Specific training in clinical forensic medicine is useful to ACEM trainees

Clinical forensic medicine in emergency departments: a pilot study of a forensic training and evaluation of its effectiveness in an Italian hospital

Because emergency departments are often the first point of contact for victims of violence, it is critical to provide the appropriate treatment in compliance with all necessary medicolegal precautions. For this reason, a randomized controlled trial was conducted at the Policlinico Hospital of Milan (Italy) in which an intervention group (12 physicians) received a 6-h course on clinical forensic medicine and their performance in medicolegal procedures in claimed cases of violence was compared with that of a control group (13 physicians) by means of a 16-item assessment scale over the 3 months before and the 3 months after the course. Overall, 195 medical records were included in the statistical analysis. Out of these cases, 105 occurred before the course (60 analyzed by the control group and 45 by the intervention group) and 90 occurred after the course (45 analyzed by the control group and 45 by the intervention group). The results showed that the overall mean score of physicians who participated to the course increased from 14.0 (IQR 7.0) to 19.0 (IQR 8.0) with a p-value < 0.0001 and that the comparison between the intervention group and the control group after the course was 19.0 (IQR = 8.0) and 14.0 (IQR = 7.0), respectively, with a p-value < 0.0001. The improvement was very little and below the expectations pointing out that educational courses, although they can be a first step towards raising the ED physicians' awareness of clinical forensics, may not be enough and that more structured training and new strategies should be implemented.

Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study

Background

The prevalence of genito-anal injuries in rape survivors varies significantly and the factors associated with the absence of injuries are not well understood. This plays a major role in the conviction of cases as the absence of injury is equated with a lack of assault. In such cases, health care providers face major challenges in presenting and defending their findings. The aim of this paper is to describe the absence of genito-anal injuries by site in a group of rape survivors and to identify factors associated with the absence of these injuries.

Methods

In a cross-sectional study rape cases reported to the police in one province in South Africa were randomly sampled using a two stage sampling procedure. Data were obtained on the survivor, the circumstances of the rape and the findings of the medicolegal examination. Descriptive statistics were conducted for the prevalence of genito-anal injuries by site and logistic regression models were built to identify factors associated with the absence of genito-anal injuries for all survivors and those reported to be virgins.

Results

In the sample of 1472 women injuries ranged from 1% to 36%. No significant injuries were reported for 749 (51%) survivors. In the multivariable model there was a significantly lower odds of having no injuries in survivors who were virgins, those raped by multiple perpetrators and those examined by a doctor with additional qualifications. In the model for survivors who were virgins, those with disabilities had a greater odds of having no injuries while those between the ages of 8 and 17 years had a lower odds of having no injuries compared to survivors below four years of age.

Conclusions

This study found that being a virgin, multiple perpetration rape and the examiner’s qualifications were significantly associated with the absence of genito-anal injuries. Health providers should thus be aware that in all other respects there was no difference in survivors who had injuries and those who did not. It is important to reiterate the message that the presence of injuries does not necessarily prove that rape occurred nor does the absence disprove the fact.

A cross-sectional study on the effect of post-rape training on knowledge and confidence of health professionals in South Africa

OBJECTIVE

To determine whether a national training program on post-rape care in South Africa resulted in improvements in knowledge and confidence in health professionals, and to distinguish baseline factors related to these changes in knowledge and confidence.

METHODS

Data for this cross-sectional study were collected over four training sessions in 2008 using questionnaires and multiple choice question papers given to 152 health professionals. Information was collected on demographics, service provision, and previous training. The change in knowledge and confidence was calculated from baseline and post-training scores. Factors related to these changes in knowledge and confidence were tested through the development of two models.

RESULTS

Seventy-four percent of the health professionals (n=112) who attended the training had completed all components of the data collection. The average age of the professionals was 41.6 years, 71% were females, and 68% nurses. Health professionals showed significant increases in percentage knowledge (40% at baseline vs 51% post training; P<0.001) and confidence (67% at baseline vs 80% post training; P<0.001) after the training. In the final multivariate models, empathy was significantly associated with a change in knowledge (coefficient -1.2; 95% CI, -1.9 to 0.4; P=0.005), while the facility level and baseline knowledge and confidence were significantly associated with change in confidence.

CONCLUSION

The training program was found to improve levels of knowledge and confidence in health professionals. Rollout of this program is critical with expansion into undergraduate curriculums.

Sexual assault training in emergency medicine residencies: a survey of program directors

INTRODUCTION

There is currently no standard forensic medicine training program for emergency medicine residents. In the advent of sexual assault nurse examiner (SANE) programs aimed at improving the quality of care for sexual assault victims, it is also unclear how these programs impact emergency medicine (EM) resident forensic medicine training. The purpose of this study was to gather information on EM residency programs' training in the care of sexual assault patients and determine what impact SANE programs may have on the experience of EM resident training from the perspective of residency program directors (PDs).

METHODS

This was a cross-sectional survey. The study cohort was all residency PDs from approved EM residency training programs who completed a closed-response self-administered survey electronically.

RESULTS

We sent surveys to 152 PDs, and 71 responded for an overall response rate of 47%. Twenty-two PDs (31%) reported that their residency does not require procedural competency for the sexual assault exam, and 29 (41%) reported their residents are required only to observe sexual assault exam completion to demonstrate competency. Residency PDs were asked how their programs established resident requirements for sexual assault exams. Thirty-seven PDs (52%) did not know how their sexual assault exam requirement was established.

CONCLUSION

More than half of residency PDs did not know how their sexual assault guidelines were established, and few were based upon recommendations from the literature. There is no clear consensus as to how PDs view the effect of SANE programs on resident competency with the sexual assault exam. This study highlights both a need for increased awareness of EM resident sexual assault education nationally and also a possible need for a training curriculum defining guidelines for EM residents performing sexual assault exams.

Knowledge and confidence of South African health care providers regarding post-rape care: a cross-sectional study

BACKGROUND

In South Africa, providers are trained on post-rape care by a multitude of organisations, resulting in varied knowledge and skills. In 2007, a national training curriculum was developed and piloted in the country. The objectives of this paper are to identify the factors associated with higher knowledge and confidence in providers at the commencement of the training and to reflect on the implications of this for training and other efforts being made to improve services.

METHODS

A cross-sectional study using questionnaires was conducted. Providers who attended the training provided information on socio-demographic background, service provision, training, attitudes, and confidence. Knowledge was measured through multiple choice questions. Bi-variable analysis was carried out in order to test for factors associated with high knowledge and confidence. Variables with a p value of <0.20 were then included in backward selection to develop the final multivariable models.

RESULTS

Of the 124 providers, 70% were female and 68% were nurses. The mean age of the providers was 41.7 (24 - 64) years. About 60% of providers were trained in providing post-rape care. The median percentage knowledge score was 37.3% (0% - 65.3%) and the median percentage confidence score was 75.4% (10% - 100%). Having a more appropriate attitude towards rape was associated with higher knowledge, while older providers and nurses had lower odds of having high knowledge levels. Working in a crisis centre in the facility, having examined a survivor in the last 3 months, and seeing more than 60% of survivors who came to the facility were associated with higher confidence. Higher confidence was not associated with greater knowledge.

CONCLUSION

The study indicated that although confidence was high, there was poor knowledge in providers, even in those who were previously trained. Knowledge seems to be critically dependant on attitude, which highlights the need for educating providers on rape and the seriousness of the problem. There is a need to train more providers in post-rape care in country, and to ensure that training is comprehensive, and that providers who are trained remain knowledgeable and skilled in current best practices.

Forensic emergency medicine: old wine in new barrels

Emergency and forensic physicians may find themselves sometimes on the same medical battleground but with different primary aims and hence often ignore or do not recognize each other's needs. The emergency physician interacts with law enforcement agencies with greater frequency than any other hospital physician and hence needs expertise with legal issues. Awareness of the forensic relevance of certain medical observations by emergency physicians, knowledge of emergency medicine methodology and techniques and of resuscitation-related injuries by forensic physicians may lead to a higher standard in both forensic and emergency medicine, a better serving of the criminal justice system, and most importantly safeguarding the rights of victims of criminal assault. It is this achievable mutual symbiosis that we would like to refer to as the concept of 'forensic emergency medicine'.