Webinar presenters Kim Basinger and Roger Blevins answered a number of your questions after their presentation, Understanding Sexual Abuse Examinations in Investigation and Prosecution Efforts. Here are just a few of their responses.
Audience Question: So, Elizabeth asked if you could repeat the reference for the timeline of the national protocol.
Kim Basinger: I’m not sure quite how she’s asking, but the National Protocol for Adults and Adolescents, I believe, was 2016 and pediatrics was 2013 or it might be the other way around. But both of those protocols are online, you can Google them and it pulls the National Protocol, and you can print it out or whatever you want to do with it.
Audience Question: If the patient does not know or remember when the assault occurred, which exam do you use?
Kim Basinger: Well, typically, law enforcement will decide to do which exam to do. They will, a lot of times, if the child is not sure and they can narrow it down enough, they’ll do it as a non-acute. But sometimes, if they’re just not sure and can’t get any fact. Sometimes, they’ll do it as acute.
Roger Blevins: Yeah. You can usually get enough history from a caregiver or investigators because you have a suspected perpetrator. You can find out when the last time the child was around the perpetrator, that’s tough if it’s somebody in the home. But you can often get a good ballpark idea of when the last time something could have happened to the child.
Audience Question: Are there strategies that either of you recommend for building rapport with the patient?
Kim Basinger: I just give them all the time that they want to. I sit down in a chair where I’m at their level. Whether it’s adult or child, it doesn’t matter. They’re my only patient, I don’t have other patients in the ER that I’m taking care of at the same time or at the child advocacy center. So, I’ve got all the time in the world to visit with that child or that adult, play with that child to, to build that rapport.
Roger Blevins: Yeah, I will usually do most of my past medical history with the child there with the parent, so that they can get used to me. Also, I have a comfort person. If they want a comfort person, that usually helps. And the last thing is, I make them laugh. If I can make a path before we get into this child sexual abuse exam and during the general physical exam, they’re probably going to be fine. So, I do a lot of kiddie stand-up comedy.
Audience Question: How long does it take to do the acute exam process? If you don’t mind sharing both of a sharing?
Kim Basinger: When I do an acute, the one that’s not complicated, it’s about four hours. So, that’s not four hours touching the patient. Part of that is, but part of it is also, the setting up of the equipment, the setting up at the kit. The protecting the kit from getting contaminated, letting the advocate visit with the patient to give what they need to do. Taking them, taking care of the patient. And then once the patient is dismissed, I still have other things that are part of the exam. Even though the patient’s not in the room, as per taking care of the evidence. Be sure and I’m packaging it right. Labeling it right. Following the chain of custody and when law enforcement picked up. That’s about the average of an acute exam that’s not complicated. It can be longer if they have other issues such as strangulation, head injury, other life-threatening issue’s going on, it can drag out for a lot longer.
Roger Blevins: Yeah. The delayed exams usually take me about an hour from start to finish, getting the history to telling the child that they’re okay, most of the time. And my ano-genital exam actually, usually takes a couple of minutes. All I have to do is very gently pull out on the major lips of the vagina. Everything will open up. And I can see everything I need to see. Look at the anus. And if the kid is co-operative, we don’t have any technical problems. And it’s a normal exam. I’m out of there.
Audience Question: Are there ER physicians also that are trained for the sexual assault exams to or is this a hit and miss?
Kim Basinger: It’s a hit and miss. However, there is a manual out, it’s called the evaluation of the sexually assaulted, sexually abused patient in the Emergency Department. It’s put out by the American Academy of Emergency Physicians. I got my first copy of it in 1996, so it’s been out there a long time. It was updated in 2013 and it’s a guide for all ER doctors to do these exams if they don’t have a SANE nurse around, I’ve been a nurse longer than there’s been SANE in my area and doctors used to do these exams, and the nurse would do most of it. The doctor would come in and do the pelvic. And those cases still went to court and got convicted. But, since SANE came along, doctors got real standoffish, in a lot of cases. But there is that manual out there that’s written for them, by them, on how to do these exams, if they don’t have a SANE nurse.
Audience Question: Is there still an extensive backlog on processing these kits?
Kim Basinger: I will say that Texas is not an extensive backlog anymore. They can do a good turnaround in about 90 days. And but that’s because of some mandates that came out. We also have a statewide Kit Tracking System, so when I do a kit, I enter it into the database. Before I hand it off to law enforcement. Law enforcement then has to enter that they’ve received it. Then it has to be entered by the crime lab. Texas has 30 days to get the kit to the crime lab. So there, so that’s an extra 30 days onto the 90 days turnaround. But that’s still a lot better than it used to be, but this system is tracked so good that I’ve gotten calls from Austin going… Can we say that you signed this off to a kit? This kit off to an agency that isn’t in our system, which they’re mandated to be in the system, but they just haven’t done what they’re supposed to do to get in this system. Can you tell me what law enforcement agency it is so that we can correctly track this kit? So, they’re staying on top of it at the state level, And we actually give a card to the patient, and they can actually track the kit themselves. It does not give test results, but it’ll let them know where it is. And once it leaves the crime lab, it goes back to law enforcement. Then they know they can go to that law enforcement agency and find out if there was anything found in the kit. That information doesn’t come back to healthcare. It goes back to law enforcement only.
Audience Question: Do you not draw blood as well as collect urine on a patient? She was commenting that they do both in Kansas. So, she was just wanting a point of comparison.
Kim Basinger: It depends on the situation and on the history. The urine is more for the drugs, and the blood is more for alcohol. However, you can detect the drugs in the blood as well. It just, I kind of base it on the history given by the patient, but, as I said, that’s going to be in your acute examination, and that acute examination is a lot more invasive. So, if I am having to draw blood for blood alcohol content, yeah, I’m going to have to do something invasive, but those are not put in the kit itself. The kit is kept separate. So that can go into dry storage because that’s where a big shortage is a shortage of refrigerated storage. So, we want that kit to go into dry storage. And we, the urine and blood kit is kept separately. And it’s a lot smaller so it can be refrigerated and not take up much space.
Audience Question: We have a number of questions about consent. Could you please discuss the importance of consent during the exam process and how you handle this? You know, they don’t have to consent to 100% of the exam if they don’t want to, they don’t have to contact law enforcement. Could you just kind of talk through some of that as well?
Kim Basinger: Absolutely. Everything that we do is patient-driven. We let them know right up front, that they drive the train, and we will tell them before we do any procedure what we’re going to do. And they can decline that if they want to. We try to educate them as to why we need to do it, but if they say no, we’re not going to do that, that would be assault, if I touch their body against their will. Consent is very, very important, that they understand what they’re consenting or dissenting to. So, it’s not just do you want me to do this yes or no. You’ve got to give them the information for it to be informed consent. That’s going to be a lot different than when they signed the consent form for treatment. They’re signing consent to be seen in the ER, but they’re not signing saying. And that consent, yes, you can touch my private area. So, we typically get consent from everybody for every single thing that we’re going to do. And that includes children. If a child, now, when I say that I’m talking about a child that’s old enough to talk and understand what I’m doing, refuses to let me touch them, I’m not going to force an exam on that child. The way that they’re behaving when they’re refusing is what I call psychological evidence. And I document that, a document that the child recoiled and clamp their legs shut and cry because kids don’t typically do that. The kiddos are typically a little more they’re not as private with their body, they don’t mind being naked, and so when we have that, that kid or an adult, that’s adamant that you’re not going to touch them, we’re not going to force that on them, right, Roger?
Roger Blevins: That’s correct. We never hold the kid down or do anything to a child that’s going to be traumatic and forcing an exam is traumatic.
Audience Question: How old should the child be to obtain consent? How old should they be to obtain consent?
Kim Basinger: I don’t think there’s actually an age. It’s going to be on their developmental status. I’ve got a granddaughter that was very articulate at the age of three. But her brother at the age of six still isn’t articulate enough to understand everything. So, you’ve got to use your clinical thinking skills. And talk to the child. And see if they understand what you’re saying. Parents raise children to don’t let people touch your private parts. And so, if they do not want this, to touch the private parts were not go into. Now some exceptions to that. As I had. I did an exam on a one-month-old. A one-month-old, does it have any concept of what I’m doing? And so, I did have the caregiver hold the child, the child cried. They were mad because they were being held down but I wasn’t doing anything that hurt the child, but if they’re old enough to understand. And at that age, it’s not a number, that’s where I make my decisions from.
Roger Blevins: Occasionally, you’ll get into a situation where the child really doesn’t want an exam but they’ve got evidence of infection. They’ve got nasty vaginitis going on or perhaps they have a foreign body or some other reason. Then you have to push it a little bit because it’s for the child’s health, for their life and limb, or I have to go with what the parent says.
Kim Basinger: I totally agree with Roger on that. If there is a medical necessity, we’re holding them down and getting it done. Then you have to do that. Like if they’re bleeding, I have to find the source of the bleeding to stop it. So, if there’s a medical reason for holding them down, absolutely. But we don’t hold them down just for the sake of evidence collection.
Audience Question: Could you please explain the concept of two positions and positive findings again?
Roger Blevins: Well, I didn’t explain it very well, to start with, I’m sorry. Most of the time, we will do our exams in the supine frog-leg position. So we’ll have the child lay down and I’ll have them bend their knees and tell them, okay, now, drop your knees out, like a froggy, some people will use butterfly, and we can do the exam there because gravity is pulling on the hymen and sometimes, things in the genitalia can be a little sticky. You can get funny looking hymens in that position that make you wonder if there’s something wrong or not. So, what we’ll do is, if we can, we’ll put those children over on their abdomen. And, uh, we’ll have them put their little rear end up in the air and use gravity to help pull that hymen down. And many times, when you change the position like that, you get a ———- hymen from something that wasn’t very normal. You can also float it with some normal saline. There’s a lot of tricks that you can use, but, we always confirm things in two positions.
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