Border Flu Shot Protest: 4 Docs arrested

Border Flu Shot Protest: 4 Docs arrested

Four physicians and two others protesting their inability to vaccinate migrant detainees at the U.S. Customs and Border Protection (CBP) headquarters here were arrested last Tuesday for failing to comply with federal orders to disperse.

They were held for about an hour, according to some of those who were arrested.

The two groups of protesters — about 60 people in total — had gathered in two driveways leading to CBP headquarters for about an hour when one of the groups received a warning from federal officials that if they stayed in the driveway, they would be arrested, said Marie DeLuca, MD, an emergency room physician from New York who was one of those arrested. Some of the members had blocked the driveway by laying down across the road while others chanted, “No more death.”

“We stayed peacefully in the driveway entrances of their building and said that if they weren’t going to let us in to vaccinate against the flu, we were going to remain. They didn’t let us. Instead they chose to arrest members in one of the two groups,” DeLuca said.

She said her hands were secured behind her back with zip ties by officials from the Department of Homeland Security (DHS) as she and the other protesters were led into a conference room and told to wait. After about an hour following the protest, they were issued tickets with a court date for “failure to comply with the lawful direction of federal police officers or other authorized individuals,” and then released, she said.

A San Diego Union-Tribune reporter posted a video of some of those doctors being arrested.

At about 2 p.m. Tuesday, DHS’s press secretary tweeted a picture of the protesters and said, “Of course Border Patrol isn’t going to let a random group of radical political activists show up and start injecting people with drugs.”

Sen. Elizabeth Warren (D-Mass.) also tweeted a link to a video of the protesters, saying that “Children are dying in CBP custody due to the flu. Refusing to administer flu vaccines is neglectful and cruel.”

Other doctors arrested, who were part of the group Doctors For Camp Closure, included Mario Mendoza, MD, a former anesthesiologist who now lives in New York City and runs the organization Lifeundocumented.org; Hannah Janeway, MD, an emergency room physician in Los Angeles who helps run the Refugee Health Alliance; and Mathieu De Schutter, a pediatric hospitalist from San Luis Obispo, California. The non-physicians arrested were Rebecca Wollner of Jewish Action San Diego and Matthew Hom, a graduate student from Cerritos, California, who works with the group Never Again Action.

On Monday, the physicians began their three-day vigil and protest of federal immunization policies at the gate of the detention center in San Ysidro at about 11:30 a.m. They stayed until about 4:30 p.m. with no response despite repeated requests. Tuesday’s action took place nearby at the Chula Vista CBP headquarters.

DeLuca said the doctors and their supporters planned to return Wednesday to try one more time to administer the 120 influenza vaccines they brought with them for the detainees. They say it’s important for public health, not just to protect these detainees, but also everyone else they come in contact with.

Members of the groups chanted slogans and carried banners and signs calling on federal officials to let them administer the vaccinations to those inside. The vaccines were purchased with financial donations.

Originally published in MedPage Today.

The Problem of Pain: Prescribing Opioids to Addicted Populations

The Problem of Pain: Prescribing Opioids to Addicted Populations

Between 2006 and 2012, more than 32 million prescription pain pills circulated through Berkshire County, Massachusetts, a rural area of about 130,000 people.

Patients recovering from opioid addiction are seen at the local emergency department every day, according to Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies alumna. Roberts works in Berkshire’s emergency department, which sees 50,000 patients per year — more than a third of the county’s population.

“It’s challenging,” she said. “It’s also an opportunity to help those patients in a way that may improve their outcomes.”

Patients in addiction recovery aren’t exempt from the need for pain relief in the case of acute injuries, surgical operations, or chronic pain. Providers like Roberts are tasked with finding and offering alternatives to opioids.

How can clinicians balance the weight of ethical responsibility with a patient’s need for immediate relief?

Opioid Dependence and Addiction in the United States

About 21% to 29% of individuals who are prescribed opioids misuse them, and 8% to 12% of them develop an addiction, according to the National Institutes of Health. Though only a small percentage of patients are likely to develop an addiction, there is still a chance of dependence, which is characterized by a physical reliance on the medication that, if unaddressed, can lead to addiction.

Even if the patient is not demonstrating symptoms of addiction, providers look for specific signs of dependence, according to Dr. Jill Ogg-Gress, assistant Family Nurse Practitioner (FNP) program director at Georgetown University.

“Opiate medications have side effects of dependence,” said Ogg-Gress, who works as a board-certified emergency NP in several Iowa and Nebraska emergency rooms. “If a provider recognizes that a patient is experiencing dependence, or if a patient demonstrates behaviors of dependence, it should be recommended to the patient they should talk to their primary care provider or the prescriber of the opioids.”

Signs of opioid dependence
  • Taking painkillers more frequently than prescribed
  • Taking higher doses than prescribed
  • Seeking a euphoric effect to counter physical pain
  • Experiencing excessive sleepiness or irritability

Taking these signs into account, providers can evaluate patients’ needs on an individual level to assess the magnitude of pain. If the patient is likely to develop a dependence, the providers may need to help them find an alternative treatment plan that is effective and sustainable.

Ruling out opioids altogether isn’t a realistic approach, Roberts said.

“There are still some painful injuries that will benefit from short-term opioid use,” she said.

Her key to implementing an effective treatment plan is working with the patient to assess their needs and openness to non-opioid pain medication.

Commonly Used Alternatives to Opioids

Opioids are a class of drugs that can be prescribed for pain relief but are highly addictive and illegal for consumption when not prescribed by a health care provider.

Individuals recovering from drug addiction might encounter injuries or surgical operations that require management of immediate acute pain or chronic pain in the long term. Providers can evaluate a patient’s needs when creating a treatment plan to manage that pain.

Pharmacological alternatives to opioids

Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.

Acetaminophen can be used for pain relief and fever reduction, but it does not reduce inflammation. It’s one of the most common pain relievers among Americans, used by roughly 23% of adults each week.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can treat acute pain and inflammation. A 2018 report found that NSAIDs make up 5% to 10% of all medications prescribed each year.

Gabapentinoids: This class of drugs includes gabapentin and pregabalin and has been historically used for seizure prevention. It is available by prescription to address pain but only in circumstances set by the Food and Drug Administration. While these painkillers can be an alternative to opioids, Roberts said they are not her intervention of choice because studies show there are other, more effective alternatives.

When medication isn’t appropriate or preferable, many non-pharmacological options exist to relieve pain and suffering.

“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these pain therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”

Non-pharmacological alternatives to opioids
  • Localized numbing
  • Ice
  • Massage
  • Exercise
  • Physical therapy
  • Acupuncture
  • Relaxation

Supporting Patients in Recovery

Every patient deserves time and attention to explain their case and their needs to a provider who is listening thoughtfully. Providers treating addicted populations must keep a constant eye out for identifying drug seeking behaviors, without stereotyping or wrongly assuming a patient’s motives. A 2016 report published by the National Institutes of Health described several types of drug-seeking behaviors:

Common Drug-Seeking Behaviors
Requests and complaints
  • Describing a need for a controlled substance
  • Asking for specific opioids by brand name
  • Requesting to have a dose increased
  • Citing multiple allergies to alternative pain therapies
Inappropriate self-medicating
  • Taking more doses than recommended by the provider
  • Hoarding a controlled substance
  • Using a medication despite not being in pain
  • Injecting an oral formula instead of consuming orally
Inappropriate use of general practice
  • Visiting multiple providers for controlled substances
  • Calling clinics when providers who prescribe controlled substances are on call
  • Frequent unscheduled visits, especially for early refills
  • Consistently disruptive behavior
Patterns of resistance
  • Hesitancy to consider alternative pain treatments
  • Declining to sign controlled substances agreement
  • Resisting diagnostic workup or consultation
  • Being more interested in the medication than solving the medical problem
Illegal activity
  • Obtaining controlled drugs from family members or illicit sources
  • Using aliases or forging prescriptions
  • Pattern of lost or stolen prescriptions

Clinicians who have identified these behaviors can use electronic medical records and crossover notes from other providers to see how many times a patient has sought medication for the same problem.

“People are here for assistance, but they’re not taking personal responsibility,” Roberts said. Engaging with patients to help them understand treatment plans can build a sense of agency over their own care.

Roberts said providers can help patients identify ways to care for themselves before writing a prescription for opioids. She recommended a gradual approach to trying different types of treatment:

A Step-Wise Approach for Pain Management

  1. Get to know the patient
  2. Use analgesics to address pain symptoms
  3. Use non-pharmacological treatments as intervention for side effects
  4. Encourage patient to stop smoking and drinking alcohol
  5. Eliminate foods that irritate the stomach or digestive system
  6. Reflect on previous steps: Did you really exhaust everything?
  7. Consider opioids as a last resort, and only enough to support immediate pain relief

Nurse Practitioners who work with a multidisciplinary team are uniquely positioned to provide holistic care. Clinicians serving communities with large addicted populations have to be familiar with law enforcement, social work organizations and, in the case of making a referral outside the clinic or emergency department, recovery programs and child protective services.

Roberts also acknowledged that providers working in communities fraught with addiction are at a high risk for fatigue. “If you have three back pain patients in a row, you’re going to be pretty burned out within two hours of working your shift, so you really, truly have to look at each case individually,” she said.

Taking time to self-reflect on personal motivations for treating patients can help remind providers of why caring for others is important to them.

“It’s hard to walk in and do a good job if you’re upset about the work you’re doing,” Roberts said. “Make sure you can do this without letting your own bias get in the way.”

Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: [email protected], the online DNP program from the School of Nursing & Health Studies

Climate Change Awareness: The Role of Health Providers

Climate Change Awareness: The Role of Health Providers

As trusted professionals in the eyes of the public, health providers are considered stewards of public health and safety.

A view of Hong Kong smog from Victoria Peak.
A polluted morning in Hong Kong.

Health providers are ethically bound to advance health holistically, and with climate change, this means translating information into advocacy. The effects of climate change call for the many roles that medical providers take on: first responder to disaster, risk educator of patients and public, and — in an almost exact reenactment of Florence Nightingale’s work — defender of clean water, nutritious food, and sanitation.

The scope of climate-related effects on human health is simultaneously as broad as global drought and as specific as increased incidence of skin cancers. Health providers are uniquely positioned to address the health implications of climate change, providing education within the context of direct patient care and speaking with authority on policy decisions that affect public health.

Climate Change and Human Harm

Health providers warn that climate change can cause or increase the severity of a range of dangerous respiratory ailments.

Scientists are still working to understand the full impact of climate change on human health; however, there are existing studies that show severe effects on human health as a result of environmental hazards. According to the National Institutes of Health, there are several key areas of concern regarding climate and health, and many opportunities for health providers to offer prevention and education.

THREATS TO RESPIRATORY HEALTH

Implications: Lung disease, allergies, and asthma will be worsened by longer allergy seasons and deteriorating air quality.

Health Provider Recommendations: Support staying inside on poor air quality days and remind vulnerable populations to adhere to medical treatment plans and medication.

VECTOR-BORNE DISEASES

Implications: Ticks and mosquitoes will be more active for longer and range farther.

Health Provider Recommendations: Encourage people to use bug repellent when outdoors or in any areas with insects. Monitor and record reports of disease outbreaks. Inform others about signs and symptoms of diseases and when to call a health care provider.

WEATHER-RELATED ILLNESS AND INJURY

Implications: Extreme temperature fluctuations affect outdoor laborers, children, pregnant women, and older adults and can cause pulmonary and cardiovascular problems and dehydration. In addition, increased particulate matter, ozone concentrations, and extreme weather events may trigger stress and respiratory issues that lead to heart disease.

Health Provider Recommendations: Educate about the risks of heat exposure. Ensure access to air conditioning for vulnerable or older adults and homeless populations. Also, encourage people to drink enough water throughout the day and not just when they feel thirsty.

MENTAL HEALTH AND STRESS DISORDERS

Implications: Extreme weather can be destructive to property and quality of life, often resulting in the loss of homes, belongings, and loved ones. Prolonged exposure to these stressful experiences can manifest psychologically as people try to navigate grief and loss with interrupted access to care.

Health Provider Recommendations: Encourage others to speak openly about their grief to reduce stigma. Identify gaps in mental health literacy and teach patients about signs and symptoms of mental health risks. In addition to educating, refer at-risk patients to a mental health provider as soon as possible.

Spreading the Word About Disaster Preparedness and Dangers

One result of climate change is more frequent and more powerful natural disasters, like hurricanes. Pictured are specialists testing the flooded river during Hurricane Harvey
Flooding after hurricane Harvey

In a 2018 World Health Organization report on climate change and health,  experts state that “globally, the number of reported weather-related natural disasters has more than tripled since the 1960s.” For this reason, it’s essential that health providers inform their communities about disaster preparedness and dangers. The best time to get involved is before a disaster; therefore, it’s critical for providers to leverage any one-on-one time with patients to address holistic health and emergency concerns. Special attention should be paid to those who may be vulnerable in the wake of disasters. For example, this could include people with chronic conditions, physical disabilities, or respiratory diseases; infants and children; pregnant women; and older adults.

Thin Ice: The Life-Threatening Effects of Climate Change

Air Temperature Change

  • Increase in heat exhaustion
  • Spread of disease vectors among animals, insects, and people

Air Pollution

  • Increased movement of airborne allergens and diseases
  • Higher risk of respiratory illness  
Climate change affects pets, too. Rescued dogs from Hurricane Harvey are being treated by volunteer health providers.
Volunteer care providers treat pets rescued after hurricane Harvey.

Extreme Weather

  • Chronic stress
  • Geographic displacement
  • Loss of loved ones and pets

Water Temperature Change

  • Changes to coastal ecosystem health that will affect food supply and erosion
  • Increased likelihood of extreme precipitation, drought, or flooding
  • Water contamination due to harmful chemicals and pathogens

Food Security

  • Malnutrition, especially for prenatal or early childhood development
  • Exposure to pesticides and toxic contaminants
  • Increase in harmful algal blooms

Source: Health Effects of Climate Change.  U.S. Department of Health and Human Services, 2018. Accessed April 23, 2019.

All health providers are important voices in preemptively educating patients about disaster preparedness, but nurses specifically make up a crucial part of disaster response.

More than 20,000 licensed and student nurses serve the Red Cross in a variety of roles — some as first responders and CPR educators and others as supervisors and organizational managers.

While the effect of climate-related health issues increases alongside the shortage of nurses and other medical providers, there’s great reason for all providers to advocate for change.

A Rising Tide Lifts All Boats: Advocacy for Climate-Related Health Policy

Nurses and other health providers are advocating for climate action.
Alliance of Nurses for Healthy Environments at September 2019 rally in D.C.

Climate change may be politically polarizing, but illness and injuries seen by first responders and health providers are concrete outcomes and can translate into loss of life on a global scale.

In a 2018 report on climate change and health that accounted for continued economic growth and medical progress, the World Health Organization stated that “climate change is expected to cause approximately 250,000 additional deaths per year between 2030 and 2050.” These fatalities are projected to come from the following climate-related health complications:

— 38,000 due to heat exposure in older adults

— 48,000 due to diarrhea

— 60,000 due to malaria

— 95,000 due to childhood undernutrition

Health providers can draw awareness to this dire need for attention at the policy and community levels. They can also share firsthand experience and research. This is an ethical duty that can result in widespread support of strong public health programs and climate justice.

How to Get Involved in Climate and Health Policy

In addition to in-person education with patients, health providers can do a variety of things to spread awareness about climate and health policy in their communities:

Leverage social media. Share articles with verified, evidence-based information on social channels. Use hashtags related to climate and health that make your posts easier to find. For example, #ActOnClimate, #Go100Percent, #Renewables, #SaveThePlanet, and #ClimateChange.

Continue your education. Request or attend an educational presentation from a trained professional, then collaborate with community organizations to educate people in your area. Volunteer with climate- or policy-focused organizations to gain perspective.

Participate in civic engagement. Call your representatives to let them know whether you support specific legislation. And always, vote in local and national elections.

Organizations for Further Reading or Involvement

If you are a health care provider looking to learn more about climate and health policy, you may wish to visit the websites of these organizations.

Citation for this content: [email protected], the online DNP program from the Simmons School of Nursing

“It’s a beautiful thing to witness…” A Talk with the Director of the VNSNY Gender Affirmation Program

“It’s a beautiful thing to witness…” A Talk with the Director of the VNSNY Gender Affirmation Program

In early 2016, Mt. Sinai Hospital* approached the Visiting Nurse Service of New York (VNSNY) to propose that VNSNY offer home care services to post-operative transgender patients. This was the genesis of VNSNY’s Gender Affirmation Program (known as GAP), which to date has provided home care to over 400 transgender patients.
*a strategic partner of VNSNY

DailyNurse recently interviewed Shannon Whittington, RN MSN PCC C-LGBT Health, the Clinical Director of GAP at VNSNY. We asked her about the nature of gender affirmation treatment, the home nursing care that VNSNY provides, and the outstanding LGBT-friendly services that VNSNY offers to patients across the Tri-State New York area.

 Shannon Whittington, the Clinical Director of the Gender Affirmation Program at VNSNY
Shannon Whittington, the Clinical Director of the Gender Affirmation Program at VNSNY

DailyNurse: What is gender affirmation surgery (GAS)?

SW: A surgical procedure that creates or removes body parts that align with the patients’ gender expression. E.g. vaginoplasty, phalloplasty, metoidioplasty, facial feminization, breast augmentation/masculinization.

DN: Is this the same thing as “sex-change surgery?”

SW: It is the same thing but we don’t use the terms “sex-change surgery” anymore.

Gender Affirmation or Gender Confirming surgeries are the correct terms now.  Understanding that this is a linguistically fluid language, words and meanings are always changing and we need to be mindful of correct terminology.

DN: What are the components of the VNSNY Gender Affirmation Program?

SW: The program emphasizes home care following surgery from other providers. I train clinicians (nurses, social workers, physical therapists, home health aides, speech and occupational therapists) in cultural sensitivity as it particularly relates to transgender patients.  The training is extensive and they are also educated in how to teach the patients to care for their new or altered body parts (i.e. penis, vagina, breast, face)

DN: How did you come to specialize in the treatment of Gender Affirmation surgery patients?

SW: Fortunately, I was chosen for this project by my manager.  I had no idea what I was saying yes to but this has literally changed the trajectory of my career path.  I discovered a passion that I did not know I had!

DN: What sorts of clinical training do nurses in the program need to take care of GAS post-surgery patients? 

SW: They need to know what to assess for and what is normal and what is not.  They learn about vaginal dilation because the patients who undergo vaginoplasty must do this on a regular basis. Patients come home with VACs, JP drains, foleys and supra pubic catheters. Although the nurses are already familiar with these devices, they need to teach the patients how to manage them. The clinicians are also trained in social determinants of health for this cohort.

DN: What sorts of cultural issues do nurses need to learn about before tending to a GAS patient?

SW: We really need to understand that these patients, like all of our patients, are patients first who happen to be transgender. We must respect their chosen names, their pronouns and their gender expression. We focus on getting them better and integrated back into society. It’s a beautiful thing to witness and an honor to be associated in such a transitional journey.

DN: How does the Gender Affirmation Program reflect the larger VNSNY commitment to LGBT patients?

SW: It reflects our commitment to this population on an agency wide basis.  What is great is that we are now getting non-operative transgender patients who are seeking home care services for reasons other than gender affirming surgeries.  They feel safe here and seek care outside of gender affirming surgeries. 

We are initiating various ways to continue to be inclusive along the binary spectrum by hiring gender non-confirming and non-binary individuals. These individuals have a lot to offer and need to be the best expressions of themselves in their work environment just like the heteronormative society we all live in.

DN: And can you tell us something about the SAGE training in your organization?

SW: All divisions of the Visiting Nurse Service of New York have been awarded Platinum certification (the highest level possible) from SAGE, the world’s largest and oldest organization dedicated to improving the lives of LGBT older people.

More than 80 percent or more of VNSNY’s clinical and other staff have received SAGE Care LGBT cultural competency training, further establishing VNSNY as a preferred health care provider for New York City’s LGBT residents.

The SAGE training is designed to increase awareness among VNSNY clinical and administrative staff of cultural issues and sensitivities around sexual orientation and gender identification, so as to ensure a welcoming and respectful health care environment for all individuals within the LGBTQ community.

Among other things, the training stresses the importance of approaching each patient in a non-judgmental fashion and never making assumptions about anyone’s sexual orientation or family structure. We want every patient to feel they can be totally open about who they are with every member of our GAP team who walks through their door.

From Forensics to Advocacy: What it’s Like to be a SANE (Sexual Assault Nurse Examiner)

From Forensics to Advocacy: What it’s Like to be a SANE (Sexual Assault Nurse Examiner)

When people experience sexual assault, they may sustain more than just physical injuries; trauma also affects short- and long-term mental health. The medical treatment needed may require a provider to examine parts of the body that were recently violated, which can cause more distress. When reporting an assault, survivors often lack the information they need about how to proceed.

Sexual assault nurse examiners (SANEs) are trained to help survivors across this spectrum of patient care. From providing evidence-based treatment to performing assessments to collect forensic evidence that can be used in a criminal trial, these nurses play a critical role in supporting survivors at the beginning of their recovery process.

What Is the Role of a Sexual Assault Nurse Examiner?

When a sexual assault survivor comes to a SANE-certified hospital or community health center, a sexual assault nurse examiner is the first point of care, according to Kim Day, forensic nursing director for the International Association of Forensic Nurses (IAFN). SANEs ask the patient if they would like a forensic exam, which can be completed even if the patient decides to not report their assault to law enforcement.

“Just going through the process with someone and providing holistic patient-centered care for that patient during a traumatic time in their life can really impact the way they leave the hospital,” Day said.

Forensic exams are meant to document trauma from the assault and collect evidence that could be used in a criminal trial. This includes taking a medical history; documenting scratches, bruises, abrasions, and other injuries on a body map diagram; taking photos of injuries; collecting DNA swabs to be processed; and observing the patient’s behavior. In cases where toxicology information is relevant, SANEs will also perform those tests on a patient.

In addition to performing a forensic exam, the main duty of a SANE is to provide holistic nursing care for the patient. Survivors of assault may need access to testing for pregnancy, as well as prophylactic antibiotics to prevent the contraction of diseases. Depending on the patient’s needs, SANEs also provide referrals to see other specialists, such as a licensed professional counselor, who can help them in their recovery process.

The SANE in Court: It’s Not Like “Law and Order”

Beyond working in the clinical setting, SANEs are qualified to testify in court if a patient’s case goes to trial. The specialized training SANEs receive prepares them to effectively answer questions regarding evidence discovered during a forensic exam. However, while SANEs can play a critical role in the trial process, the legal aspect of the job is not the main focus, Day said.

“If the nurse goes into this work thinking that they’re going to get the bad guy and put him behind bars, they will fail at this… because that is not what we do,” she said. “The work we do is nursing. We take care of the patients.”

This is a key factor to consider when choosing to become a SANE. Nearly 80 percent of sexual assaults are not reported to law enforcement, according to a Justice Department analysis of violent crime in 2016 (PDF, 669 KB). While performing a forensic exam and being prepared to provide evidence in court is a requirement of the job, the emotional and medical needs of a patient come first.

SANEs are trained to work within a multidisciplinary team, also known as a Sexual Assault Response Team (SART), which includes survivor advocates, members of law enforcement, and mental health providers. Together, these professionals coordinate the response to survivors of sexual assault.

What Is a Sexual Assault Response Team?

SANEs and other trained health care providers: When an individual decides they would like to have a sexual assault forensic exam (SAFE), health care providers like Nurse Practitioners (NPs) or SANEs address the initial physical and psychological needs the patient might have as a result of their assault.

Survivor advocates: Individuals who need access to information and emotional support can work with an advocate to navigate their path to recovery. A survivor may reach out to an advocate via a crisis center, or one may be brought in to support someone who has decided to seek treatment at a hospital or report their assault to the police.

Law enforcement: In cases where an individual decides to report their assault, police officers and detectives are responsible for taking statements, coordinating with the hospital to receive the results of the forensic exam, and investigating the alleged assault.

Prosecutors: In cases where the survivor has chosen to report their assault and enough evidence is present, prosecutors are tasked with making the decision on whether to bring the case to court.

Therapists and counselors: In the aftermath of an assault, whether a case goes to trial or not, survivors need additional support to continue their recovery process. Mental health professionals trained in working with sexual assault survivors may provide care at any step in the recovery process, from coping with the immediate aftermath of an attack to navigating long-lasting trauma.

Why Is Access to SANE Care Important?

According to the Centers For Disease Control and Prevention (CDC), one in three women and one in four men have experienced sexual violence involving physical contact during their lifetimes. The effects of experiencing an assault can be both physical and psychological, necessitating specialized care that embodies the concept of cura personalis, or care for the entire person. This holistic attention to the entire individual is the expertise of clinicians like nurses.

SANE education programs are designed to train nurses to address survivors’ specific needs. After completion of this training, SANEs become uniquely qualified to treat this vulnerable patient group. This means that they can provide trauma-informed care to minimize the harm of invasive exams that may trigger a patient. In doing so, they can also equip their patients with forensic evidence that can be used if they decide to report their assault.

Not all hospitals have SANE programs. IAFN’s database of registered SANE programs   indicates that there are currently 962 in the United States. As a result, patients are sometimes required to travel long distances to access SANE care, according to a 2016 report on the availability of forensic examiners (PDF, 191 KB).   This means that the facilities with SANE expertise must be ready to do what they can to help every patient who walks in the door.

Trauma-Informed Care and Practicing Consent

One of the key challenges of completing a sexual assault forensic exam (SAFE) is examining a patient’s physical injuries without retraumatizing them. To help survivors feel comfortable, SANEs ask for consent during each step of the way while providing information on why they are doing each test.

“Consent is not just a piece of paper with a signature on it,” Day said. “It’s a process throughout the exam.”

In practice, the process of asking for consent may resemble the following:

  1. The SANE will inform the patient what body part they will examine and ask permission to do so.
    “I’m going to examine your neck now to see if there are any injuries. Do I have your permission to do so?”
  2. If the patient grants this permission and the SANE notices something that may require a sample collection, the nurse will again ask for permission to collect a specimen and explain why collecting that evidence is appropriate.
    “I notice a scratch that wasn’t mentioned when I documented your health history. There may be DNA or other materials near this wound, so I would like to swab it. Is that OK with you?”

In any instance where the patient does not want a test performed, the SANE is directed to honor the patient’s request. This integration of consent throughout the exam is meant to give the patient a sense of control, a feeling that may have been lost during their assault.

What Are the Requirements to Become a SANE?

Because SANEs work with a patient population that requires specialized care, nurses are required to meet certain expectations in order to take on this role. While some nurses go through training at the local level or through smaller programs, IAFN offers the most recognized certification for SANEs. Nurses can become certified as a SANE-A to care for adults and adolescents or a SANE-P to work in pediatrics. Some nurses elect to pursue both certifications so they can provide care to patients across all age groups.

Steps to SANE Certification
  • Education: To become a certified SANE, a nurse must have the minimum of a registered nursing (RN) license.
  • Experience: Prior to starting the certification process, a nurse must have at least two years of clinical experience working as an RN or at a higher level, such as an NP.
  • Training: As part of the certification process, nurses are expected to complete 300 hours of SANE clinical skills training.
  • Testing: The final requirement to become a certified SANE is to pass a certification examination. IAFN holds exams two times a year.

Information for Further Reading

Citation for this content: [email protected], the online MSN program from the School of Nursing & Health Studies

Anti-Vaxx: a Sane Perspective on a Crazy World

Anti-Vaxx: a Sane Perspective on a Crazy World

The anti-vaccination (“anti-vaxx”) movement is a global phenomenon that has received a great deal of press, but how much do we really know about it? How do educated adults come to turn against medicines that have been saving literally millions of lives since the early days of smallpox inoculations?

Doctors prepare to vaccinate an infant.

One partial explanation is offered by health policy reporter Stuart Lyman. In a February column for STAT, he writes, “The [pharmaceutical] industry has been engaging in bad behavior for several decades, and these self-inflicted wounds have turned much of the public against it…” After reciting a horrifying litany of pharma-company scandals the public has witnessed, he concludes, “All of this has contributed to the prominent anti-pharma themes voiced by the anti-vaxx crowd.”

Anti-Vaxx is No Longer In Its Infancy

But “the anti-vaxx crowd” shows no signs of giving up their crusade anytime soon. From their original focus on parents of autistic children, they have proceeded to target orthodox Jewish communities and recently bereaved parents. Perhaps the most influential US group behind anti-vaccine campaigns is ICAN (Informed Consent Action Network). According to the Washington Post, ICAN, founded by former daytime television producer Del Bigtree, is largely funded by New York city philanthropists Bernard and Lisa Seltz, who have contributed $3 million since joining in 2012.

Lisa Seltz now serves as ICAN president, and continues to fund the organization’s message that the government and “Big Pharma” are colluding in a massive coverup regarding the hidden dangers of vaccines. Robert F. Kennedy, Jr, a nephew of the late president, runs Children’s Health Defense, his own anti-vaxx organization, and another flush-with-cash group, The National Vaccine Information Center, is run by Barbara Loe Fisher (who claims her son’s learning disabilities were the result of a 1980 DPT shot that was followed by “convulsion, collapse and brain inflammation within hours”).

Some Quick Tips from NSO’s Georgia Reiner

Considering that these wealthy and powerful organizations are finding fertile ground in today’s conspiracy-minded culture, DailyNurse interviewed Georgia Reiner, a risk specialist for Nurses Service Organization (NSO), to request a few tips for nurses who find themselves confronted by this strange controversy.

DailyNurse: What are the actual dangers posed by the anti-vaxx movement?

GR: It is important to state up front that the vast majority of people do vaccinate. However, the anti-vaccination movement has gained a lot of attention and helped foment outbreaks of largely preventable diseases that can be deadly. The anti-vaxx movement spreads misinformation and conspiracy theories online on social media, and by word-of-mouth in tight-knit, culturally isolated communities.

Anti-vaxx propagandists have helped to create pockets of unvaccinated people, which have contributed to public health issues like the measles outbreak seen recently in Orthodox Jewish communities in New York and New Jersey. These outbreaks of highly contagious diseases such as measles put vulnerable people, including newborn babies and people who have weakened immune systems, at great risk.

Outbreaks also distract and divert resources from other important public health issues, and cost state and local governments millions of dollars to contain. However, nurses are in an ideal position to counter this messaging.

DN: What are nurses doing to counter the anti-vaccination movement?

GR: Nurses are a trusted source of credible information and can have tremendous influence over the decision to vaccinate. This is true even for parents who are vaccine-hesitant. Working on healthcare’s front lines, nurses can help inform families about vaccinations and the role they play in keeping their children healthy and stopping the spread of disease. Nurses can also learn about questions parents may ask about vaccines, and how to effectively address common concerns.

DN: How can nurses cope with anti-vaxx parents?

GR: First, nurses should assume that parents will vaccinate. Research has shown that when healthcare providers use presumptive language, significantly more parents accept vaccines for their child. Then, if parents are still hesitant or express concerns, nurses should work with the treating practitioner to convey the importance of vaccines.

Nurses should listen to parents’ concerns, work to understand why they are questioning the science, and respond respectfully. Provide parents with information about vaccines and vaccine-preventable diseases, both verbally and in writing. Document parents’ questions and concerns.

If parents still decline to vaccinate, the parents should sign a Refusal to Vaccinate form. Parents should sign a new form each time a vaccine is refused so there is a record in the child’s medical file. To minimize potential legal exposure, nurses should document all discussions, actions taken, and educational material provided.

For further information, visit the American Academy of Pediatrics site document “Countering Vaccine Hesitancy.”

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