1. Domestic Violence: Domestic Violence: The medical response

2. Objectives: Review Data on DV Discuss how victim may enter healthcare system Reporting vs. non reporting How is a forensic exam helpful Victim Judicial system What is a forensic exam and how is it different from a routine exam. Evidence collection Recognizing Strangulation Treatment options Testimony of the forensic nurse

3. Domestic Violence Domestic violence is an assault on our society. It encompasses all manner and form of injury: Physical, mental, financial, and property

4. Violence & Trauma in Texas: 2009 111 women lost their lives to domestic violence/ trauma 179,435 hotline calls 12,905 Adults sheltered 35,588 Adults receiving non-residential care 15,588 children required emergency shelter (not counting those sent to other family members) Texas Council on Family Violence

5. How big is the problem? DV Cases seen in hospitals Best estimates report that between 20 & 30 percent of women and 7.5 percent of men in the United States have been abused by their intimate partner.

6. What if? Physical violence without forensic exam Mary. Late 70’s Triaged with husband. Accidental fall Seen by ER MD X-rays performed Treated for bruises and sprain Followed up as directed with PMD 3 days later. Physical violence with forensic exam Mary is triaged with husband Accidental fall Seen by ER MD who examines patient without husband present Notes that patient gives inconsistent history Patient admits to being abused by husband. Due to Mary’s age, LE is involved and a Forensic Exam is ordered.

7. Which evidence is more compelling? Sterile ER record documenting bruises and statement by patient and patients husband that she fell down in the home…several times over the past two days. Comprehensive medical and forensic examination with use of diagrams and photo- documentation. Patient statements admitting that her husband hit her arms and legs repeatedly with her purse because she did not make what he wanted for dinner.

8. What is the difference? Non forensically trained medical personnel MD’s Little to no education on specialty of forensics “See one- Do one- Teach one” method of learning. RN’s BON requires 2 hrs. of forensics….once in a career Forensically trained MD’s University level specialized training Child Abuse Elder Abuse Sexual Assault RN’s University Level training Professional Association Certifications State Certifications

9. Case Review: Police involved Patient arrival/ report screening Determine if they want police involved Contact police for appropriate jurisdiction

10. Police Arrive Depending on agency policy Police arrive within minutes of call Talk to victim Obtain authorization to have Forensic Nurse Exam Authorize FNE to provide exam

11. Activation of Forensic Nurse Charge nurse/ physician activates SANE/ FNE SANE/ FNE contacts Victim Advocate on Call SANE/ FNE reports to hospital to see patient

12. Consent and explanation Written and or verbal consent prior to starting exam Right to refuse Right to have advocate present (specific to SA) Right to retain clothes Right to stop at any time Right to refuse blood or urine collection

13. History of event Key to understanding events as they happened. Medical examination NOT a criminal (forensic) investigation interview We need some of the same information as LE but are primarily concerned about signs, symptoms, and potential outcomes (physical and emotional)

14. History continued Medical Need to Know When did it happen? Time line for injuries Where were you? Safety planning What happened to you? What type of injuries can I expect to find? What did the person, who hurt you, do? Injury (physical and emotional) expectations Positions during event Injury potential Types of injuries inflicted, if known? Treatment options Did you attempt to injure or ward off the other person? How? Emotional/physical powerlessness

15. Purpose of history True purpose To determine actual and possible injuries as they are conveyed by mechanism of injury. i.e. “He hit me on the left side of my face with a pillar candle” Given the history, the patient would need a CNS exam, possible CT of the head, and sutures for the large laceration. Secondary, legal advantage for the patient Medical personnel who obtain a history during the course of an examination may testify as to what the patient told them as a part of the medical examination. Exception to the Hearsay Rule.

16. Importance of history Without a history the caregiver is made to rely solely on what can be seen. Many injuries do not appear until hours, days, or weeks later.

17. Who should be present during history taking Differing schools of thought Patient has the right to have the persons of their choosing Interpretation of the law is varied. Discussion: Advocate Family Nurse only Law Enforcement

18. Value of history to LE Provides details of the incident as it pertains to injuries, time, persons involved. As a rule, nurses are confided in more often than law enforcement. The assumption by most individuals is that nurses are here to take care of me while the police have to figure out where the truth lies…..

19. Difference Medical history Used to determine type of injuries Render a diagnosis Formulate a plan of care Provide treatment Fault not a consideration LE Interview Used to determine what kind of crime occurred Who was involved? Who is the perpetrator? What connection does the victim have to the perpetrator? Is the complaining witness the victim?

20. BREAK

21. Physical portion of exam

22. Head to toe looking for trauma

23. Provide compelling testimony

24. Why trauma? Trauma informed care Trauma informed care in very simple terms, means that we evaluate the patient based on an assumption that trauma occurred, either mental or physical or both, and apply nursing process to that ends.

25. Linking history to exam When a history is taken we use the information gained in the history to guide us in our overall physical and mental assessment. Person Place Time Acts Responses Actions during Actions after Discharge options

26. Head

27. Torso

28. Extremities

29. Ano-genital with consent

30. Female / Male

31. Cervix

32. Vaginal

33. Anal

34. Evidence Collection Medical exam findings Labs X-rays Medications administered Pain Infection prevention Referrals to specialists Forensic History Exam Swabs Photos Treatment

35. Kit CONTENTS: 1- 999-550 FDA Manufacturer’s Insert 2- KCP118 Integrity Seals 1- KCP206 Biohazard Label, 1” x 1.25” (2.5cm x 3.2cm), Black on Orange 1- VEC1001 Kit Box, Factory-Sealed 1- VEC1002 Kit Instruction Sheet 1- VEC101 Authorization for Collection & Release Form, 3- Part 1- VEC102 Victim Medical History & Assault Information Form, 3-Part 1- VEC103A Foreign Material Bag with 23” x 35” (58.4cm x 88.9cm) Paper Sheet 1- VEC103B Panties Bag,br> 2- VEC103C Outer Clothing Bags 1- VEC104 Debris Collection Env. w/Paper Bindle, Swab Box & Nail Scraper 1- VEC105 Pubic Hair Combings Env. w/Towel & Plastic Comb 1- VEC106 Pulled Pubic Hairs Env. 1- VEC107 Vaginal Swabs & Smear Env. w/Slides, Sterile Swabs & Boxes 1- VEC108 Rectal Swabs & Smear Env. w/Slides, Sterile Swabs & Boxes 1- VEC109 Oral Swabs & Smear Env. w/Slides, Sterile Swabs & Boxes 1- VEC110 Pulled Head Hairs Envelope 1- VEC111 Known Saliva Sample Env. w/Specimen Disc 1- VEC112 Known Blood Sample Env. w/6ml ACD & 7ml EDTA Blood Tubes 1- VEC113 Anatomical Drawings Form, 3-Part NCR 1- VEC114 Law Enforcement Forms Env.

36. Photo documentation

37. Documentation

38. Interpretation of findings

39. What does it all mean? Discussion with LE Discussion with MD

40. Testimony Expert Fact

41. Questions Please be advised that we are unable to answer ANY math questions.