Regardless of whether you work at a large tertiary center or a referring hospital, unfortunately, you will be faced with the pediatric sexual assault victim. Most of us, despite our training and clinical experience, are still very uncomfortable managing these patients. The diagnosis and management of DKA is complex; however, the wide range of potential injuries, both physical and emotional, combined with the potential for persistent pain lasting into the distant future and the tangled social issues all mixed the presence of the legal system makes these cases extremely daunting.
Additionally, our reflexive desire to “diagnose” conditions can lead to errors and potential harm to the patient. How? Simply put: obtaining a history from a pediatric patient presenting to you for potential sexual assault can be perceived as an “interview” and if that is done incorrectly, the defense lawyer will be able to use that as evidence that the child’s perception of what happened was altered or tainted (your questions adjusted the child’s recollections). The child’s recollection is susceptible to distortion. That is a problem.
So, what do we need to do to help the patient and avoid doing any harm? Fortunately, recently, a friend and colleague of mine, Dale Woolridge, MD, wrote an article on this matter for the ACEP Peds Section. I will summarize it below:
Job #1: Medical Screening exam!
- Just like always – fortunately, we are great at this!
- Check vital signs!!
- Ensure that there are no significant life or limb threatening injuries (Hemorrhage? Significant head injury? Injuries to internal organs?).
- Critical history to determine patient’s medical stability (see below).
Job #2: Make the patient as comfortable as possible.
- Introduce yourself and explain that you are there to help.
- Involve Child Life resources if you have them available.
Job #3: DO NOT “INTERVIEW” THE PATIENT!
- Certainly this is age dependent, but I do not want to be wishy-washy on this point.
- If a teenager presents and openly discloses the assault, feel free to obtain a history from the patient.
- Even still, in this situation, you are not Columbo (or Magnum PI, or any of the detectives from Law and Order).
- Don’t “interview” the patient with a goal of detecting clues and finding “the truth.”
- Ask medically pertinent questions to guide your exam and potential evidence collection.
- Were there drugs or ETOH involved?
- Where are your injuries? What hurts?
- Was there oral, vagina, and/or anal penetration?
- Open-ended questions should be utilized as much as possible.
- You record everything the patient discloses as direct quotes.
- Certainly, the younger child will not be able to fully understand your questions and your attempts to ask direct questions can be interpreted as you performing a Forensic Interview, which you are not trained to do and, hence, could be blamed for tainting the child’s recollections.
- Obtain history from the guardian who brings the child for evaluation.
- Get this history from the guardian in an area separated from the patient.
- Document as much as you can as direct quotes also.
- Make note that you obtained this history while the patient was not present and therefore not able to be influenced by the conversation.
- If the child discloses any information, again, make sure to record that disclosure as direct quotes (word-for-word).
- Use the terminology that he or she uses.
- Do not edit.
- Disclosures must be in the patient’s own words.
- Do not introduce new terminology to the child either.
- If the child chooses to disclose, become a recorder. Do not lead or “coerce” any additional information.
Job #4: Evidence Collection
- This is for another Morsel on another day…but,
- Follow your group’s policies.
- Contact a certified Sexual Assault Nurse Examiner (hopefully you have a group… or your protocol may be to transfer the patient to where one is… again, Medical Screening must be done first).
- Chain of custody is paramount – so, any evidence that is collected will need to be maintained in a controlled fashion and given to the authorities (Follow protocols! Part of the reason having a trained provider who does this commonly is very valuable).
- Just because you don’t see any abnormalities, does not mean there was not an assault. Be very careful with how you word this in your documents and to the patient and family.
Job #5: Ensure that the patient has appropriate follow up.
- Ideally you have a local Advocacy Center that can conduct true Forensic Interviews.
- Involve Social Work to help coordinate as well.
So, while we all would like to play sly detectives in the movies or on TV, we should leave the “interviewing” to the professionals and focus on the medical and emotional health of the patient… and tread lightly… and record everything said verbatim.
See ACEP Resources on Sexual Assault: http://www.acep.org/search.aspx?searchtext=sexual%20assault