SANE nurses discuss sexual assault exams

This is the second of a two part article.

April is Sexual Assault Awareness Month. The mystique that surrounds sexual assault examinations has kept some people from getting the help they need. The Daily Record sat down with Kimberly Hansen, the director of the Sexual Assault Nurse Examiner program, and one of the nurses in the program, Debbie Swain. They explained the process from beginning to end in hopes of allaying potential fears in those who may need their services.

"Most of our calls come from the hospital or law enforcement," said Hansen, "but we've had a few calls where they've just called through the hotline at 627-8361."

According to the National Institute of Justice, 68 percent of battered women report that their partner also sexually assaulted them. The subject of domestic violence is an important part of the exam.

"We ask about domestic violence because we need to make sure if these people are safe," Hansen said. "Can they go back home? Do they need to find a friend? Do we need to find a place for them at the shelter?"

"If it's teenagers and it's the boyfriend who's raped them," Swain said, "I always tell them that we advise against contact because we do want to ensure that they're safe. If someone finds out that it has been disclosed that they raped someone, they may come after them."

Another factor is drug facilitated assault.

"We do ask about drug facilitated assault," Hansen said. "Were they drinking, did they have one or two drinks and suddenly become drunk."

In the event of a drug facilitated assault there is more paperwork, and a sealed evidence box that they bring into the process.

"If it's within 24 hours we draw blood and get urine," Hansen said. "If it's over 24 hours we just get urine."

Out of respect for the patient, there are times when the evidence box is not used, even if the assault was drug facilitated.

"We don't do it on somebody who is not involving law enforcement," Hansen said, "because if it goes to the crime lab it has to go through law enforcement."

Not everyone who fears the involvement of law enforcement is afraid of getting arrested.

"Fifty percent of domestic violence cases have children present," Hansen said, "so they can be afraid someone is going to take their kids."

Another checklist helps them segue into the hardest part of the exam.

"We go through a post assault checklist," Hansen said. "We ask if they went to the bathroom, took a shower, all that kind of stuff. Then we come to the part of the exam where we ask them 'tell me what happened in your own words?'"

This can be taxing on many levels for a patient.

"They sometimes don't want to tell this part because of who is with them as support in the moment," Hansen said. "When they're giving a narrative it's very rare that it's chronologically accurate. This process brings it back into perspective."

Throughout the exam, they have to remain aware of the patient's status.

"We want to make sure they're stable so we check their vitals and we continually assess pain," Hansen said. "If we're seeing someone soon after the assault we may not see bruises, because bruises have to come up through the adipose tissues. So, if they tell me they have soreness we put that on the body map we put that they are tender to the touch or whatever they're experiencing, and mark that area.

"We also have to think about if they're coherent enough to do the exam, especially if alcohol is involved. If they can't consent I can't do the exam."

It's also helpful when the patient allows them to collect certain items they wore.

"If they're wearing the clothes that they came in we collect them," Hansen said. "We let them choose what we collect and what we don't. What we really want is anything that's been close to the skin right after the attack. So if we can get underwear and bras that'd be great. We keep underwear and tank tops to give them along with tee-shirts, sweats, socks and flip-flops."

One of their investigative tools is a blue dye.

"Toluidine blue is a dye that we use to help accentuate injury in small areas," Hansen said. "The vaginal area is about the size of the palm. If there's a break in the skin the Toluidine Blue adheres to the nucleated cells. We put the dye on the skin and we wipe it off using either a vinegar solution or K-Y Jelly. If there's a break in the skin it will adhere to those cells. So if there's a tear it helps them show up better.

"We collect swabs first because it can destroy evidence, but after that we do the toluidine blue. We do need their permission to use it, and we can't use it if they're allergic to iodine or shellfish."

There is another factor in sexual assault that doesn't have the level of public awareness it should have.

"We have a whole different body map for strangulation," Hansen said. "Although I appreciate that it has a checklist for me to mark for physical and subjective signs, the reality is half of all strangulation victims will have no marks on their body, but can still have bad enough injury to die from it."

The throat is far more vulnerable than most people realize.

"If you compress the carotids you can cause problems in the arteries," Hansen said. "You can cause clots. All these sorts of things that can cause death, but no marks. As people age little spines grow on the trachea and if one of those breaks off you could have air leakage or fracture."

Something even more alarming is what happens to the perpetrator once they cross that line.

"We know that once someone has strangled or attempted to strangle a partner the risk of that person killing them goes up 40 to 60 percent," Hansen said. "More research shows that people who are willing to strangle their domestic partners are more likely to hurt children, more likely to shoot and kill cops.

"When a woman comes in who has been strangled we try to get her to not return to her abuser because the next time she returns she most likely won't be alive. People will say, 'There's no marks so I'm OK.'

"Right now strangulation is not a felony. We have legislation in place trying to make it a felony."

The discharge instructions are generally as detailed as the exam.

"We give them prescriptions based on if they have allergies and what they've told us," Hansen said. "Primm Drug has been amazing, they've been with us from the beginning. They fill the prescriptions at no cost to the patient. They bill us. We bill the coalition.

"If we do a pregnancy test the results are here. If they're really sore we'll talk about doing a sitz bath. If this is somebody who needs an immunization, or Hepatitis B immunity, we'll refer them to the health department. I don't always refer for HIV testing.

"We refer if the perpetrator is known to have HIV, or just out of prison, or someone who does IV drugs. Alianza has been willing to take anybody we refer. If they want an HIV referral, or if they don't know about the perpetrator, I'm happy to do that."

The care doesn't end when the exam does. Hansen said counseling can be arranged following the examination, she said, as well as a call back to ensure the person who has just had the exam has a place to go and has not contacted the perpetrator.

After the advocate has walked the patient out, the nurse begins the next part of the job.

"If we've collected evidence we have a checklist," Swain said. "We check if we collect miscellaneous swabs, such as a hickey on the neck. If we collected an evidence kit. We include who we signed it over to. If we collect toxicology for drug facilitated incidents and if we had to make any referrals."

The SANE nurses do exams on men as well as on women, and Hansen also examines children who have been assaulted. They know their work will never be done, but with support they keep on doing it just the same.

Features reporter Curtis M. Michaels can be reached at 575-622-7710, ext. 205, or at reporter04@rdrnews.com.