Encounter One (initial emergency department encounter)
DNP role: I am the DNP student and pediatric nurse practitioner seeing this patient for initial evaluation.
Identifying Information
Site: New York pediatric Level I trauma ED.
Setting: Pediatric ED.
Chapter 8 Adolescent With Suspected Sexual Assault
81
Reason for encounter: Intoxication.
Informant: Patient, patient’s friend, EMS, and mother.
Chief complaint: Patient complains of nausea and vomiting, dizziness, and headache. Patient admits drinking vodka with her friends approximately six hours ago but is unable to recall detailed events of the day.
History of Present Illness
As per EMS record, when EMS arrived on the scene, patient was sitting in the back seat of a truck of two women who stopped to help the patient and her friend. The patient and friend were found on the street, passed out in the snow. Soon after, the patient’s biological mother arrived at the scene.
As per patient and her friend, they cut class today and had been drink- ing Smirnoff vodka with a couple of school friends at one of their homes.
The patient passed out and was in a room with two male friends for approxi- mately two hours while her friend was drinking with the other school friends in another room in the house. The patient was found by her friend several hours later with pants undone and shirt torn. Patient cannot recall details of what occurred in the room or whether there was sexual activity. Her friend states the two male friends told the other friends that they were in the room and had sex with the patient. Patient states that she did not shower, douche, brush her teeth, or change underwear or clothing after the alleged sexual assault.
Past Medical History (as per mother)
Perinatal history: No complications or infections.
Prenatal history: Mother admits receiving prenatal care.
Gestation: Full-term, 40 weeks.
Birth history: Normal spontaneous vaginal delivery with no complications;
went home in two days.
Common childhood illness: None.
Illness: Denies.
Operations: Denies.
Hospitalizations: Denies.
Accidents: Denies.
Current medications: None.
Allergies: No known drug, food, or environmental allergies.
Immunizations: Up-to-date as per patient’s mother.
Social History
Household composition: Patient lives with her mother and 15-year-old
•
sister. Parents are divorced. Father lives nearby and patient speaks to her father daily and visits with him every other weekend.
Support systems: Patient has good relationship with paternal family, which
•
includes a large extended family.
Family relationship: Patient is very quiet and keeps to herself most of the
•
time at home and at school. She does have many cousins that she is close to on her paternal side of the family.
Cultural: Parents are from Guyana.
•
Socioeconomic: Mother is currently unemployed and father works as an
•
electrical engineer.
After-school activities: Patient does not participate in after-school activities,
•
as per mother, and is very shy and quiet.
Family stresses: Parents have been divorced for the past six years. Mother
•
states that the 15-year-old sister is very argumentative and disrespectful.
The sisters are very different and not very close. Mother states their father
“spoils” them by purchasing them whatever they want. Parents discipline patient by removing computer time and taking away her cell phone. Denies any physical punishment.
HEADSS (patient interviewed in private)
Home: Patient lives with mother and older sister and visits with her father
•
every other weekend. Father usually drives her to school in the morning and mother picks her up after school. Mother usually cooks at home, and patient eats well-balanced meals with occasional junk food, and she enjoys drinking soda.
Family dynamics and relationships: See Social History.
•
45 y healthy
unknown unknown unknown unknown
42 y healthy
Guyana Guyana
15 y healthy 13 y healthy
No consanguinity
Family History
Chapter 8 Adolescent With Suspected Sexual Assault
83
Education: Recent change in school from elementary to middle school.
•
Patient is in the sixth grade and is enrolled in honor classes. She has never been in trouble in school and does not have any history of behavioral problems.
School attendance: Rarely absent from school. Mother or father drives her
•
to and from school every day.
Grades: Grades averaging in the high 90s.
•
Attitude about school relationships: She has met some new friends in her
•
new school.
Activities: She does not participate in any after-school activities, teams, or
•
clubs.
Spare time: She talks to her friends on the computer or goes out with her
•
cousins.
Physical activity: Plays with her cousins when the weather is nice outside.
•
Drugs: Denies ever experimenting with drugs or using drugs regularly.
•
Tobacco: Has tried smoking but does not smoke regularly.
•
Alcohol: Has tried drinking before with friends, but this is the fi rst time she
•
has been intoxicated.
History of harm to animals or others: Denies any history.
•
Suicide ideation: Patient denies any prior suicidal ideation or attempts. She
•
denies self-mutilating behaviors.
Internet: Has own laptop computer. The only time there is restriction is
•
when she is being punished.
Chat rooms: Talks to her friends only. Denies talking to strangers or dating
•
online or viewing violence or pornography.
Violence: Denies any domestic violence in the home but admits her parents
•
don’t get along and argue.
Sexuality: Patient denies having sexual intercourse in the past. Identifi es
•
herself as heterosexual.
Gang: Denies any gang membership or having friends in gangs.
•
Review of Systems (as per mother and patient)
General: Has not been sick recently.
Skin: Denies rashes.
Head: No history of head injury.
Eyes: Denies wearing contacts or glasses.
Ears: Denies any hearing defi cits.
Nose/sinus: Denies frequent cold, nasal discharge, nosebleeds, sinus pain.
Throat: Denies frequent tonsillitis/pharyngitis.
Dentition: Has braces and sees orthodontist every couple of months.
Neck: Denies stiffness or pain.
Respiratory: Denies cough at night or with activity or shortness of breath, TB.
Heart: Denies having murmur, palpitations, or chest pain.
Gastrointestinal: Denies frequent abdominal pain, was nauseous and vomited twice upon arrival, denies diarrhea or constipation history.
Genitourinary/reproductive: Denies having frequent urinary tract infections or vaginal discharge.
Female: First menstrual period (FMP) at 11 years old. Last menstrual period is reported as minimal amount two weeks ago. Complains of menstrual cramps with menses. Menses are irregular in frequency and amount. Denies any prior pregnancies.
Musculoskeletal: Denies muscle or joint pain, stiffness or backache.
Neurological: Denies fainting, seizures, weakness, numbness.
Hematological: Denies anemia or bruising easily.
Psychiatric: Denies anxiety, depression, mood swings, suicide attempts, violence.
Endocrine: Denies heat or cold intolerance, excessive sweating, excessive thirst, hunger, or polyuria.
Physical Examination
Vital signs: Temp 97.9ºF oral; apical pulse 103; respirations 18; blood pressure 106/60; SaO2 100% room air.
Growth: Weight 100 lb (25–50th percentile); height 62 inches (25–50th per- centile); BMI 18.29.
General: Patient is drowsy but arousable. Cooperative and quiet during exam.
Skin: No ecchymosis or lacerations or lesions.
HEENT: Bilateral tympanic membrane grey with light refl ex; pupils round, reactive to light; conjunctiva slightly injected; no oral lesions.
Lymph: No lymphadenopathy.
Neck: Supple, full range of motion with no tenderness.
Lungs: Bilaterally clear with good air exchange.
Breast: Tanner stage III/V.
Cardiovascular: S1S2 with no murmur heard; +2 capillary refi ll in four extremities.
Abdomen: Soft nondistended, nontender with no organomegaly.
Genitalia: Deferred at this time.
Anus: Deferred at this time.
Chapter 8 Adolescent With Suspected Sexual Assault
85
Extremities: Full range of motion with 2+ deep tendon refl exes in all four extremities.
Spine: Midline with no tenderness.
Neurological: Speech slurred, gait unsteady, CN II–XII grossly intact.
Mental status: Oriented ×3; drowsy but arousable.
Thought processes: Appropriate for age and coherent.
Assessment
13-year-old Guyanese female brought to the pediatric ED by EMS for unsteady gait, slurred speech, amnesic episode, nausea, and vomiting due to alcohol intoxication and alleged sexual assault by two male friends. She is accompanied by her friend and mother. Based on the patient’s history of drinking vodka during the day with classmates and her clinical presentation of unsteady gait, slurred speech, and nausea and vomiting, alcohol intoxica- tion is the most likely diagnosis. Other possible causes for the patient’s clinical presentation need to be explored with further laboratory toxicology testing (D1, C3, PO A, C, D).
ICD Codes
Nausea and vomiting: 787.01
Observation following alleged rape: V71.5 Idiosyncratic alcohol intoxication: 291.4
Plan
Laboratory Tests
CBC, basic metabolic panel, urine pregnancy, urine toxicology, and serum ethanol level (D1, C3, PO D).
Therapeutic Interventions
Intravenous insertion for fl uid bolus of normal saline 1 L over 30 minutes (D1, C3, PO E).
The most frequent electrolyte disturbance found in this study was hyper- natremia, with a prevalence of 41.3%. Rauchenzauner, Kountchev, Ulmer, Pechlaner, Bellmann, Wiedermann & Joannidis investigated acutely intoxi- cated patients in the ER who were probably still in the phase of increasing blood-alcohol levels, leading to suppression of antidiuretic-hormone release from the pituitary gland and consequent polyuria. The result would be a mild hypernatremia associated with lack of fl uid intake due to intoxication. Chlo- ride was elevated in 20.9% of our patients. The third most frequent electrolyte disturbance found in our study was hypermagnesemia. Investigations of the
short-term effects of alcohol ingestion found an increase in serum-magnesium levels six hours after alcohol ingestion; this was attributed to transient hypoparathyroidism induced by alcohol ingestion. Hypermagnesemia may also refl ect hypertonic dehydration, which would explain the highly signifi - cant correlation between magnesium, sodium and chloride. This study shows that in patients admitted to the ER for acute alcohol intoxication the pattern of electrolytes signifi cantly differs from that seen in chronic alcohol abuse or in patients treated on a general ward, with hypernatremia being the predomi- nant disturbance. This further indicates that hyperosmolar dehydration is the most frequent disturbance in acute alcohol intoxication and suggests that vol- ume substitution is one of the most important fi rst measures (Rauchenzauner, Kountchev, Ulmer, Pechlaner, Bellmann, Wiedermann & Joannidis, 2005).
Oxford Centre for Evidence-Based Medicine (CEBM), level 1b.
Family Education
As per mother’s request and patient’s consent, a sexual offense evidence col- lection kit will be performed. Both mother and patient are instructed to have very little contact and handling of clothing before sexual offense evidence col- lection is completed. Patient is asked to undress with a sheet beneath to catch debris for evidence submission. Mother is asked for permission to give up the patient’s clothing for evidence submission and to have patient’s father bring a change of clothing to wear for discharge to home (D1, C3, PO E).
Patient Education
The patient is educated in private for preparation for a pelvic examination that includes an external genitalia examination or observing the external vaginal perineum area for signs of trauma or injuries. Because this will be the patient’s fi rst pelvic examination, the procedure, examination speculum, and what will be visualized during a pelvic or internal intravaginal examination are explained to the patient. Also discussed are the various laboratory tests that will be performed for detection of sexually transmitted infections. I rein- force to the patient that results of the laboratory tests for sexually transmitted infections are for medical purposes and will not be submitted into the sexual offense evidence kit.
The sexual offense evidence collection process is discussed with the patient. I inform the patient that the collection will be performed with all women clinicians and that the 12-step head-to-toe collection of evidence will be lengthy and must follow an orderly manner. I explain that some evidence collection will be uncomfortable, such as hair sample collection and pubic hair sample collection.
Referrals
Family is unable to be referred to pediatric ED social worker for family support and child safety risk assessment due to lack of availability of social worker, at this time. Therefore, I page the hospital director of social services to arrange for social work evaluation the following day on an outpatient basis (D3, C2, PO A, C).
Patients who have been sexually assaulted will experience psychological trauma to one degree or another. The effects of this trauma may be more
Chapter 8 Adolescent With Suspected Sexual Assault
87
diffi cult to recognize than physical trauma. Every person has her own method of coping with sudden stress. When in crisis, patients can appear calm, indif- ferent, submissive, jocular, angry, or uncooperative and hostile toward those who are trying to help. It is important for the caregivers to understand that all of these responses are within the range of anticipated normal reactions.
A judgment about the validity of the patient’s account of the assault based on her demeanor can further traumatize the patient and hinder the collection of complete and objective data (NYSDOH, 2007).
CEBM, level 5.
Encounter Two (one hour later in the ED)
Patient states she is feeling less nauseated and dizzy and her headache is resolving. Patient is able to tolerate clear fl uids without vomiting. Patient admits drinking vodka with her friends seven hours ago at her friend’s house but still is unable to recall details of the entire day. Patient is unsure of type of violation and if sexual assault occurred. Patient is unsure of vaginal or anal contact or condom use.
Vital signs: Temp 98.4ºF oral; apical pulse 106; respirations 22; blood pressure 114/62; SaO2 100% room air.
Physical Examination (performed by all-female emergency medicine fellow, pediatric resident, primary registered nurse, and myself)
General: Patient is alert but sleepy. Cooperative and quiet during exam.
Skin: No ecchymosis or lacerations or lesions.
Genitalia: Tanner IV staging, shaved pubic hair on mons, no lacerations at vaginal introitus, no lesions or erythema noted in external genitalia, slight whitish discharge on vaginal orifi ce, hymen membrane noted and intact with no laceration or blood. Internal exam deferred due to intact hymenal membrane.
Anus: No lesion, lacerations, or blood noted.
Laboratory result review: CBC, basic metabolic panel are within normal range. Urine pregnancy and toxicology tests are negative. Blood ethanol level is 176 mg/dL, normal is less than 10 mg/dL.
Alcohol test results from clinical, research, and forensic lab results are expressed in grams or milligrams of alcohol per fi xed volume of fl uid (100 mL of blood or serum) or per 210 L of air (for some breath test instru- ments). United States, breath testing instruments are calibrated to convert grams per volume of breath into milligrams of alcohol per 100 mL of blood (mg/dL) or grams per 100 mL (g%). Milligrams are easily converted to grams by dividing the value by 1,000, and g% is easily converted to mg/dL by multiplying the value by 1,000. A blood alcohol concentration (BAC) of
80 mg/dL is the same as 80 mg%, which is the same as 0.08%. If the labo- ratory measures alcohol in serum, the results are not equal to whole-blood test results. This may have important implications for scientists comparing test results or in instances where such results are used as evidence in a criminal or civil litigation. As alcohol is distributed throughout the water- containing compartments of the body including the blood, serum alcohol is not the equivalent of a BAC because serum contains more water than the whole blood from which it is derived. Therefore, the concentration of alcohol in whole blood is less than that of the serum in proportion to their respective water contents. In other words, a hospital serum alcohol con- centration will be higher than a whole BAC drawn from the same patient at the same time.
When information about drinking is limited, the circulating alcohol burden (CAB) is a useful measure of the total amount of alcohol ‘’on board’’
at the time of a blood or breath test. The CAB is independent of 2 variables, rate of absorption and rate of elimination, and is therefore useful when insuffi cient information is available to account for these variables. However, CAB estimates assume that alcohol absorption is, for all practical purposes, complete. Circulating alcohol burden may underestimate consumption in some instances because about 80% of alcohol consumed is absorbed within about 30 minutes of the last drink. As CAB is the alcohol burden at a single moment in time and does not account for elimination, it is a good estimate of minimum alcohol consumption. In other words, the total alcohol intake will always be greater than the CAB. The variables that affect absorption are complex and may vary with beverage concentration, volume, presence or absence of food, genetics, or other factors. Consistent with empirical studies, most medical references describe the majority of alcohol as being absorbed within 20 to 30 minutes, with a maximum BAC occurring about 60 to 90 minutes after the last drink. The accuracy of such estimates can be enhanced by using a range of elimination rates and anthropometric formulas to estimate total body water.
Alcohol is distributed throughout the water-containing compartments of the body, and all other factors being equal (e.g., absorption, elimination, weight), the peak BAC produced by any dose will vary as a function of changes in the ratio of muscle to fat. On average, men tend to be more muscular than women and muscle contains more water than fat (Brick, 2006).
CEBM, level 5.
Assessment
Based on the patient’s amnesic episode of the day’s events and her inabil- ity to recall how her shirt was torn and pants unzipped and details of what occurred when alone with two male friends, the risk of alleged sexual assault needs to be considered, since the patient and her friends’ accounts of sexual activity are inconsistent. Forensic evidence needs to be collected for law enforcement involvement, as per mother’s request and patient’s assent (D1, C3, PO A, C, D).
Chapter 8 Adolescent With Suspected Sexual Assault
89
Since the mid-1990s, there have been a growing number of unconfi rmed reports of assailants surreptitiously using prescription and nonprescription drugs to induce disinhibition, sedation and amnesia to facilitate rape. This type of victimization is most commonly referred to as drug-facilitated sexual assault (DFSA). Although fl unitrazepam, in particular, has been maligned as a “date rape drug,” many other easily accessible substances have report- edly been used to facilitate sexual assault, including alcohol and alprazolam, chloral hydrate, gamma hydroxybutyrate, ketamine, lorazepam, ziploclone and zolpidem. Few studies have systematically measured the occurrence of drug-facilitated sexual assault. Because there is no agreed upon defi nition of the phenomenon, comparisons across studies are diffi cult. Rapes involv- ing incapacitation were more likely to have occurred following time spent in a bar or at a party and were more likely to involve higher levels of drinking and self-reported intoxication. In this study, the reasons for suspecting DFSA were vague sensation that something is wrong (51.1%), woke to fi nd clothing in disarray to unclothed (42.4%), reported by witness to have been seen in compromised circumstances, (16.3%) (DuMont, Macdonald, Rotbard, Asllani, Bainbridge, & Cohen, 2009).
CEBM, level 1b.
Plan
Alleged Sexual Assault Laboratory Tests
The following tests are performed for baseline sexually transmitted infec- tion (STI) status and will not be used as data for sexual offense evidence:
trichomoniasis, bacterial vaginosis, gonorrhea, chlamydia cultures, Rapid Plasma Reagin Assay and acute hepatitis panel (hepatitis B core IgM anti- body, hepatitis B surface antigen, hepatitis C antibody, and hepatitis A IgM antibody). HIV-1 antibody test (ELISA) counseling and consent are obtained before testing (D1, C3, PO D, E).
Laws in all 50 states strictly limit the evidentiary use of a survivor’s previous sexual history, including evidence of previously acquired STIs, as part of an effort to undermine the credibility of the survivor’s testimony. Trichomoniasis, BV, gonorrhea, and chlamydial infection are the most frequently diagnosed infections among women who have been sexually assaulted. Because the prevalence of these infections is high among sexually active women, their presence after an assault does not necessarily signify acquisition during the assault (CDC, 2006).
CEBM, level 5.
An initial examination should include the following procedures: testing for N. gonorrhoeae and C. trachomatis from specimens collected from any sites of penetration or attempted penetration. Culture or FDA-cleared nucleic