Hi, my name is Jocelyn Anderson. I am a PhD student at Johns Hopkins School of Nursing. And I'm going to talk today a little bit about medical forensic examination and talk about some limitations or opportunities in low-resource settings. Some objectives for this content, just an overview. We're going to talk about what is a medical exam versus a medical forensic exam. Talk about types of evidence that can be collected during a forensic examination. Talk about some issues related to low resource settings, I also want to talk about what is chain of custody and the importance of chain of custody in collecting forensic evidence. So just starting out with what is forensic you can see the definitions listed there on the slide. What kind of catch all way to talk about forensic is pertaining to the law, so forensic just means any time that something might pertain to law. And so in this case we're talking about forensic medical examinations, and so places where forensics and medicine or nursing interact and intersect in the realm of patient care. So comparing those two a little bit more directly, so for a victim of sexual violence, what is a medical exam versus a medical forensic exam? So the medical exam is conducted for the purpose of health assessment, it includes medical care and treatment, possibly diagnostics, radiology, laboratory testing following a sexual assault. Some of the most common medical care and treatment items are prophylaxis for pregnancy and sexually transmitted infections, may also include referrals to follow up care, specialty care, mental health or physical health follow up, pieces that survivors or victims may need following that assault. And on the other side the forensic aspects of it that get added. So say the medical forensic exam includes all of those comprehensive medical exam pieces, but also includes the addition of evidence collection documentation that may be useful for investigative or prosecutorial proceedings. So before beginning any type of patient care, consent of the patient is necessary and I would say in the setting of a post-sexual assault exam, most places most providers will use an informed consent style, the more formal and informal consent, than just the oral consent that is done for different types of medical care. So, the purpose of that is to ensure that the patient is informed of their right to participate or to not participate in the exam process, as well as to inform them what that will mean for them down the road if they participate or don't participate. What that may mean for their medical care as well as any legal proceeding they may be participating in. It's usually completed by the provider who completes the exam. Although some jurisdictional issues sometimes there is a law enforcement component that goes with the evidence collection pieces if the police are involved. There are pieces of the consent that maybe once that evidence is released to the police we can't uncall the police or unrelease that evidence to them. It's each completed before the exam is started, although making sure to keep the patient informed and to continue throughout the exam every step of the exam get their consent for any piece of evidence you're going to collect anything that you're going to be doing with them. And so they know what is going on throughout that exam is also important And as I said, it's usually a preformal written consent document of some sort that details what's going to happen, what their options are. It allows them to sign which pieces of that consent they may be all right with. Whether it be medical exam, only in medical exam, in evidence collection, medical exam evidence collection, in photography, different places kind of operationalize that differently, and so that those specifics will likely vary. Some special cases in the world of informed consent the most common that we run into are minors, people who are usually below the age of being able to provide their own legal consent. And this is again, everything is going to vary, the legal system is very different from place to place. So everything is going to vary a little bit based on where you are and what the local regulations are. So in most places in the United States, minors do have the ability to consent for their own care following sexual assault. It's one of those kind of emancipation pieces, they're allowed to consent for those pieces of care related to that. But that is not always the case, so I would say knowing whether or not a minor can consent for their own care or whether you would need to seek care of the parent or guardian is important, as well as a patient who is unconscious or otherwise lacking capacity to provide consent. Another many ways that different systems deal with that, so whether it's needing a signature or consent from a next of kin legal decision maker, whether it's a decision that is made by the treating physicians in the best interest of the patient, or whether it's something that is considered more of a law enforcement piece. And that if the investigative team feels that it's necessary to collect evidence from a patient who's unable to provide consent, that a court order, some type of other legal document would be necessary. So the most common thing that people think about when they think about a sexual assault exam, is what is commonly referred to as a rape kit. Also I'd say probably more appropriately referred to as a physical evidence recovery kit, because it is a kit used for the recovery of evidence, really can be used for other things then I would say then just rape specifically. Particularly since rape has got very specific definitions legally. It's used for evidence collection throughout an exam. It contains all of the necessary kind of pieces to do that evidence collection and save that evidence. And it's standardized throughout a jurisdiction. So here in the state of Maryland Maryland State Police have decided what items go in a kit and everybody who performs these exams in the state of Maryland gets their kits from the Maryland State Police. And so they're all the same. And so more specifically what is in this kit? This kit is an envelope that contains different pieces of evidence collection items. Paper bags, envelopes, cotton swabs, vials for collecting blood. It also contains forms both with the instructions for kind of how to do a kit in the event that you've never done one before. That's kind of from day and time when there was much less attention paid to completing these In a standardized way and using standardized people to do them. As well as the documentation forms that you would need to document your exam findings. So common stuff that we collect during an exam. Blood, for usually for a known blood sample. DNA analysis is going to be going on. Blood, I would say, we can either do spotting blood on a blood card, versus collecting blood in some type of blood tube, benefits of the blood card are that the entire kit can be stored dry on the shelf. Whereas if blood is stored in a tube it usually needs to be refrigerated, which makes storage, handling, transportation much more difficult. Swabs are the other most common thing that's collected as part of this kit, and swabs from a variety of places on a patient's body that might have come in contact with areas of a perpetrator's body. We also may collect urine and that may either go as part of a kit to law enforcement, depending on who runs those testing for drug facilitated sexual assault or date rape drugs. Sometimes goes to an external lab, sometimes goes with the police to the crime lab. Combings from pubic or head hair looking for foreign debris or other hair materials etc that could have been transferred from the perpetrator to the victim during the crime. Underwear is the most common piece of clothing that we collect as part of this kit and part of this exam. But also as they can potentially collect other items of clothing as well if they were worn during the assault. Particularly if they may have trace evidence on them, or if they may have some evidentiary value as far as having rips, tears, things that could be shown as potentially indicating force was used. So, like I said, underwear the most common clothing we collect, but as I say, any article of clothing that was worn during the assault may potentially be collected based on the patient's history. We collect them in paper bags. And why is paper so important? Paper is so important because, it allows for easy and safe storage, in particular, if there is anything wet anywhere on that item, and it gets stored in a plastic container, physical evidence, particular biological evidence will degrade. Literally grow mold in some cases and become not useful. And so paper allows that evidence to be stored for a much longer period of time without some risk of degrading biological evidence. So some of the documents that are contained within the kit. History taking and record keeping documents to record the history that you take from the patient as well any findings that you have throughout your exam. Body diagrams, so pictures of the human body that one can note injuries on. Evidence collection forms to say what pieces of evidence you collected, what clothing you collected, what swabs you collected, and many kits also contain chain of custody forms so that you can begin documenting that chain of custody from the time you collect the evidence to the time that you hand it off to the next person in that chain. So documentation kind of key points, best practices. When you're documenting a patient's history, use the patient's words whenever possible. So quotation marks are wonderful to document what the patient told you exactly but making sure to clarify what's necessary. So they are all sorts of slang terms for sex acts and body parts and so if the patient is using a terminology that I'm not familiar with, making sure to clarify and add that to my documentation, in brackets, so that I know what exactly the patient said as well as what does that mean if I ever have to interpret that statement in court. Using body diagrams to show findings so body diagrams are a wonderful way to kind of get all of your findings into one picture and pictures both act as good ways for you as a clinician to see what's going on with your patient in one. Place as well, as I would say transmits very nicely into the justice system as far as being able to give the investigator a very clear picture of what you found, being able to potentially give a judge or jury a very clear picture of what you found as well. And then I would say, with any documentation, but particularly if there's a high likelihood that your documentation is going to somehow end up within the judicial system is to make sure that it is both thorough and legible. The justice system often moves very slowly and so it may be years between the time that you see a patient, do the exam, collect the evidence, document their injuries. And the time that you are asked to read them aloud in a court room and to tell the court what your clinical judgement based on your experience is what those injuries mean for that case. And so it's very important that when you have only that one piece of paper in front of you that you're able to read it, know what you said. And that you're consistent in how you document things so that you're able to interpret your findings all that time later. So some pros and cons of using kits particularly in reference to settings in which resources may be limited. So the standardization, ease of use, and having kind of a comprehensive everything one stop shop everything is there in order to be able to do the exam. Those are all really wonderful things. The kits themselves because they are prefabricated by a manufacturer can be expensive to buy as opposed to buying boxes of sterile swabs to use for evidence collection. And then if the other resources to utilize some of those kit pieces aren't in place, so if there's not a crime lab available that has fancy DNA analysis techniques, the ability to do hair analysis, etc. Then collecting some of those pieces of evidence may not be as useful. So another key piece of a forensic examination tends to be photography. It's something that's used very, very commonly during a medical forensic exam. It's a very good way to document findings. Those photographs can become part of the records, they can be part of the medical records the medical forensic record. And allow kind of helping one's memory years down the line when your bringing that case forward again if you got your bio diagrams which kind of give you a very good summary of everything that you found. But sometimes having those photographs being able to utilize these photographs in court is also helpful, as a note here the photo should not take the place of good written documentation. Not all jurisdictions are going to allow your photographs into court, or if they are they may not allow all 50 of them you took during an exam into court, they may only allow two, and so being able to still have that summary document is important with photographs as a supplement. So some tips for best practices. If using photography in a forensic exam, make sure that you know who and what you're taking pictures of, is very important and seems silly. But again with the time that happens with all of the things that happen between the day that you take those photos and the day that you're asked to speak to them in court it's very important to taking at least one photo that includes the patients whole body and our face so that the patient is identifiable in that photo. And or including some other identifier of the patient, so if you're in a hospital setting where the patient has an ID band or an ID card. That you could photograph with them to make sure that you're identifying that this is who I'm taking photos of. And kind of going along with that, making sure that you're taking enough photos in your series to know what body part you're taking a photo of. So if your patient has injuries on their arm and on their leg and your taking very close up photos of a bruise on an arm and a leg. So that you can't see anything other than the bruise, being able to tell which of those is which can be difficult. So keeping a log of the photographs that you take, or making sure that there is some identifiable body part in each photo. A scale or ruler is another kind of best practice to be used. So if you have a ruler in your photos you can both identify what it is you're looking at sometimes, as well as the size of the injury for documentation purposes as well. And I would say the use of point and shoot digital cameras on the market nowadays also has made this extraordinarily easy, it's an easy technology for clinicians to adopt in their practice then. The cameras are very self-explanatory, they don't require all of the fancy lenses and things that the old 35 mm cameras used to require. And they allow you to immediately review your photos and see if you're taking good photos. See if your photos are clear and visible, or if you need to take a few more photos in order to make sure that you're getting all of the things that you want to include. So, I would say, is there a bit of a catch-22 in the world of evidence collection, particularly in settings where fancy crime labs and DNA analysis and things may not be available. So not matter how good my evidence I collect is in any setting, it doesn't guarantee that that case is going to result in an arrest, a prosecution, a conviction. I may collect the best evidence the patient may give me. I may provide great medical care to that patient, collect all of these wonderful pieces of evidence. Even if they are all analyzed and a wonderful investigation takes place, we may not ever be able to identify a suspect. Or we may be able to identify a suspect, but for some reason are unable to prosecute and convict that suspect. However, on the other hand, without collecting that evidence, the chance that we're going to be able to successfully investigate, prosecute or convict perpetrators of sexual violence is even lower. And so I would say it sometimes feels potentially like we're doing a lot of work as clinicians and putting patients through a very long exam process to collect some of these evidence pieces to take a complete history. And if you're some place where, either the legal system or the police system is such that it is not taking these issues very seriously. It can feel like you're putting the patient through a great deal of time and energy for something that may not result in a positive outcome for them. But if we don't begin to change that mentality, that cycle is just going to continue. So some issues that we can talk about in low-resource settings, lack of training or continuing education for providers related to best practices in completing these examinations. In some settings, there is an expectation that's placed on a health care provider to determine if a rape has been committed. Which is something that there is no medical or scientific literature to base that judgment on. There is no injury or finding or lab test or x-ray, that can prove or disprove a sexual assault. And then as well as just the overall lack of resources, lack of space, time, personnel, equipment to spend the time and do the exam and/or analyze test results of items collected during an examination. So, a model of care that's commonly used here in the States to ensure that best practice forensic and medical care is provided to victims of sexual violence, I would say there's some alphabet soup. They're all different letters, different words for people who do very similar things. They're healthcare providers, nurses, physicians, physician's assistants, nurse practitioners, who completed some additional training to gain one of those sets of letters behind their name. And they're really trained to provide care to patient's who've experienced sexual violence. And so some of the benefits of using SAFE, SANE, FNE Examiner roles in providing this care. They've had specialized training in order to provide comprehensive medical and forensic care. So they do the combined medical and forensic exam. They provide medical treatment as needed, most commonly pregnancy or sexually transmitted infection treatment or prophylaxis. They're usually very well versed in their community as far as knowing where victims can go for follow up care, for both their physical and mental health needs. They also as part of their training usually have some time that they spend getting to know their local law enforcement and prosecutorial systems. So having some knowledge of the reporting process, what the victim may be able to expect moving forward with law enforcement or with prosecutors. And with that, they're also usually trained and aware that their job description may call upon them to testify as a witness in court, either as a fact or an expert witness on what it is that the examination they completed and their findings. So switching gears for a little bit to our chain of custody discussion. So chain of custody is something that needs to be maintained in order for evidence to be admitted into a court. And it basically says that from the moment that evidence is created, collected, etc, it needs to be accounted for until the moment it's placed in front of judge and jury. So any time that that evidence changes hands, so if it moves from the nurse of physician who collected it to a police officer, to someone in a crime lab, each of those exchanges needs to be documented. And all of the time in between needs to be accounted for. So if its collected by a provider at 6 PM, and handed off to a detective at 9 PM, what happened to it in those three hours? Was the nurse with it? Was it locked in an evidence locker that has controlled access? What happens to it for each of those periods of time needs to be maintained in order for that evidence to be admitted. And so some common things that can compromise the chain of custody, if each piece of evidence isn't accounted for at each step. So if you've got multiple particular paper bags with clothing, you've got three of them and if only two of them make it onto a log sheet at some point in time. Failure to properly document an exchange, so when it went from a police detective to a crime lab representative we need to know who those people were. And how that evidence was transferred and stored during that exchange. If a sealed package is opened, so our evidence envelopes and bags are sealed and signed with tamper-resistant tape to show if they've been tampered with. And so if those seals are broken at some point in time and that's not accounted for by the crime scene, the crime lab folks analyzing that, that can be an issue. And if at any point in time from the time it was created to the time that it's admitted into evidence in the courtroom that it can't be accounted for. So, another model of care that is commonly used here in the states to try to improve care for patients who have experienced sexual assault overall is a sexual assault response team or SART. And so it brings together members from various disciplines within the community to work out some of the things we can do to provide better care to patients. So I would say bring in law enforcement, medical personnel, advocacy personnel, justice system personnel, lawyers, to talk about what issues do we have in providing care and getting victims to report and getting victims the support they need to continue throughout the entire extended process of investigation and prosecution. And, so I say this allows open discussion, collaboration between these groups of people, which is really, I would say, kind of key to being able to make any progress. Any one of these systems alone can try to make changes, but if there isn't some type of collaboration and communication between all of these disciplines that the patient is going to have contact with. The outcome is unlikely to be as good. And so identifying community resources, that's one of the things the SART can help to do is each of those different players at the table has a different role to play in the community and can help promote health and well being in different ways. So, police, often times, may be able to help with immediate safety concerns, where as the healthcare practitioners can talk about both the acute and chronic medical needs for patients following sexual assault. Identifying legal resources for patients who need maybe an order of protection if their perpetrator was someone they knew and knows where they live. Or if their perpetrator is someone who is maybe a partner, and they're needing to have new housing found for them, so lots of different issues that patients have and being able to work together with other disciplines to identify those. Each of the different disciplines within the start kind of has things that it excels at and bringing them together so that everybody at the table kind of has an idea of who to refer for based on what the patient's needs are. So just a quick summary of some of the things that I covered today. So the medical forensic exam is a comprehensive examination. Includes both medical care and evidence collection pieces. You've got examination and documentation is as essential to that medical forensic exam as some of those fancy DNA analysis pieces maybe. So I say it's possible with just using good documentation of a patient's history and injuries that can be as powerful and as meaningful in a courtroom as DNA linking a perpetrator to a victim, particularly since many sexual assaults are committed by known perpetrators and identifying them with DNA is not going to be the primary issue in the case. Ensuring chain of custody is maintained throughout the evidence collection procedure through the entire prosecution of a crime is absolutely imperative. And then teamwork and collaboration also being essential in order to more successfully respond to incidences of sexual violence. So that is what I have for you this afternoon. Thank you very much for your time. And I hope you are enjoying this course.
