Sexual Assault - Scenario Posed in my class, What would you do?

[reaper]

I know what you wrote in your last post. I was referring to your previous posts!

I am trying to help you. Many have come on here and made posts, that were taken wrong. they learned from it and became great members that have grown into excellent health professionals.

You seem to want to keep up the attitude. This will only get you to a point where no one will want to answer your questions.

Start fresh, ask great questions and learn all you can. You will find that this can be a great place to learn about things you would never think about.

 

[Ridryder911]

The main point. Oxygen is a drug. Alike any other medication there are great benefits to the use and as well there are severe risks associated with it as well. Yes, even oxygen. Again, alike any other medication unless you are quite aware of these things, one should not be "slapping" or administering anything half hazardously.

Would one give aspirin (ASA) as well? Again, one should be able to justify your reason for treatment, not because "its not going to hurt" or "why not" answers. The patient needs psychological first aid much more than physical treatment. Hence, as discussed that EMS does not have enough or not even taught pyschological treatments.

Even as a trained and certified sexual assault nurse, I recognize and realize my limitations. I can initially perform a psychological debriefing, and the detailed rape exam up to the internal examination. There are many medications and treatment one could do or administer that would not cause harm, but again alike any other treatment(s) we have to ask ourselves on each case and patient. Is it needed? Is it warranted? Can we justify performing or administering it? Not just because we can; or believe it might help.

I see this even in medics starting IV lines. Many use the "my protocols described I could" or "it won't hurt" statements. One should be able justify using those protocols. Was there a need for an IV? For there are only two reasons for an IV: fluid replacement or administration of medications. That's it, no other reason can be justified in the prehospital arena. Yet so many treat their protocols NOT the patients just because they can.

We need to pull back and do what is the best for our patient at the time. This maybe means doing nothing more than projecting yourself as a good empathetic caring professional. Providing reassurance, projecting safety: both physical and emotional, and displaying non judgemental expressions or statements. This can be performed by a medic of either sex, again another myth that one is more preferred or is better than another.

Treating accordingly and appropriately to the patient is the key. Very few patients fits the exact categories of protocols or treatment regimes. That is why protocols should be written as suggestions not exact.

R/r 911

 

[VentMedic]

Rid,

I respect your opinions. But, not everyone who is raped will be the healthy 18 y/o female. That was the initial topic. Just because a person is "only raped" by your cookbook standard does not mean there can not be other medical issues also that must be treated. Just because rape is the only in your face complaint does not mean other things can not also be occuring within the body from pre-existing conditions or new conditions that have stemmed from a violent assault. Don't put blinders on just because you do not consider rape to be a medical problem also. An assessment should still be done if possible. And if the person is short of breath or has irregular breathing one should be able to use some judgement. Don't discount that a rape doesn't warrant O2 because it is "just a rape". I've had all age groups and gender on ventilators in the ICU following a rape with many medical issues. Some are caused by the rape itself and others from medical problems that were exacerbated from pre-existing problems. One punch to the face, head, chest or abdomen can do some damage that is not immediately detectable by either the health care provider or the patient who may still be too emotional or "numb". Again, using the cookbook and placing all rape victims under one heading and not allowing each patient to be assessed for their own individual needs is dangerous also.

I have the greatest respect for O2 but I also respect what rape victims tell me or how they present. Emotionally traumatized patients are the most difficult to assess. The hysteria can also mask other symptoms. Women also do not always present as men do with pain initially, especially CP. I'm not going to discount anything because a cookbook says it is a "rape". Thus, "no O2 is warranted". If you are not able to determine the severity of the person's injuries or do a thorough assessment immediately,yet the patient appears to be "air hungry" there is nothing haphazard about giving O2. If the person is truly have difficulty breathing but you write if off as hysteria or "not warranted" because it is just a rape by the cookbook, that will be a problem.

Nor should a hysterical person be denied O2 because you think they "might be hyperventilating". I've seen very young patients coming in with some pretty bad PNAs that were hysterical on RA and a PaO2 of 40 with no supplemental O2 because the Paramedics thoght they were suffering from hysteria and didn't bother to assess further. With new resistant strains of bacteria and now increasing numbers in AIDS, this will be more common again unfortunately. There are times when you have to assess the patient or listen to their symptoms and not make a doorway diagnosis.

I know this is hard for you to imagine yourself, but picture being a woman, clothes ripped off, vulnerable and 6 FireMEN with 2 PoliceMEN (typical FL response) walk into your bedroom. This also occurs in cases of domestic violence when the male EMS providers start talking and laughing with the husband (alledged attacker) in the room about football in front of the patient. "He seems like a nice guy and is sorry, you really don't want to press charges against him?" Scene control with the person the patient feels the most comfortable with should be considered. They could also feel comfortable or more secure with a male. However, there are reasons why male, and sometime female, doctors have a female RN or other professional present when women are intimately examined. It is protection for themselves and the patient's protection and/or comfort.

For a 10 minute ambulance ride, the risks with O2 is minimal. One must weigh risks versus benefits. If the patient calms with a little O2, it will be difficult in the ambulance to determine if it is physiological or psychological. The O2 can always be removed. Is O2 always warranted for every medical condition? No. But in those that you can not truly determine if there are any other underlying conditions besides "just the rape", it may be of benefit. At the Paramedic or EMT level there is little psychological counseling you are qualified for except to provide supportive care/treatment and scene security. While you, Rid, might have had more training with this as an ED RN, others here have not.

 

[Ridryder911]

If the patient warrants oxygen it is not usually the "rape" itself; rather the medical conditions associated with the violent act or associated injuries. Again, Rape is a legal term that is only determined by prosecution; we need to remember potentially sexual assault victims in perspective usually does not have the extreme physical trauma as in comparison to the emotional and psychological trauma . We also need to remember that sexual assault occurs in both genders, and it is predicted is much higher in males than reported but not reported.

I agree on some aspect but respectfully disagree with you on other factors:

Yes, oxygen can and should be part of the treatment regime but it self if it is determined to be justifiable. True, it may not hurt; but installing philosophy of administering oxygen is better than doing nothing was where I disagree. Again, treat the patient accordingly and appropriately. When we are treating for serious illnesses or injuries the assault itself is secondary. If they need oxygen, then by all means administer it. Those conditions that you illustrated are much more involved than the just occurrence of the sexual assault itself, true they maybe induced by such but not all assault victims have such responses. Again, these injuries and illnesses should treated aggressively because of what they are, not just the mechanism of injury. If one wants to treat prophylatically then know that is what we are doing and be able to justify it.

Yes, sexual assault patients definitely should be assessed and treated for physical injuries, never described or stated differently. One needs to assess as well the patients history for predicting indicators such as medical history, age, and other potential underlying problems such induced toxins (drugs, alcohol), medications, and other substances. As well, a good a brief physical exam to detect life threatening injuries should be performed, but this is where I differ and teach to use caution. A detailed secondary assessment examination needs to be very careful not to destroy or even remove evidence. Yes, again let me point out, life threatening injuries should always be treated immediately but to perform a detailed secondary assessment just for the sake to perform one should be differed if possible. This again is if the patient appears to be stable (physically) and no apparent life threatening wounds, injuries r/t MOI. Even physicians will only briefly examine an apparent stable sexual assault victim leaving a detailed sexual assault exam for the Forensic Nurse to perform. Nothing is more discouraging to the victim to have learn later that evidence was destroyed, not obtained, or be able to be obtained due to the poor system of treatment. That the chain of evidence was not carried through, changes of linen, clothes, cleansing of lacerations, bites, can drastically be challenged in the legal system.

As you know, but many may not, that a sexual assault examination is a very, very detailed complicated examination. They usually take over four hours for me to perform. From examining and documenting every scratch, bruise, torn fingernail, to performing and obtaining STD, DNA swabbing. A good forensic nurse will detect any secondary trauma if it is presentable at the time. Again emergency treatment should never be withheld.

It is even recommended that most sexual assault victims not even be seen most ED's. I know in my area, very few ED's are prepared to see such cases. A designated ED to care for all such cases or an off site clinic is usually preferred. When I am notified, I will meet with other team members including a crisis team member, psychologist or specially trained sociologist, a member of the D.A., and possibly a trained former sexual assault victim counselor. The location of the center is only known by those that need to know for privacy and protection as well as the Forensic Nurses (formerly SANE) in my area are deputized through the District Attorney's with privileges of such.

I also disagree that the gender for the immediate response and rescue is a importance as much as we first thought. Much research has disproved different ideas, and thoughts. In fact some research has described that males may present a more non-biased demonstration and empathy than usually expected. I myself as I also teach attempt to ask the victim if possible (conditions allowed) if they prefer a female. Usually, I have seen it is the rescuers that is much more uncomfortable than the victim themselves.

Unfortunately, in any of the ED's I have worked at the staff never get to choose the gender they treat. Unless the patient specifically request, either gender is expected to perform all treatment and procedures. I am in the room with physicians performing pelvics as much as the females. I do understand the emphasis you are describing and one has to be extremely wise and cautious. This now includes the same for all sexes, nowadays.

As much as I hate spin off classes, I do think this is an area that a either good CEU or course should be developed in association and cooperation with other specialized organizations. There is much more than the initial treatment that has to be considered in this delicate and horrible tragedy. Long term effects not just in regards to medical care but to the crime scene, careful documentation and well planned organization for prosecution needs to be considered.

R/r 911

 

[VentMedic]

I also disagree that the gender for the immediate response and rescue is a importance as much as we first thought. Much research has disproved different ideas, and thoughts. In fact some research has described that males may present a more non-biased demonstration and empathy than usually expected. I myself as I also teach attempt to ask the victim if possible (conditions allowed) if they prefer a female. Usually, I have seen it is the rescuers that is much more uncomfortable than the victim themselves.

I don't know what the cultural make up is of Oklahoma but there are areas where we must be sensitive to many different customs for both men and women. This even goes for the many different cultures for the "all-American". There still must be some respect and it is not always okay to just say "the literature says".

including a crisis team member, psychologist or specially trained sociologist, a member of the D.A., and possibly a trained former sexual assault victim counselor.

All of these people, except the D.A., may have some training to recognize that more medical attention is required. They are also very well trained in providing the support and asking the right questions to calm a patient.

Give the MDs and RNs in EDs some credit for knowing when not to destroy evidence. Not every ED is a non caring facility with ignorant employees. While taking care of the patient is their first priority, many have been trained, just as you have, in what is required for rape victims.

Those conditions that you illustrated are much more involved than the just occurrence of the sexual assault itself, true they maybe induced by such but not all assault victims have such responses. Again, these injuries and illnesses should treated aggressively because of what they are, not just the mechanism of injury. If one wants to treat prophylatically then know that is what we are doing and be able to justify it.

There are many degrees to sexual assault. I hope you are not saying this is just a passive act. Not all ambulances carry CT Scanners or X-Ray machines nor may the patient be immediately able say where it hurts. Give the victim the benefit of the doubt.

Yes, again let me point out, life threatening injuries should always be treated immediately but to perform a detailed secondary assessment just for the sake to perform one should be differed if possible.

Exactly. If you can not do a thorough assessment but may have reason to believe there is the potential for more injuries, one may have to make a judgement call about the oxygen.

How many times have you given ASA and O2 to a man c/o chest pain and shortness of breath? How many times have they been discharged later when that hot dog digests? Do we "asume" it isn't an MI if we had prior knowledge of the hot dog or do we still continue to treat the symptoms just incase? How many times have we treated nonspecific EKGs until other diagnostics are done?

Should we assume that the rape victim just layed there and didn't experience any violence or that her/his body suffered no physical pain or responses? Does the woman or man have to be beaten to a pulp for it to be a "violent act"?

And that takes us back to your first sentence:

the patient warrants oxygen it is not usually the "rape" itself; rather the medical conditions associated with the violent act or associated injuries.

My point is it is difficult to adequately assess the full extent of other conditons or injuries. Oxygen should not be withheld just because you can not see obvious injuries.

 

[papyrusman2000]

I think you guys need to take a vacation and hit the strip clubs.



Thank you for all of your time, brothas.

Im peacin on this one. Getting way to deep for me.

 

[Bosco578]

I think you guys need to take a vacation and hit the strip clubs.



Thank you for all of your time, brothas.

Im peacin on this one. Getting way to deep for me.

Try some O2, it might help....

 

[VentMedic]

I think you guys need to take a vacation and hit the strip clubs.



Thank you for all of your time, brothas.

Guess you didn't read my posts either.

Do you think I'd be kicking Rid around so unmercifully on some things if I was a man?

I am a little disappointed about the strip club remark since this is a thread about sexual assault and part of our comments were about respect for women (or men) on a very sensitive issue. Not that strippers aren't respectable, but it just opens up a stereotyped view about women in certain occupations.

 

[Ridryder911]

Ahh.. it was not a bad kick. What many do not understand as a good intellectual debate, meaning we can agree to disagree and both can be right or wrong in various parts of the issue (although, I am right ) .

Now, I what I emphasize was oxygen, ASA, or what ever that is a medication needs to be understood as such. That we should not be endorsing to immediately apply to most or almost every patient because the "what ifs?" In fact many sexual attacks occur without any major trauma and although I do not have the statistics in front of me, but I would describe EMS is hardly ever called in the majority of the cases. Fortunately and unfortunately many time there is not gross physical injuries and therefore many of the times the violation does not even get reported.

I caution on those on documentation as well. Alike so many other subjective things; if documenting events write per " quoted as per patient" of description of event. Keep strictly to the facts. Avoid terms such as rape, sodomized, etc. as only and if the patient stated them. Writing exact statement of the chief complaint of history. The EMT is not trained to differentiate wounds as type seen with such occurrences. One can describe "response to a possible sexual assault" etc. Even though, we all might agree of the occurrence, prejudging is one of the emphasis the defense attorneys love to use. Stick with the objective data such as abrasions, lacerations, bruising, etc making sure to describe location, size and other physical descriptions. This is a PCR that has a 99.9% chance probability to be subpoenaed so review with your partner for mistakes, spelling and grammar.

R/r 911

 

[Airwaygoddess]

Professionalism comes with empathy

I think you guys need to take a vacation and hit the strip clubs.



Thank you for all of your time, brothas.

Im peacin on this one. Getting way to deep for me.

Dealing with human suffering is part of EMS, I would hope if you were responding to a assault call you would have empathy for the patient no matter what gender they are.............. -_-

 

[papyrusman2000]

dear god I guess no matter wtf I say there Is going to be some uptight self-righteous nerd schooling me on how wrong I am and this and that.

I'm looking forward to meeting more people like you guys in the field. It will remind me how lucky I am to have a personality and a life... a FUN one at that.

get bent.

 

[papyrusman2000]

Guess you didn't read my posts either.

Do you think I'd be kicking Rid around so unmercifully on some things if I was a man?

I am a little disappointed about the strip club remark since this is a thread about sexual assault and part of our comments were about respect for women (or men) on a very sensitive issue. Not that strippers aren't respectable, but it just opens up a stereotyped view about women in certain occupations.

No, I didn't read your :censored::censored::censored::censored:in' post because I was sick of reading your crap. Sorry. There's the truth.

I give up. You win. I lost interest in this post a while ago, and I'm really not interested in figure 8ing with any one any more, so... I SURRENDER! Spare me you ridicule.

Leave me alone please, and I'll do the same.

 

[papyrusman2000]

"blah blah blah if I was a man?"

I didn't know you were a chick, so get off your Hig-horse, lady. Trying to judge me and my moral standings and characteristics THROUGH AN INTERNET FORUM!? LOL.

Sorry to burst your bubble, but I'm not a chauvinistic pig and I have PLENTY of respect and compassion for all humans on this earth, male/female/black/white/old/young/gay/straight (whats my Avatar?)....

and I LOVE THE STRIP CLUB.

Ok that's it I'm done. Enjoy your life.

 

[VentMedic]

papyrusman2000,
WuLabsWuTech started this thread and you hijacked it for your own agenda.

So, Bye Bye!

 

[ffemt8978]

That's way more than enough of this one.