A man, woman or a child may be brought or come to the ED alleging rape or indecent assault. It can be one of the most difficult emergencies to manage because of the physical, psychological and legal implications. Responsibility should be shared as quickly as possible with Gynaecology staff, or the Gardaí if the patient consents. The our role in the ED is dealing with:-
- Injuries or medical conditions requiring immediate attention.
- The psychological emergency.
- Preserving and recording any evidence that might be required later.
It is the responsibility of the health professional to which they present to evaluate risk of pregnancy and either to prescribe emergency contraception or to ensure appropriate management.
The Gardaí should be involved as early as possible with the patient's consent. It is also important that a garda doctor is involved at the earliest opportunity so that important evidence is not inadvertently destroyed or overlooked. The Gardaí and their designated doctor will then involve care and follow up through the Sexual Assault Unit at the South Infirmary/Victoria Hospital.
- Never suggest by word, tone or attitude any hint of reproach. 'Stage whispers' and unguarded telephone calls within earshot of the patient may be particularly distressing and remembered long after the incident
- Never 'interrogate' the patient about the incident. If the patient seems distressed then ask them if they would prefer you to ask questions to which they only need to reply yes or no. Only ask questions about symptoms, injuries or relevant past medical history but allow the patient to talk as little or as much as she wishes, noting down carefully - as far as possible verbatim - what is said.
- Never allow any articles of clothing to be discarded, including handkerchiefs.
Medical issues to consider
- Reduce the risk of pregnancy with Levonelle-2 or IUD (Milne centre)
- Reduce the risk of infection (see below)
- Rapid course Hepatitis B vaccination should be offered to all
- Remember there is a risk of HIV (HIV test consent advice)
If they do wish the Gardaí to be involved
Please telephone the Gardaí. Do not examine the patient. The Gardaí are responsible for contacting the relevant forensic persons. Once the Gardaí are involved, an examination by a forensic specialist (usually a ban Garda surgeon) will be arranged by them.
If the person does not want the Gardaí to be involved
- Address any immediate concerns.
- Note exact time of examination
- Note general state and demeanour of the patient
- Note whether there is a smell of alcohol.
- Note the state of clothing and make-up
- Note any bruises, scratches or other injuries. It is wise to make a full general physical examination.
- Engage the advice of the social worker
- Involve the patient's GP
- Do not attempt any form of pelvic examination.
- The patient may later wish to report the matter to the Gardaí after the shock of the crisis, so it is important that evidence should be available if required later.
- Consider admission, as a "haven" to allow recovery.
- Assess wish/need for referral for further assessment and screening particularly for sexually transmitted infections and counselling.
- All victims should be referred to the Sexual Assault Treatment unit at the SIVUH.
In the unlikely event of a patient presenting early enough and giving a clear history of an assailant known to be HIV then clinical management should be implemented according to post exposure prophylaxis guidelines after discussion with a senior doctor.
If person does want STI screening/counselling
- Telephone xyz
- If out of hours, telephone xyz and leave a message on voice mail giving patient details, phone number and address and provide the person with a sexual assault leaflet and Sexual Health appointment card for 9am or 2pm the following day when they will be seen
If person does not want STI screening/counselling:
Consider offering antibiotic prophylaxis:
- Ciprofloxacin 500mg & Azithromycin 1gm stat.
- If pregnant / breast feeding use Amoxicillin 3 gm+ Probenicid 1gm stat & Erythromycin 500mg bd for 14 days (beware Erythromycin if on warfarin)
Consider offering accelerated Hepatitis vaccination
- Provide a Sexual Assault leaflet with telephone numbers for future reference.(Sexual Assault Unit Referral Form)