Section VI: Caring for special patient populations

MA protocol for adult/adolescent SANEs

Adolescent patients (12—17 years)

Principles of care

While some adolescents usually respond well to safe touch (e.g. touching on shoulder or arm), sexual assault patients need to have their physical boundaries respected to avoid feeling that they have no control over who can touch their bodies.

• Always ask if it is okay before you initiate any touch.
• Respect the patient’s personal boundaries. Do not pressure them for details they are not comfortable providing, or discuss details of the assault with their guardian without their consent.
• Inform them what you are required to do as a mandated reporter (see “Mandated Reporting” below).

Be honest: Do not tell adolescents you will keep secrets or not tell anyone if you know you cannot. You can tell the patient that you will do your best to support them and help them feel safe, but do not make any promises you cannot keep or may not be able to keep. Remember, telling an adolescent that you will “try” to do something is usually taken as a promise! Regaining their own trust of self and of others is extremely important for the patient. Sexual assault victims often feel tremendous shame and guilt, so the more you let them control information surrounding the assault, the better they will feel.

Helpful tips for working with adolescents

• As with adults, adolescent patients should be given as much control over their exam as possible, including setting the pace of their exam.
• Allow adolescent to choose their support person such as a parent, guardian, friend or rape crisis advocate.
• Engage with adolescent using non-threatening questions.
• Listen without judgment.
• Be mindful of your own body language; try not to appear rushed or distracted.
• Allow teen to set the pace of this encounter.
• Don’t promise what you can not deliver, especially as it pertains to confidentiality
• Avoid asking “why” questions. “Why” questions tend to put people on the defensive. Consider rephrasing such as: “Can you tell me more about ______?”
• Match the adolescent’s emotional state, unless it is hostile. Reflecting someone’s mood helps the individual feel understood.
• Recognize and respect possible potential ambivalence. Reassure patient that ALL of his/her feelings are normal.

Obtaining adolescent consent

• Adolescent patients may independently seek post-assault care under MGL Chapter 112/Section 12F.
• All adolescent have the opportunity to consent and decide who is present for the exam without the influence of the parent/guardian.
• Parents/guardians must be informed that a forensic examination/forensic evidence collection will not be completed without the explicit consent of the adolescent.
• Adolescent patients must consent to SANE care, and the completion of a forensic examination and forensic evidence collection, and should sign Form 1 Patient Consent.
• Adolescents < 16 years should be informed that their forensic evidence kit will be analyzed by the crime lab whether or not they choose to report their assault to the police.
• Adolescents who are 16 -17 years of age should be informed that their forensic evidence kit will not be analyzed unless they report their assault to the police.
• Adolescent patients should be notified that the SANE is a mandated reporter and must submit a 51A report to the Department of Children and Families (see Mandated Reporting below).
• While the adolescent may not want to report their assault to the police, a 51A filing indirectly notifies the local criminal justice system. However, adolescents should be notified that they have the right to participate in discussions/decisions about their level of interaction with the criminal justice system.

Mandated reporting (see also Section III: Mandatory reporting)

• Mandated reporting is required by SANE clinicians for all patients < 18 years of age when there is concern or report of sexual assault, regardless of the relationship between the patient and the assailant.
• Mandated reports for child/adolescent sexual abuse/assault are known as 51As, and are filed with the Department of Children and Families (DCF). This is a two phase process: immediate verbal report and follow-up with a written report.
• DCF is required to “screen in” for investigation all 51As that involve the abuse by a guardian or potential caregiver, and if there is concern for the Commercial Sexual Exploitation of Children (CSEC).
• While DCF may “screen out” and thus not investigate 51As for abuse/assault committed by non-caregivers, DCF is required to refer ALL 51As filed for sexual abuse/assault to the local District Attorney’s Office.
• While the adolescent may not want to report their assault to the police, a 51A filing indirectly notifies the local criminal justice system. However, adolescents should be notified that they have the right to participate in discussions/decisions about their level of interaction with the criminal justice system.
• While most adolescents present for care with a parent or guardian, there are times when an adolescent will request that their parent/guardian not be notified of their sexual assault. However, because of the mandatory reporting requirement the SANE should:

1. Explain that she cannot guarantee that the patient’s parent/guardian will not learn this information.
2. Ascertain the patient’s concerns about their parent/guardian knowing about their assault and whether it poses a safety risk to the patient. The SANE should notify the hospital social service department if there are concerns in this regard.
3. Tell the patient that you will verbally communicate with DCF about the patient’s concerns, and also document such concerns on the written 51A
4. Ask the patient if there is a supportive person in their life who could help the patient in discussing the assault with the patient’s parent/guardian

Use of the MA Pediatric Sexual Assault Evidence Collection Kit (MA Pedi Kit) for adolescents

• While the MA Pedi Kit was designed for patients 11 years of age and younger, there may be situations in which the SANE determines that based on the patient’s emotional and physical development that the younger adolescent would benefit from the use of the MA Pediatric Sexual Assault Evidence Collection Kit (MA PEDI KIT).
• In these situations, the SANE should limit their interview of the patient to the basic questions of Who, What, Where and When, and questions to guide forensic evidence collection. These patients may benefit from a forensic interview and referral to a Pediatric SANE/Medical Provider at the local Children’s Advocacy Center (CAC).

Preparing female adolescent patients for the SANE exam (see Appendix 3: Adolescent Speculum Examination Algorithm (PDF) | (DOCX)

The following guidelines will help SANE decision-making when determining the best approach for conducting a limited pelvic examination and evidence collection.

• Adolescent has not reached menarche. If a patient has not reached menarche:

The SANE may determine that the MA PEDI Kit is the preferred evidence kit to use. In this case, refer to MA PEDI Kit Instructions.

• Adolescent has not reached menarche.
  • The SANE may determine that the MA PEDI Kit is the preferred evidence kit to use. In this case, refer to MA PEDI Kit Instructions.
  • A speculum exam should never be done for a patient who has not reached menarche, as unestrogenized hymenal tissue is extremely sensitive. In these situations, the SANE should only obtain external genital swabs.
  • Document reason for not obtaining vaginal swabs on MSAECK Step 15 Envelope.
  • If there is a concern for significant bleeding or a foreign body, consult ED Attending.
• Adolescent has reached menarche but has never had a speculum exam.
  • A speculum exam should not be done for adolescents who have never had a speculum exam. In these situations, labial traction, Q-tip exam of the hymen and/or use of vaginal swabs without the speculum should be used (see below). If there is a concern for significant bleeding or a foreign body, consult with ED Attending.
• Adolescent has reached menarche and has previously had a speculum exam.
  • In this situation, a speculum exam may be done with the patient’s consent. If the patient reports pain or requests the exam to be stopped, the SANE should immediately stop the exam. In the event that a speculum exam is not completed, less invasive examination techniques (labial traction, Q-tip exam of the hymen, and/or evidence collection utilizing vaginal swabs without the speculum) should be used (see below) with patient consent.

Adequate lighting is an important adjunct when utilizing the following techniques in order to maximize visualization:

• Labial traction: Gently retract the labia majora between the thumb and forefinger pulling the labia downward and outward (towards examiner) until hymen is well visualized. This technique allows good visualization of hymen, vaginal walls and internal structures (if using this technique, with the use of a speculum, apply labial traction and visually inspect the area before inserting the speculum). This will prevent misinterpretation of any redness that might be caused by the speculum insertion).
• Q-tip exam of hymen: This exam should only be done on an estrogenized hymen (the hymen becomes estrogenized at menarche). Gently roll the Q-tip along the inside aspect of the entire hymenal rim assessing the edges for lacerations, abrasions, granulated tissue clefts, tears, narrowing and scars.
• Evidence collection using vaginal swabs without speculum: If the patient is unable to tolerate a speculum exam, carefully pass the collection swabs through the hymenal opening to obtain forensic evidence. If the hymen is estrogenized this should be well tolerated. If the patient is uncomfortable or complains of pain the SANE should stop the exam. As a last resort, the SANE may allow the patient to collect the vaginal swabs under the direct observation of the SANE.

Commercial Sexual Exploitation of Children (CSEC)

1. Overview
   1. A commercially sexually exploited child is one under the age of 18 who engages, agrees to engage in, or offers to engage in sexual conduct in exchange for money, food, shelter, clothing, education, or care. It is not unusual for these teens to not identify as victims.
   2. CSEC is a form of child sexual abuse. Because the victims are unable to consent to any sexual activity, they are victims not “child/teen prostitutes”. This is true regardless of whether or not they perceive themselves as victims
   3. As with other forms of sexual abuse, these children/teens are targeted because they are vulnerable and are often groomed by their perpetrator with attention, promises of “love”, gifts and/or other valued items.
   4. CSEC includes sex trafficking, child pornography, and child sex tourism.
2. Statistics
   1. Most frequently identified age of a person entering the commercial sex industry in U.S. is 12-14 years for females, 11-13 for males.
   2. 70-90% of commercially sexually exploited youth have a history of prior child sexual abuse.
   3. As many as one-third of teen runaways/throwaways will become involved in prostitution within 48 hours of leaving home.
   4. Shelter is the primary traded commodity in return for sexual activity; almost 50% of minors engaging in commercial sex do so for a place to stay.
3. Risk Factors
   1. Societal:
      • Lack of awareness about CSEC
      • Sexualization of children in society, media etc.
   2. Community:
      • Peer pressure
      • Social norms/isolation
      • Gang involvement
   3. Relationship:
      • Family conflict/disruption
   4. Individual:
      • High risk of child abuse, neglect, maltreatment
      • Homeless, runaway, “throwaway”, LGBTQIA, high risk of being systems involved (DCF, DYS, etc.)
4. General Indicators
   1. Multiple reports of running away with no explanation of whereabouts.
   2. Unexplained absences from school for a period of time.
   3. New clothes or accessories with no explanation as to how they were obtained.
   4. Police reports of child located in areas known for prostitution.
   5. Brands or scarring indicating ownership (tattoos, brands etc.).
   6. Sexual paraphernalia such as condoms, lubrication, sex toys, etc.
   7. Hotel keys, bags, receipts, etc.
   8. Presence of overly controlling “boyfriend” or older female.
   9. Multiple cell phones/electronic devices.
   10. Minors with slips of paper/notebooks containing phone numbers, dollar amounts, hotel names etc.
   11. Lies about age/identity.
   12. Looks to others before answering questions.
   13. Uses terminology such as “the life,” “the game,” “daddy,” “wifey,” or “the track.”
5. Tips for Working with CSEC Victims
   1. Recognize that the child may not identify themselves as a victim.
   2. Be sensitive about asking too much too soon.
   3. Build rapport over multiple encounters if possible.
   4. Assess and satisfy immediate, basic needs of child first:
      • Shelter & Food
      • Safety Planning
      • Mental Health
      • Detox if necessary

Patients with intellectual/developmental disabilities (I/DD) and/or physical disabilities

General tips

• When caring for a patient with an intellectual/developmental disability (I/DD), always PRESUME competence first.
• Patients ages 18 – 59, who have disabilities, are their own guardian unless adjudicated otherwise in a court of law, and are able to consent to SANE care and a forensic exam.
• If the patient is unable to consent to a forensic exam or forensic evidence collection due to a cognitive or intellectual disability, follow MA SANE Informed Consent Protocol (refer to Section IV: Obtaining Patient Consent) for guidance regarding guardian or administrative consent.
• Parents accompanying the patient are not automatically the patient’s guardian. If they report being the patient’s guardian, request to see guardianship documents.
• The SANE is required to obtain consent for the SANE exam from the patient/patient’s appointed guardian. This can be obtained in person or via phone.
• If a guardian does not accompany the patient to the hospital, and the patient is unable to independently answer questions, contact DPPC Hotline [phone]. Request to speak to the on-call agency representative who can assist in obtaining consent from the guardian.
• If there are strong indicators that a sexual assault has occurred, and the guardian is refusing evidence collection, DPPC can obtain a temporary order of protection to allow evidence collection if the patient consents. (DPPC staff can usually obtain a protective order within hours and fax it to the hospital).
• An impartial ASL, Signed English, or other appropriate translator should be accessed to assist in consent, exam, and rape crisis counselling processes if the patient is unable to communicate verbally.
• If the patient is not able to sign the consent form because of upper extremity mobility impairment or compromised manual dexterity, the SANE should obtain verbal consent from the patient for each component of the exam, and have an impartial witness sign as a witness on the consent form.
• As with all patients, regardless of guardianship status, a SANE will not conduct an exam or complete evidence collection without the patient’s consent.

Communication barriers

Some individuals with a physical disability including (but not limited to) those with multiple sclerosis or cerebral palsy may have speech that is difficult to understand at times. Their speech may be slightly slurred, leading to misconceptions that they are intoxicated or perhaps even cognitively impaired. It is important to not make assumptions or allow others in the health care team to color your perceptions of the patient before assessing them yourself.

• If the patient is unable to communicate verbally, an impartial ASL, Signed English, or other appropriate translator should be accessed to assist in the consent, exam, and rape crisis counselling processes.
• If the patient is unable to provide the history of the assault due to I/DD or dementia, document the name of the person who provided the history of the incident or the signs/symptoms that raised a concern for sexual abuse/assault on MSAECK Form 3. For situations in which the details of the assault are unknown, the SANE should conduct as many steps of evidence collection as the patient allows/can tolerate.

Tips for effective communication

• Allow adequate time for the patient to provide the history of their assault.
• Give your whole and unhurried attention to the patient — be patient and encouraging.
• Avoid the temptation to put words into the patient’s mouth — don’t speak for them or try to correct.
• Do not be afraid to ask for clarification if you do not understand.
• Remember that speech impairment is not related to intelligence.

Consent considerations

In order to ensure that patients with intellectual/developmental disabilities (I/DD) are treated with dignity and respect, the following approaches may be beneficial:

• The SANE may need to allow more time for the consent process so that the patient has sufficient time to ask questions, have questions answered, and to communicate consent before the patient signs the consent form.
• A person with I/DD may indicate understanding or agreement by nodding their head, raising a hand, making a signal, or orally answering questions.
• After each step or procedure has been explained, the SANE should ask the patient to confirm their understanding through an individualized expression of consent.
• The patient can be asked to explain their understanding of any procedure described.
• Patients with I/DD may not initially reveal the disability. The SANE must develop a relationship of trust and respect with the patient so that the full extent of the patient’s disability can be revealed. Establishing trust with the patient reduces the chance that the patient will feel intimidated.
• Patients suffering from mental health conditions deserve the same dignified and respectful approach used for patients without such challenges. Patients with mental health challenges may remain competent to give informed consent.
• A person with mental health challenges may be admitted to the Emergency Department pursuant to an emergency restraint as a precautionary protective measure. However, a Section 12 restraint does not necessarily mean that the patient is incapable of giving consent for a SANE exam and evidence collection. When the patient is deemed medically safe and can cooperate with the exam, the SANE should obtain the patients written consent on Form 1.

Obtaining medical history and history of assault

• It is important to know the nature of any physical impairment, underlying disease, or injury in order to safely perform the exam.
• Patients with a spinal cord injury (SCI) should be assessed for level of injury and history of autonomic dysreflexia (AD). If the patient has history of AD, the attending physician must conduct the pelvic examination.
  • Assess patient for history of muscle spasm and triggers.
  • Assess patient for latex allergy.

Experience with pelvic exams

As with all patients, inquire about the patient’s history of pelvic examinations by asking the following:

1. Have you ever had a pelvic or speculum exam before?
2. Do you know what a speculum is?
3. What was your experience with the exam?
4. What positions have been most comfortable for you?
5. Do you experience increased muscle spasms or dysreflexia with pelvic exams?
6. What can I do to make the exam more comfortable for you?

Conducting the SANE exam: general exam tips

• Relax — project confidence and knowledge and don’t be afraid to admit what you don’t know, and ask for help from the patient or other providers.
• Do not touch or move a patient’s wheelchair or assistive device without the patient’s permission.
• Keep assistive devices within reach of the patient at all times, whenever possible.
• Ask patients what has worked for them in the past with exams and transfers and involve the patient as much as they desire.
• Ask patient if they should disrobe before getting on the table or after.
• Keep assistants/people in the room to a minimum and make sure that the patient consents to their presence.
• Adjust the lighting and limit distractions according to the patient’s comfort level, especially for patients with autism or dementia.
• Speak directly to the patient (especially when using an interpreter) and always presume competence; ask follow-up questions of the guardian/caregiver only if unable to elicit the information from the patient.
• Provide the patient extra time to process the question and be able to answer.
• Always tell the patient what you are doing, why you are doing it, and always make sure you have their consent to do it.
• “Check in” frequently with the patient to insure that they are physically and emotionally comfortable with the exam.
• For patients unable to communicate due to I/DD or dementia with a significant concern or abuse/assault, the SANE should conduct as many steps of evidence collection as the patient allows/can tolerate.
• Bear in mind that people, especially women, with disabilities may have had unpleasant experiences with healthcare providers in the past, making this difficult exam even more arduous and anxiety provoking.
• The physical safety of the patient and SANE is paramount!
• Remember that people with disabilities, including people with spinal cord injury, can feel painful or unpleasant sensations when stimulated; be gentle during all aspects of the exam.

Modifications to forensic exam and MSAECK steps

As is true of all patients, patients with I/DD or physical disabilities have unique circumstances that may require adjustment to the order of MSAECK step completion to fit the patient’s tolerance level. Providing multiple breaks, using distractors such as music/TV/books, and utilizing other calming/soothing measures may be very helpful.

1. Step 2: Control swabs
   No alterations to protocol anticipated
2. Step 3: Toxicology testing
   • If the SANE has concern for a drug-facilitated assault that occurred within the past 96 hours, and the patient consents, collect blood and urine samples in accordance with MA SANE Protocol. For patients with physical disabilities, a bladder regimen or indwelling catheter may need to be considered. If the patient uses intermittent catheterization, you may incorporate this into the exam. AFTER swabbing for forensic evidence from the external genitalia and perineum, and before the speculum exam, either catheterize or have the patient self-catheterize for a sample.
   • If the patient has an indwelling catheter, collect a urine sample from the leg bag and a fresh sample from the bladder and document on each sample from where they were obtained.
3. Step 4: Blood sample
   Consider option of using Buccal Swab testing if most appropriate.
4. Step 5: Head hair combing
   The examiner may need to hold the paper or have an assistant hold the patient’s head over the paper during the combing (make sure that it is acceptable to the patient to hold head in this manner or have the patient comb their own hair while you hold the paper).
5. Step 6: Oral swabs and smears
   The examiner may need to be aware of difficulties a patient may have in holding their mouth open for the swabbing. Ask the patient what assistance they need for this- consider effective techniques that may have worked for them when having had dental work.
6. Step 7: Fingernail scrapings
   Patients who are tactile defensive (such as those on the autism spectrum) may not tolerate this. Ask patient if they would like to assist, and let them scrap under their own nails.
7. Steps 8A, 8B and 9: Foreign material collection and clothing collection
   These Steps will need to be altered based on the individual physical impairment of the patient. Patients who are unable to stand will not be able to stand on the foreign material collection sheet to disrobe. Patients who have balance problems may be unable to complete this Step in the traditional manner as well. Make sure that you ASK the patient what they are able to tolerate and assist them as needed with disrobing. Suggested Alterations:
   1. If the patient arrives via ambulance, save the sheet from the stretcher
   2. Place the foreign collection sheet on the exam table and leave in place until patient is disrobed and exam completed
   3. If patient prefers to disrobe while in wheelchair, try tucking sheets around the wheelchair — avoiding the wheels — to catch debris as the patient disrobes
   4. If patient uses a wheel chair, do not put the chair on the paper as debris from the wheels can contaminate evidence
   5. Based on history, it may be indicated to swab the patient’s wheelchair — always ask permission first
   6. If the wheelchair is at home (ambulances will not transport a wheelchair), and the crime has been reported, suggest that the police collect evidence from the chair at home
8. Step 10: Bite marks
   No alterations anticipated
9. Step 11: Additional swabbing
   No alterations anticipated. Remember to ask permission to swab wheelchairs or assistive devices and accurately document location of swab collection.
10. Step 12: Pubic hair combing
    Refer to positioning techniques for pelvic exam below
11. Steps 13, 14, 15: External genital swabs, perianal swabs/smears and vaginal swabs/smears
    During the pelvic exam portion of the exam, refer to the pelvic exam information below. The actual evidence collection during this portion of the exam should be carried out as per protocol.
    Note:
    • If applying water-soluble Lidocaine gel to the perineum or anal area to reduce risk of dysreflexia, this should be done after swabs are collected for forensic evidence.
    • Urine catheterization for patient comfort or to reduce risk of autonomic dysreflexia, should be done PRIOR to the speculum exam but AFTER evidence collection to avoid contamination.
12. Step 16: Anorectal swabs and smears
    Because there is a risk of Autonomic Dysreflexia (AD) when obtaining rectal swabs and smears, perform this collection Step only when indicated. Hospital staff should follow ADR procedures below for prevention and treatment techniques.
13. Step 17: Completion of forms
    Complete mandated report forms, both written and verbal reports if indicated (see Section III: Mandatory Reporting):
    • 19 C — Report of Abuse of Persons with Disabilities (18-59 years of age)
    • Provider Sexual Crime Report (PSCR) Kit Form 2A
    • If assault occurred in health care/long-term care facility, speak with hospital staff regarding the need to file a Health Care Quality (HCQ) Report with the MA Department of Public Health
    • Assist with Victim Compensation processes

Alterations to digital photography protocol

Photographing injuries is often a crucial part of the evidence collection exam; however, patients with mobility impairments may not be able to assume the traditional positioning for forensic photography. For instance, they may not be able to turn their head to establish identity when photographing back wounds, or they may not be able to move their legs into position for an ideal photo.

Recommendations:

1. Fully and carefully document all bruises and wounds on Form 4 body map to correlate with photos obtained.
2. If you are unable to establish the patient’s identity by including the patient’s face in a photo, include a distinguishing mark or scar near the wound in the photo if possible.
3. Be creative with positioning for the photos.
4. Document any mobility limitations that interfere with ideal forensic photography.
5. Remember to appropriately drape and position all patients to insure privacy and dignity, bearing in mind that these photos may be enlarged and displayed to a courtroom.

Mandatory reporting

MA SANEs are responsible for contacting the Disabled Persons Protection Commission (DPPC) to provide a verbal report for a sexual assault involving a person with disabilities.

Disabled Persons Protection Commission (DPPC)
For patients 18 to 59 years
Immediate verbal report: 1-800-426-9009

Post-assault services for persons with disabilities

The Sexual Assault Response Unit (SARU) within the Disabled Persons Protection Commission (DPPC) provides I/DD sexual assault survivors with free and confidential information and assistance accessing trauma services. SARU navigators help survivors with a disability access post-sexual assault services, such as medical care, legal help, financial assistance, and counseling. SARU Peer Support staff offer I/DD sexual assault survivors encouragement, active listening, peer support, inspiration, and belief. SARU staff is also available to help friends, family and support staff access services. In addition, the SARU provides technical assistance and case consultation to professionals throughout the state.

To contact the SARU during regular business hours, please call [phone] x301.

Incarcerated patients

The risk of sexual assault in prisons, jails and house of correction is significant. Incarcerated sexual assault patients deserve compassionate care that is respectful, dignified and considerate of the patient’s safety. At the same time, the SANE must consider their own safety as well as that of other hospital staff during all aspects of the patient encounter. This includes appropriate alterations to exam procedures in collaboration with the accompanying Correctional Officer (CO), and specific considerations for documentation and discharge planning.

Important Considerations

• Maintain a safe environment for patient and SANE.
• Keep supplies organized and any sharp objects at a safe distance from patient.
• Never give anything to the patient.
• Never allow the patient to make a phone call.
• Never take the patient away from an area without the consent of the Correctional Officer (CO).
• Never relay any information, or perform “favors” for the patient.
• Never share personal information about yourself, family or co-workers.
• Do not ask the CO to verbally relay any health/clinical information.
• Do not ask the CO about details of the patient’s assault.
• Do not divulge any treatment timeframes or schedules with the patient.
• Consult with the patient’s escorting CO if restraints interfere with patient care and evidence collection procedures, and follow the instructions of the CO as he/she is the most knowledge about the patient’s safety risks.

MSAECK Exam Modifications

1. Step 1 Documentation Forms: Signing name may be awkward for the patient if restrained.
2. Step 3 Toxicology Testing: Obtaining blood draw and urine sample may require restraint management.
3. Step 4 DNA Sample: Use Buccal Swab
4. Step 5 Head Hair Combings: Use of restraints may interfere with evidence collection. Consult with the CO regarding restraint management.
5. Step 7 Fingernail Scraping: Evidence collection may be awkward if patient is restrained.
6. Steps 8A, 8B, and 9 Foreign Material Collection and Clothing Collection: This step may require alteration based on the patient’s restraint status. Often times, the clothing worn during the assault will be collected at the correctional facility using their chain of custody protocol, prior to hospital transport.
   1. Handcuffed and shackled patients will have balance issues preventing the completion of these steps in the traditional way.
   2. It may be impossible to collect clothing without the removal of restraints. If restraints must remain, clothing may be cut-off, with patient and CO consent. Be sure to document how and why the clothing/evidence was collected on the evidence collection envelope.
7. Step 10 Bite Marks: Use of restraints may interfere with evidence collection. Consult with the CO regarding restraint management.
8. Steps 11-16 Additional Swabs, Pubic Hair Combing, External Genital Swabs, Perianal Swabs, Vaginal Swabs and smears, Swabs, Anorectal Swabs and Smears, and Pelvic Exam: Use of restraints may interfere with examination and evidence collection. Consult with the escorting CO for assistance regarding restraint management prior to this portion of the exam.
   1. Ensure that the patient’s privacy is maintained in the best way possible.
   2. Drape and position the patient to ensure privacy and dignity.
   3. Consider turning the stretcher so the patient is facing the wall, if approved by CO.

Forensic Photography

• Restrained patients may have difficulties in assuming traditional positions for forensic photography. Consult with the patient’s escorting CO regarding restraint management.
• Appropriately drape and position the patient to ensure privacy and dignity.
• Be creative with positioning.
• If unable to include patient’s face in photo, include distinguishing marks or scars to help establish the patient’s identity.
• Document any mobility limitation (like handcuffs and shackles) that interfere with ideal forensic photography.
• Carefully document all bruises and wounds on the body maps to correlate with photos.

Documentation Considerations

1. Form 1: Consent
   1. Patient Address: Correctional Facility
   2. Follow-up Phone Call: Correctional Health Service Department
2. Form 2A: Provider Sexual Crime Report (PSCR):
   1. Document name of the correctional facility in field entitled “Specific Surroundings at time of Assault”
   2. Place a copy of the completed PSCR in a hospital envelop and mark envelop as “SANE Discharge Envelope A.” Seal the envelope and address to: Warden/Sheriff, Correctional Facility. Give the envelope to the escorting CO for delivery to the patient’s correctional facility.
   3. Fax copy of PSCR to the Executive Office of Public Safety and Security (EOPSS).
3. Form 6: Treatment and Discharge
   1. Aftercare Instructions
      • Do not write in dates for follow-up.
      • Discuss future treatment options in general terms with the patient. Due to security reasons, do not divulge any treatment timeframes or schedules with the patient. Express to the patient that the SANE’s treatment plan is a recommendation.
      • Assure that follow-up care will be facilitated by the Correctional Facility’s Healthcare Staff.
   2. Safety Planning
      • If the patient states that they do not “feel safe” returning to their correctional facility, communicate that information to the Emergency Department Physician, the escorting CO, and the Correctional Health Service Charge Nurse. Document the communication and note who you spoke to, to convey the information, on Form 6 under “safety planning.”
   3. The SANE must contact the Correctional Health Service Charge Nurse (during hours of operation) prior to the patient’s discharge from the hospital for a report/review of the SANE discharge instructions.
   4. Place the completed yellow Form 6 in marked “SANE Discharge Envelope B.” Address: “Attention Health Service Department Charge Nurse” with the name of the Correctional Institution. Seal the envelope and give the envelope to the patient’s escorting CO for transport back to the correctional facility.

Mandatory Reporting

Complete Mandatory Reporting Forms as necessary (Refer to Section III: Mandatory Reporting).

MSAECK Transportation

The accompanying CO can transport the kit to the Crime Lab (log the kit into the log book first, and then sign it out when you hand it over) unless the reported assailant is an employee of the correctional facility. If the assault involves correctional staff, call the MA State police for kit pick-up and transport to the Crime Lab.