Sexual assault victims are a unique class of patients that require a multidisciplinary approach to care, often involving emergency department providers, social workers, law enforcement officers, victim advocates, specially trained nurse examiners, mental health providers and EMS providers. While most victims self-present to the emergency department, some victims either call for emergency services or have someone call on their behalf. The paramedic or EMT responding to the call may have had little training in caring for these patients, may not have policies in place offering treatment guidelines, and may not have clearly defined destinations on where to transport these patients for the most appropriate care.
Patients who have experienced sexual assault require a medical evaluation, trauma-informed care, post-exposure prophylaxis, and acute and ongoing emotional support. In California, victims of sexual assault are offered a forensic examination performed by a specially trained nurse examiner (sexual assault nurse examiner, or SANE), physician assistant or physician, as well as a specially trained advocate to address the patient’s psychological needs. Several models exist to offer the forensic exam and specialized counselors trained in the assessment and support of sexual assault victims, as not every emergency department in California has the onsite available resources. Hospitals either employ SANEs or physicians on staff to conduct the exam, contract with regional SANE groups to respond to the emergency department when needed, or transfer patients to another hospital that can offer the forensic exam. When staff is not employed directly at the hospital, the delays caused by the response time of the contracted SANE to the emergency department or transferring the patient to another hospital can become barriers to care, discourage patients to undergo the exam, and can increase psychological injury.
The care delivered by EMS and emergency department personnel can have lasting effects on the psychological and physical well-being of the patient. An emergency department that has patient-centered, trauma-informed care with SANE teams available for forensic testing offers compassionate, caring and thorough care. This structured formalized form of care facilitates the provision of a reassuring, safe environment following a sexual assault.1 SANE providers themselves, largely due to their additional focused training, offer compassion-based, trauma-informed care that is often perceived as “humanizing” to the patient.2 Regardless of the model created by emergency departments to offer the forensic exam and a patient advocate, compassion, empathy, and the ability to adequately collect forensic evidence while maintaining chain of custody with law enforcement are the key elements to a successful and supportive resource for the patient.
Related
- The Role of EMS in Helping Survivors of Campus Sexual Violence
- Provide Emotional First Aid When Responding to Sexually Assaulted Patients
- SAFE Program Fights Sexual Assault
In California, the EMS system is comprised of 34 different Local EMS agencies (LEMSAs), each of which creates its own policies and procedures, including hospital destination guidelines for EMS patients. Most agencies have systems of care in place to best care for patients suffering from trauma, STEMI, stroke, or cardiac arrest. Paramedics and EMTs are educated on the signs, symptoms and best treatment for each of these cases. They transport the patient to the most appropriate receiving hospital that is designated by the LEMSA. With regards to EMS policies on offering treatment guidelines for patients of sexual assault, eight of the 34 LEMSAs in California have such a policy. Nine of the 34 LEMSAs offer destination criteria for these patients to receive the forensic exam. While most paramedics learn through on-the-job training about where to transport these patients for the exam, it is not codified in policy or destination guidelines for most of the systems in California.
While most prehospital personnel are aware of the capabilities of each hospital to offer treatment of STEMI and stroke, fewer are informed of the capabilities of each hospital in their system to offer the forensic exam to victims of sexual assault. We conducted a voluntary survey of both private and fire-based paramedics and EMTs in two counties in California. The survey inquired about their knowledge and comfort in treating victims of sexual assault, and their knowledge of which hospitals in their system offered the forensic exam. Not all of the hospitals in the systems were able to conduct the forensic exam and neither county designated hospitals for receiving sexual assault victims. Of the two counties, only one county had a sexual assault treatment policy in place.
Survey results: We received 164 responses to the survey. Respondents were 82% men, 10% women, 2% non-binary, and 6% preferred to not answer. When asked how many sexual assault victims they had responded to in their careers, 59% responded less than 5, 23% responded 6-10, and 17% responded more than 11.
As shown in Figure 1, 21% of the survey respondents were under the impression every hospital in their system was equipped to perform the forensic exam and 30% were unsure of the capabilities of the hospitals.
Figures 2 and 3 show the responses when asked their comfort in treating these patient and willingness to learn more; while most respondents were somewhat comfortable in treating these patients, even more felt it would be helpful to receive more education on the topic.
The survey results suggest that most paramedics and EMTs are either unclear or incorrect on whether every hospital in their system can conduct the forensic exam for patients in the emergency department. The survey results also suggest that having a designated sexual assault receiving center in LEMSA policy would offer destination guidance consistent with other systems of care such as trauma, STEMI and stroke. While the average response would indicate that paramedics and EMTs are neutral in how comfortable they are in treating these patients, they also indicated a willingness to learn more.
The approach to caring for patients who experienced sexual assault can vary from each state as EMS systems are structured differently throughout the country. Currently in California, only eight of 34 LEMSAs have policies addressing how to care for sexual assault patients, and only nine of 34 provide guidance on where to transport these patients to offer them the forensic exam. Just as stroke centers have specialized training to assess and care for stroke patients, some hospitals can offer the full spectrum of assessment and treatment that sexual assault victims need. Introducing treatment and destination guidelines may reduce barriers to appropriate care for sexual assault victims presenting to the EMS system. Continued training and education in treating patients who have experienced sexual assault is welcomed by EMS personnel to further their knowledge and comfort in caring for these specialized patients.
References
1. Ericksen J, Dudley C, McIntosh G, Ritch L, Shumay S, Simpson M. Clients’ experiences with a specialized sexual assault service. J Emerg Nurs. 2002 Feb;28(1):86-90. doi: 10.1067/men.2002.121740. PMID: 11830744.
2. Fehler-Cabral G, Campbell R, Patterson D. Adult Sexual Assault Survivors’ Experiences With Sexual Assault Nurse Examiners (SANEs). Journal of Interpersonal Violence. 2011;26(18):3618-3639. doi:10.1177/0886260511403761
