A Case of a City Performing Rapid Rape Kits

About Tiffany’s Rape Kit Exam

Oregon publishes guidelines that instruct medical practitioners how to conduct rape kit exams for people 15 years of age and older in the Oregon Medical Guidelines for Sexual Assault Evaluation. (To learn more about the protocols of various states for rape kit exams, go to the SAFEta website.) Oregon’s guidelines are just that - guidelines. There is very little a forensic nurse is required to do in Oregon for most sexual assault victims other than offer STD prophylaxis and birth control.

Tiffany’s rape kit exam was conducted by a forensic nurse employed by Rapid SAVE Investigation LLC (RSI). As previously mentioned, RSI conducts rapid rape kit exams. Even though Tiffany’s RSI nurse was of the opinion that Tiffany’s body showed evidence of sexual assault, the RSI nurse rushed through the exam and did not follow Oregon guidelines. The paperwork completed by the RSI nurse for Tiffany’s rape kit exam is a perfect exam of how RSI is failing the most vulnerable patients. RSI’s paperwork not only contradicts itself, but also contradicts the Legacy hospital’s records for the emergency room visit in which Tiffany had her rape kit exam performed.

In billing paperwork, the RSI nursebilled Oregon State for services that were not provided to Tiffany:

• In billing paperwork, the RSI nurse billed for a rape kit exam over 120 minutes. In exam paperwork, the RSI nurse wrote that the exam began at 18:46 hours, and that the evidence collected during Tiffany’s rape kit exam was locked at 20:30 hours. This means her exam was under 120 minutes.

• Per CDC guidelines, every adult patient underdoing a rape kit exam should be offered prophylactic treatment for sexually transmitted infections. An emergency room doctor offered Tiffany STD prophylaxis, but the RSI nurse did not. The RSI nurse did not even mention that a medication called PrEP exists. PrEP can prevent a person from developing HIV after they have had unprotected sex with an HIV-positive person. In exam paperwork, the RSI nurse indicated that she did not provide Tiffany any prophylactic treatment for STDs. However, the RSI nurse billed Oregon State for prophylactic treatment for STDs.

• In billing paperwork, the RSI nurse billed for a tetanus vaccine. However, in exam paperwork, the RSI nurse indicated that she did not provide Tiffany a tetanus vaccine because her tetanus vaccination status was up-to-date.

Presumably because the RSI nurse rushed through Tiffany’s rape kit exam, the RSI nurse entered incorrect information in the exam paperwork:

• The RSI nurse wrote that the sexual assault occurred at a time about a full day earlier, but also wrote that 13 hours had elapsed before the exam since the sexual assault.

• During the exam, the RSI nurse asked Tiffany how she preferred to be contacted, and then incorrectly indicated in paperwork that the only safe way for Oregon State to contact Tiffany was via text.

• The RSI nurse wrote on paperwork that the evidence tape seal was applied to Tiffany’s rape kit (her rape kit contained swabs - Tiffany’s blood vials and urine cup were packaged separately) at 17:30 hours. However, the rape kit exam hadn’t even started by that time. An emergency room nurse named Melinda wrote that at 17:46 hours, the RSI nurse had been notified that Tiffany needed a forensic exam, and that the RSI nurse was heading to the emergency room in Vancouver, Washington from Oregon City, Oregon.

• In exam paperwork, the RSI nurse indicated that Tiffany’s posterior fourchette was within normal limits. "Within Normal Limits" (WNL) is a medical term indicating that physical exam findings or test results are within the expected, healthy, or "normal" range defined by clinical standards. It signifies that no significant abnormalities or issues were detected. Tiffany’s posterior fourchette was not within normal limits because it had been operated on the day prior. Since it had been operated on, Tiffany’s posterior fourchette was bloody and contained sutures at the time of Tiffany’s rape kit exam.

• Oregon State guidelines instruct forensic nurses to routinely collect underpants that victims wear to a rape kit exam, even if the underpants were changed after the assault. Tiffany wore “period underwear” (underwear designed to collect blood) to her exam because she had surgery the day prior on her vulva. She put these underwear on while getting dressed at the hospital shortly after being raped. However, the RSI nurse wrote on exam paperwork regarding Tiffany’s clothes that “[patient] doesn’t have them,” and did not collect any clothing. According to a document detailing what a forensic scientist found in Tiffany’s rape kit, the RSI nurse labeled a paper bag for underpants “not wearing underpants.”

• The RSI nurse had Tiffany sign paperwork indicating that the RSI nurse had explained the reporting process, and information regarding resources for advocacy, counseling, and a crime victims’ compensation fund, but no such information was mentioned to Tiffany. Instead, the RSI nurse simply asked Tiffany to sign where the RSI nurse had drawn “x”s on signature lines.

Because she rushed to complete the exam, the RSI nurse also skipped steps in the exam:

• Oregon State guidelines indicate that all sexual assault patients should receive a complete head-to-toe physical examination. Although the RSI nurse indicated on paperwork that she completed a full examination of Tiffany, she did not complete a full exam. Tiffany was never asked to remove her hospital gown during the exam. For this reason, the RSI nurse never saw or noted the 2 large circular bruises on Tiffany’s right outer thigh.

• Oregon State guidelines indicate that a forensic nurse should use an alternate light source with the room lights dimmed to scan a patient’s skin surface for biological fluids such as saliva or semen. The RSI nurse did not use any alternate light sources, such as a Wood’s lamp, and instead swabbed random areas on Tiffany’s neck and breasts.

• Oregon State guidelines instruct forensic nurses to use, during an internal examination, a good light source, in addition to magnificationwith an otoscope, visor, or colposcope. Instead, the RSI nurse asked an emergency room doctor to conduct an anoscopy. The emergency room doctor couldn’t find a light for the anoscope, and instead of giving the emergency room doctor time to find the light, the RSI nurse held up her cellphone flashlight nearby as a poor light source.

• The only injuries the RSI nurse bothered to note on the body map section of exam paperwork was that Tiffany had redness (chafed skin) around her anus. The RSI nurse declined to fill out the section of the exam paperwork requesting a narrative description of a patient’s injuries. Tiffany was so badly injured that about a year later, while she was using the restroom, her rectum entirely fell out of her body and she had to push it back in with her hands.

• The RSI nurse did not use Toluidine blue to identify abrasions on the skin surface. If she had, numerous fissures would have been apparent to the naked eye during the exam, before Tiffany experienced swelling.

• Oregon State’s guidelines instruct forensic nurses to collect head hair samples from all sexual assault patients. No head hair was collected from Tiffany.

• Oregon State guidelines instruct nurses to comb, pluck, or cut a victim’s pubic hair, if any, to collect debris that may contain offender DNA. The RSI nurse did not offer to conduct this task on Tiffany, and instead falsified on exam paperwork that Tiffany declined the combing of her pubic hair.

• National and international guidelines (NIJ National Best Practices for Sexual Assault Kits, OSAC standards, SWGDAM recommendations, and multiple peer-reviewed studies) all specify that people should use firm pressure while rotating or rolling swab heads across a surface while collecting DNA to dislodge sufficient cells from the skin or mucosal surface. Firm pressure + rotation is explicitly recommended because it dramatically improves DNA yield compared to light touching. However, the RSI nurse who collected Tiffany’s swabs used extremely gentle, feather light-like swabbing. Extremely gentle/feather-light swabbing is a known cause of poor DNA recovery in sexual assault kits and is not recommended by any forensic authority. “Feather-light” or extremely gentle swabbing fails to dislodge sufficient cells from the skin or mucosal surface. Multiple studies show that light swabbing recovers significantly less DNA — often 50–90 % lower yields — than moderate-to-firm pressure with rotation. In low-template scenarios (such as swabbing areas of external sexual contact, or swabbing internal residue after semen expulsion), feather-light swabbing is one of the most common reasons for trace or negative DNA results. The nurse’s extremely gentle, feather-light swabbing on the external anal rim was almost certainly a major contributor to the trace-only male DNA results in Tiffany’s case.

• The RSI nurse did not collect the internal swabs herself. Instead, she asked an emergency room doctor to collect the internal swabs. To avoid contamination, Oregon State guidelines instruct medical practitioners to not insert lubricant in a patient before collecting internal swabs, and to not collect internal swabs during an anoscopy. The RSI nurse failed to advise the emergency room doctor of these facts. During Tiffany’s rape kit exam, lube was applied to an anoscope before it was inserted, and all internal swabs were collected while the anoscope was inserted.

• During the exam, Tiffany was experiencing a pain level that, when unmedicated, was an 8 out of 10. The RSI nurse did not offer pain medication or coordinate with an emergency room doctor to provide pain medication to Tiffany. A nurse (not the RSI nurse) employed directly by the emergency room gave Tiffany 1 hydrocodone pill, and the emergency room doctor only offered Tiffany lidocaine gel. Tiffany’s excruciating pain extended to about 5 inches inside her anus.

• After forensic nurses collect swabs, they should place the swabs in a “swab box,” which suspends the tip of swabs in the air. While the nurse did place some swabs in a “swab box,” she put some swabs collected during Tiffany’s exam loose in an envelope instead. As explained in this document detailing what a forensic scientist found in Tiffany’s rape kit, the forensic nurse suspended Tiffany’s neck swabs, breast swabs, and anoscopy swabs in swab boxes, but put Tiffany’s mouth swabs, perineum swabs, and anal rim swabs loose in envelopes. One envelope contained the anoscopy swab box plus the anal rim swabs loose in the same envelope.

• When the RSI nurse was done with the exam, she was supposed to package Tiffany’s blood vials for safe transportation. Instead, she put Tiffany’s blood vials loose in a bag for the police to pick up. According to a police report, a dutiful Clark County police officer who came to the emergency room to collect Tiffany’s rape kit took it upon herself to place the blood vials in a box to protect the blood vials from damage.

The RSI nurse also spent time conducting an unnecessary task instead:

• The RSI nurse spent time swabbing the tips of Tiffany’s extremely short fingernails. Oregon State guidelines instruct forensic nurses to swab under the fingernails if victims report scratching their assailant. Tiffany did not report scratching her assailant.

When the RSI nurse first arrived at the emergency room, Tiffany asked the RSI nurse if her rape kit would be tested by Oregon State or Washington State since Tiffany lived in Washington State, was in an emergency room in Washington State, and her assault occurred in Oregon State. The RSI nurse told Tiffany her kit would be processed by Oregon. Tiffany then offered to go to an Oregon emergency room, but the RSI nurse said she wanted to conduct the exam at the emergency room they were already at. Because they were located in Washington State, the RSI nurseused incorrect paperwork:

• The RSI nurse used Washington State exam paperwork for Tiffany’s exam when she should have used Oregon State paperwork. 

• The RSI nurse gave Tiffany paperwork about how to track her rape kit on Washington State’s rape kit tracking website when she knew Tiffany’s rape kit would be processed and tracked by Oregon State. 

• The RSI nurse incorrectly gave Tiffany paperwork for the Crime Victims Compensation Program for Washington State instead of for Oregon State.