CASE: ACUTE SEXUAL ASSAULT
Note: Evaluation of the acute sexually assaulted patient may be challenging for health care professionals. For many, acute sexual assault is an emotionally difficult topic. Be mindful of your own feelings as they arise and make note of them; this could be an indication of how you may feel when actually responding and caring for a patient in a similar situation.
It is Saturday morning at 6am. You are the triage nurse in a busy ED. As you are walking across the waiting room, a young woman, Lorraine, comes up to you and states in a hushed voice, “Can I talk to you in private?” Together you walk to triage room where others cannot hear. She starts to cry and says, “I need the morning after pill…I was just raped.”
You are in a large ED with mental health providers and GYN (via the academic affiliate) available on-call 24/7. Social work is available on-site from 8am to 12am and on-call otherwise. Your VA has an agreement with a local SANE/SAFE organization to provide 24/7 on-call on-site services. Radiology, lab and pharmacy services are available on-site 24/7. Your VA in is a non-mandatory reporting state.
ABCs are intact. Lorraine, who is 27 yo, appears anxious and tearful when discussing the assault which occurred 3 hours ago at a friend’s house. She denies any acute injuries, pain, or any other symptoms of concern. Her LMP was 1 week ago. She denies thoughts of hurting herself or others, and no one has accompanied her here today.
VS: T 98.8, HR 98, BP 134/76, RR 24, 98% on room air
Pain: 0/10
Lorraine expresses interest in a sexual assault (forensic) exam, but does not want to notify law enforcement. You notify her that you are going to call the charge nurse to ensure a private room is available. You tell Lorraine she will be offered a chance to talk to a mental health provider. Lorraine asks that her roommate be called. She requests you don’t share any details, except she is safe and would like her to come to the ED. She also requests female nurses and providers, if possible.
You escort Lorraine to her room and provide handoff to the primary nurse including letting her know she is going to call the roommate and will let them know when she arrives. The charge nurse informs there is a female provider available.
Lorraine is oriented to her private ED room and introduced to you as her primary nurse. When asked what would make her more comfortable, she says she’d like to use the restroom. You confirm with Lorraine her desire to have a forensic exam, but not notify law enforcement. You answer questions she has about the forensic exam including explaining urinating may compromise the collection of important evidence and it would be best to wait until the forensic exam is performed. Lorraine acknowledges this and feels as though she can wait to use the bathroom until the forensic exam.
Lorraine discloses to you the sexual assault occurred 3 hours ago. The perpetrator, an acquaintance, held her down forcibly by her wrists and had nonconsensual, unprotected vaginal intercourse. Lorraine also shared that she went to a friend’s house after but her friend was not home, so then she came to the ED. She has not showered or changed her clothes since the assault. She asks if she can talk to the ED provider about being treated for sexually transmitted infections and “the morning after pill”. Lorraine expresses interest in talking with mental health.
She says her wrists are feeling sore, but denies other physical injuries. She takes no medications and has no known allergies.
Lorraine continues to be tearful at times, but appears to appreciate the direct communication about the next steps in her care.
Reassessment reveals stable vital signs.
The charge nurse knocks on the door and announces Lorraine’s roommate has arrived and asks her whether it is okay if she comes back to the room. Lorraine is relieved to have her friend with her and asks if her friend can remain in the room for her entire evaluation. The charge nurse and friend remain with Lorraine as you step away to communicate with the ED provider.
The primary nurse contacts mental health on-call per provider orders. The ED provider enters the room.
After expressing empathy and gaining permission for additional questioning, you confirm Lorraine does not want to report the assault to law enforcement right now, but she is interested in having forensic evidence collected and is aware a SANE/SAFE will be called in for this. She doesn’t think drugs were used to facilitate her assault, but she agrees to collect a urine specimen for testing and feels like she can still wait a little while longer before she’ll need to urinate. She is interested emergency contraception, and STI treatment, but isn’t sure about HIV testing. She is aware mental health is being called per her desire. You ask the primary nurse to contact the SANE/SAFE organization.
Lorraine shares a more details of events surrounding the assault with you as the ED provider: During a party with friends, she had a few drinks and was approached by a male friend of a friend who was flirting with her. As the night went on she decided to go lie down in a back room because she was not feeling well. He entered the room, started kissing her, she tried to push him away, and he became more aggressive. He forcibly held her down and raped her vaginally without barrier contraception; she believes he ejaculated. He left, but she stayed there for a while unsure of what to do before going to a friend’s house. When her friend was not home, she came to the ED. “I still can’t believe this happened to me, I am so embarrassed.”
You perform a targeted physical exam wearing gloves and with Lorraine fully clothed. You find no bruising, erythema, edema, abrasions, or skeletal injury to document. The SANE provider arrives with a victim advocate. The SANE performs the evidence collection exam for Lorraine.
Nursing reassessment reveals Lorraine is stable and feeling emotionally fatigued, especially after the forensic exam. Her roommate remains supportive and by her side. Lorraine is made aware that the on-call mental health provider is ready to meet with her and further evaluate her safety after the ED provider discusses treatment options.
In consultation with Lorraine, you recommend STI empiric treatment for gonorrhea, chlamydia, trichomonas, bacterial vaginosis; Hepatitis B immunization; prophylaxis for HIV and emergency contraception. Lorraine declines HIV testing, but consents to post-exposure prophylaxis as well as empiric STI treatment, immunization and emergency contraception.
The mental health provider updates the ED provider and nurse on Lorraine’s evaluation. Lorraine denies any thoughts of harm to self or others. She feels safe returning to her home with her roommate. The mental health provider collaborates with Lorraine to come up with self-care strategies Lorraine may use in the next few days including seeking social support, taking time to rest, exercise, not isolating, and as needed being willing contact the ED, the crisis hotline, or other resources such as local rape counseling center. Together they come up with a plan for the next few days.
Education is provided to Lorraine about symptoms she may experience in the following days (i.e. nightmares, trouble sleeping, self-doubt, hypervigilance, etc.) to normalize this experience, and reassure her that this does not mean she is going crazy or that these symptoms will last forever. The mental health provider discusses options for follow-up care such as weekly sessions and makes an appointment for Lorraine to be seen for a mental health follow-up within the next week as per policy.
Lorraine is anxious to go home, shower and get some rest. She is greatly appreciative for the compassionate care she received by her ED team, SANE and mental health provider.
KEY LEARNING POINTS
- Follow VHA Directive 2010-014: Assessment and Management of Veterans who Have Been Victims of Alleged Acute Sexual Assault
- Know how to access up to date information on your state’s policy on mandatory reporting (e.g., National Association of Attorneys General (NAAG):
- Ensure the EDis a safe and supportive environment focusing on acute medical and psychological treatment and support
- Acknowledge it is not the ED staff’s role to determine whether or not an assault occurred, rather it is their role to tend to the needs of the survivor
- Acknowledge that it is not the ED staff’s role to rescue the sexual assault survivor completely from her distress, rather to know this is the first step in her recovery
- Be aware that caring for those sexually assaulted requires a special sensitivity to restoring a sense of control and safety through informed consent and emphasizing the patient’s right to accept or refuse any portion of care offered
- Avoid revictimization by minimizing recounting of the event and focusing medically relevant information gathered in a non-judgmental and caring way
- Recognize that comprehensive sexual assault care requires a multi-professional approach potentially including SANE/SAFE examiners, victim advocates, medical and mental health professionals, social work, and law enforcement
- Appreciate that caring for those sexually assaulted is a challenge on both professional and personal levels; self-care takes a team approach; debrief with colleagues
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