Transcript Role of AED in managing sexual violence cases

Role of AED in
managing sexual violence
cases
Dr Paulin Ng
FRCSEd, FHKAM (Emergency Medicine)
Senior Medical Officer
Tuen Mun Hospital
Sexual Violence (性暴力)
• Indecent Assault (IA)
• Sexual Assault (SA)
Sexual assault (rape)
A man commits rape if he has
unlawful sexual intercourse with a woman who
at the time of the intercourse does not consent
to it; and at that time he knows that she does
not consent to the intercourse or he is reckless
as to whether she consents to it.
# penetration of labia
SV cases in TMH (NTWC)
Sexual violence case in TMH AEIS
60
51
49
Number of case
50
41
40
40
33
30
23
20
20
10
0
2000
2001
2002
2003
Year
2004
2005
2006 (up
to Oct)
Information Source: AEIS
SA cases in TMH
• Sexual intercourse (rape) cases:
– 13 (32.5%) in 2005
Unknown
18%
Body touch
37%
2005
Intercourse
32%
Penetration by other
means
13%
Roles of AED
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Treatment of acute injuries
Prevention of pregnancy
+/- Prophylactic Treatment of STD
Psychological rehabilitation
• Forensic examination and collection of evidence
Management of Sexual Assault
case in AED
• Principles
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Confidentiality
Minimize interview by different professionals
Avoid unnecessary traumatizing procedures
Ensure privacy and comfort
• Clear explanation to the patient to minimize
stress
Resuscitation and stabilisation
• ABC
• Treatment of acute injuries, e.g. Head
injury
Patient Flow (1)
• Registration
Patient Flow (2)
• Triage
• Category 1-5
• Designated nursing
staff of same sex
assigned to take care
of the patient
Role of the designated nursing
staff (Nurse coordinator)
• Keep the patient company
• Explanation of the anticipating procedures and
workflow
• Liaison work
• Psychological support
Scenario 1
• Patient approaches AED on her own
• Social Worker (case manager) is not present
Introduce the available social
services
• Designated workers of SWD and the Crisis
Centre as case manager
• Obtain consent and call the 24-hour designated
referral line
Introduce the available social
services
• In the meantime, the Nursing Coordinator may
enlist assistance of the medical social worker
If patient refuses,
• The Nursing Coordinator should give
reassurance to the victim and address the
victim’s concern
• Introduce other NGOs e.g. RainLily
Scenario 2
• Case manager accompanies the victim to AED
• A call to the NO ic of the A&E Dept
beforehand may help
Role of the designated nursing
staff (Nurse coordinator)
• Keep the patient company
• Explanation of the anticipating procedures and
workflow
• Liaison work
• Psychological support
After triage
• The wait will depends on how busy the dept is
at the time
• A quiet place will be arranged by the nurse
coordinator while waiting
Patient Flow
• Evaluation in cubicle
with nurse coordinator as
chaperone
Medical Consultation
• Build up rapport
– Usually by a female doctor if available
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Obtain consent
History taking
Physical examination
+/- collection of evidence
History taking
• Be tactful and non-judgmental
• Detailed history concerning the gynae history
and the event will be taken
• Prepare the patient psychologically
History taking
• Gynae history
• The event
Gynaecology history
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Marital status
Last menstrual period
Any contraception
Date of last intercourse
Delivery history
The event
• Time, location
• Type of sexual violence
• Details of the event
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Number of assailants
Restraint used
Acts committed
Penetration/Ejaculation/?Condom
Loss of Consciousness
Other relevant history
• Drug history
– substance of abuse, alcohol
• Drug allergy and current medications
• Past medical history
– esp. recent surgery/injury around anogenital region
Physical examination
• General examination
– General appearance
– Clothes
– External injuries
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e.g. face, lips, medial thigh, perineum
lacerations
bruises (color)
pattern of abrasions
Physical examination
• Pelvic examination
– External genitalia, perineum
– Vaginal examination, collection of specimens
(preferably left to Forensic pathologist)
For patients suffering from rape
• Unstable patients
– Admission after initial stabilisation
– Examples: significant head injury; vaginal bleeding
• Stable patients
– Baseline investigations
– Offer emergency contraception
– Medical follow up services
Baseline investigations
• Urine for pregnancy test
• Blood for
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urgent HbsAg/HbsAb
hepatitis C
VDRL or Syphilis(RPR)
HIV (consent)
• STD screening after forensic examination (not
indicated in most cases)
Emergency contraception
• Risk of pregnancy
– Around 8% for unprotected intercourse
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Check urine for pregnancy test
Earlier the better
Up to 5 days: LNG 1.5mg PO stat
>5 days: FU for pregnancy test
Refer SV/gynae clinic for FU
PEP for Hep B
• Transmission risk (0.318-3.18%)
• Check blood for HBsAg/ AntiHB Ab
• FU AED 2 days later
PEP for HIV
• Transmission risk (0.1-3%)
• Current QEH special medical service
recommendation: not for PEP
PEP for STD
• Overall risk: 5-10%
• Immediate PEP is offered if perpetrator is known to be
infective or the victim has S/S of infection
• Refer SV/gynae clinic for FU 2 weeks later
Medical follow up services
• Hepatitis B
– AED follow up service within 48 hr
• Pregnancy, STD, AIDS
– Sexual violence clinic follow up in ~2 weeks’ time
Medical follow up services
• Sexual violence clinics
– 4 designated sexual violence clinics in different
clusters
– A referral letter is provided with consent
– The patient or case manager, as patient advocate,
could make an appointment in any one clinic
subjected to her wish
Psychosocial support
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Case manager
Medical Social Worker
RainLily hotline
Other NGO
Report to police
• Advise patient to report to police
• Police will decide on whether or not to refer to
forensic pathologist for evidence collection
Thank you
Question time later