 And Cinderella and the Prince got married, and they lived happily ever after. What comes next? The end. The end, that's right. Okay, give me a snuggle. Come on. I'll be home. Remember what I told you about Daddy? Okay, Daddy won't be home tonight, but he's not very far away. I'll be home tomorrow as soon as he sees a man and he'll give you a snuggle, then. Okay, honey? Okay. Shut up. I'll use this on both of you. Anything you want. And if your kid wakes up, I'm gonna cut her. This is happening to me, but a man just broke into my house and I've been attacked. Uh, yeah. No, I didn't know what to do. Yeah, she's asleep. Okay, call the police. Oh, okay, all right. Okay, bye. I've been raped. Can I help you? Yes. This is Mrs. Farrell. She's been a victim of an assault and we would like to have her examined. Hello, Mrs. Farrell. My name is Lynn Paraly. If you can wait here a minute, I'll go get the nurse to be taken care of you. Our primary concern when a sexual assault patient comes to the emergency department is to ensure priority and triage, privacy in all aspects of her care, and companionship throughout the process. I'll call the count for you. Okay. In my initial contact with the patient, I want to make her comfortable and give her a feeling of safety. Mrs. Farrell? Hi, I'm Mary Noble. I'm the nurse that's gonna be taking care of you. Okay, Mrs. Farrell brought in some extra clothes, so I'm gonna need all the ones you're wearing now for evidence. Okay. Thank you very much. We'll be in the copy room. We'll wait for you while you're getting examined. Why don't you come with me, Mrs. Farrell? I'm gonna take you to a room that's a little bit more private. Mrs. Farrell, would you sit down right here? It's a little chilly, let me just get a blanket here. Thank you. I think you've been through a pretty rough experience. I thought that he was gonna kill me. Are you still frightened? It's like it's not real. I can't believe it. And I've always been so careful. I never thought that anything like this would happen to me. I don't want to talk about it. I just wouldn't forget it happened. I don't want to talk about it. I understand how you feel. It must be still very painful for you. But we found that it really does help to talk about it. Don't feel quite as alone with your fear. Would you like me to call him for you? No. My friend, staying with my daughter, she's gonna call him and he's gonna come soon. Would you like me to check with her to see if she got a hold of him? No. I'd just like to explain to you what we'll be doing here. And the first thing that we're gonna be doing is a physical examination. The doctor will be asking you specific questions in relation to the physical exam. And he'll probably also ordering some lab tests for you too. He'll discuss that with you. Then we're gonna want to collect evidence. And we'll need a consent for us to do that. And then we'll need a separate consent from you to give that evidence to the police. Okay. Yeah, I'll do that. I want to give it to the police. Okay. And then we'll have you talk to a counselor regarding the emotional feelings that I'm sure you're having. And we probably will have for a while. I used to think rape was something that happened only to women who somehow invited it or who weren't as careful as I am. But in talking to rape victims, I find that most of them are just as careful as I am and many of them live in neighborhoods just like mine. Rape is on the increase. We're seeing more and more victims in the emergency department. It makes me realize that it could happen to me and my family. And that's real scary. But even though I have my own feelings, I want to help the patient while she's here. I want her to know that she's now in control of what's happening to her. That's what I try to communicate to her the whole time I'm with her. I know that what I do and say will make a difference in her recovery. I also feel very responsible for making sure all the evidence collection is done correctly because I know how important it will be to the victim if the case is prosecuted. Seems okay. Dr. Martin. Yes. We just admitted women who have been sexually assaulted. If you get them ready to go, I'll leave right now. Hello, Mrs. Farrell. Dr. Martin, and I'll be taking care of you while you're here. I know you've been through a bad experience, so we'll try to make you as comfortable as we can. Sexual assault patients should be considered victims of multiple trauma, and they should be given appropriate treatment priority. Their care involves very complex medical, psychological, and legal issues. It's very important that every emergency department should maintain and follow a formal written protocol. While many of these patients have no physical injuries, their psychological trauma often is serious. So psychological support and evidence collection are the main tasks. It's particularly important to approach these patients with a non-judgmental attitude. Because of the powerlessness and helplessness experienced during the assault, it also is important for the physician to help the patient regain feelings of control. You give the patient control by explaining what you wish to do, and why, before you do it, and also by involving the patient in each of the decisions affecting her care. The next thing we'll need to do is a physical examination to make sure you're okay physically. Because sometimes you have injuries you're hardly even aware of. And at the same time, I'll be collecting evidence that may be needed later if you decide to prosecute. And I'll try to explain everything as we go along and tell you about each step, but feel free to stop and ask questions if you have any. So why don't we start with some general questions about your health? I usually begin with questions about the patient's general medical history to give myself time to establish rapport with the patient before I get to the more sensitive questions. Occasionally I'll get some really important information. A recent illness or abdominal surgery, for example. This would indicate a much more careful evaluation. Then I ask about gynecological history including parity, parity, date of last menstrual period, and the use of contraception. Then I go on to ask about the assault itself. As I approach each section of the history, I explain the reasons for the questions I'm asking. The purpose of all these questions is to help me know what to look for when I examine you. So why don't we sort of start at the beginning and let you tell me about what happened during the assault? It was about nine o'clock and I was upstairs putting my daughter to bed. When I got to the bottom of the stairs, somebody grabbed me from behind and I turned around and it was a man with a ski mask on and he had a knife and he said shut up. And then he yanked my arm up behind my back and pushed me into the bedroom and threw me on the bed. Please, take anything you want. Later. Now what happened next? You mentioned that he yanked your arm. Where did he grab you? On my wrist. Does it hurt? A little bit. And you mentioned that he had a knife. Did he use it in any way? No. He didn't cut me but he threatened to and he had it against my face. And after he threw you on the bed, what happened then? He threatened to hurt my daughter and then he pushed me down and I pushed him back but he had my neck and my wrists and then he raped me. I know this is very difficult for you but I do need to get some details for the exam and for evidence. Can I go on? Was there vaginal penetration? Yes. Could you tell whether or not he ejaculated? Yes, I think. Yes, I'm sure he did. Was there any anal, any rectal penetration or any attempt? No. Was there any kind of oral sex? Was there any other type of sexual or physical abuse? We need to identify all the areas of sexual contact. We also need to ask if the patient lost consciousness or was forced to take drugs or drink anything. The purpose of these questions is to help determine the kinds of injuries the patient may have and to guide collection of evidence. This is also why we ask whether she scratched or injured the assailant and what she did after the assault. I only have a few more questions. After the assault, did you change clothes? No, this is the skirt. It has stains on it. We can use that later for evidence. Did you wash or bathe or douche? No, I didn't know what to do. Did you use the bathroom? No. Did you take any medications? No. All right, that's all the questions for now. And the next step is the physical examination. I know this has been kind of hard for you, but the information you've given is very helpful both for the exam and for the evidence. I'd like to have the nurse help you get into a gown and I'll be back in just a minute. All right. This is Farah while I'm getting you undressed here. I'm also checking for any scratches and bruises. And I'll also want to examine your clothing for any evidence of the assault. Notice some red marks here on your neck. That's pretty sore, huh? Yeah. I think the police are going to want to take pictures of that just to give them an idea of the force that he used on you. I was really scared. I mean, I kept thinking that my daughter would wake up and I felt so helpless. It's really terrifying being so powerless. That's what I was. I was powerless. That was the worst part. Do you know if there's any stains on anything else like the bedclothes at home? No, the police checked it. Okay, Henry. We want to just have a seat right there on the bed. Each article of evidence should be placed in a separate paper bag. And each bag must be carefully labeled. We're going to need a urine specimen from you. It'll make you feel more comfortable for the exam. If you come with me, we cannot get that. The specimen will allow us to do a baseline pregnancy test to find out if the patient was pregnant prior to the assault. And the urinalysis may reveal sperm in the specimen. If I think the patient has not had a pelvic exam before, I make sure to explain the procedure before the doctor begins. First, I'd like to do a general physical exam, okay? So let's go ahead and start with the head. Any tenderness up here? No. The physical examination of the sexual assault patient begins with a general inspection of the body. The physician's responsibility is to carefully search for and document information that will help corroborate the patient's history of the assault. We especially look for signs of force, such as bruises and scratches, or even tender areas. This is the sore wrist, right? Squeeze my fingers. Pain. Very good. Signs of trauma are often found on the victim's neck, back, and forearms. Just lie back. Now I'd like to do the pelvic exam. I'll try to make this as general and comfortable as possible. But if you experience any pain or have any discomfort, I'll go and I'll stop. And then I won't start again until you're okay. All right. Is that evidence kit ready? Yes, it is. Because communities have different requirements for evidence collection, it is important for each hospital to establish a protocol in cooperation with their local law enforcement and criminal justice agencies. What we're going to do first, Mrs. Farrell, is check for any signs of external injury. And you may feel some strange sensations while I'm collecting surface specimens, okay? Okay. We also look for any stains or foreign matter, such as hairs or fibers, and usually take pubic comings. When foreign matter is found, it is collected, preserved, and labeled. Okay, that's fine. I don't see any sign of any injury on the outside. So now I'm going to do an internal examination. And for that, we're going to use this speculum. We've warmed it in water to make it a little more comfortable. Are you ready? It will go slow and easy. Try to relax as much as you can. And it might help if you do breathe in and out through your mouth. Nice and easy. We don't use a lubricant on the speculum because it would contaminate the laboratory examination of the specimens we'll be collecting. How are you doing? Fine. This part of the exam is often very difficult for the patient because it reactivates the vulnerable feelings she experienced during the assault. Flashbacks are common at this point. It helps the patient if the doctor keeps talking with her, letting her know his findings. Now I'm going to collect some specimens for evidence. We swabbed the posterior fornix, being careful to avoid the cervical os. Now you're going to feel a little touch inside. If the assault had occurred more than six hours ago, we would take a second swab from the cervical os also. Be sure and let those slides air dry. The swab and the slides will be examined for sperm and acid phosphatase. If there are any pool secretions in the vaginal vault, we place the aspirated specimen in saline. I'll examine a slide later under the microscope for the presence and motility of sperm. Now one last specimen to collect. Do you have that there, Martin? We take a GC culture at this time and draw blood later for a baseline BDRL. Now I'm going to remove the speculum very slowly and as I come out we'll check and see if there's any sign of injury inside. Everything looks fine. Now I'll be doing a bimanual examination. I'll have one hand from the inside and one hand pushing on the abdomen. If the patient's description of the assault had indicated, we also would examine for tissue damage and collect specimens from the perianal and other areas. What about the way over on this side? No. Now we finish the pelvic exam. We'll help you slide back up on the table and then we can talk about treatment. Because of the assault, you've been exposed to some health risks. I could be pregnant, couldn't I? Well, it is possible. Because of the time in your menstrual cycle, there's about a 5-10% chance. And that's certainly something we should discuss and see what could be done. And basically there are two options. What are the options? In the treatment discussion, the physician should cover two issues. First, the patient should be informed of the chances she might become pregnant as a result of the assault. Second, the possibility that she may have acquired venereal disease should be explained. In both cases, the patient may elect to receive immediate prophylactic treatment or to wait and reassess the problem later. The patient needs to be fully informed about the purpose of the baseline pregnancy and VD tests, the need for follow-up tests, and the risks and side effects of the various options. Whenever there is no clearly preferable clinical course of action, the final decisions on timing of therapy should be left to the patient. Making your own decisions also helps the patient regain her sense of control. You can either take antibiotics now and hope to prevent any infection, or you can maintain very close follow-up with your private physician. And then if a culture is positive or if you develop any symptoms, then take the antibiotics. I want to take it now. Mary can give you the medication and then you can get dressed. Now that we've dealt with the medical aspects of things, I'd like to help you deal with the emotional impact of what has occurred. We have a specially trained counselor, and I think it would be very helpful for you and your family to spend some time talking with her. I'd like to call her in as soon as I'm finished. Okay. Her name is Ellen White. While Mrs. Farrell is with Ms. White, could you take the evidence down to the police? I'm sure. I also have this specimen you wanted to look at under the microscope here on the counter. The nurse will tell you about the follow-up care before you leave. You're okay medically, but be sure to have the follow-up tests we talked about, all right? Okay. Do you have any questions? I'm really sorry this happened. Thank you. Hi, Bob. Yeah, the specimens are in this bag here. And then I just need you to sign this right here for chain of custody. Okay. Okay, thank you. What medical personnel do in the hospital makes a difference as to how successful we are in court. The doctor and the nurse truly have to be very knowledgeable in knowing what to look for. It is extremely important to keep complete and thorough records of your findings. The doctor's chart is very powerful and persuasive in court. It is relied on by judges and juries. If it is legible and if it is complete, often times stipulations can be obtained in advance saving the doctor the necessity of coming to court. Successful prosecution of the offender is one of the few ways that a victim can do something about what happened to her and prevent it from happening to other people. But rape is a very hard crime to prove. Sometimes the only corroboration we have is the evidence found in the hospital. That is why we work so closely with hospital staffs and encourage the use of systematic procedures. In short, by working closely with the staff of a hospital, it makes it easier on a victim and much safer for our community. I should have fought more. Maybe I could have stopped him. Why is it you think you could have done? I could have screamed or hit him with something. What do you think would have happened then? I think he would have stabbed me with a knife and I didn't want my daughter to wake up. Your choices were really limited. It sounds like you thought he might have killed you. I was trapped there in the house and I just kept thinking about my daughter. Alice, it sounds like you were really worried for her safety. I'm really worried about going back into that house. I don't know how I'm ever going to feel safe there again. Feeling afraid is very understandable after what you've been through tonight. Is there anything that you think might make you feel safer? Well, I think that I'll call the police and ask them to come out to my house and make sure that it's secure. That's a good idea. How long is this going to last? Because I keep thinking about it over and over. You've been through a really traumatic experience. It's a normal reaction to feel upset and unsettled for a while. If you'd had a physical injury you'd need time to heal. This is an emotional injury. It needs time too. I keep seeing it over and over again. I've seen it over again is what we call flashbacks. After an assault we know that people may have trouble sleeping or concentrating as well. These are all very common reactions and they last a while. I'm here to help you through that. And we know that talking about it too can help to relieve some of the control the event has over you. Talking about it does help. It does make me feel less shaky. But I can't imagine talking about this to my husband or to my friends. I'm going to be really upset. Could you talk to him first? I'd be glad to do that. When something happens to one member of a family the rest of the family is affected too. That's why we have follow-up counseling here for all of you. And Alice we have dealt with some of your concerns but I imagine there are a lot more feelings you'd like to talk about and we could do that in our next visit. Could I call you the next day or so and make arrangements for another visit? Is there anything else you'd like to ask me about? Mrs. Farrell? Your husband is here. He's out in the waiting room. Could you go down there first? Sure. I'll be glad to and I'll see you before you leave. I have your after-care instructions here and what I've done is listed all the things that we've done for you today like the lab tests and the medications that we've given you. The after-care instructions should explain common reactions following these assaults and list the phone numbers and locations for community resources. Medical legal and counseling referrals specifically and financially accessible to the patients and responsive to her unique crisis needs. It's important to get several phone numbers work, family, friends where we can reach the patient for follow-up because rape victims often change their residence suddenly. It's also important to make sure the patient has a safe place to go and transportation to get there. How have things been going the past few weeks? All right. Um, I'm still having a little trouble concentrating. What kind of trouble? Well, I keep thinking that it's over and then it all keeps coming back to me. Like, I'll be right in the middle of something all of a sudden. I'll just remember everything that happened. That makes it really difficult for you. But it's really normal. Good. But I'm trying to take your advice and I'm trying to let as much out as I can to my husband and my friends. That's good. Is there anything else you think might help? Yes, there's one thing. I'm having trouble with... my daughter keeps asking questions and she wants to know why I'm so jumpy and why I check the house carefully at night and I know that she senses something is wrong. I told her about what's happened. Well, I told her that somebody broke into the house and scared me. But actually, I've avoided talking much about it at all and I really need some help on this. Well, Jeanne is eight years old. She may need to have a little more information. Children may notice many things they're curious about. Changes in mother's behavior. New locks on the door. A special concern on father's part. The child was at home. The parents can never be sure the child didn't hear the attack but is too frightened to bring it up or perhaps has even repressed the memory. It's best to be truthful and help the mother to give whatever information is appropriate to the child's age and agrees with what the child did see or hear. But even though I have my own feelings as a nurse I want to help her cope with her feelings. I'm a caring person as well as a professional. I try to show her this in everything I say and do. Even more than other patients rape victims should be informed about every procedure before it is done and they should be involved in each of the decisions affecting their care. This will help to restore their feelings of safety and control. The psychological impacts of rape trauma can be long lasting. If counseling begins early as part of the victim's initial care her opportunity for a good recovery is greatly enhanced.