Forensic Nursing Unites With Emergency Services
By Kathy Dix
 Many small communities outsource their exams for sexual assault and domestic
violence to the closest large city. But Amador County in California realized it
had a large unmet need, and decided to do something about it.
Amador County is located in the Sierra foothills,
and the population is only 36,000. The area covers 605 square miles and it is
situated on Highway 49 of Gold Rush fame.
“There was nobody in this community that was doing sexual
assault; all of our sexual assaults were going to Sacramento, which is an hour
and 15 minutes away from where we live,” recalls Rinice Phillips-Matson, RN, who is a nurse with the
SART/CCT nurse program but also a sexual assault response team (SART) nurse for
the city of San Jose, two and a half hours away.
“The victim, the police and the advocate would all go down
to Sacramento, where they would wait their turn to have the two-to three-hour
exam, then turn around and come back to Amador County,” she says. “So there was a huge, huge gap.”
Phillips-Matson had begun working in her own community as a
critical care transport (CCT) nurse with American Legion Ambulance, Post 108.
The American Legion has operated the county’s nonprofit ambulance service
since 1929.
Al Lennox, the general manager at American Legion Ambulance,
asked Phillips-Matson if she thought their service could start providing local
exams for victims of sexual assault and domestic violence. “Mr. Lennox is
absolutely community-minded; he loves this community and wants to make it
better,” Phillips-Matson states. “So he paid for the other two nurses to get training at the
University of California at Davis.”
In March 2003, American Legion Ambulance signed a contract
with the Sutter Amador hospital to provide forensic examinations for SART
victims and suspects. The program began March 1; since then, the program has
handled more than 18 cases.
“The ambulance program has 25 paramedics, 24 emergency
medical technicians (EMTs) and four nurses,” says Barbara Light, RN, who is a
SART nurse for the program and a paramedic for the ambulance company. “There was a need in the county for someone to provide
sexual assault exams, and we were in a position of being able to do that because
we had nurses on staff. I was in charge of the CCT division, so when we decided
to start doing these sexual assault examinations, I added that to the CCT
division.”
The program has four nurses, two of whom are also full time
paramedics for the ambulance company. Nurses are on call 24 hours a day, seven
days a week, for SART as well as CCT. All four nurses are CCT nurses and RNs. None of the nurses has been SART-certified yet; the testing
sites and times have simply not coincided with their free time.
Phillips-Matson works five days a month in San Jose as a SART
nurse for Santa Clara County. Ashli Hertzog, RN, works in the ICU and the ER and
as a paramedic, and also does SART call and CCT. Kati Krayk, RN, works in
Calaveras County in the OB department and works in Sutter Amador hospital in the
ER, then picks up CCT call and SART call. Barbara Light works 10 days a month on
an ambulance as a paramedic, then does call time for CCT.
The ambulance company signed a contract with the hospital,
which provides a room in the emergency department (ED) and equipment for the
exams. The police transport the patient to the hospital, and the patient is
registered as an outpatient in the ED. “The sheriff’s office dispatch system contacts the shift
supervisor and the shift supervisor calls the on-call SART nurse,” Light
explains. The room is not a dedicated space, but all the equipment is
available at need. Currently, the volume of cases is not large enough to merit a
dedicated room.
Seventeen years ago, Phillips-Matson had no intention of
becoming a SART nurse. The first state protocols had just been released and the
state was desperate for nurses to support sexual assault victims. “I was
working in the old ED and I had enough night work; I didn’t figure I needed
anything else to do,” she says. But one patient waiting patiently for her
sexual assault exam led Phillips-Matson to believe that she was meant to take on
this new role. “That’s why I started doing SART, because of this woman, and
I don’t even remember her name, but I’ll never forget her,” she says.
When this role first was created in California, nurses did not
perform pelvic exams, Phillips- Matson remembers. “We did the whole state
protocol, put the evidence in a little drying box, but we weren’t actually
allowed to do the pelvic. The state protocol was just out, and they were afraid
that there might be pathology and we would miss it and we would be liable. After
about two years in collected statistics, it was determined that ... less than 2
or 3 percent had serious injuries that would require seeing a physician. So then
they retrained us. They sent us to a nurse practitioner center and sent us for
another 60 hours of training, and then we ended up doing the pelvics. And then
they gave us our own suite of rooms in Santa Clara County. So I’ve continued
to go back, lo these many years, two and a half hours west of where I live, to
do this. I live up by Lake Tahoe and I go down to San Jose. I go two days one
part of the month, three days another, to do pickup calls in Santa Clara County.”
What is so exceptional about the Amador County program is that
the nurses perform suspect exams as well. No one had been doing those exams
before the program’s establishment; the suspects had been taken to a large
city for an exam, just like the victims. “There was this giant void,” she says. “(There’s an) hour and 15-minute (commute), and it pulls police and emergency personnel out of the county.”
Since March, the nurses have also been called upon by private
attorneys and do work for domestic violence and photo documentation.
The local police and district attorney are very pleased with
the program; Phillips- Matson stresses that the small community necessitates
good relationships between the healthcare providers and law enforcement.
However, the close-knit community atmosphere means taking
extra precautions. “Everyone knows everybody,” Phillips-Matson points out.
The nurses therefore must take extra precautions to preserve medical
confidentiality.
The patients must be registered in the emergency room, but the
exam room is outside the ED. “What we do is we keep all paperwork,”
Phillips-Matson says. “They have to be triaged by the triage nurse, according
to Emergency Medical Treatment and Active Labor Act (EMTALA) regulations.
We take them to a room just outside the ED and then we seal
our medical records in manila envelopes. We totally seal them, tape them and
date them like evidence, and they go to medical records sealed. They’re not
handled — once we do the chart, we seal them, give them back to the clerks and
they’re hand-carried over to medical records.”
The police get a sealed copy, as does medical records, and a
third copy is kept at the ambulance company under lock and key.
The program also utilizes digital photography instead of
printed photographs. “We use a five-mega-pixel Olympus camera and we run off
CD-ROMs for the police and for our records,” Phillips-Matson says. “We keep
a copy by month and date and case in our office under lock and key. So it’s
secure.”
The program keeps its own copy so that it is not necessary to
dig through the hospital’s medical records if the nurses are required to go to
court. The program is sensible economically; the nurses are already
on-call 24 hours a day to do nurse transfers, which are critical transfers out
of the ER, ICU (intensive care unit) or OB (obstetrics). “The same way they
access us for CCT, they can access us for SART or domestic violence,” says
Phillips-Matson. “We already have the system in place. That’s the beauty of
doing it this way. We’re already on-call.”
When asked how this program might serve as a model for other
communities, Phillips-Matson hesitates. “We’re serving a small community, so
probably the most nurse transfers I’ve had in a day has been three. In a large
community like Santa Clara County, where people are doing transfers all day
long, where they might run five or six nurse transfers in a day, this program
probably wouldn’t work. But I see this as a great model for a small community;
if you have someone on-call in a small independent ambulance company, you can
use them for more than one thing.”
The nurses receive $150 per day as on-call pay, and then are
paid per transfer. “It’s the same way with sexual assault. We are paid a
certain amount for domestic violence and for a suspect exam. It’s a system
that makes sense for us,” she reiterates.
In Santa Clara County, Phillips-Matson estimates there are
perhaps as many as 325 sexual assault exams a year. “And the most I’ve had
down there, in two and a half days on call, was six cases in one day. I’ve had
three come in at one time. So obviously, our system wouldn’t work there.”
The program is under the administrative eye of Barbara Light.
“Barbara is really the organizational guru,” Phillips-Matson says. “Barbara is really an administrative genius.” The program is a marvelous prototype because it has a one-time
buy-in that is minimal, she observes. “The hospital supplies us a room, and
our boss bought us the light-staining microscope and a little cabinet where we
keep all our stuff, and it’s locked. It’s a one-time expense; the rest is just ongoing training
and keeping people ‘up to snuff,’” she says.
The most surprising aspect of the program has been the
consultation work for private attorneys. “We did not anticipate being called
by private attorneys to do domestic violence photo shoots for emergency
restraining orders and temporary restraining orders. We didn’t anticipate
going in that direction. We anticipated doing suspect and victim exams, but to
be of use to private attorneys is fine. Basically they’re only paying you for
your expertise; no one can buy your testimony. We just go see the person and
document, and then tell them what we find and whether it’s consistent, which
is certainly within our scope because that’s all we do in court on suspects
and victims,” she adds.
Any future expansion of the ambulance program will naturally
include bringing both the CCT and SART divisions with it, says Light. “We’ll
probably be providing this service to other counties in the future. We may even
at some point have a mobile SART unit, where we could go to another county or to
an off-site location,” she adds.
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