To start, I'd like to thank KC Johnson for the excellent post over at the Durham - in - Wonderland blog. Next, I'd like to clarify a couple things: First, I'd like to make it clear that I'm not trying to attack the Durham SANE Nurse or law enforcement in general. On the contrary, I have nothing but the highest regard for both my fellow nursing colleagues and all law enforcement personnel.
I'm lucky in that we work with such an excellent group of detectives [and the DA's Office] who behave with the highest level of professionalism I've seen and I'm proud to have the chance to work with them. I've been asked if I'm sympathetic to the defense. The answer is no. However, there have been many things I have questioned since this incident happened.
I'd also like to clarify the role of the forensic nurse examiner [SANE / SAFE] a bit more. I have read, in the past, opinions which imply that SANE nurses are very biased towards the victim. Nothing could be further from the truth. We are forensic nurses, not victim's advocates. Victim's Advocates have their job, we have ours.
As nurses, Our role, first and foremost, is to treat our patients. Note I said, "Patients", not "victims". I never use the word "victim" in my chart notes. In fact, our guidelines discourage that. Use of that term could denote bias and part of our job is to be completely objective and non-biased. Otherwise, our credibility on the stand could be compromised.
Our secondary role, is the collection of evidence and maintaining the chain of custody of that evidence according to very strict protocols. All SANE nurses go through extensive, advanced training in order to fulfill that role. During the initial training course, our speakers are usually detectives from the local sexual assault units, the District Attorney's office, SART members, and Victim's Advocates. In the initial training course I attended, we were lucky enough to also have an FBI criminal profiler as one of our speakers. He was an excellent speaker and we learned a great deal from him.
We have been instructed in what the law requires for collection of evidence, maintaining chain of custody, and testifying as an expert witness. Prior to a case going to trial, we are free to interview with the defense as well as the prosecution. We are there for the truth only and to do what the law requires of us. While part of our job is to provide emotional support, just as we would with any other patient, we are not victim's advocates.
The SANE Exam
When a patient arrives at the hospital, he / she has usually been brought by the police. If there are no immediate injuries which need medical attention, the patient is placed in a family room or other private room, where the detective will do an interview. Once the detective has cleared the case, we get called in to do the examination. Once we arrive, the patient is taken to a locked SAFE room, or a private room in the ED, in which the SANE nurse stays with that patient throughout the exam.
The name of any person in that room, besides the nurse, must be documented. If it's an unlocked room, the door is shut and the curtain is pulled to protect the patient's privacy. The staff know not to enter and the nurse must remain in the room with the evidence until it's locked up. The only other persons we [in our unit] allow in the room, would be either a physician or another nurse the FNE has asked to come in to assist with something. They're usually only in the room a few minutes. Once certified, we function independently, so there's no need to have anyone else in the room with us.
Photos
One of the first things I wondered regarding the Duke SANE exam, was how many photos were taken. That's a clue to the extent of any injuries. Aside from the face shot and complaint number, we only take photos if there are injuries. No injuries, no other photos. If there were photos taken of the vaginal wall as well, then there should be 3-4 photos total. One interesting fact, when using a digital camera: sometimes the digital will pick up an imprint bruise that is not readily seen by the naked eye. I had it happen when another nurse and I were trying to photograph an area that was supposedly hit. We couldn't see it but it showed up on the digital camera as plain as day.
I've also had the UV light (Wood's lamp) show up the outline of a bruise, on dark skin, that I couldn't see otherwise. In addition the the photos, diagrams are another important part of the SANE report. I am curious as to what was drawn on the diagrams in this case. For every injury, there must be a diagram. Often, the judge will not allow the photos in court. So we must then be able to rely on our diagrams. All injuries are drawn, with measurements included. That should include points of pain or tenderness. No injuries, no diagrams.
Diffuse Edema
I have questioned, in my other post, the fact that there was diffuse edema (alone) reported as a characteristic of blunt force trauma (BFT). I have questioned it because you usually do not see edema by itself, as a result of BFT. You usually see other symptoms as well. This is why:
Blunt force trauma is caused by an impact of some sort - either by something impacting against the person in some way, or the person impacting, or being pressed, against some object. When this happens, an injury occurs. It may not be observable but it happens nonetheless. Anytime an injury occurs to the body, that body's defense mechanisms kick in to destroy the cause of the injury( for example, infection) and to heal the area. This is called the "inflammatory response" to injury. It happens whether an injury is mild, and restricted to a local area, or whether the injury is catastrophic and life threatening.
The first phase of this inflammatory response, is called vasoconstriction. The blood vessels will suddenly constrict and a whitened area will appear. This lasts a few seconds. The second phase is vasodilation, in which the blood vessels will dilate, and a reddish area (erythema) will appear, followed by edema (swelling). The two go together but the vasodilation (and redness) happens first. This phase can last from several hours to days. This is why I questioned the media report. As I stated in my previous post, I usually see redness along with the edema, not edema alone, with absolutely no other symptoms.
You know, I always try to look at things logically. I ask myself: Does this make sense? Is this consistent with what I know to be true? So, let's look at this logically:
This was supposed to have been an extremely violent assault - One in which the accused claimed that she was choked, beaten, and kicked, raped, and forced to engage in oral and anal sex. She claimed she was viciously raped by 3...5..or however many, men. Either way, this was not your typical rape scenario. Now, going back to the body's response to any insult / injury, is it logical that she would have no red marks anywhere on her body? No bruises, no abrasions or lacerations, no swelling - no pain - anywhere?
The posterior fourchette is the usual point of impact in a rape case involving vaginal penetration. This is the outer area just below the entrance to the vagina. This is where we see the "mounting injuries". This was supposed to be a minimum of 3 people viciously raping her: IMPACT. IMPACT. IMPACT. Considering the body's inflammatory response to injury - caused by impact - would it be logical then that there was absolutely no redness (erythema) of the outer vaginal area at all?
Considering that the vaginal area is highly vascular, with many blood vessels, which dilate, does it make sense that there would be no redness and swelling in that area after three vicious rapes? Does it make sense that there would be edema, and only edema, of the inner vaginal walls, without having redness and edema showing on the outer vaginal area first? Shouldn't one occur before the other? Considering that vasodilation, with redness, comes before edema, shouldn't that have been seen in the vaginal vault, especially around the cervix, as well? I believe so.
It's common knowledge that most rape victims have no injuries. Even victims of gang /rapes /don't always have injuries. But, in an extremely violent case like this, to have only one symptom - edema - of the vaginal walls alone, and nowhere else, with absolutely no other injuries or symptoms, defies logic.
Yes, bruises can show up later. Red marks can show up right away. Pain definitely. If someone hits you in the arm, the bruise may not show up right away, but I can bet that your arm is going to be hurting immediately!
9/18/06 Correction: Impact stated above (3) times, as written, referring to 3 vaginal rapes incorrect. Impact supposedly occured vaginally, anally, orally. The body's inflammatory response will be the same for both vaginal and anal. For anal assault, there can be redness, swelling, tears and abrasions. In oral assault, we look for torn frenulums (like under the tongue), and pettechial hemorrhages as well.
Claims for injuries at work are often a delicate issue because the employee usually wishes to remain working for the employer and does not want to damage working relationships.
Posted by: Injuries at Work | January 22, 2011 at 04:41 AM