Identifying and Defining Populations Served by the SANE Program
Every program should provide an open door for all patient populations. A patient should never hear “it’s not my job” from a provider. Patients may need to be provided referrals if they need additional services that are not immediately available (e.g., pediatric patients), but all members of the team and the ED staff should know the protocols of who can be served and where to refer someone if needed.
Patients may require triage and treatment of certain medical concerns beyond the capacity of the SANE program. This may be more applicable to community-based programs. In hospital-based programs, most of these services should be readily available. Medical evaluation and treatment of strangulation, provision of HIV prophylaxis, and ability to treat vaginal trauma, while not needed for every patient,69 are services that should be readily available to all sexual assault patients. For cases when those services are not available, or for community-based programs, establish memorandums of understanding (MOU) with specific agencies and develop mechanisms for a timely transfer of patients to those locations.
Triage and treatment of medical concerns beyond sexual assault—
Pregnancy. Women and transgender men may find out they are pregnant during the medical forensic examination, or may already have a viable pregnancy at the time of their assault. For the most part, pregnant women and trans-masculine individuals do not need any different treatment. The program should have predetermined medication and HIV prophylaxis protocols that are safe for the pregnant patient and fetus. Genital examinations can proceed as usual; however, use caution in the second/third trimester patient with vaginal bleeding. An examination in conjunction with an obstetrical provider is warranted. Also, a woman or trans-masculine individual past 20 weeks gestational age with trauma, abdominal pain, or contractions should be sent for an emergent obstetrical evaluation. Sometimes, the patient may report to Labor and Delivery for evaluation and disclose the sexual assault. The SANE may be called to the unit to perform the medical forensic exam.
Mental health/suicidal patient. People with underlying mental illness can be victims, and actually may be victimized at a higher rate than others. Rape and sexual assault may induce suicidal ideations in any patient. Patients should be evaluated for suicidality and referred to appropriate services (ED, crisis response center, etc.). A difficult situation is the patient with mental illness who repeatedly makes unsupported claims of sexual assault. These patients require a multidisciplinary team approach to their problem.70
ICU/Trauma. Patients may suffer serious medical illness and/or traumatic injuries that require ICU admission or trauma center evaluation. In programs where the medical screening exam is performed by the SANE, the presence of certain complaints or mechanisms of injury may require medical evaluation by ED or a trauma surgeon. For these patients, their medical/traumatic needs take priority over their forensic needs. The medical forensic examination should be deferred until the patient is stabilized. Some programs may elect to do a simple, modified exam prior to procedures/surgical interventions and then do a more thorough examination after stabilization. A coordinated team approach is required and a written protocol should be in place to explain this process. The SANE nurse may be called to the ICU, OR, or inpatient unit to perform an evaluation.
Unconscious. Unconscious patients provide a difficult challenge to the SANE program.71,72 An unconscious patient is unable to give informed consent for the exam, provide an assault history, or actively participate in the exam process. Because valuable evidence may not be properly identified or collected and may be inadvertently destroyed by therapeutic intervention, time, and bodily functions, an examination should be performed as soon as possible. Some would argue that no exam (particularly pelvic/genital) should be performed on the unconscious patient, as doing so would violate their autonomy and right to self-determination, but also that it is a second assault on the patient and their body. Others argue that the examination is no more invasive than other procedures that can be emergently performed on a seriously injured patient, and there is often no consent process for those procedures (central line, laparotomy, craniotomy), and that most victims would want the opportunity to have the evidence collected.
Some states have specific statutes that address the issue of performing a sexual assault medical forensic examination on an unconscious patient, but the majority of states do not. A program should have a specific policy and protocol for SANE examination of an unconscious patient in order to protect the institution, program, SANE, and most importantly, the patient. Options include: (1) deferring an exam for a period of time, waiting to see if patient regains consciousness; (2) deferring an examination until a surrogate decisionmaker/legally authorized representative (LAR) is identified (spouse, parent, sibling); (3) not performing an examination at all if consciousness is not regained; and (4) proceeding with the medical forensic exam and holding the evidence until the patient or designated LAR provides consent for police involvement and release of information.
As stated in the National Protocol for Sexual Assault Medical Forensic Examination, “Examiners should develop policies and procedures for providing sexual assault care to the unconscious patient. Such care should respect the autonomy of the individual and be consistent with jurisdictional interpretations of emergency exceptions to informed consent.”73 When developing a protocol, input from the district attorney, hospital counsel/risk management, and/or an ethicist may be sought. If a patient is incapable of providing consent for a period longer than 5 days, thereby creating a real time conflict about examining an unconscious patient, risk management or the hospital ethics committee should be consulted.
Incapacitation. Patients may be incapacitated for a number of reasons, and the incapacitation may be permanent, long-term, or short-term. Patients with permanent or long-term incapacitation often have a designated power of attorney, legally authorized representative (LAR), guardian, or family member to give consent for the examination. More frequently, incapacitation is short-term, from alcohol, drugs, or mild injury. In these cases, it is appropriate to wait until the patient regains the capacity to consent to and participate in the process.
Pediatric Non-Accidental Trauma and Elder and Vulnerable Adult Abuse. Some patients may present with findings indicative of physical abuse or neglect, at which time a history or physical exam may suggest sexual victimization. Conversely, patients may present with concerns for sexual victimization and findings of physical abuse or neglect may be discovered during the evaluation. Therefore, it is important that medical professionals coordinate the evaluation and care of these patients, regardless of the setting (inpatient versus outpatient). Child abuse pediatricians, emergency medicine, or other medical providers and SANEs may have shared responsibilities for these patients. Institutional policies and procedures and/or MOUs should be implemented to make such cases as seamless as possible. If physical abuse or neglect is suspected, the SANE should report the findings to child welfare in accordance with the local mandated reporting laws. Of course, the medical needs should always be prioritized over the forensic medical exam and collection of evidence.
Consultation with other providers. A consultation with other providers may be required at some time during the evaluation of the patient. Examples of specialty care that may be consulted include gynecology if there is vaginal or cervical trauma, infectious disease if there are problems prescribing HIV prophylaxis, or psychiatry if there are significant mental health concerns. In hospital-based programs, this is often accomplished by calling for a consult with the specific specialty provider. Other programs may find the easiest solution for urgent referrals is to send the patient to an emergency department for evaluation by a specialist. These programs should have specifically designated referral hospitals. Which hospital to use depends on the patient’s needs. Outpatient referral may be appropriate, and all efforts should be made to assist the patient in getting a followup appointment.
There are some common referrals that patients need following a SANE evaluation. For these services, the program should have specific referral patterns, and those providers should know that they will be receiving referrals from the SANE program. An MOU may be required. These referrals usually include, but are not limited to—
Rape crisis center
Social services agency
HIV N-pep follow up. All programs should be able to provide immediate access to HIV medications, but may refer patients for the ongoing care required during the 28-day treatment period (public health, infectious disease, immunology)