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Evidence Collection and Care of the
Sexual Assault Survivor
Copyright 2001 Violence Against Women Online Resources Evidence Collection and Care of the Sexual Assault Survivor Table of Contents
Introduction
Violence has a significant impact on the physical and psychosocial health of millions of Americansevery year. It is essential that victims who present to emergency departments (ED) for even minortrauma be thoroughly evaluated. ED staff must be aware of the types of injuries most likely resultingfrom violence, and the victim must be asked about the cause of the trauma to determine if it is theresult of violence and further evaluation is required ( ). When violence, such asrape, is identified, further evaluation is usually necessary, including proper evidence collectionmaintaining chain-of-custody, crisis intervention, pregnancy and sexually transmitted infection(STI) risk evaluation, and preventive care.
It has been only in recent years that our health care facilities have begun to recognize their respons-ibility to have trained staff available to provide this specialized service for victims of sexual assault.
Evidence Collection and Care of the Sexual Assault Survivor Treating injuries alone is not sufficient. In 2000, Coney Island Hospital was fined $46,000 by stateregulators after a rape victim came to the medical facility and a sexual assault evidentiary examin-ation was not accurately performed. She was made to wait three hours before being examined andthen potentially significant evidence, including her underwear and vaginal swabs, was lost. TheDepartment of Health investigation also found that the hospital did not provide her with medicationto prevent pregnancy and they failed to provide complete care. The authorities believed that hadcorrect evidence collection and chain-of-custody (the signature record of everyone who had posses-sion of then evidence) occurred, the evidence may have been useful to secure a conviction againstthe serial sex offender charged with her rape. As a result New York passed the Sexual Assault ReformAct requiring New York State medical facilities to develop specialized sexual assault examinere ).
It was as recently as 1992 that the guidelines of the Joint Commission on the Accreditation ofHealth Care Organizations (JCAHO) first required emergency and ambulatory care facilities tohave protocols on rape, sexual molestation and domestic ab ). By 1997 they alsorequired health care facilities to develop and train their staff to use criteria to identify possiblevictims of physical assault, rape or other sexual molestation, domestic abuse, and abuse or neglect ). While JCAHO certainly does not require that speciallytrained forensic examiners (FE) or Sexual Assault Nurse Examiners (SANEs) be available to dothe evaluation, these requirements do mean all medical facilities must identify and provide appro-priate and complete services to victims of rape and abuse. These requirements have effectively setthe stage for the further development of the SANE role as an important component of the emergencymedical response to survivors of sexual assault.
To be most effective, it is essential that the SANE, FE, or any other medical care provider workwithin a coordinated Sexual Assault Response Team (SART) model. At a minimum the SARTshould include the SANE (or medical care provider), an advocate, a law enforcement officer, anda prosecutor. Other members may include domestic violence victim advocates, state crime laboratorypersonnel, clergy, and social services staff ( ). This article will discuss the initial carenecessary for the sexual assault survivor and the SANE-SART model for providing this care.
SANE-SART Development
As a part of this same movement to better meet the needs of this under served population, the first
Sexual Assault Nurse Examiner (SANE) programs were established in Memphis, TN, in 1976 (
; ),
and Amarillo, , these nurses worked in
isolation until the late 1980's. In 1992, 42 individuals from 31 programs across the United States
and Canada came together in Minneapolis for the first time at a meeting hosted by the Minneapolis,
Minnesota, based Sexual Assault Resource Service and the University of Minnesota School of
Nursing. It was at that meeting that the International Association of Forensic Nurses (IAFN)
was formed facilitating the further organization and development of SANE-SART programs ( ). While the initial SANE development was slow, with only three programs operating by the
end of the 1970's, development today is progressing much more rapidly. By March 2001 there were
403 SANE programs registered on the Office for Victims of Crime (OVC) funded SANE-SART
Evidence Collection and Care of the Sexual Assault Survivor web site operated by the [ (www.sane-sart.com).
The impetus to develop SANE programs began with nurses, other medical professionals, counselors,and advocates working with rape victims in hospitals, clinics, and other settings across the country.
It was obvious to these individuals that the services to victims of this horrific crime were inadequate,and not at the same high standard of care as other ED clients ( ; ). When rape victims came to the ED for care they often had to wait as long as four to twelvehours in a busy, public area, their wounds seen as less serious than the other trauma victims, com-peting unsuccessfully for staf; ). They were often not allowed to eat, drink, or urinate while they waited,for fear of destroying e ). Doctors and nurses were often notsufficiently trained to do medical-legal exams, and many were lacking in expert witness testimonyability as well ( ). Even when they had been trained, staff often did not complete asufficient number of exams to maintain their level of proficienc ). Even when the victim's medical needs were met, the victim's emotional needs alltoo often were overlooked ( ), or even worse, the survivor was blamed forthe rape by the ED staff ( ).
Typically, the rape survivor was faced with a time-consuming, cumbersome succession of examinersfor one exam, some with only a few hours of orientation and little experience. ED services wereinconsistent and problematic. Often the only physician available to do the vaginal exam after therape was male ( ). While approximately half of rape victims were unconcerned withthe sex of the examiner, for the other half this was extremely problematic. Even male victims oftenprefer to be examined by a woman, as they too are most often raped by a man and experience thesame generalized fear and anger towards men that female victims experience ( ).
Evidence of SANE-SART Efficacy
Unfortunately, little research data is available on the efficacy of the SANE-SART model. Most ofwhat is available in the literature is testimonial or based on case studies.
Better collaboration with law enforcement
SANE programs, working collaboratively as a part of a SART can ensure that police obtain recordsof exams in a more timely fashion, and interpret the findings for them when necessary. Some SANEsroutinely ask for the name, address and phone number of friends or relatives with whom the survivormight decide to stay, and through whom they may be later contacted and this information is oftenvork with a fewforensically trained nurses because in many ways it makes their job easier ( ).
Higher reporting rates
In EDs without a SANE program available, survivors sometimes encountered busy, insensitivedoctors, nurses, or police and may have decided it was not worth the effort to report and follow Evidence Collection and Care of the Sexual Assault Survivor viding the rape survivor with additional assistance,resources, and support, SANEs facilitate the follow through with the leg ). program 38% of 337 rape survivors were uncertain about reporting when they first came to thehospital ED. After working through their fears and concerns with a knowledgeable SANE, an addi-tional 12% decided to report and the police were called to the ED. An additional 23% agreed tohave an evidentiary exam completed because they thought they would report. Only 3% of the 337surviv Shorten examination time
Not only does a SANE program shorten the wait for the survivor before the exam is begun, butSANEs also shorten the time a survivor must ultimately spend in the ED. Unlike the ED physicianwho may be called away during the rape exam to see a more urgent ED case, the SANE is able tostay with the survivor until the entire exam is completed ( ). In a client satisfactionquestionnaire mailed to 201 survivors two weeks after they were seen by a SANE for an exam,93% of those returning the questionnaire were satisfied with the care they receiv).
Better forensic evidence collection
Just as with any other specialized clinical skill, competent forensic evidence collection is the resultof both training and experience. It does not necessarily take a medical degree. Unfortunately,forensic principles are not taught in most medical or nursing schools. Even when doctors and nurseswho work in EDs are taught the basic forensic principles of evidence collection, few have the op-portunity of conducting sufficient rape exams to develop or maintain this proficiency. A primaryadvantage of the SANE program is that with a limited number of dedicated nurses completing allof the evidentiary exams in a given hospital or regional area, they are able to complete an adequatenumber of exams to develop and maintain this proficiency.
As a result of periodic meetings with the prosecuting attorneys about the use of evidence in thecourtroom, the quality of evidence collected has evolved over the years of the SANE program op-eration and today is more complete and helpful in obtaining convictions. For instance, one programnow routinely collects an extra tube of blood that can be held and run for drug or alcohol analysisif the assailant claims the victim was so drunk that she doesn't remember giving consent or that sheexchanged sex for drugs ( ).
Results of research data collected by SANE programs on the incidence of injury to rape victims orof finding sperm after a rape, has also been helpful to county attorneys needing to explain that thelack of injuries or the absence of sperm does not mean the victim w).
Evidence Collection and Care of the Sexual Assault Survivor More complete documentation
In a study comparing 24 sexual assault evidence kits collected by SANEs to 73 evidence kits col-lected by non-SANEs the SANE kits were overall better documented, more complete, and alwaysmaintained proper chain of evidence, whereas the others did not. Thirteen kits, 18%, of the kitscompleted by non-SANEs, either had no indication of who had collected the evidence or it was il-legible, making the evidence useless. All the SANE kits were properly labeled ( Improved prosecution
The role of the SANE does not end with the initial collection of evidence. Courtroom testimony isalso important. In fact, there are several reports of county attorneys who were initially concernedabout the testimony of SANEs, later finding that SANEs were extremely credible witnesses in courtas a result of their extensive experience and expertise in conducting the sexual assault exam. Theyare also more accessible and more willing to adjust their schedules to testify, as it is an expected ). Prosecuting attorneys have come to trustthe competence of the SANE as a witness if the case goes to trial ( ). Solid credentialsback up the testimony of the SANE as do impressive numbers of victims seen ( It was based on this solid SANE education, training, and experience that Tennessee more broadlyinterpreted their state laws to allow the SANE to testify in court ( A commonconcern of physicians turning over the exam to the SANE is that they will still be called to testifyin court. While physicians are called to testify about injuries that they treated, in thousands of casesthere has not been one case where the testimony of the SANE alone was not sufficient ( The Santa Cruz County Attorney actually believes that having the SANE collect evidence and beavreported a 100% conviction rate for over three years in cases that went to court and in which theSANE testif ). Another SANE program has an impressive 96% conviction ratein cases in which the SANE did the exam ( ). In New York City the prosecutor reportedthat an assailant continued to deny he had any sexual contact with the rape victim until he wasconfronted with the evidence collected by the SANE. He pled guilty to the maximum charge andaccepted a 15-year prison sentence ( SANE Program Operation
Initial Medical Evaluation
The ED staff is typically responsible for initially responding to the sexual assault survivor, includingtaking vital signs and treating any serious injuries prior to the arriv). A routine physical exam is not recommended, because that is not why the victim has come to theED. This is explained to the client vis also important that whenever possible, the physician wait to treat injuries until after the SANE Evidence Collection and Care of the Sexual Assault Survivor documents injuries with pictures and collects evidence. Sometimes, even with serious injuries, itmay not be detrimental to delay treatment until after the forensic e ).
The Evidentiary Exam
In 1987, California became the first state to standardize their sexual assault protocol statewide ( ). Few states have done so even today and there is still significant variation in whatevidence is collected and how it is collected in different locations even within the same state. Anumber of articles explain the specific components of the evidentiary exam, some step-by-step ( ; ; ; ). All include the following components: obtain writtenconsent; get an assault history including orifices where violence was used or penetration occurredand by what, forms of violence used and where; obtain pertinent medical information includingallergies, current pregnancy status, and menstrual cycle; conduct physical exam for trauma andareas of tenderness; examine involved orifices for trauma and to collect sperm and seminal fluid;collect any foreign matter present; comb the pubic hair for foreign hair and matter; complete finger-nail scrapings; collect the survivor's blood for type, and DNA screen; collect saliva for secretorstatus; collect torn or stained clothing. The areas of variation in these protocols include: the amountof documentation; prophylactic treatment for STDs vs. culturing; what clothing is saved as evidence(all vs. only torn or soiled clothing); if head and pubic hairs are plucked and how many; and thecollection of additional blood specimens for drug and alcohol analysis.
Time frame
Today most national, state, and institutional protocols recommend that evidentiary exams be com-pleted within 72 hours after a sehour exams are, however, sometimes conducted in cases when there are injuries that can be docu-mented or when the victim has not changed clothes or showered and evidence may still be availablefor collection.
The nurse examiner on call is typically expected to be at the paging facility to begin the exam, from30 minutes ( ) to a maximum response time of 60minutes after being paged ( ). An uncomplicated exam, without injuries, can take oneto fiv ). It will more likely take tw Evidence collection
SANEs look for evidence to confirm recent sexual contact; to show force or coercion was used; tohelp identify the suspect; and to corroborate the survivor's story ( Afew programs still collect a vaginal normal saline aspirate ( 15 to 20 head hairs and pubic hairs ( many laboratories do not analyze the root ( xperts today, however, do not re-commend collection of vaginal aspirates or collection of head or pubic hair evidence in the ED,because if hair evidence is needed from the victim it is retrievable at a later date in time ( Evidence Collection and Care of the Sexual Assault Survivor vidence, however, and it isessential that the forensic examiner is aware of the local standards.
DNA Evidence
In 1987, the first man was convicted of sexual assault with the help of DNA evidence. The casewas upheld on appeal the following year ( inal Apprehension (BCA) Laboratory became the first state crime lab to identify a suspect on thebasis of DNA alone. As a result of this valuable investigative resource, an otherwise unidentifiedrapist was found and con The recognition of deoxyribonucleic acid (DNA) as a valuable investigative tool, and the knowledgethat many rapists are repeat offenders, led to the development of the FBI Combined DNA IndexSystem (CODIS) ( The federal DNA Identification Act, included in the 1994 CrimeBill, allocated $40 million to expand DNA testing capabilities on a national basis. Today, as a result,57 laboratories in 27 states participate in the CODIS system ( ). These databases areused for "DNA fingerprinting" in much the same way as conventional fingerprint databases areused. Genetic profiles found in semen and blood evidence are now used to link serial cases,identify offenders of multiple assaults, and exonerate falsely accused suspects ( ).
DNA evidence should be obtained by collecting any available blood evidence that could be fromthe assailant on the skin or clothing of the victim. If the survivor reports she scratched the assailant,fingernail scrapings should be collected in hopes of collecting the assailant's blood. DNA can alsobe obtained by swabbing the involved orifices with a standard size cotton tip swab for sperm andseminal fluid ( In addition, when the SANE or forensic examiner completes the evidentiary exam, blood evidencemust be collected from the survivor for DNA analysis to distinguish her DNA from that of the as-sailant ( Seminal fluid evidence
It is important to remember that the absence of positive sperm or seminal fluid findings does notprove there was no recent sexual intercourse ( ). Studies haveshown that 34% or more rapists are sey ), Seminal fluid evidence is usually analyzedfor sperm, motile (alive and moving when observed under the microscope) or non-motile, and forprostatic specific acid phosphatase. This enzyme, acid phosphatase, is present in large quantitiesin seminal fluid and minimal concentrations in vaginal fluids, thus if a high level of acid phosphataseis collected in a sexual assault victim, this would be indicative that recent sexual contact occurred.
Cases are typically negative for sperm and positive for acid phosphatase when the assailant had avasectomy, b ). Unfor-tunately, there has been little study of the results of sexual assault exams and the likelihood ofgetting specimens positive for sperm or acid phosphatase.
Evidence Collection and Care of the Sexual Assault Survivor In one study of the results of 1007 rape survivors examined, sperm was found in only 1% (N=3)of the 369 cases involving oral rape. All of the positive oral specimens were collected within threehours of the rape. Of the 210 cases with rectal involvement, only 2% (N=4) were positive for sperm.
These exams were all completed within four hours of the rape. In the 111 skin specimens collected,19% (N=12) were positive. All but two of the positive specimens were collected within four hoursof the rape. Of the 919 vaginal specimens, 37% (N=317) were positive. Of these, the majority, 263were examined within five hours and 317 were examined within 12 hours of the rape. Only 7 ofthe positiv ).
In this same study, the acid phosphatase results were better by approximately a factor of ten. Ofthe oral specimens, 11% (N=40) were positive; 12%(N=32) of the rectal specimens were positive;43% (N=72) of the skin specimens were positive; and in 62% (N=566) of the cases involving va-ginal assault ( ).
Another study comparing PAP (prostatic acid phosphatase) to PSA (prostatic specific antigen)found, in a sample of 212 women who had consenting sex within four days, that more positiveresults were obtained with PAP analysis. While both were positive 59% of the time, PAP waspositive 84% of the time and PSA was positive 60% of the time. PAP was negative only 2% of thetime when PSA was positive, and PSA was negative 25% of the time when PAP was positive ( ).
Sexually Transmitted Infections (STI)
In the past, forensic examiners tested for STIs in the ED and then again at follow up. The rationalewas that if a victim was negative initially, and positive on follow up, the assailant, if apprehended,could be tested as well. If he was positive for the same STI this could then link him to the crime.
Because there are so many variables that could account for a positive STI test, this has not beenuseful forensic evidence and is no longer recommended practice for adult and adolescent examina-tions. It is still recommended for ongoing child sexual ab ).
STIs are, however, a concern for victims from a clinical perspective and must be addressed as apart of the initial examination. While one study found 36% of the rape victims coming to the EDstated their primary reason for coming was concern about having contracted a STI ( ), the actual risk is rather low. The CDC estimates the risk of rape victims getting gonorrhea is 6%to 12%, chlamydia is 4% to 17%, the syphilis risk is 0.5% to 3%, and the risk of HIV is less than1% ( ery expensive and time-consuming for the survivor, who mustreturn two or three times for each test, and unfortunately, most victims do not return ( ). In one study, 25% of the survivors seen in the ED returned for the initial STI follow-up visit ( , only 15% returned. They were able to contact 47% ofthose who had not returned for follow-up and they found an additional 11% of these went elsewherefor medical follow-up, however, only 14% told the physician they saw for follow-up about the rape( ). Most clinicians recommend prophylactic treatment for Evidence Collection and Care of the Sexual Assault Survivor STIs. Except in child sexual abuse cases, cultures taken need not be handled as evidence, becausethe Since the early 1980's HIV has been a concern for rape survivors even though the actual risk stillappears to be low. The US Center for Disease Control and Prevention estimates that the risk is 1aginal or rectalpenetration, tested for HIV in the ED, at three months post-rape, and again at six months post-rape,not one became positive for HIV. The study also found, however, that even if the survivor did notask about HIV in the ED, within two weeks it was a concern of theirs or their sexual partner. Whilethe researchers did not recommend routine HIV testing, based on the recommendations of the studypopulation, they recommend that even if the survivor does not raise the issue of HIV or AIDS inthe ED, the SANE or forensic examiner should, in a matter of fact manner, provide them with in-formation about their risk, testing and safe sex options. This will allow them to make decisionsbased on f ). How to best deal with the issue of HIV is complicatedand controvary from state to state,so does the actual risk of infection. As the antiviral agents that are used after possible exposure aretoxic and have side effects that will likely make the victim very nauseated and these prophylacticagents are still of uncertain efficacy ; ).
Pregnancy
While the risk of pregnancy from a rape is the same as the risk of pregnancy from a one timesexual encounter ), pregnancy is a concern of mostsexual assault victims and must be addressed at the time of the initial examination even if thetreating medical personnel or the medical facility does not support termination of an existingpregnancy. The National Conference of Catholic Bishops has agreed that "A female who has beenraped should be able to defend herself against a potential conception from the sexual assault. If,after appropriate testing, there is no evidence that conception has occurred already, she may betreated with medication that would prevent ovulation, or fertilization (p. 16, National Conferenceof Catholic Bishops: 1995: 1995). The importance of offering complete care to sexual assault victims,which includes care to prevent pregnancy when the victim wants this care, was further strengthenedby the fine against the New York City hospital, which did not ensure that a victim received a fullbirth-control prescription to prevent pregnancy ( ).
Most programs offer pregnancy prevention care for the women at risk of becoming pregnant, ifthey are seen within 72 hours of the rape, and have a negative pregnancy test in the ED. Sometimesreferred to as "the morning-after pill," oral contraceptives such as Ovral, or Lovral are used foremergency contraception ( The Yuzpe regimen using a combined oral contraceptiveis currently the most common emergency contraceptive ( This will reducethe risk of pregnancy by 60% to 90%.
However, more recently clinicians have begun to use a newly available progestin only contraceptive,Levonorgestrel 0.75 mg. (Plan B). Plan B is slightly, but non-significantly, more effective in reducingthe risk of pregnancy. When started within 72 hours of unprotected intercourse, 85% of pregnancies Evidence Collection and Care of the Sexual Assault Survivor were prevented in one study, compared to 57% using the Yuzpe regimen (Task Force on PostOvulatory Methods of Fertility Regulation: 1998). The effectiveness of both methods decreases asthe time between the assault and the first dose increases. When given within the first 24 hours PlanB reduced the risk of pregnancy by 95%, but only by 61% when given between 48 and 72 hoursafter unprotected intercourse. The significant difference was in the only side effect, nausea andvomiting, which was significantly reduced with the use of Plan B to 23.1%, from 50% with theYuzpe method (Task Force on Postovulatory methods of Fertility Regulation: 1998).
Crisis intervention and counseling
One of the basic components of the evidentiary exam is crisis intervention, mental health assessmentand referral for follow-up counseling. While this will be the primary role of the rape crisis centeradvocate when one is present, the SANE or forensic examiner is also responsible to provide crisisintervention and ensure follow up counseling services are available ( ).
When domestic violence is suspected or substantial drug or alcohol abuse appears to be an issue,it is important to have a protocol in place for screening and/or referral. Many medical facilitieshave domestic violence victim advocates available who can be called to the hospital like rape crisiscenter advocate. If available, these services should be utilized. It is also important to be aware ofthe availability of shelters for victims of domestic violence who may need a safe place to go afterthe evidentiary exam.
Continued fear and anxiety resulting from the rape can significantly affect the survivor's life, in-
cluding her work, school and relationships with others, fThe
psychological impact and treatment needs of the survivor have been addressed extensively in the
psychological literature, review of which is beyond the bounds of this summary. Dr. Burgess
summarized and labeled the psychological impact Rape T ). Self-help books such as Recovering From Rapevailable for the
large majority of rape survivors who do not return for counseling.
Non-genital injuries
Physical injuries are probably the best proof of force and need to be photographed, described ondrawings, and documented in writing on the exam report ( meant to take the place of good charting ( ic consent to photograph isnecessary, but may be included as a standard part of the exam consent. Two sets of pictures shouldalways be taken. One set always remains with the chart. The second set should be given to the policewith the other sexual assault evidence, and will usually be the pictures used in court. When picturesare taken, the first picture should always be of the survivor's face and others should follow in asystematic order, such as head to toe, or front to back. They should be taken first without a scaleto show nothing is being hidden, then with a scale to document size. While a coin such as a quarteris sufficient, a gray photographic scale will also assist with color determination.
Evidence Collection and Care of the Sexual Assault Survivor Each picture should include a label with the survivor's name and/or case number in the picture. Onthe back of every Polaroid the SANE should print the date, time, client number and/or name, andthe examiner's name and title. It is recommended that photographic documentation of injuries becompleted using a 35mm camera with a standard 50mm lens and 100-200 speed (ASA) color film.
A disadvantage of 35mm pictures is that they must be sent out for developing and often are notavailable to the police when they investigate, or to the prosecutor deciding to charge the case. Po-laroid pictures have the advantage of being available to the police during their initial investigation,but they have the disadvantage of poorer quality, especially for close ups. Polaroid film is also veryexpensiv ). Some experts recommend taking both Polaroid pictures (for use inthe initial investigation and the charging decision making process) and 35mm pictures (that can bedev While some examiners have been historically hesitant to take pictures of victims' breasts and gen-itals, not properly document injuries with pictures may result in liability for failure to document ( ). The survivors' dignity can be maintained and proper evidence made availableby taking close up pictures of the injury and by properly draping exposed areas.
Significant physical injury from a sexual assault is rare and occurs in only 3% to 5% of rape survivorsacross studies. Less than 1% of rape victims have been found to need hospitalization. Even minorinjury is usually documented in only about one-third of the reported rapes. Injuries, when they dooccur are, however, more common in stranger rapes and rapes by someone the victim knows intim-ately, such as a domestic partner, rather than in date rape or acquaintance rape situations ( ; In one study of 351 rape victims, the rate of physical injury for male rape victims (40%) was foundto be higher than for female victims (26%). While 25% of the men and 38% of the women in thisstudy sought medical care after the rape for their physical injuries, only 61% of them told thetreating physician they had been raped. The women expressed a strong preference for medicaltreatment and counseling by a woman. The male victims were, however, less likely to express agender preference ( ). A more recent study of 1,076 sexual assault victimsfound non-genital trauma more often than preprove the lack of force or coercion and does not prov).
It is important that the forensic examiner is aware of the likely pattern of injuries from violence inorder to know the appropriate questions to ask and where to look for injuries on the basis of thehistory given. Intentional injuries tend to be more central, and accidental injuries more toward theextremities. Especially if domestic violence is involved, injuries are most often inflicted where thevictim can easily hide them. The most common injuries are broken ear drums from slapping, neckbruising from choking, punch bruising to the upper arm, and "defensive posturing" injuries to theouter mid-ulnar areas of the arms. Also common are whip or cord like injuries to the back; punchor bite injuries to the breasts and nipples; punch injuries to the abdomen, especially in pregnant Evidence Collection and Care of the Sexual Assault Survivor women; punch and kick injuries to the lateral thighs; and facial bruising, abrasions and lacerations( The literature cautions the forensic examiner against trying to date the age of a bruise by its color.
While we know that in people with light skin recent bruising is red or dark blue in color, and olderbruising may be green-blue or yellow-blue, and older still bruising may be barely visible, peoplevary greatly in their rates of healing. Medications may affect bleeding and healing response as well.
Experts suggest that the size and color should be documented, e.g. "2 cm X 3 cm, deep blue-purple ). It is also important to remember that itcan be very difficult to even identify bruising in individuals with dark skin if alternative light sourcesare not available. Unfortunately, since these light sources are very expensive, most medical facilitiesdo not have them available.
Genital Trauma
The literature suggests that colposcopic genital examination is extremely useful to visualize anddocument genital abrasions, bruises, and tears, as they are often so minute they cannot be seen withthe naked eye ( When the colposcope is used inthe forensic examination of the sexual assault survivor it is simply used to magnify minute traumain the genital area that is not readily visible with the naked eye, or not easily photographed. It isnot being used to identify pathology. It is well documented in the legal arena that the use of thecolposcope is an accepted practice in the forensic examination of adults and children (IAFN: 1996), ). Thecolposcope is an especially important part of the examination of children ( When a colposcope is used it is important to always document the magnification, the positions forexamination, and a method of measurement should also be used ( ).
Most research on sexual assault documents the likelihood of genital trauma identification withoutthe use of a colposcope to magnify the trauma is similar to that of non-genital trauma; 1% severeinjury and 10% to 30% minor injury across studies ( ). In a recent study viewed. Unfortunately, the researchers do notindicate if a colposcope was used during the examination. With colposcopic examination genitaltrauma has been identified in up to 87% (N= 114) of sexual assault cases ( ). Justas with non-genital trauma, the absence of genital trauma does not indicate consent.
Rape victims often fear vaginal trauma, and are concerned that their genital area has been perman-ently damaged. Since this is rarely true, it is helpful and reassuring to a traumatized victim to havethe extent of the trauma, explained to them after the forensic e ). When a video colposcope is available it can be helpful to turn the screen so that the survivorcan also view the genital area during the examination.
In one study, vaginal injuries represented only 19% of the total injuries, and they were always ac-companied by complaints of vaginal pain, discomfort or bleeding ( ). Another study found only 1% of rape victims have genital injuries so severe they requiresurgical repair, 75% of these are upper vaginal lacerations. Upper vaginal lacerations usually present Evidence Collection and Care of the Sexual Assault Survivor stress when forceful stretching occurs, and it is the point of first contact of the penis with the vagina, ). In a studythat compared 311 sexual assault survivors to a group of 75 women who had consenting sexualcontact, researchers identified genital trauma in 68% (N=213) of the rape survivors, while only11% (N=8) of the women had injuries from consenting se Both the colposcope and anoscope have been shown to improve the identification of rectal trauma,however, the colposcope may be less helpful than the anoscope. In a study of 67 male rape victims,all examined by experienced forensic examiners, 53% had genital trauma identified with the nakedeye alone. This number increased only slightly, 8%, when the colposcope was used, however, thepositive findings increased a significant 32% when an anoscope was utilized. The combination ofnaked eye, colposcope, and anoscope resulted in a total positive findings in 72% of the cases ( Blood evidence
The SANE should always draw the victim's blood for type and DNA ( it is recommended that an additional tube of blood routinely be drawn for blood and alcohol ana-lysis should this become an issue later when the case is char Urine evidence
While alcohol has long been used to facilitate sexual assaults, today newer, memory erasing drugssuch as, flunitrazepam (Rohypnol), other benzodiadepines, Ketamine, Gamma Hydroxybutyrate(GHB), Gamma Butyrolactone (GBL) and many others are being used in drug-facilitated sexualassault (DFSA). Symptoms include a history of having only a couple of alcoholic beverages butquickly becoming extremely intoxicated. The victim can often remember very little of the incidentother than flashes, sometimes referred to as "cameo appearances," until she awakens. She may thenfind herself undressed, or partially dressed, with vaginal or rectal soreness making her believe shehas been raped ( ).
Whenever a victim of a potential drug-facilitated sexual assault is seen within 72 hours of the likelyWhile 72hours is the recommended time limit because most substances cannot be detected beyond that time,newer techniques of drug analysis are being developed and the time frames may change. While thetechnique is still under study, a new process of analysis can now detect a 2mgm dose of flunitrazepamfor up to 28 days after ingestion. While these processes are currently only in the research stage,once developed they will allow for the identification of substances as long as twenty-eight dayspost ingestion of a single 2 mg dose of flunitrazepam ( Even though there is little memory and perhaps no certainty of a sexual assault, whenever the victim'sstory is consistent with a DFSA, or suspicious, the forensic examiner should collect a urine specimenfor DFSA analysis as a part of the sexual assault evidentiary examination. If the victim calls prior Evidence Collection and Care of the Sexual Assault Survivor to coming to the hospital or clinic, she should be told to not void unless necessary, and if she mustvoid to collect her first voided urine in a clean container and bring it with her (Ledray: 1996b;Anglin, Spears & Hutson: 1997).
Maintaining chain-of-evidence
Maintaining proper chain-of-evidence is as important as collecting the proper evidence. Withoutthis complete documentation, with signatures, of chain-of-custody from the individual who collectedthe evidence to the courtroom, the evidence will be inadmissible (Ledray: 1993). If the SANE mustleave the room for any reason during the exam, the evidence must go with her ( ).
It is not necessary, nor is it appropriate, for the police officer to be in the exam room when theevidence is collected to maintain proper chain-of-evidence. The police can leave the area and thenurse can call them when the exam is completed, in two to three hours, to return and pick up theevidence. Both signatures on the chain-of-evidence document are all that is necessary. When thepolice cannot immediately return, the SANE can place the evidence in a locked storage area,preferably a refrigerator with limited access, and when the police do return any available nurse cansign (Ledray: 1993).
Maintaining evidence integrity
While it is suggested that the specimen be refrigerated for long-term storage to prevent deteriorationof the specimens, it is essential that the evidence be kept in an area of less than 75 degreesFahrenheit and the blood not be frozen. This means that storage in an air-conditioned room is suf-f Documentation
Many authors caution against the forensic examiner collecting detailed investigative informationand suggest that the SANE should ask only for information necessary to collect the proper medicalevidence, deal with the immediate physical and psychological needs of the survivor, and collectand interpret the physical and laboratory findings. The SANE or FE must remember they are con-ducting a medical forensic interview that centers on the survivor and not other assault details orinvestigative information, such as the height or weight of the assailant. Details reported by thenurse, which differ from the police report, may be used by the defense attorney to show discrepanciesin the survivor's story. The only documentation that is necessary is that needed to guide the examand treat the survivor ( Evidence Collection and Care of the Sexual Assault Survivor • actual and attempted penetration of which orifice by penis, objects or fingers • activities of the victim that may have destroyed evidence, such as bathing, douching, bowel • consenting sex within the last 72 hours and with whom • victim's general appearance and response during exam It is important to remember that in addition to the SANE assault exam report, the entire chart is apart of the legal record and can be submitted as evidence if the case goes to court. All statements,procedures and actions must be accurately, completely, and le ). It is important to accurately and completely document the emotional state of the survivorand quote important statements made by the survivor, such as threats made by the assailant ( ; When appropriate, qualifying statements such as "patient states.patientreports." should be used. If the exam findings match the history given by the survivor the examiner ).
The term "alleged sexual assault" should never be used in documentation of a sexual assault as theterm has negative connotations and may be interpreted by judges and juries as indicating the victimexaggerated or lied ( ).
Evidence Collection and Care of the Sexual Assault Survivor After the Exam
Many medical facilities now have a place for the survivor to shower, brush her teeth, and changeclothes after the exam. They often pro ; It is not unusual for the victim to be afraid to return home alone, so it is important for the advocateor forensic examiner to offer to call a friend or relative to be with the survivor during the exam andto take her home ( Alternative safe housing, such as a shelter, may be required andreferral sources should be available.
Since the survivor may be in a state of shock in the ED, it is important to provide her with writteninformation to takollow-up phone calls within 24 to48 hours to check on her status, medical compliance and assist with follow-up referrals are alsorecommended ( ).
Significant advances in the medical legal examination of the sexual assault survivor have occurredin recent years. Much of the improvement can be accredited to the development of SANE programsand SART teams. By working together, members of the SART have improved services to the sur-vivor, increased reporting rates, improved medical-legal evidence collection, and facilitated aseamless system response. The continued coordination of effort between the professionals workingwith the survivor of sexual assault is essential to furthering the advancement of our knowledge andto supporting survivor recovery.
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