Readers, Forensics Talk is back off of hiatus, in a limited capacity, thanks to my daughter loaning me her laptop. I was told by her computer expert friend today that my hard drive is almost ready to come home.
Anyway, on to other things. After reading various posts and comments on line, I'd like to clarify some things about how a SANE unit runs, the evidence collection process, and the training of SANE/FNE's.
SANE Units
While we all work under standard guidelines, not all SANE units are set up the same, nor do we all do the exam the exact same way. For example, some units have the patient stand on a sheet to disrobe. Others, including ours, don't. Just because it's not done doesn't mean the evidence collection was done wrong.
Not every unit does a toxicology test on every patient. In fact, more units are going towards not collecting a tox screen. Our unit does do a tox screen on every patient. However, even with a signed consent, the patient still has the right to refuse the test. We can't force a patient to submit to testing against their will. If they do refuse - which I've rarely had happen, it's charted that they decline the test.
I've read comments questioning if a tox screen is done in the ED and kept on the medical chart, as opposed to the SANE chart. I can't speak to other units. We generally don't do that. Sometimes a patient may have to be kept in the ED for quite awhile, to allow them time to sober up. Patients have to be alert enough to sign the consent.
In that case, if our ED nurse draws the blood, it's signed off on the SANE physician order sheet. There are two separate physician order sheets. One for the ED and one for SANE. Anything related to the SANE exam is signed off by the nurse on the SANE exam order sheet.
Another fact to consider, is that not all ED's have a separate SANE unit. Some ASA patients are seen in the ED (Emergency Dept.) only. If there is a separate SANE unit, then it's generally the SANE/FNE who does the exam, not an ED nurse or physician, in a separate (locked) exam room, usually located near the ED.
Unless the ED is holding over an intoxicated patient, triaging, or there are separate medical issues, there's usually no need for the ED nurses to get involved. They have their patients, we have ours.
On our unit, as in many others, the patient is seen first by a detective, then cleared medically, before the nurse is paged to come to the hospital. In some hospitals, the patients still have to be seen by a physician in order to be medically cleared.
In others, like my own, the triage nurse medically clears the patient. Unless there are medical issues which need to be addressed, our patients never even see the doctor. After being medically cleared, our patients wait for the nurse in a private, locked family room.
SANE Staffing
SANE/FNE's work an on call schedule. While a unit is supposed to cover 24/7, that's not always the case. What the general public may not realize is that many units are under staffed and there is often a high turnover. Many SANE/FNE's have years of clinical experience behind them and now choose to work in the SANE unit part time.
For many, like myself, they come into this field towards the latter part of their careers. Some work full time at other facilities (which I have done), while others may be semi-retired. And more and more legal nurse consultants are obtaining their forensic nursing certification, in order to combine the two.
For the rest of the SANE units, it can be a struggle, especially covering nights. When no on call time is filled at night, two things can happen. First, technically, the managers are supposed to come in if there is no one else on call.
However, realistically, that can get old real fast, so some units have been forced into closing the SANE unit at night. In those cases, the patient is either held over, or told to come back in the morning when a nurse is on call at 7am.
If a patient comes in at 3am, it's not uncommon for that patient not to see a SANE nurse for several hours, even if someone is on call. It can take hours for some patients to sleep off the alcohol enough to sign consents.
At other times, it can take quite awhile to get the patient interviewed by a detective, then registered and medically cleared. Only after all that is done, is the nurse paged. Then we have an hour response time. As in my case, many nurses work in the city but live in the burbs, so it can take an hour to get to the hospital.
However, there is still supposed to be a regular SANE who arrives and takes the case, not a neophyte in training or an ED nurse. ED units should not have to call for a float nurse if there is a separate SANE unit.
Signs of Infection vs. Semen
All patients are asked if they've had any symptoms of vaginal infections in the last two weeks. Have they had any abnormal discharge, burning, itching, etc.? Have they been treated for any infections in the last two weeks? Most of my patients answer no.
Many are surprised, once I do a pelvic exam, when I suggest they may have an infection. Many of my patients denied even being aware they had an infection, even though they had significant outer vaginal redness and swelling. Often, I don't see any signs of infection until I do the internal exam. Not every female patient exhibits symptoms of infection, including yeast - one of the most common causes.
Some SANE units still collect swabs to take to the lab (others, like ours, don't any more). Once in the lab, the technician creates a slide and looks at it under the microscope. They're looking primarily for sperm. However, in many cases, all they see are clue cells. Clue cells are cells from the vaginal lining which are loaded with bacteria. Bacteria can cause a thin, whitish discharge and foul odor, or there can be no sign at all.
The normal vaginal discharge is usually clear, watery in appearance. However, there can be a variety of "normal" discharges. Infection often causes a change in the discharge, redness, swelling, itching, burning, and painful urination.
Some women have painful symptoms, some have none. One of the most common causes of vaginitis is yeast. Yeast infections are caused by a fungus called Candida Albicans. It may cause a thick, whitish discharge, much like cottage cheese. However, not all women have symptoms.
In units where specimens are not taken to the lab, there is no way we can know for sure exactly what, if any, a patient may have, except for STD's. We do take a swab to check for Gonorrhea and Chlamydia, and we take blood to check for Syphilis. We usually get those results back within 7-10 days. (Those results come back to the SANE unit, not to the ED)
All of our patients are given an antibiotic before discharge to prevent certain STD's. Also, before discharge, all patients sign and are given a copy of the discharge instructions, which instruct them to follow up with a GYN exam within two weeks.
Culposcopy
Culposcopy is a tool which enables the nurse to have a magnified view of the vaginal areas. It looks like a long, thick pen, and has a camera and magnifier inside. Culposcopy is required on all patients, since some injuries may not be noticible to the naked eye.
When examining a patient, we first do a visual search of the outer vaginal areas. If we see any injuries, they are diagramed and photographed. The secondstep is to apply the toluidine dye on the posterior fourchette area (the 6 'clock position).
Toluidine is a special dye that will adhere only to injuries in which the top layer of skin is scraped off. After a few moments, the dye is wiped off and we view the area with the culposcope. If there are any injuries, the dye will stick. If it all wipes off, there are no injuries. If there are injuries, photographs are taken with scale and without.
The next step is to do the internal exam with the speculum. Once the speculum is inserted, we view the internal vaginal area with the culposcope. Since it shows up on the monitor screen, we often turn the monitor so the patient can see.
Most of my patients want to see the view. They're often worried that they've been seriously "damaged". While viewing internally, with the culposcope, we look for injuries. It's rare to have injuries ofthe vaginal walls themselves, unless an object has been used. If there's any injury, it's usually to the cervix, although that's rare too. Usually what we do see, are signs of a vaginal infection.
SANE Training
After reading some recent post and comments, I feel it necessary to clarify some things about the training SANE nurses receive. Most important, SANE training is meant to be a beginning, not an end. It is expected, and in our state required, that FNE's continue their forensic training.
Each year, at license renewal time, we have to provide proof that we've taken appropriate, related courses, published articles, or attended seminars, symposiums, or completed CEU's. As far as DNA goes, most of my education on DNA (to start) was obtained by taking a criminalistics course, prior to taking the SANE training.
That course was taught by the head of our state crime lab. Unfortunately, not everyone does that. For those considering becoming a forensic nurse, I strongly recommend it. All SANE/FNE's should have a good knowledge of criminalistics.
And of course, nothing beats experience. As I've said, many SANE/FNE's come to this field with several years clinical experience. That's important, I believe, for a variety of reasons. However, with the increased popularity of forensics these days, more and more nurses are entering this field with fewer years of clinical experience behind them.
SANE nurses should also have a strong science and nursing educational background. Those who have gone through a regular nursing program usually do. A good knowledge of anatomy and physiology, chemistry, microbiology, pharmacology, psychology and sociology is a must.
Most SANE nurses are on call part time. We can sign up in increments as little as four hours at a time. We're required to sign up for at least 16 hours/month. Some sign up only a few hours a month. Others, like myself, sign up for much more (I'm usually on call at least three 8-12 hour shifts/ week, plus week ends).
Some units get far more patients than others. A county unit may only see 10 cases a year, while a busy city unit may see 300 or more. Often, it's like feast or famine with ASA cases. We may get slammed for a couple weeks, then virtually nothing for awhile.
Our unit is usually busiest around the holidays, vacations and week-ends and on Sunday, Monday, and Wednesday nights. We have two permanent positions which cover those nights and week-end nights.
IAFN Certification
The IAFN certification for SANE is nice. It's not essential but nice to have, especially when testifying in court. It's a matter of sitting for an exam. One of the requirements is that the person must have been an RN for at least two years. The exam is given twice a year. This year it's being given in May and October.
Many experienced SANE/FNE's (including yours truly) don't have the IAFN SANE certification. In our state, we already have our state certification - and the exam is costly. Many have applied the cost towards other training programs.
Modified 5/6/07 6:57pm
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