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Management of sexual assault in the ED

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Management of sexual assault in the ED

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Management of sexual assault in the ED

  1. 1. August 2015 Dr Sarah Jolly Joanne Willox
  2. 2.  Questionnaire  A Case Study  Definitions  Legislation  History & Examination  Early Evidence Kits  SARC services
  3. 3.  I 3 point ID completed verbally with pt.  S 38yo ♀ referred to SW by Medical for psychosocial and safety assessment post sexual assault.  O Pt was observed to be scared, frightened, withdrawn and very teary.  B Numerous grief/loss issues (parents deceased, estranged from sibs, not caring for children), hx of IVDU and physical assaults
  4. 4.  A Attempt to contact NOK at pt request (distinction between being alone and lonely). On-going liaison with WAPOL re forensic specimens: ROG, Response Team, SA Squad On-going liaison with SARC. Access to refuge accommodation (8 calls) Consultation with CPFS re care status of child.  R Comprehensive Discharge Plan including Safety Plan, accommodation, clothing, transport, counselling and crisis payment info.
  5. 5.  Fortunately we do not see a lot  SARC see >300 emergency cases per year
  6. 6.  Broad definition Any sexual activity carried out against the will of a person through the use of violence, coercion or intimidation, even if it did not end in penetration.
  7. 7.  Any unwanted sexual touch  Being forced to masturbate or watch someone else masturbate  Being forced to give/receive oral sex  Being forced to perform sexual acts on oneself or others  Sexual penetration by penis/object/other parts of the body into vagina/anus/mouth
  8. 8.  WA Criminal Code -Sexual penetration without consent -Aggravated sexual penetration without consent Aggravated can include: causing injury; using a weapon; detaining the complainant; the complainant’s age; if the complainant has a disability -Indecent assault -Aggravated indecent assault Consent = freely given & voluntarily given without force/threat
  9. 9.  16 years in WA  18 for anal sex in Queensland  Some nations only 15 years  PNG – 16 yrs for girls and 14 yrs for boys  People of authority
  10. 10.  Is a free agreement – which cannot be given if intoxicated, frightened, asleep, unconscious, forced or coerced, no capacity to understand what is happening, too young  Consent can be withdrawn at any time
  11. 11.  If belief that a child/young person (<18yrs) has been subject of sexual abuse Freephone: 1800 708 704 www.mandatoryreporting.dcp.wa.gov.au
  12. 12.  Lifetime prevalence of sexual abuse/assault?
  13. 13. Sexual Assault & Abuse Mental Health Issues Alcohol & Drug Issues
  14. 14. Has an impact on-  The likelihood of the person seeking further assistance  The likelihood of the person/complainant reporting the crime and proceeding through the criminal justice system
  15. 15.  Listen & Believe  Private space  Reassure & be empathic  Uncomfortable for both pt & staff
  16. 16.  Open Direct disclosure of sexual assault Brought to ED by police  Indirect presentation Injury/Domestic violence Requiring emergency contraception/STI screen Intoxication +/- memory loss Mental health w self-harm/suicidal ideation
  17. 17. Psychosocial issues Medical issues Forensic issues Mandatory reporting Consult SARC early
  18. 18.  Is patient safe? From perpetrator From themselves Other mental health problems  Are children safe?  Does pt have somewhere safe to go?  Psych/Social worker referral  Pt can call/be seen by SARC for counselling
  19. 19.  Injuries -Acute medical takes priority over forensic -5% have moderate & 1% severe physical injury (head injuries, strangulation, fractures, widespread soft tissue injuries) -likelihood of significant genital injury is uncommon (except in pre-pubertal girls & post- menopausal women)
  20. 20.  Contraception -Risk of pregnancy? -Emergency contraception -Give ASAP up to 72 hours (or ?longer, may be have some effect up to 5 days)
  21. 21.  STI screening -First void urine -Serology – Hep B, C, HIV, syphilis -Genital/oral/anal swabs if appropriate, but consider need for forensic examination/specimen collection
  22. 22.  Azithromycin 1g orally for chlamydia alone  ?Gonorrhoea - depends on region, risk & likelihood of compliance Ceftriaxone 500mg in 2mls 1% lignocaine IM AND Azithromycin 1g orally  Hep B vaccine/Ig if at risk  HIV PEP is rarely required
  23. 23. HIV  1/1250 risk from penile/vaginal & 1/60 from penile-anal with a known HIV positive male  Risk increases w genital injury, concurrent STI, receptive anal assault, assailant factors (high prevalence countries, IVDU & MSM)
  24. 24.  2 anti-retrovirals for 1 month  Side effects rare GI upset, headaches, rash, renal/liver dysfunction  D/W Immunology Reg on-call
  25. 25.  Sexual health clinic  1 month: repeat swabs & urine, pregnancy test  3 months: repeat serology  Hep B vaccinations at both if required
  26. 26.  A forensic medical examination can only be conducted with a patient’s fully informed consent  It is not done for therapeutic reasons, but to assist a criminal investigation  Informed consent -is specific -freely given, no coercion -competently given -pt needs capacity
  27. 27.  May consent to one part, but not another  Right to withdraw consent  <18 yrs – need child’s assent AND responsible person’s consent  <18 yrs – can consent to medical, but not forensic component depending on if police are involved  Intoxicated – must wait until sober, but consider EEKs
  28. 28.  Not required in our ED  Unlikely to ever need to do it  Very detailed  Takes a long time
  29. 29.  Brief history of assault and any injuries  Date, time and duration of the forensic examination  Document source of information – police, patient/victim  Direct quotes are helpful - patient’s own words  Volunteered v direct questioning  When, where and who of the alleged incident  Number assailants  Relationship to assailant
  30. 30.  Force or weapon, threats  Penetration or attempted penetration  Patient actions in defence eg. scratching  Possible ejaculation and where on body/clothing  Condom use, lubrication, saliva  Any discomfort, dysuria, genital or anal bleeding  What has happened since the alleged assault eg showering, changing clothes  Anything else?
  31. 31.  As you would for any other patient  Injury Do you have any injuries that are not obvious to me? Head injury, loss of consciousness, strangulation, genito-anal injury.  Gynaecological history Last menstrual period, pregnancy, contraception, sexual partners within last 10 days, pre-existing discharge or concern, previous sexual abuse/assault  Mental health Have you suffered from stress or depression in the past? Have you ever thought of hurting yourself? Do you feel safe from yourself? Are you safe from others? Who would you go to for support in difficult times?
  32. 32.  Site  Position (distance from anatomical landmarks)  Injury type  Colour (shape, surface, margins, healing)  Size /Dimensions  Associated swelling/debris/infection
  33. 33.  Bruise  Abrasion  Laceration  Incised wound  Mixed
  34. 34.  Redness – could be from infection, inflammation or trauma  Tenderness - subjective
  35. 35.  Leakage of blood from blood vessels in the skin and subcutaneous tissues, which have been disrupted by blunt force  You cannot age a bruise
  36. 36.  Petechial – often arises from disruption of small venules, eg. above site of strangulation, suction type injury  Tramline – struck with a rod-like object  Fingerpad  Patterned
  37. 37.  The presence of yellow discolouration in a bruise indicates it is older than 18 hours  Very subjective
  38. 38.  Result from simultaneous application of force and movement to the skin causing disruption of its outer layers -linear -brush  Can be a directional component with skin tags at the end of the abrasion  Describe any bleeding, scabbing or dehiscence of scabs, but it is not possible to give an a clear indication of its age
  39. 39.  Result from the application of a blunt force which causes splitting or tearing of the skin and/or subcutaneous tissues  Different to an incised wound which is caused by a sharp force
  40. 40.  Incised wounds – length greater than depth  Stab wounds – depth greater than length, underlying structures damaged  Other - burns (heat, eg cigarette & chemical) - gunshot
  41. 41.  Not practical in the ED  NO personal mobile phones  Police photographers  Chain of evidence
  42. 42.  Associating injury w possible causes/mechanism  Rare in medicine for a finding to have only one possible mechanism of causation  Risk of over-interpreting  Need to be objective  Respect boundaries of expertise  Exact mechanism often not able to be determined by physician
  43. 43.  May still be worthwhile even if -the patient has showered/bathed/been for a swim -the person has had consensual sex w another person before/after the assault -the complainant doesn’t think the assailant ejaculated Samples can be collected & stored for up to 3/12
  44. 44. Oral DNA- 6 hours usually up to 24 hours possibly Affected by oral intake Vaginal DNA- up to 24 hours usually up to 3 days is likely 5-10 days is possible Anal DNA- up to 24 hours up to 48 hours possibly Affected by bowel actions Skin DNA- only 46 cells to identity DNA up to first shower
  45. 45.  Formerly known as Preliminary Forensic Kits
  46. 46. Allows patient comfort with preservation of evidence, prior to a formal forensic examination It patient unsure if they want to report to police/undergo formal exam  Urine (biology & toxicology)  Labial/Penile wipe +/- peri-anal wipe  Oral rinse  Blood (Toxicology)  Clothing
  47. 47.  Blood  Urine Assists if victim was unable to consent to sexual contact due to intoxication  Document patient weight and collection time  May have to collect before pt able to consent, but await capacity before handing over to police
  48. 48.  Available in the ED  Standard hospital supplies can be used  Plain labels (NOT hospital pt labels)  Consent  No need for these to be observed
  49. 49.  10mls sterile water  1 yellow top container-labelled as “oral rinse”  1 pair of gloves
  50. 50.  Pt to wear gloves & hold pot  Place sterile water in mouth & thoroughly rinse around  Spit fluid into pot and replace top  Label with pt name & date of birth
  51. 51.  2 yellow pots  Labelled “urine” & “vulval wipe” or “penile wipe”  Sterile gauze  10mls sterile water for men  Pair of gloves  Bright yellow sticker (Please fwd to C.C.WA)
  52. 52.  Pt given items & go to bathroom  Pt puts on gloves  First part urine into pot & replace top  Use gauze to gently wipe vulva  Men – moisten gauze w sterile water & wipe shaft & tip of penis  Place in pot, allow to dry before replacing lid  Attach yellow label to urine sample
  53. 53.  If required  Same procedure  Gloves, moisten gauze with 10mls sterile water & wipe around anus  Place in pot, allow to dry
  54. 54.  Following suspected drug facilitated assault  2 x fluoro-oxalate (grey) or 2 x EDTA (purple) blood tubes  Sterile water to clean skin  Plain labels, Exact time of collection  Toxicology consent form
  55. 55.  If pt wishes to change  Separate PAPER bag for each item of clothing, change gloves between items  Seal & Label each bag
  56. 56.  Place all specimens, copy of consent & list of specimens in envelope/plastic bag  Seal w Evidence Label/completed label & sign across it with your name, date & time  Hand either to police OR to patient to take to SARC (keep in fridge if going home first)  Document in notes
  57. 57.  Always phone SARC for advice
  58. 58.  Document times and events  Note who, what is done, when & where  Seal all specimens in forensic envelopes with red evidence tape to ensure that it is tamper proof
  59. 59.  Swabs, slides, tape, envelopes etc in the Full SARC sexual assault examination kits  Probably only required in regional EDs/rural clinics  Here – go to SARC
  60. 60.  Awareness of risks  Clean environment  Use of bleach/trigone to clean surfaces pre & post examination  The Vincent Enquiry
  61. 61.  24-Hour Emergency Line (08) 9340 1828 Freecall 1800 199 888 Business line (08) 9340 1820
  62. 62.  SARC  N.E.I.Langlois and G.A.Gresham, “The Ageing of Bruises”: A review and study of the colour changes with time,” Forensic Science International, 50 (1991) pp227-238  Maguire S, Mann MK, Sibert J, Kemp A (2005), 'Can you age bruises accurately in children? A systematic review', Arch Dis Child 90:187-189  http://what-when-how.com/forensic-sciences/sexual-assault- and-semen-persistence/  http://aifs.gov.au  http://www.mandatoryreporting.dcp.wa.gov.au
  63. 63.  Any questions?

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