Welcome, and thank you for attending this webinar on Alternative Exam Techniques. My name is Karen Carroll, and I am a Forensic Nursing Specialist at the IAFN. My name is Tammy Scarlett, and I am also a Forensic Nursing Specialist with the IAFN. This presentation contains vaginal diagrams and photos with varying degrees of injury. It is intended for medical professionals, and viewers may want to be mindful of others who can see their screen. The planners, presenters, and content reviewers of this course disclose no conflicts of interest. Upon viewing this course in its entirety, due to the criticality of the content, and completing the course evaluation, you will receive a certificate that documents the Continuing Nursing Education contact hours for this activity. The International Association of Forensic Nurses is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center's Commission on Accreditation. Upon completing instruction in the following topics, the participant will have the knowledge required to perform in the role of the adult adolescent SANE in assessing, identifying, and confirming physical findings in the patient using a multi-method approach. Here is an example of female genitalia diagram that may be used for documentation purposes. When discussing the female genitalia, an important distinction is that many people and some clinicians inaccurately refer to the entirety of the female genitalia as the vagina. Our terminology needs to be specific and correct, and you should understand that the vagina is one specific structure of many in regards to the female genitalia. In addition, the vagina is an internal structure viewed with the use of a speculum, not an external one. In referring to external female genitalia as a whole, and in general, a better term is vulva. Even if you practice in a region where it is acceptable and other clinicians refer to the entirety of the genital area as the vagina, as a nurse in this specialty, it is advised to avoid this inaccurate terminology. In this diagram of the vulva, you will note the major structures identified. Our first technique is gross visualization. This is accomplished once our patient is in the lithotomy position. The lithotomy position and other types of positioning will be explained in subsequent slides by Tammy. It is optimal to obtain a photograph of the patient's vulvar area once the patient has been positioned and prior to evidence collection, speculum insertion, and any of the other exam techniques we will cover today. Findings and injuries can be identified in gross visualization. However, other techniques should be used to confirm these findings. The face of a clock is often used to indicate the location of an injury or a finding. For example, if you were educating in the courtroom about an injury you assessed, you could describe the location using the clock face analogy. Using a diagram, you'd explain that the center of the mons pubis is at 12 o'clock and the anus is situated at 6 o'clock. And here are the 3 o'clock, mid left labia majora, and the 9 o'clock position at the right mid labia majora. To adequately assess the external genitalia on any female patient, you'll utilize a technique called separation and traction. To perform this with gloved hands, you grasp each labia majora at the 3 or 4 o'clock position and pull away from one another, separating them. A, the adult adolescent patient, and diagram B is the pediatric patient. This will give you a better view, but still not the best. To achieve the best view, you'll then pull towards you and perhaps slightly down, depending on the patient's anatomy, using traction. Traction is needed to help open the structures up, affording the best opportunity for visualization. You can use this technique on any aged patient. The patient feels pulling, but should not feel pain. This is a photograph of an adolescent patient taken during gross visualization. Note there are findings at the 6 o'clock position, however, separation and traction are required to better visualize the exact location of the findings. Here you see a picture of the vulva without any labial manipulation. This is the same patient. When the nurse moves the right labia minora to the right, the right labia minora separates from the right labia majora. The entire area is easily visualized. With close-up inspection and photography, the bruise to the right labia minora is visible. It was not visible prior to separating the labia minora from the majora. Here is a photograph of an adult female's vulva with labial separation. This technique allows the examiner to better visualize the urethra and most of the hymen. Labial traction would allow for more optimum visualization of all of the hymen. Here is another view of gross visualization. This is the same patient with the examiner using separation and traction on the labia to visualize an injury to the hymen and the fossa navicularis. This is a non-acute exam photo of a 15-year-old female who had a history of sexual abuse at the age of nine. Utilizing proper labial separation and traction, the healed hymenal transection is easily visualized. Now Tammy is going to discuss how to position your patient for maximum visualization of the external genital structures. Positioning is something that should be considered when preparing to complete the anogenital portion of the exam. We will discuss the following positions, some which are frequently used and some which are used in specific scenarios. We will review lithotomy, supine knee chest, supine frog leg, side-lying, and prone knee chest. Any position allows for direct visualization of the anogenital anatomy. In this position, the patient is on their back with feet placed up in the footrests. Hips and knees are flexed and thighs are apart. Something to consider is instead of moving the patient's legs apart on your own for visualization, try placing your hands outside of the knees and encouraging the patient to bring their knees to that width. This gives them that control back. The patient's buttocks should also be at the end of the bed. Some programs or locations might not have a pelvic bed with the capability to use footrests for lithotomy positions. A few alternatives to consider would be a bed pan turned upside down, covered in a sheet or a chucks pad, the pelvic wedge placed under the buttocks of the patient, or even a blanket, pillow, or towel. These allow for better assessment and visualization, along with allowing for speculum insertion. Lithotomy position is useful for the anogenital exam, but there will be times you need to alter the positioning approach to meet the patient's needs when the patient is not able to tolerate that or when you need a different visualization. A few examples may be a patient with limited mobility, a patient who is intubated or has significant enough injury that they're unable to be positioned at the foot of the bed. Supine knee chest is one of these positions that allows for easier anal assessment. Discussing these positions with your patient to assess their level of comfortability is again important as well. Supine knee chest utilizes visualization with the patient on their back. At that time, have the patient bring their feet and knees together while holding their knees to the chest and wrapping their arms around to hold legs in place. You may need to utilize the supine frog leg position in some instances. In this position, the patient lies on their back and they bring their feet towards their pubic area with bottoms of the feet touching while letting the knees fall open, hence the image of frog legs or butterfly wings. This will allow for better visualization of the genital structures. However, in this position, it is not advisable for comfort reasons to attempt to insert a speculum unless you are able to lift the patient's hips with the use of a pelvic wedge or the other alternatives discussed earlier so that the speculum and its handle can be comfortably accommodated. Another position that may need to be utilized in special circumstances is the sideline technique. This is where the patient lies on their side with knees slightly flexed. The leg that is not against the exam table opens and the patient places the bottom of that foot against the exam table for support. While this is not the best position for the examiner to visualize all of the structures, in some cases, it may be the best option for any visualization to occur. For example, a patient who has muscular dystrophy and has contracted lower extremities. The sideline technique may be the only position they can tolerate for an anogenital assessment. Finally, the prone knee chest position is more commonly used in the prepubescent population. However, in case it is ever a technique that you will need to utilize, we will review it here. In the prone knee chest position, the patient is on the exam table in the prone position with head and torso flush with the table, knees separated and down on the exam table, and buttocks raised. Notice how the hands are positioned. It's a good technique to move thumbs out and up when applying traction to the buttocks. Practice with this technique is important as well in order to understand the nuances of how to get all the moving parts to work together. Next we're going to review some additional exam techniques, starting with floating hymen. Sometimes when the hymenal tissue appears to be folded in on itself or sticking to itself, the use of saline may be beneficial. In this technique, use the saline in limited amounts to gently moisten the hymenal edges. This will cause the redundant edges of the hymen to float apart. It may also help to ask the patient to bear down. In this photo, the examiner's assistant is applying saline to assist visualizing the hymen. The saline may also aid in removing blood from the area to better visualize an injury. Tests should be taken prior to applying the saline and also after the saline is applied. Evidence collection was done prior to the application of the saline. This is the same patient after saline has been applied to more fully visualize the injury. Dr. Rene is now going to discuss the Foley catheter technique. Utilizing a Foley catheter would provide a better assessment of the hymenal injury for this patient. The Foley catheter technique is used to better visualize the hymenal edges when the hymenal tissue is redundant. Much like the speculum, we want to consider if our patient is premenarchal or not, as we want to make sure we are not doing anything that would cause pain. For this assessment, the clinician inserts a Foley catheter using a clean, non-sterile technique into the vagina approximately 2 to 3 inches or until the deflated balloon is in the vaginal vault. Using a syringe, the clinician inflates the balloon with approximately 10 to 20 cc's of air. Using water or saline would cause the balloon to be too heavy, resulting in the balloon not staying in place. The technician then withdraws the inflated balloon until the hymenal edges are against the balloon and better visualization of the hymen edges are achieved. Assessment occurs, then photography, if appropriate. The balloon should then be deflated with a syringe and removed. Now, some programs or jurisdictions have policies in place regarding this process, and prior to using, you should be able to establish competency. Like in these pictures, this is something that can be demonstrated to the patient for education prior to use. The image you see here is that of an adult female. The clinician is unable to fully assess the hymen with this view, despite good traction and separation. So, using the Foley technique, the clinician is able to manipulate the Foley balloon in different angles to visualize the edges of the hymen. One way to assess is to use one hand for separation of the labia to one side, and then use the other hand to angle the Foley on the opposite side, as seen in these pictures. This allows for better visualization than attempting to separate both sides at once. The hymen being assessed here is an estrogenized hymen and is a good example of a hymen that has hymenal remnants or tags. As of note, there's no acute injury in these photographs. These are images of an adolescent female. Note how much easier it is to assess the edges with the Foley. Even though we are able to see most of the hymen circumferentially, we cannot assess under the folded overtissue separation and traction alone, such as in the picture on the left. And this is important for ruling out injury. This is a good example of when this technique is useful. In these photos, we are able to see injury to the hymen without the Foley. But when the Foley is utilized, we are able to see the full extent of the injury. Along with assessment of the hymen, there are times when we need to assess the anus. Karen will talk about this in the next few slides. The anus and perianal area is roughly circular and includes anal folds. These anal folds allow the skin to stretch to help accommodate large stool elimination. The skin is more pigmented and more coarse than the skin on the buttocks. There is a change in the pigment with age and in different races. The anal area is sensitive to pain and stimuli, and there are no sources of external natural lubrication. Incidentally, in this image of an anus, there is an anal tag at the 12 o'clock position. The pectinate line, also referred to as the dentate line, is a sawtooth line of demarcation between the anal canal and the rectum. The color of the pectinate line is a beefy red, and the sawtooth appearance is distinct. This line may be apparent when the external and internal anal sphincters relax and the anus dilates. When doing an anal assessment and the anus dilates, you very well may be able to see this line of demarcation, and it's important that it is not mistaken for injury. This is another area where incorrect terminology may be used, even by clinicians. In our specialty area, clinicians need to be clear in the understanding that the anus and the rectum are different structures. Remember, the rectum is superior to the pectinate line, and the anal canal and anus are inferior to the pectinate line. Evidence kits may also use incorrect terminology. I have seen kits that have envelopes labeled rectal swabs when they are actually referring to anal swabs. Like genital injury, when anal injury is identified, it is most often minimal, meaning that repair is not necessary. This image is showing two anal lacerations at the 5 and 6 o'clock positions. Use of an anal scope allows for visualization beyond the pectinate line. If the patient has bleeding post-assault, or a foreign body was inserted during the assault. Anoscopy is not used in every sexual assault program, but is beginning to be used a little more frequently by forensic nurses. Anoscope examinations should only be performed if the examiner has had education and training on its use, has met clinical competency skills, and performance is within their scope of practice. If you have a patient who requires anoscopy due to bleeding, excessive pain, or a retained foreign object, and anoscopy is beyond your scope of practice, you should have a procedure in place for a trained professional to perform this procedure. In the images seen here, you are viewing an anoscope on the left-hand side, and a rectal tear at the 1 o'clock position in the image on the right that is only visualized because an anoscope was being used. Our final alternative technique is the application of Toluidine Blue Dye. Toluidine Blue Dye is a tool and technique that may be used to assist in the documentation of genital and perianal findings during the medical forensic exam. Toluidine Blue Dye, or T-Blue, as we might refer to it as, is not used to search for injury, but rather as a way to highlight injury you have assessed with your own visualization. The epithelium of the external genitalia does not have nucleated cells, and therefore the stain does not come in contact with the nuclei. But where the epithelium is damaged and the underlying nucleated cells are exposed, the blue dye will stain these nucleated squamous cells. We can see this staining due to an acute injury that exposes those cells. It does not work on mucosal surfaces and should not be applied to the hymen. Care should be taken that the dye does not enter the vaginal vault. When the stain is used on intact epithelial tissue, it will easily wipe away, indicating no injury. But the staining agent is used based on the rationale that neoplastic or damaged cells will absorb or contain more of the dye than normal skin surfaces. This means that areas of disease, in addition to injury, may also absorb the dye. In knowing that a disease process could be a reason for dye absorption, we need to be careful to educate ourselves on other possible reasons for uptake, as it could be seen in lesions, cancer, trauma, areas of inflammation with nucleated cellular infiltrate, and many benign diseases. There has to be careful distinction among these, as some of these are medical concerns that may need to be addressed further with follow-up and should not be categorized as injury. It should also be noted that acute tissue swelling and transudation may not stain and may bleed off rapidly. In addition, genitalia re-epithelializes rapidly, so uptake can become patchy after 24 hours. Sometimes when assessing structures, we might find areas such as scarring or those areas of re-epithelialization, that uptake will not occur. This is okay, as this is why we use T-Blue, to help determine those injuries that are or are not acute exposed nucleated cells. When looking at how to use T-Blue, there are several manufacturers of toluidine blue, not just the one shown in this image. This is an example of another type of T-Blue dye applicator. Now, when considering where to apply the dye, we need to remember what we learned about how the dye works. Here we see areas that T-Blue might be used to highlight injury in a male patient. The labeled genital structures are places where epithelial tissue can be injured or abraded, resulting in exposed nucleated cells. These are areas we might use T-Blue in a female patient. Note that we do not use T-Blue on mucosal tissues, such as the hymen, vaginal canal, urethral meatus, or cervical tissue. Applications should be done prior to any digital or speculum examination, in order to make sure there is no injury prior to the possibility of practitioner-caused injury. Also, make sure to collect evidence prior to application. If you are assessing anal injury prior to injury to the vulva, make sure to use a new applicator before returning to the vulva. Now, when applying T-Blue, gently dab on the area you want to highlight. Do not rub, as this might cause more injury. Be mindful of how much you are applying, as you will need to wipe off the excess, and this might spread. When it is time to remove the dye, you can use a 1% acetic acid solution, or more commonly in medical forensic exams, a water-based lubricant on a 4x4 or swab, or with a soft baby wipe. Now, when removing the dye, the clinician should dab gently to remove. Be careful to remove as much excess as possible, so it's easier to identify the uptake. Here are some other considerations. When using T-Blue, we discuss it as positive uptake, as in the dye did bind to the exposed nucleated cells, versus negative uptake, as in there was no binding due to no exposed nucleated cells. When there is positive T-Blue uptake, we know this means a possible injury or finding. If there is a negative T-Blue uptake, we know this means there is not an acute injury or finding. Know how to spell toluidine blue dye, and be prepared to speak to the process and findings. This is important, as you are the person who will educate the patient, law enforcement, and anyone involved in the judicial process on this. Upon discharge, it is also important to educate your patient on the possibility of the dye being shed and being found either in their underwear or when the patient wipes. Also, remember to document with photos, if there is a capability within your program, as this will help capture the nature of the injury. Some programs or jurisdictions, again, have policies in place regarding this process, and prior to using, you should be able to establish competency. Now, let's look at T-Blue in use. On the left, we can see possible injury upon initial visual assessment. Now, in order to highlight this for a more accurate defining outline of where the injury is, we see that T-Blue has been applied in excess and wiped away. If you note the definitive area of blue, you may be able to detect some faint and diffuse blue coloring from the dye application. Now, these diffuse and light areas are not considered to be uptake. Positive T-Blue dye uptake cannot differentiate consensual from nonconsensual lesions. As noted earlier, T-Blue is best used on non-mucosal surfaces. The anus is an area where T-Blue application may assist in documentation efforts. Here, you see that T-Blue works to highlight the multiple tears to the perineal area. You can also see how the excess T-Blue has been removed in order to see the uptake areas more clearly. Overall, there are many techniques that can be used during the medical forensic exam, and being able to know how best to assess and help your patients is an important part of your job. Hopefully, going through some of these will strengthen your practice and give you confidence in caring for your patients. Thank you, everyone, for joining us. If you have any questions following this presentation, please do not hesitate to reach out to either me or Tammy, and our contact information is provided here on this slide. You can also reach out to any of the forensic nursing specialists at the IAFN at info at forensicnurses.org, and they would be happy to answer any of your questions as well. Again, thank you for joining us.

forensic nursing assessments

proper positioning

physical findings

patient positioning

external genital structures

Toluidine Blue Dye

competency