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Dr. Jones: The following conversation is about caring for victims of sexual assault. This might be difficult for some listeners, so feel free to leave the podcast episode and join us in some of our other "7 Domains of Women's Health" podcasts.

Many years ago, when I was in training as an OB/GYN resident, I was introduced to the rape kit. It was a box for collecting and documenting physical samples from victims who presented to our very busy city emergency room with a history of sexual assault. The instructions sounded like this. Just open the box and follow the instructions. That's all you need to do.

I was terrified and traumatized. There must be more training than this. Can't we at least open up, under supervision, this box and pretend that we're going to do the examination and collect evidence? Nope.

Some years later, when I was a clinician and educator, I asked a nurse who I knew had training and experience to come talk to our residents for an hour. This was a nurse specially trained in sexual assault, and she was wonderful. But the residents were terrified and traumatized. "Shouldn't we just call someone?" And the answer is, "Yes, please call the right person for the job."

Today in The Scope studio, we're talking with Haley Lichtie. She is a specially trained and certified sexual assault nurse examiner, a SANE nurse. Thanks for joining us, Haley.

Haley: Thank you so much for having me.

SANE Nurse Training and Qualifications

Dr. Jones: So tell me a little bit about your original training. Are you an RN?

Haley: Absolutely. I am an RN. I actually graduated from the College of Nursing at the U. From there, I spent a few years in the pediatric field. I worked at Premier Children's. And then I decided to take a few years off and be at home with my kids. And then when I decided to come back to the nursing field, I knew about this forensic nursing, the SANE nurse, and it's really what I wanted to do. So I called up Wasatch Forensic Nurses, which is the group that I currently work for, and I got trained and hired and have been there since 2017.

Dr. Jones: Are there SANE nurses on call 24/7? Are you guys always . . . someone's carrying a beeper always?

Haley: Always. One hundred percent of the time. So we have someone on call 24 hours a day, 7 days a week, all holidays, all the time. There are other SANE teams throughout the state of Utah. Many are hospital-based, which means you would go to the hospital, they would call in their SANE nurse, and it's done that way. What's different about us is that we travel to any hospital within those counties that the patient chooses to go to.

Dr. Jones: Is this a national program? Are there a whole bunch of trained nurses all over the country?

Haley: Yeah, we are everywhere in the country, even worldwide. Like you said, with physicians, it's so hard to do these rape kits in the ER. And so nurses really took that on, back in the '90s, and kind of said, "Hey, there's nothing that's being done during the sexual assault examination that's out of our scope of practice. So why don't we take the burden off the physicians? We can handle this." Forensic nursing and SANE nursing was born. So there are programs everywhere. As I said, some are more hospital-based. Others are more community-based. It just kind of depends on the area in which you live. But yeah, there's a lot of us who are everywhere.

Dr. Jones: So tell me about your training a little bit. Can you tell me? Did you get on-the-job training or a classroom or a little bit of both?

Haley: Little of both actually. So anyone who wants to become a SANE has to go through a 40-hour training. And then once I was hired on with Wasatch Forensic Nurses, we did a lot of on-the-job things as well. We did continue to learn skills. There's a lot that goes into it that's different from any other type of nursing, particularly around evidence collection.

Dr. Jones: Right. That was the part that scared me.

Haley: Yes, exactly. And so we practiced that a lot. And then I went out on cases with nurses that had been on the team for years before and saw how they did things. And then did some cases with them looking over my shoulder just to make sure I could do it. And then I was off by myself.

Dr. Jones: Wow. I have a family member in an ER here on the Wasatch Front, and he said that you guys are amazing. He really is happy when you show up in a traumatic situation with someone who's been hurt.

SANE Nurses' Role in Caring for Sexual Assault Patients

Haley: That means a lot because when I told my mom, my mom is an RN as well, so I told her when I wanted to do this, and she worked in the ER as well and she said, "Oh, my gosh, you have no idea how terrifying it is," just like you said in the introduction, "to go in there with a patient who is so traumatized, open up a box. You don't know what you're doing. You're fumbling with paperwork. You're fumbling with envelopes and swabs." And she said, "It's not very reassuring to these patients to have us fumble around with it."

And truly, what doctor, what physician in an ER has three hours to spend in a room with a patient? It just doesn't work that way. So I love that the nurse can step up and fill that void. And so I'm so grateful that we have such good relationships with the hospitals in our community.

Dr. Jones: Well, tell me a little bit about how you might . . . Is there some kind of time constraint or some timeline after which this isn't an inappropriate exam or . . .

Haley: So obviously we want them to come in when they feel comfortable.

Dr. Jones: Yeah.

Haley: Sometimes that's right after. Sometimes that's a few days. But we say 6 days or about 144 hours after the assault is when we can still collect and gather evidence. I will always tell my patients the sooner they come in, the better because things can degrade over time. But research has shown that we can still get good evidence collection at six days.

SANE Nurses and Expert Testimony

Dr. Jones: How about the time that you might take afterward? I mean, you have to testify, or you might have to give witness to the police. And then you may have to testify in court. I think that was the other part that was terrifying as a clinician, as a physician. It's like, "I don't know how to do this. Talking to lawyers, I don't want to talk to lawyers ever." So tell me a little bit about what happens afterward because you're trained actually to give evidence in court too.

Haley: We are. We are trained on how to be expert witnesses in court. So there's something that is called an expert witness, just meaning that we can give our opinion because of how we are trained on the job. So if a case goes to court and makes it that far, we will absolutely go and testify. Generally, it's for the prosecution. There are times when we are called to testify for the defense. So it's not that we're on one side or the other. We are just healthcare professionals who are talking about what we saw and what we did.

Domestic Violence Cases

Dr. Jones: How about victims of domestic violence, because often physical assault, do you see people who are victims of domestic violence as well?

Haley: We absolutely do. So about two years ago, we started offering that service. Last summer, it really picked up. We do see a lot of domestic violence patients. We call them IPV exams or interpersonal violence exams. We do other assault exams. If there isn't a personal relationship between the patient and the suspect, we do that as well. It works a little bit differently than a sexual assault just because of the funding. But it is worth mentioning that the sexual assault exam and the domestic violence exam are free to the patient. They're at no cost to the patient. So they can go into the ER, and they can say that that's what they need, and the medical services and my exam will be offered to them at no cost to them.

Pediatric Exams

Dr. Jones: Well, what about kids? Is there a program? I read, after doing a little bit of research, that they were trying to start a SANEP, a SANE with pediatric nurses to do children's exams. What happens to little kids? Is that something that you do?

Haley: Yeah, that's a good question. So our patients are 14 years of age and older. For anyone who is 13 or younger, we would refer them to a place that's more appropriate. We can absolutely make referrals and get those patients where they need to go. But we will not do exams on anyone under 14.

Additional Services and Support for Sexual Assault Patients

Dr. Jones: So in the exam room, you are a clinical professional. Between the time you see them and their ongoing needs for some kind of clinical psychological support, is that something that you refer them for, or how does that work?

Haley: So when we respond to the hospital, we will also respond with an advocate who specializes in things like that. In Salt Lake County, we'll respond with the Rape Recovery Center. In Utah County, we work with The Refuge. And up in Park City, it's the Peace House. So those advocates are with us in the room with the patient the whole time, and they are excellent with giving them community resources for kind of that aftercare when, "Okay, I've done this exam. The evidence is collected. Now what do I do?"

Dr. Jones: Right.

Haley: There are free counseling services, group services, one-on-one services, and things like that. So if there is the need for therapy aftercare, kind of for the mental health side of it . . .

Dr. Jones: Right.

Haley: . . . they're great with many, many resources. As far as us, we will follow up with them in a few days after an exam and make sure that they're doing okay, make sure they don't have any questions. There are some things that are healthcare-related that we could kind of guide them through. But generally, the well-being, kind of the mental side of it goes to the advocacy groups. I think that we do a very good job of caring for the patient as a whole and caring for them in a way that they need to be cared for.

Dr. Jones: And what would you like people, in general, to know about the SANE nurse examiners?

Haley: You know, I wish that I was like the magician that could put everyone in jail and things, but it's not how this works. We do what we can do. My area of influence is just the patient. So I want to get that patient on the road to recovery the best way I know how.

Dr. Jones: Yeah.

Haley: So we really do like to send them off with resources and people they can call for help, hotlines, apps they can download on their phone when they're feeling overwhelmed, things like that.

Mental Health and Self-Care for SANE Nurses

Dr. Jones: How do you stay sane? I mean, what do you do for self-care? How do you help each other? I mean, how do you help each other through hard times?

Haley: Nurses I think do their job because they want to help people. And unfortunately, part of that with this job is taking on a big mental load with that. But we actually do have a social worker that we can meet with, either one-on-one or group debriefing every other month or so as a group. And it helps us when we have cases that just we can't let go of and they're stuck in our brains and they're really sticky for some reason. We can talk about that and maybe target the reasons why we're having a hard time letting it go or things like that. It's a lot. It's a lot, and I love doing it, and I feel immensely for my patients. But we absolutely have to take care of ourselves or we don't last. I think turnover in the SANE community is quite high.

Dr. Jones: Well, I want to thank Haley, thank you, and all the SANE nurses who show up 24/7/365 for people who are critically traumatized. And thank you all for joining us on The Scope.