Indian Health Service Sexual Assault Examiner (SAE) Clinical Skills Laboratory

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Lillian Young
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the Indian Health Service (IHS) two-day clinical skills

1 Indian Health Service Sexual Assault Examiner (SAE) Clinical Skills Laboratory 2012 This document outlines the Indian Health Service (IHS) two-day clinical skills training of didactically trained Sexual Assault Examiners (SAE).

2 Table of Contents Program Overview and Purpose... 3 Course Objectives... 4 Day One... 4 Day Two... 7 Students Preceptors/Clinical Instructors...10 Exam Rooms...10 Day One (Table 1)...10 Day Two (Table 2) Table Table Sexual Assault Exam Scenario One Sexual Assault Exam Scenario Two Sexual Assault Exam Scenario Three Sexual Assault Exam Scenario Four Indian Health Service 2

3 Program Overview and Purpose Overview: This live training activity is a provider-directed, provider-paced activity. The learning objectives and content covered are outlined below with the applicable time-frames as well as method of adult learning principles that will be employed. The activity is designed to promote the provider's professional performance in the role of Sexual Assault Examiner (SAE). Purpose: The purpose of the educational activity is to prepare the didactically trained Sexual Assault Examiner for clinical aspects of the sexual assault examination regardless of where the provider practices. Indian Health Service Program Overview and Purpose 3

4 Course Objectives Day One Objective Outline Time Frame Method Presenter(s) Differentiate specific structures of the female genital anatomy. Female Structure Identifies mons Identifies clitoris Identifies labia majora Identifies labia minora Identifies urethra Identifies posterior fourchette/commissure Identifies fossa navicularis Identifies hymen Identifies cervix Identifies anus, anal canal and rectum 60 min Clinical laboratory with clinical Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC-OB, FNE Describe the mechanism of action of Toluidine Blue Dye. Identify the appropriate location for Toluidine Blue application. proper application of 1% Toluidine Blue Dye. proper removal of 1% Toluidine Blue Dye Toluidine blue 1% Aqueous solution Explanation to pt. Application Removal with ky jelly/lubricant Positive uptake vs. negative uptake 60 min Clinical laboratory with clinical Elisabeth Almond, RN, SANE- A, SANE-P Indian Health Service Course Objectives 4

5 Objective Outline Time Frame Method Presenter(s) proper use of catheter for hymen Visualization. Foley catheter balloon technique Explanation to pt. Insertion Blowing up balloon Assessing hymen Removal 60 min Clinical laboratory with clinical Elisabeth Almond, RN, SANE- A, SANE-P Describe speculum insertion technique. Manipulate speculum to visualize the cervix. Describe speculum removal technique. performance of the speculum examination. Speculum Exam Explanation to pt. Insertion Use of lubricant vs. no lubricant Identification of cervix Removal 120 min Clinical laboratory with clinical Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC- OB, FNE Identify the proper collection medium for culture collection. appropriate culture collection for STD s. Collection of cultures GC CT KOH/wet prep Herpes/Viral 60 min Clinical laboratory with clinical Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC- OB, FNE; Elisabeth Almond, RN, SANE- A, SANE-P Indian Health Service Course Objectives 5

6 Identify the critical components of clinical photography. effective use of camera to document findings. Clinical Photography Patient identification Patient consent Medical record Camera Explanation to pt. Set up Close up Focus Body surface Genital 120 min Clinical laboratory with clinical Jennifer Pierce- Weeks, RN, SANE-A, SANE-P Total 8 hours Indian Health Service Course Objectives 6

7 Day Two Objective Outline Time Frame Method Presenter Identify the key components of effective history-taking. effective history taking skills. History Presenting complaint History of the presenting complaint Past medical/surgical history Drug/allergy history Contraception history Pregnancy history Family history Personal/social history 60 min Clinical laboratory with clinical Jennifer Pierce- Weeks, RN, SANE-A, SANE- P; Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC-OB, FNE; Elisabeth Almond, RN, SANE-A, SANE-P Identify the key components of the physical exam. the complete head-to-toe assessment. Review of systems Physical Assessment/Review of Systems Head to toe examination of all body surfaces General Vision Head and Neck Pulmonary Cardiovascular Gastrointestinal Genito-Urinary Ob/Gyn/Breast Neurological Endocrine Infectious Diseases Musculoskeletal Mental Health Skin and Hair 60 min Clinical laboratory with clinical Jennifer Pierce- Weeks, RN, SANE-A, SANE- P; Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC-OB, FNE; Elisabeth Almond, RN, SANE-A, SANE-P Indian Health Service Course Objectives 7

8 Objective Outline Time Frame Method Presenter Prepares the adolescent and adult for the anogenital exam. Communication about examination Has patient had this type of exam before Explains positioning Explains equipment 30 min Clinical laboratory with clinical Jennifer Pierce- Weeks, RN, SANE-A, SANE- P; Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC-OB, FNE; Elisabeth Almond, RN, SANE-A, SANE-P Identify the rationale behind collection of specific evidentiary specimens. proper body orifice and surface collection of evidence. proper material evidence collection. proper packaging of evidentiary materials. proper sealing of evidentiary materials. proper maintenance of chain of custody for evidentiary materials. Evidence collection Buccal swabs Oral swabs and smear Bite mark swabbing Other body surface swabbing Fingernail clippings/swabbings Anal swabs and smear Vaginal swabs and smear Cervical swabs and smear Head hair combing/pulling Pubic hair combing/pulling Clothing Evidence packaging Evidence sealing Chain of Custody 150 min Clinical using live model laboratory with clinical Indian Health Service Course Objectives 8 Jennifer Pierce- Weeks, RN, SANE-A, SANE- P; Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC-OB, FNE; Elisabeth Almond, RN, SANE-A, SANE-P

9 Objective Outline Time Frame Method Presenter Plan of care 180 min Clinical Inclusive of individualized patient specific needs based on scenario given Verbalizes rationale for plan to preceptor laboratory with Explains care options to clinical patient and makes patient choice a top priority Formulate a sexual assault specific plan of care based on overall assessment and diagnosis. Verbalize and defend the plan of care based on overall assessment and diagnosis. Explain care options to simulated patient. Jennifer Pierce-Weeks, RN, SANE-A, SANE-P; Angel Wilson, MSN, RN, FNP; Jennifer L. Sanchez, BSN, RNC-OB, FNE; Elisabeth Almond, RN, SANE-A, SANE- P Total 8 hours Indian Health Service Course Objectives 9

10 Students Students are distributed into five groups of four students each with no more than twenty students attending each two-day session. If there is more than one student from a location, it is preferred that they train in the same group throughout the clinical whenever possible. After receiving their group assignment, each group rotates through the specified examination room for the time period allotted. Preceptors/Clinical Instructors Each examination room is assigned a preceptor/clinical instructor specific to the content being taught, and a live patient model. The preceptor is responsible for teaching the skill the student needs to acquire, and observing the student to insure that proper procedures are followed, the live patient models are protected from harm and the student acquires the skills necessary to function in the role of SAE. The live patient models are responsible for giving real-time feedback on technique to the students. During the sexual assault scenarios, it is the instructors responsibility to ensure students consider all evidentiary, treatment, safety planning, and follow-up considerations specific to the scenario given. Exam Rooms Five exam rooms exist for training purposes within the laboratory. Each training requires two full days for each student. Day One (Table 1) Because most providers are not advanced practice nor performing pelvic examinations as a routine part of their clinical care of patients, exam rooms one and two are dedicated on day one of training to teaching the skills associated with conducting pelvic examinations of the female patient. Pelvic examination consists of assessment of the genital structures, proper insertion and removal of the speculum, finding the cervix, culturing for sexually transmitted infections, and conducting a bimanual examination. The instructor is responsible for teaching the techniques. Each student will rotate through demonstrating the technique within their group and under the direction of the instructor. Each of these exam rooms should hold a GYN stretcher or bed for appropriate examination techniques and teaching. Examination room three is dedicated on day one of training to teaching the skills associated with specific sexual assault examination techniques. The sexual assault examination techniques include application and removal of Toluidine Blue dye to the appropriate ano-genital structures; insertion and removal of the Foley catheter to assess for hymenal injury; evidence collection of clothing, from body surfaces and orifices; and utilization of a colposcope to visualize the genitalia and assess for injury. The instructor is responsible for teaching the techniques. Each student will rotate through Indian Health Service Students 10

11 demonstrating the technique within their group and under the direction of the instructor. It is preferred that this exam room also contain a GYN stretcher or bed for appropriate examination techniques and teaching, but if necessary a plain stretcher will suffice. Examination room four is dedicated on day one of the training to teaching the skills associated with digital photography techniques used to photo-document body surface and genital findings. The photography techniques include programming the camera to include ISO and macro use, focus, patient identification, images necessary for documentation, and rules associated with use of a standard (ruler). The examination room is outfitted with a manikin on a stretcher/hospital bed with some areas of moulage that can be photo-documented. Additionally a female ano-genital manikin is present for photographing purposes. Under no circumstances will a live patient model be photographed during training. Day Two (Table 2) All of the skills learned and demonstrated on day one are utilized again by the students on day two. Each group returns to rotate through each of the four examination rooms. Each examination room contains both clinical instructors and live patient models, and each exam room should contain a GYN stretcher or bed for appropriate examination techniques and teaching. In the first exam room assignment of the day, the instructor will demonstrate with the assistance of the live patient model, completing a sexual assault examination and plan of care. In each subsequent exam room throughout the day, the student groups will be presented with distinctly different sexual assault scenarios as they gather histories, conduct sexual assault examinations, and plan care for the patient under the supervision and guidance of their instructor. The scenarios are listed at the end of this document. Indian Health Service Exam Rooms 11

12 EXAM RM 1 EXAM RM 2 EXAM RM 3 EXAM RM 4 Table 1 DAY ONE Activity Pelvic Assessment Speculum Culture Collection Bimanual Pelvic Assessment Speculum Culture Collection Bimanual SA Techniques Toluidine Blue Foley Evidence Collection Colposcope Photography Instructors Wilson Sanchez Almond Pierce-Weeks 08:00-10:00 Group 1 Group 2 Group 3 Group 4 10:00-11:30 Group 4 Group 1 Group 2 Group 3 11:30-12:30 LUNCH LUNCH LUNCH LUNCH 12:30-2:00 Group 3 Group 4 Group 1 Group 2 2:00-3:30 Group 2 Group 3 Group 4 Group 1 3:30-4:30 Group 1 Group 2 Group 3 Group 4 4:30-5:00 Closing meeting Closing meeting Closing meeting Closing meeting Indian Health Service Table 1 12

13 EXAM RM 1 EXAM RM 2 EXAM RM 3 EXAM RM 4 Table 2 DAY TWO Activity Sexual Assault Exam Scenario 1 Sexual Assault Exam Scenario 2 Sexual Assault Exam Scenario 3 Sexual Assault Exam Scenario 4 Instructors Pierce-Weeks Almond Wilson Sanchez 08:00-08:30 Morning meeting Morning meeting Morning meeting Morning meeting 08:30-10:30 Group 1 Group 2 Group 3 Group 4 10:30-12:00 Group 4 Group 1 Group 2 Group 3 12:00-1:00 LUNCH LUNCH LUNCH LUNCH 1:00-2:30 Group 3 Group 4 Group 1 Group 2 2:30-4:00 Group 2 Group 3 Group 4 Group 1 4:00-5:00 Closing Meeting Q & A Session Final Practice Evaluations Closing Meeting Q & A Session Final Practice Evaluations Closing Meeting Q & A Session Final Practice Evaluations Closing Meeting Q & A Session Final Practice Evaluations Indian Health Service Table 2 13

14 Sexual Assault Exam Scenario One Twenty-year-old native woman comes in reporting that she was at a party last night with friends and thinks she might have been raped. She says she had a couple shots of tequila, but she usually does, and this time she thinks she passed out. "That's never happened to me before when I'm drinking tequila." "We were partying in a field on the rez, had a bonfire, and I woke up in the field this morning with nobody else around, but my pants were gone and it hurts down here," Indicating her genital area). Health history: None; not receiving any primary health care or prevention; uncertain of immunization status; Sexual/GYN History: Has a boyfriend x 4 months. Is having sex with him. Uses no birth control. Gravida 0 Para 0. Indian Health Service Sexual Assault Exam Scenario One 14

15 Sexual Assault Exam Scenario Two Fifteen-year-old native girl comes in reporting that she spent the night at her Auntie's two night's ago, and her Uncle came into her bedroom in the middle of the night. She reports that he was rubbing her back and told her she was beautiful and he needed her. She then reports that he kissed all over her neck, digitally penetrated her vagina, tried to insert his penis in her anus, and vaginally penetrated her vagina without a condom on. She is uncertain if he ejaculated. Health history: None; Reports that her mom always brings her to the clinic for her shots. Sexual/GYN History: Denies any previous sexual activity, consensual or otherwise; Uses no birth control. Gravida 0 Para 0. Indian Health Service Sexual Assault Exam Scenario Two 15

16 Sexual Assault Exam Scenario Three Forty-three-year old native woman comes in accompanied by the police. She reports that two hours ago her husband of 15 years came home drunk and physically assaulted her with his fists, kicked her with his feet, and hit her with the butt of his gun in the head. She said he made her perform oral sex on him, but he could not get an erection and that's when he got the gun out and hit her with it. He was then able to get an erection and vaginally penetrate her with his penis. She does not believe he ejaculated. She reports that he has some difficulty with this. She also reports that he tried to shove his whole fist into her vagina. Health history: High blood pressure, she is being treated for at the clinic, though she reports he sometimes throws away her medication when he gets angry with her; Obesity; Sexual/GYN History: Gravida 4 Para 3; Reports 1 miscarriage in the first trimester. All live births were vaginal deliveries without episiotomies or tearing. Reports that two months ago she was treated for GC at the clinic and she thinks her husband is screwing around on her. Indian Health Service Sexual Assault Exam Scenario Three 16

17 Sexual Assault Exam Scenario Four Thirty-two-year-old native woman comes in reporting that she was walking home about 4 hours ago and a border patrol van pulled up and dragged her into it. Three men dressed in border patrol uniforms forced vaginal and anal sex on her in the van. None of them wore condoms. She did not recognize any of them as men she knows. When they were done with her, they dumped her back on the roadside. Health history: None Sexual/GYN History: Gravida 1 Para 1; Married for 2 years; 1 year old at home. Indian Health Service Sexual Assault Exam Scenario Five 17

MEMORIAL HOSPITAL SEXUAL ASSAULT MEDICAL/FORENSIC RECORD

MEMORIAL HOSPITAL SEXUAL ASSAULT MEDICAL/FORENSIC RECORD Name and Location of Examining Facility: Address: Date of Admission: Time: Name of Patient: Date of Birth: Address: Brought in by: Others Present