies abuse (by deny, I mean, she says no while looking at the wall, avoiding eye contact)

 

So I alert the Nurse Supervisor, who alerts pt's social worker who usually handles all things related to DSS. Mom's BF's WERE accused of sexual abuse towards pt but apparently no investigation; however; pt is now in dad's custody for reasons unknown. So I am told SW is going to handle it and initiate an investigation, until I get a call from the clinical supervisor who says "we have already interviewed the family and they deny history of abuse, patient also denies, so we have no evidence, therefore we are not going to call DSS." WHAT?! OK,  I get it. I'm the suspicious one, so I'm the one who needs to call DSS. No problem. but the SW's  and Supervisors are now giving me so much shit like "you cant prove it" and "We have no right to delay discharge for this investigation" and "shes not acting like shes been abused" blah blah blah blah.... every freakin excuse in the book. 

 

I am just so sick to my stomach... of course now that I'm home... I call, and police will be coming out tomorrow. In my heart I know that this is what's going on with the child.... and I have gotten so much shit from SW because they don't believe it. But my exam findings are consistent with trauma. I feel that I'm OBLIGATED to report this.... I can't even think straight right now. Also, I'm NOT expert on this stuff.... why can't she go to some sexual abuse expert to be examined? I feel like I'm alerting the authorities and I need to be 1000000% sure, not just 99%. 

[GreatChecko]

In most states this is a required report, so don't equivocate, you are doing the right thing. 

 

Remember, where there is smoke, there is fire. 

 

Document the heck out of this and don't forget to privately document who is telling you what and what they are saying in case things get nasty later. 

 

I gather this is the same place you've been having issues. Sounds like sticking around too much longer could be detrimental to your license. 

[GreatChecko]

I don't know what state you are in, but this might help boost your confidence:

 

https://www.childwelfare.gov/systemwide/laws_policies/state/

[Gordon, PA-C]

Doesnt your region have an expert like a S.A.N.E. nurse to use in these situations?  

 

I remember a study coming out in Pediatrics a few years ago showing that hypersexuality is nearly pathognomonic for sexual abuse in prepubescent girls.

[peaceloveandPA]

Doesnt your region have an expert like a S.A.N.E. nurse to use in these situations?

 

I remember a study coming out in Pediatrics a few years ago showing that hypersexuality is nearly pathognomonic for sexual abuse in prepubescent girls.

Yes, we have something called the "teddy bear clinic" which is where they can go for an investigation. Hoping that's where she will go as soon as DSS is involved. I know, we see it so much, the more I think about this case, the less doubt I have that it could be anything but sexual trauma.

 

 

Let food be thy medicine

[peaceloveandPA]

In most states this is a required report, so don't equivocate, you are doing the right thing.

 

Remember, where there is smoke, there is fire.

 

Document the heck out of this and don't forget to privately document who is telling you what and what they are saying in case things get nasty later.

 

I gather this is the same place you've been having issues. Sounds like sticking around too much longer could be detrimental to your license.

Thanks.... Yes, detrimental to my license and my health. Working on getting out of there as fast as possible, just got a legal contract to see through.

 

I don't know where these social workers and psychiatrists come from, but ill be damned if I'm going to let this slip by me without reporting it.

 

 

Let food be thy medicine

[whoRyou]

Peace: For whatever it is worth, you are doing the right right thing. Keep US ALL posted ...

[ventana]

mandatory reporter - you have to report it

 

be VERY careful in talking about this on public forums or to co-workers - nothing good ever comes about divulging personal info

 

 

I would STRONGLY encourage the utilization of the SANE or some other type of specially trained (and they also take a ton o time to do exam trying to make patient feel comfortable) person - especially for female patients if you are male or for all PEDS

 

 

sorry you had to be a part of it - there is some truly evil people out there......

[peaceloveandPA]

mandatory reporter - you have to report it

 

be VERY careful in talking about this on public forums or to co-workers - nothing good ever comes about divulging personal info

 

 

I would STRONGLY encourage the utilization of the SANE or some other type of specially trained (and they also take a ton o time to do exam trying to make patient feel comfortable) person - especially for female patients if you are male or for all PEDS

 

 

sorry you had to be a part of it - there is some truly evil people out there......

Can a PA get trained in SANE?! Just curious... It would be super beneficial for me considering the high prevalence of psych pts I see and apparently there is nothing like that around here..... But a forensic detective is now in on the case, so hopefully whatever needs to be done with the pt will be done.

 

 

Let food be thy medicine

[winterallsummer]

You did the right thing.  When I was a CNA in psych I saw cases less "proven/solid" than this reported often.  The fact that others want to wash their hands clean of this is just sad as this kid needs help and cannot advocate for herself.  

 

You don't need even 80% proof to report.  The rule, as I understand, is that if there is a concern whatsoever, you are required to report; someone correct me if I am wrong.

[Avalon]

I am very curious about the answer to peace's question about eligibility for the SANE training as well.  The program was initially referred to as the SAFE program: Sexual Assault Forensic Examiners.  After reading this thread, I have only found references on the web to SANE programs, where "N" of course stands for nurse.  I'd be more than a bit frustrated if this such specialty certification is only available to RNs.  Peace is a perfect example of someone whose patient panel would greatly benefit if she were trained and certified in this area.

 

Sending you strength and good thoughts, peace....

[ventana]

SANE examiners that I have worked with have been nurses - they are not on call when they are working as it takes upwards of 2 hours to do the exam and paperwork

 

from a web search:

For years, victims of sexual assault have been forced to wait long hours in the emergency department before receiving a forensic exam. The development of sexual assault forensic examiner programs (SAFE) and sexual assault response teams (SART) has changed this and improved care for victims. A number of hospitals and communities in Pennsylvania have SAFE/SART programs.

A sexual assault forensic examiner (SAFE) or sexual assault nurse examiner (SANE) is a specially trained registered nurse, physician assistant, or physician who provides comprehensive care, timely collection of forensic evidence and testimony in sexual assault cases. The terms SAFE and SANE are interchangeable. The SAFE also takes care of medications for preventing pregnancy and sexually transmitted infections.

SAFEs work best when part of a sexual assault response team (SART). A SART is a multidisciplinary team, which works collaboratively to provide specialized services for victims of sexual assault. The team includes at a minimum, a sexual assault forensic examiner, sexual assault counselor/advocate, a law enforcement representative and a prosecutor. Other members of the community can be a part of the team. The team should be designed to meet the unique needs of each community.

For more information about SAFE/SART, including training, contact PCAR’s Medical Advocacy Coordinator at 717- 728-9740 ext. 132.

The PDF document, SART Guidelines, outlines the roles of each SART member.

[peaceloveandPA]

I am very curious about the answer to peace's question about eligibility for the SANE training as well. The program was initially referred to as the SAFE program: Sexual Assault Forensic Examiners. After reading this thread, I have only found references on the web to SANE programs, where "N" of course stands for nurse. I'd be more than a bit frustrated if this such specialty certification is only available to RNs. Peace is a perfect example of someone whose patient panel would greatly benefit if she were trained and certified in this area.

 

Sending you strength and good thoughts, peace....

That is super frustrating. You're right about the SANE training. It looks like all forensic training is offered for RNs and NPs. NPs win again. I only found one thing about a SAFE (sexual assault forensic MEDICAL officer) which would certify PAs but that was in the Navy. I'm going to keep investigating... Cause there has to be a way... Thanks for the support!

 

 

Let food be thy medicine

[SoCalPA]

Yeah you don't need to "prove it". That's the point of the investigation.  If you are suspicious you are required to report. The social workers seem a bit lazy. You did the right thing.

[whoRyou]

The following sections represent a detailed compilation of the statutory rape and reporting laws for each of the 50 states and the District of Columbia listed here --> State law are listed here and reporting requirements

 

The Sexual Assault Nurse Examiner – Adult/Adolescent certification indicates a higher level of training and specialization for those nurses who work with adult and adolescent patients who have been involved in a sexual assault. These nurses are frequently employed by hospital emergency rooms and specialty practices that treat this special patient population.

In order to take the Sexual Assault Nurse Examiner – Adult/Adolescent certification exam, the applicant must be a licensed Registered Nurse who has worked a minimum of 2 years as an RN. An accredited Sexual Assault Nurse Examiner (SANE) education course that includes either 40 continuing education hours in the classroom or three semester hours should have been completed. In addition, documentation is required that the RN has undergone supervision in clinical practice and it has been determined that he or she is competent in sexual assault practice.

The Sexual Assault Nurse Examiner – Adult/Adolescent certification exam is offered twice a year, both in the Fall, at various testing sites across the United States. The fee to take the exam is $225 for International Association of Forensic Nurses (IAFN) members and $350 for non-members.

The exam consists of 150-200 questions and the RN is allotted 4 hours in which to complete the exam. The majority of the exam tests the RN's knowledge on evaluating and managing the sexual assault patient. The exam also contains questions pertaining to the judicial process and gathering potential evidence. There are questions regarding professional practice and ethical issues as well.

The Sexual Assault Nurse Examiner – Adult/Adolescent certification is valid for 3 years. At the end of that time period, the licensed RN must have worked in the field of sexual assault nursing over the past 3 years. In addition, at least 45 continuing education hours should have been completed with at least 30 of those hours in the area of sexual assault nursing. If the continuing education hours are not completed, the RN can retake the exam in order to maintain certification. The fee for recertification is $175 for IAFN members and $300 for non-members who recertify by maintaining continuing education hours. For those RNs who wish to retake the exam for recertification, the fee is $225 for IAFN members and $350 for non-members. http://www.testprepreview.com/sexualassaultnurseexamineradult.htm

 

The National Center for the Prosecution of Violence Against Women  http://www.ndaa.org/pdf/the_voice_vol_1_no_3_2006.pdf  <--- Interesting everyone needs to read this IMO

 

 

FWIW ...

 

What does a forensic medical exam entail?

A forensic medical exam may be performed at a hospital or other healthcare facility, by a sexual assault nurse examiner (SANE), sexual assault forensic examiner (SAFE) or another medical professional. This exam is complex and on average, takes 3-4 hours. While this may seem lengthy, medical and forensic exams are comprehensive because the victim deserves and needs special attention to ensure that they are medically safe and protected. In addition, it is important to collect evidence so that if the victim chooses to report the crime to the police, they can access the stored evidence.

1. To start, the medical professional will write down the victim’s detailed history.
   • This sets a clear picture of existing health status, including medications being taken and preexisting conditions unrelated to the assault.
2. Next there is a head-to-toe, detailed examination and assessment of the entire body (including an internal examination).
   • This may include collection of blood, urine, hair and other body secretion samples, photo documentation of injuries (such as bruises, cuts and scraped skin), collection of clothing (especially undergarments).
3. Finally, the medical professional will speak about treatment for sexually transmitted infections (STIs) that may have been exposed during the assault.
   • Depending on the hospital and state, the victim may receive prophylaxis as well as referrals for follow-up counseling, community resources and medical care. http://www.rainn.org/get-information/aftermath-of-sexual-assault/preserving-and-collecting-forensic-evidence   

 

One last thing I promise ... I just happen to find "A sexual assault forensic examiner (SAFE) or sexual assault nurse examiner (SANE) is a specially trained registered nurse, physician assistant, or physician who provides comprehensive care, timely collection of forensic evidence and testimony in sexual assault cases." http://www.pcar.org/healthcare/safe-sane-sart 

I do not live in PA it is just something I found ... I am sure this is available everywhere

[Guest Paula]

I conducted a forensic medical exam once when I worked locum ER.  It ended up being delegated to me as none of the physicians had time and there were no SAME nurses available.  It was a bit disconcerting since I had only 1 class on conducting as exam in PA school.  Plus, I had a 4th yaer med student who was at the ER that day and she was working with me......I was a proxy preceptor.

 

The physician just told me to make sure I followed every single step to the letter and that "it's not that hard...just detailed".  It took several hours and there was a police officer present for most of the exam and he stepped out of the room when the internal exam started.  The med student and I looked a little bumbling since we had to read the directions for each step........ identify the right containers....swabs..etc but we accomplished our goal.

 

I never heard what happened to the young lady, but the situation was not an outright rape.  It was an angry mother who brought her daughter into the ER who had run away from home.  The daughter was living with her boyfriend....she was 16, he was 17 or 18 and it was about 1 week out of when she ran away.   It was a strange situation.   Definitely consensual but still was against the law since 17 is age of consent in the state I was in.

[skyblu]

Your job is not to determine whether this girl is being abused. Your job is to report that you have clinical suspicions, and Child Protective Services' job is to conduct an investigation.

 

Based on your description, I find there is more than enough reason for YOU (not SW) to file on this case.

 

You don't have to be 1000000% sure there was abuse. You have to be suspicious, then someone else's job is to investigate, determine the outcome, and then decide how to proceed regarding prosecution, removing the child, etc.

 

I just filed a report for a 6 year old with what clinically was consistent with genital herpetic lesions. The viral swab confirmed it but not for days. DCF came to the ED right away. Child was not removed from Mom, as Mom was found to be appropriately concerned and cooperative with the investigation, but child did spend several days at Grandma's with Mom's consent while Mom's BF was being investigated.

 

A forensic examiner might be in order. Did you do a rape kit? Photographs? DNA and other forensic evidence collection?

[ventana]

For years, victims of sexual assault have been forced to wait long hours in the emergency department before receiving a forensic exam. The development of sexual assault forensic examiner programs (SAFE) and sexual assault response teams (SART) has changed this and improved care for victims. A number of hospitals and communities in Pennsylvania have SAFE/SART programs.

A sexual assault forensic examiner (SAFE) or sexual assault nurse examiner (SANE) is a specially trained registered nurse, physician assistant, or physician who provides comprehensive care, timely collection of forensic evidence and testimony in sexual assault cases. The terms SAFE and SANE are interchangeable. The SAFE also takes care of medications for preventing pregnancy and sexually transmitted infections.

SAFEs work best when part of a sexual assault response team (SART). A SART is a multidisciplinary team, which works collaboratively to provide specialized services for victims of sexual assault. The team includes at a minimum, a sexual assault forensic examiner, sexual assault counselor/advocate, a law enforcement representative and a prosecutor. Other members of the community can be a part of the team. The team should be designed to meet the unique needs of each community.

For more information about SAFE/SART, including training, contact PCAR’s Medical Advocacy Coordinator at 717- 728-9740 ext. 132.

The PDF document, SART Guidelines, outlines the roles of each SA

 

 

 

 

 

 

 

 

 

please note, this is not limited to

NPs or nurses, you can do it as a PA.