TAASA handout version 2.pptx

3/5/14
The ABC’s of Pedi SAEs
Sarah Keymer RN, BSN, CA/CP SANE, SANE-P
&
Kara Faletto MA, CCLS
Learning Objectives
• Understand key aspects of different developmental age
groups as they pertain to challenges encountered during
pediatric sexual assault examinations.
• Explore proper technique in conducting age sensitive sexual
assault examinations in the pediatric population.
• Recognize normal anatomical variants to anogenital areas as
seen in the pediatric population during sexual assault
examinations.
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One Size Does Not Fit All
• Developmentally appropriate exams allow SANE to:
‐ Establish trust with patient and family
‐ Reduce additional trauma for patient and family
‐ Perform thorough, safe exams
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Door to Discharge Timeline
• Check in/registration
• Quick Triage
• SANE and social worker interview with parent/patient
separately depending on age
• Involve Child Life if appropriate while SANE preps exam
room
• Exam – including photos, evidence collection and medication
administration
• Patient/Parental education and discharge home
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Overview
Breakdown of each step in the process for developmental
age group
Toddlers
1-3 years old
Preschool
3-5 years old
School Aged Children
6-11 years old
Adolescents/Teenagers
12+ years old
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The Interview Overview
• Purpose of the interview is to obtain necessary information to
decide plan of care for patient.
• Social worker and SANE perform interview together
• Patient and caregiver interviewed separately.
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Developmentally appropriate Interviews:
Toddlers and Preschool Age
• We interview patient >5 years old
• For younger children, we obtain history from caregiver
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Developmentally appropriate Interviews
School Aged Children:
Establish Rapport and
Asses verbal/cognitive
abilities, comforts, attention
What’s your name? How old are you?
Do you have any pets?
What grade are you in?
Ask about home, daily living,
relationships
Where do you live? Who lives with you?
Where do you sleep?
Where do mommy/daddy sleep?
Establish difference between
truth and lie
If I said that your shirt is green, is that a truth or a lie?
(Remind child to only tell the truth)
Identify hair, eyes, mouth, belly button etc.
Ask to identify body parts
What part of your body should nobody touch?
including names for genitalia
What do you call those parts?
Do you know why your mom brought you to the hospital today?
Has anyone ever touched those parts that nobody should touch?
Can you tell me about that?
Open ended questions
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Developmentally appropriate Interviews
Adolescents/Teenagers:
Establish trust and informed
consent at the beginning
What is said in this room, stays in this room… UNLESS you
tell me that someone has hurt you or you want to hurt
yourself.
Establish Rapport and Asses
verbal/cognitive abilities,
comforts, attention
What’s your name? What grade are you in?
What school do you go to? Do you like school?
What’s your favorite subject? Do you have any hobbies?
Ask about home, daily living,
relationships, especially
friendship
Where do you live? Who lives with you?
Do you have friends at school?
Do you have a boyfriend/girlfriend?
Ask to identify body parts
including names for genitalia
Allow patient to use terms he/she uses with peers for body
parts, no judgment
Open ended questions
Do you know why your parents brought you to the hospital?
…And then what happened?
…What happened next?
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The Interview
• Use of body diagrams or dolls for demonstration
• Outcry in form of a written note
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The Exam Overview
• Patient brought to exam room
• Placed in gown – clothing evidence collected
• Use of Bluemaxx fluorescent light
• MD and SANE perform head to toe physical exam and body surface
photos if indicated
• Oral swabs
• Anogenital exam, swabs for evidence and testing, colposcope photos
• Blood specimen obtained
• POPSICLES!!!!!
• Patient redressed and returned to ER room prior to discharge
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Child Life
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Child Life Specialist’s Role
! Provide developmentally appropriate education prior
to exam
! Allow patient to see and manipulate medical
equipment that will be used during exam
! Provide distraction, education and emotional support
during exam
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Preparation
• Provide Patient with developmentally appropriate
language and education about the exam.
‐ “The Dr./Nurse wants to check your body to make sure you
are healthy”
‐ “The Nurse will look at your body from your head all the way
to your toes”
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Preparation cont.
• Explain using sensory information, what the patient
will see, hear, feel, and smell.
‐ Show patient medical equipment and materials that will be
used during exam.
‐ “Some kids say it feels like…”
‐ Provide pictures of exam room/ materials
‐ Explain positioning and allow patient to practice
“cannonball”
“butterfly”
“cat”
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Developmentally Appropriate Exams:
Toddlers
• Explore surroundings
• Show the around the exam room
• Seek adult companionship
• Fear separation from primary
caregiver
• Parent at bedside
• Position patient in parent’s lap during
exam
• Assert independence
• Allow patient to participate
• Fear of pain
• Begin exam with something familiar
• Listening to their heart/lungs
• Allow patient to touch swabs
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Developmentally Appropriate Exams:
Preschool:
• Physically active, enjoy games
• Distraction with iPad, games, etc.
• Sometimes misunderstand words,
misconceptions common
• Use concrete examples
• Fear the unknown
• Explain process in simple steps
• May see medical procedure as a
punishment
• Explain reason for the exam
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Developmentally Appropriate Exams:
School Aged Children:
• Able to reason and think logically
• Explain purpose of exam concretely
• Have an awareness of body and
function
• Give patient a job during exam
• Fear body mutilation, pain, death
• Check for misunderstanding/concern
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Developmentally Appropriate Exams:
Adolescents/Teenagers:
• Concerned with peer acceptance
• Build rapport with patient
• Concerned with body image
• Preserve patient’s modesty
• Changes in body and sexuality are
important
• Assure them that their body is
“normal”
• Self centered
• “It can’t happen to me” attitude
• Post-exam safety education
• Allow patient to ask questions
• Fear loss of independence and
invasion of privacy
• Maintain confidentiality
• Allow them to decide who
accompanies them to exam room
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Distraction/Coping During Exam
Toddler
• Bubbles, light up toys
• Parent and/or CCLS presence for calming
• Relate exam to diaper change
Preschool
• Books, bubbles, singing, counting
• Parent and/or CCLS presence for comfort
Teenage
• Music, iPad, movie
• Parent presence vs. CCLS support vs. no
support for privacy
School Age
• Books, games, videos
• Parent and/or CCLS presence for support
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Case Reviews
Pediatric Sexual Assault Exams
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Patient #1
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History
• 12 year old Caucasian female
• Parents are separated/divorced, have joint custody
• Outcry to Mother the day after she was picked up from
father’s house
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Interview with Patient
• Patient stated that while visiting her father, he started
inappropriately touching her which led to her being fully
undressed and finally oral/vaginal contact
• “I thought it was weird… But he is my dad… So I did.”
• “He told me not to tell anyone… But that’s not something
you should keep inside!”
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Type of Contact
• Fondling
• Oral/vaginal contact
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Plan of Care
• Detailed head to toe and genitourinary exam
• Photo Documentation
• STI/Pregnancy Testing – Results were negative
• Evidence collection
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Exam
• Menstrual blood present
• Septate hymen with no signs of acute trauma
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Septate Hymen
• The hymen is a thin membrane that partially covers the
opening of the vagina
• A septate hymen is when this membrane has a band of
extra tissue in the middle that creates two small vaginal
openings instead of one
• Congenital disorder = Present at birth
• Diagnosis can be made through a physical exam
• Treatment may include minor surgery to remove the extra
band of tissue to create a single, normal-sized vaginal
opening
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Disposition
• The patient was discharged home in the care of her mother
• CPS/PD involved and will follow-up in home
• Discharge instructions were given to have the patient followup with GYN clinic for further evaluation and possible
treatment of a septate hymen
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Patient #2
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History
• 6yo female brought in by mother with concerns r/t vaginal
bleeding/lesion on vaginal area
• Mother concerned because patient was with father
(divorced) 9 days prior, unknown etiology of lesion
• Patient seen by OSH and PCP prior to arrival, on Bactrim
for diagnosed UTI
• Patient with recent history of constipation
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Interview with Patient
• Patient able to identify private parts
• No outcry for sexual abuse at this time.
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Type of Contact
• None known/unknown
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Plan of Care
• Anogential exam
• Pediatric Gynecology consult
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Exam
• Dark brown mole lateral to right labia majora
• No trauma to any areas
• Mass of dark pink tissue attached at 12:00 and
moveable during exam, no active bleeding,
consistent with urethral prolapse.
• Gynecology at bedside during exam
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Urethral Prolapse
• Often confused with genital trauma
• Most commonly seen between 5 and 8 years old
• May present with bleeding
• Treat with topical estrogens and sitz baths
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Follow up
• CPS notified due to mom’s concerns
• Discharged home with Premarin cream BID until
gynecology clinic appointment.
• Plan for 2-3 week gynecology follow up.
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Patient #3
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History
• 5 year old Hispanic female
• Vaginal pain
• Burning when voiding and defecating
• Severe pruritus
• Clinic personnel where concerned for abuse sent the
patient to ER – mother did not have concern for abuse.
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Interview with Patient
• The patient denied being touched inappropriately
• No outcry for sexual abuse
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Type of Contact
•  Unknown
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Plan of Care
•  A voided urine was collected – Results were normal
•  A genitourinary exam
•  Photo documentation
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Exam
•  Hypopigmentation in a figure-8 pattern to external
genitalia, including the labia majora and perineum
•  Excoriation with bruised and irritated areas
•  Noted tenderness and discomfort
•  Pruritus
•  Hymen with no signs of trauma
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Lichen Sclerosis
• Exam results consistent with lichen sclerosis
• Most often in 3 to 7 year olds
• Lesions appear shiny, white, well-circumscribed
patches
• “figure-eight” distribution - involving vulva and perianal
skin
• Pathogenesis is unknown
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Disposition
•  The patient was discharged home in the care of her
mother
•  Discharge instructions were given to have the patient
follow-up in the gynecology clinic for continued care of
Lichen Sclerosis
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Other Normal Variant
Findings
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Labial Adhesions
• Common finding – occur
in up to 1 in 3 girls
• Most common under 2
years of age
• Emphasize good hygiene
• Extensive adhesions
treated with estrogen
cream.
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Labial Adhesions
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Poor Hygiene
• Common Finding
‐ Parents sometimes
mistake for discharge
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Works Cited
•  Adams, J. A. (2011). Medical evaluation of suspected child sexual abuse: 2011 update. Journal of Child
Sexual Abuse, 20(5), 588-605. Retrieved February 21, 2013, from http://dx.doi.org/
10.1080/10538712.2011.60
•  Adams, J. A., Kaplan, R. A., Starling, S. P., Mehta, N. H., Finkel, M. A., Botash, A. S., et al. (2007).
Guidelines for Medical Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and
Adolescent Gynecology, 20(3), 163-172.
•  U.S. Department of Justice Office on Violence Against Women. (2013, April). A National Protocol for
Sexual Assault Medical Forensic Examinations Adults/Adolescents (2nd ed.). Washington, DC: Author.
•  Jenny, C. (2011). Child abuse and neglect diagnosis, treatment, and evidence. St. Louis, Mo.: Saunders/
Elsevier.
•  Finkel, M., & Giardino, A. P. (2002). Medical evaluation of child sexual abuse: a practical guide (2nd ed.).
Thousand Oaks, Calif.: Sage Publications.
•  Berk, L.E. (1999). Infants and Adolescents. Needham Heights, MA: Allyn and Bacon.
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Questions?
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Thank you!
Sarah Keymer - [email protected]
Kara Faletto -
[email protected]
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