Welcome to today's webinar, the third in the series, Medical Forensic Examinations for Asylum Seekers, the Physical Exam and Utilizing the Istanbul Protocol, brought to you by the International Association of Forensic Nurses. In just a moment, I'll introduce today's presenters. First, however, I want to mention that continuing education is offered for attending today. To receive your certificate, you must complete an evaluation and case studies presented in this webinar are based on real-life examples and identifying details have been purposefully withheld to ensure confidentiality is protected. Let me introduce today's presenters, Amanda Payne and Dr. Mary Jo Fink. Dr. Mary Jo Fink, family physician, has focused on women's health over the past 30 years in the USA to serve marginal populations, including undocumented, incarcerated, and HIV seropositive women in Brooklyn, Albany, and currently in Washington Heights, Manhattan. Until 2016, she included intrapartum OB in her clinical practice. From 2008 to 2017, she was the associate director of the clinical skills course that included teaching the physical exam at Columbia University Medical School. Currently, she teaches and works with residents in women's health at the Family Medicine Ambulatory Care site in Manhattan. A focus on justice and equity preceded her medical studies through civil rights campaigns, worked with anti-Vietnam War efforts, and farm workers organizing with the United Farm Workers Union. When completed the training with Physicians for Human Rights in 2014, she collaborates with the asylum group, including faculty and students at Columbia University Medical Center to evaluate and examine asylum applicants for the purpose of writing affidavits to the court. Amanda Payne is a board-certified forensic nurse examiner currently working on the Forensic Assessment and Consultation Team at Inova in Fairfax, Virginia. She was trained in the medical forensic examination of asylum seekers through Physicians for Human Rights at the Yale Center for Asylum Medicine. She's a member of IAFN's Social Justice Committee and has served as a representative on the Georgia State Human Trafficking Task Force. She recently authored the paper, Sane Forensic Examinations for Immigrant Victims, a case study published earlier this year in the Journal of Forensic Nursing. At this point, I am pleased to turn this over to these highly qualified presenters, Amanda Payne and Dr. Mary Jo Fink. Hello, my name is Amanda Payne. I just wanted to do a little recap here. This is the third webinar in the series of medical forensic examinations of asylum seekers. In this webinar, we will discuss the physical exam and utilizing the Istanbul Protocol Diagnostic Guide. We hope by the end of the session, you'll understand the basic elements and best practices of conducting a comprehensive medical forensic exam of someone seeking asylum. We'll review various forms of torture and persecution common around the world, which leaves lasting physical evidence. This series is intended for current forensic nurses at all levels who'd like to improve their understanding, cultural competency, and framework for working with immigrant populations. It's also intended for those who'd like to expand their current clinical practice to include working within the U.S. and international immigration systems. As the third installment in this five-part series, we'll recap. In part one, we reviewed the legal framework for immigrant victims of crimes, torture, and persecution, and provided an introduction to the Istanbul Protocol, which is the United Nations manual regarding the investigation and documentation of torture. In part two, we discussed the clinical interview and considerations for vulnerable populations, including those in detention centers. After this webinar, in part four, we will discuss the evaluation of female asylum seekers and discuss the major forms of violence against women that are ground for asylum, review female genital mutilation or cutting, and its health consequences with Dr. Deborah Ottenheimer. In part five, we will discuss writing a medical legal affidavit and providing oral testimony, and we'll do that again with Ms. Leila Hlaas from Tulane Law School. Our next webinar will be Friday, May 3rd at 1 p.m., so mark your calendars. And I'll turn it over to Dr. Fink. Okay. Well, thank you very much, Amanda, and thank you for that introduction. I am privileged to speak with all of you today about a topic that is very important, especially at this time in our country. So in terms of a couple of acknowledgments, I wanted – you will notice in a couple of the slides that the decal from Cornell is affixed. I have a couple of the slides from Dr. Sorontan of that group. I'm also grateful that our free press and major news agencies have kept us up to date with worldwide migration related to political pressure and torture, as well as to changes in the climate that are only going to be exacerbated over the next years, I feel. And last, I would like to dedicate this talk today, as I usually do, to my brother-in-law, a Guatemalan-born union organizer who left in 1979 in the back of a garbage truck, made his way to Canada, where he was afforded asylum. So in his name, I will continue today. The goals of the talk today are basically outlined in three separate sections. In the first, I describe what I call preparation, to know the types of torture and physiologic effects. And I find it difficult to consider some of the pictures and view the photos and drawings, yet I know through my years of teaching the physical examination that one sees more clearly and completely if one knows what to look for. So that's the first section. The second section reviews the exam itself, including notes on the history and physical exam. And oftentimes in performing the exam, you may uncover things that the client has not mentioned. So it can sometimes even addend the history. And then thirdly, I will cover basics of documentation using very precise language and so forth. But let me start now with what I call the preparation. I'm going to mention several of these specific torture methods and what you may expect to find in them. Some of these you may not have ever heard of. I know that I was not aware of falanga and teléfono or barotrauma. So I will go through each of them and give specific examples. In terms of suspension, as you can imagine, suspending someone and tying them by an extremity to a post will result potentially in scarring and also potentially in lifelong nerve damage. And here I'm even thinking of someone like John McCain, who apparently was tortured in this way. And in this next picture, you see pictures after this type of restraints with markings on the hyperpigmentation at the clavicles or more acute ischemia of the foot. In terms of burns, these may be inflicted as part of ritual markings or torture. And therefore it's really important to ascertain in the history exactly what was the cause. Whipping, for instance, may be indistinguishable from intentional markings and this is where it's important in preparation to review the culture of a group that this individual may be a part of. And frankly, in my own experience with this, the client noted which of the scars were intentional markings from his culture and which were scarrings from torture. The use of electrical current or shock may result in scarring as a result of the burn and you may note entry and exit wounds as depicted here on the foot or the hands. Here I mention asphyxiation and something that became very well known to us as waterboarding. And if the person lives through this type of torture, he or she may have scarring on the neck. Unfortunately, in this case, the individual did not live. It's an autopsy. Penetrating injuries may be singular or multiple and depending on the timeframe of when you see the individual, you may note scarring and the scarring may be exaggerated if there was a super infection, for instance, after such an insult. I mentioned a minute ago the word falanga or in some cases it's known as bastinado. And in this, it is a form of torture that applies pressure to the plantar fascia for hours and sometimes days, which can result in severe edema, pain, difficulty walking. So you may find thickened fascia and, as I mentioned, difficulty even moving. Gelefono or the use of barotrauma, this can result in a rupture of the tympanic membrane with repeated pressure on either one or both ears. However, if you see the individual long after the barotrauma, you may see a normal tympanic membrane without even scarring. So it's important to document what you note. Crush injuries, as the name suggests, the impact to the tissue depends on the size of the instrument used and the amount of pressure. And here in this case, the foot was pretty ischemic and in need of a dermal transplant. The finger was crushed and sutured. However, if the individual you're seeing was not afforded surgery, the limb may show signs of chronic ischemia and even nerve damage. Chemical attacks are reported, especially against women, and these scars are very disfiguring, especially to the face. As a note, this is the only slide I have on women's torture. I removed the rest of the slides since I know that you will be hearing Dr. Ottenheimer's excellent presentation. So at this point, I'm going to turn to the second part of the talk, which is the examination itself. And we will review what to ask and how to examine, including interpreters and notes on the history and the physical exam. So I may not need to mention this to you, as professional women, I often am dealing with students, and therefore I mention dress, that it be professional attire, certainly no white coats, and also to have your equipment ready with you. If you're seeing the clients in your own office, you will probably have anything you need. However, if you are going into a detention facility, you will need to carry your tools with you, and usually the lawyer that you're working with will register the equipment with the facility beforehand. Also just a note on the camera, very important to mention that you will have one, we usually use a phone, that you're taking one phone into the facility with you, or in the office. Most of us need interpreters for one language or another, given the number of countries that are represented by our clients, and just a few notes on interpreters, it is the responsibility of the lawyer to provide them, and important to get the contact information from the lawyer beforehand, and we usually contact them the day before, just to make sure they're going to come, because so much is pending their presence. If you are in your own office, you could use one or other interpreter service, but if you're in a facility or another situation, you will need to make sure that they're going to be there. It's important to position the interpreter slightly behind the client, and for two reasons. One is to remind yourself that you're speaking to the client in the second person, in other words to you, and not to him or her, and the other reason is that the client will be less likely to start a one-on-one conversation with the interpreter, although that does sometimes happen, especially for clarification of what they meant, but it's less likely, unless, for instance, if they're sitting next to you, it can really be difficult. You'll notice that I also have in this slide where the students will be sitting. And I'm not sure if this is relevant to your situation, whether you're going to be going in alone or with someone. But if you have other people, that they would basically be sitting next to you on either side or one side to take notes or to help out. This is a very important slide in terms of the history. It's the who, what, and where questions. Who was involved? The number of people who were involved and what roles they had, whether they were part of the police or prison facility. What was used? What specifically? What was the object? Its shape and size? Out of what material was it? Was it glass or metal, plastic? Where on the body did the injury take place? To get a very concrete information about this. And what are the long-term sequelae of the abuse? And here we get into sometimes current signs and symptoms and long-term PTSD. So it's important to be very careful in taking a detailed history. Lastly, we want to know whether treatment was rendered by a fellow prisoner. Was it by the medical center in the facility or outside? And perhaps there is even a report on the use of a gun. There's a report on that. So the more detailed you can be in the history, the better off is your report. What are we looking for in terms of the physical exam? Basically, any changes. First of all, normal findings are important to document, but also any changes that could be related to the events. And also to document physical findings that are not related to the reported events. Now, in performing the physical exam, it's important to start in any order. Most of us start head to toe or some other systematic way and record all abnormal findings, any deformities and scars. One note, I said we usually start with head to toe, and that is true, but just as an example, if the individual is sitting in a wheelchair, it might make sense to start with an examination, a motor examination of the lower extremities just to ascertain whether he or she can move to the exam table or if the exam must be done in a wheelchair, just as an example. The complete physical exam, as I said, head and neck, chest and back, abdomen, extremities and neuro, and if necessary, genital exam. Now, the next two slides will give you examples in specific detail on explicit defects or deficits that you should be aware of in performing the complete physical exam. These references are helpful if you are not doing complete exams as part of your work every day. And I'll just click on the next one as well. I'd like to thank Amanda for sharing these two with me. She and we feel that having very specific methodology in terms of what you're looking for and not forgetting any of these steps is important, in particular if you tend to do exams that do not include the whole body. And you will have these as references when you have the slides. Okay, so that wraps up the discussion of the examination, the history and physical itself. And then the question is, how do we report it? What language do we use? What is the format? I'm going to go into that in detail and using several examples now. So the legal document depends on your history and exam using very precise objective language. And you are asked to comment on defects as they relate to a mechanism of injury per your clinical opinion. And as I mentioned, we have several examples of that. Let me just make one comment about the document itself. You will document the client's narrative and the medical history and then move on to the physical exam. Now in the document, I use a very traditional format. You outline what your qualifications are, everything in your professional history that brings you to this point of writing an affidavit for the court. That's the first part of the document. Then you move on to the client's narrative using quotes. It's very helpful if you can quote exactly what they're saying. And the third part of it is the medical history. Now notice here when I mention the medical history, I did not use the term HPI, history of present illness, which is what we teach. But I certainly did include and ask the client about current signs and symptoms of their illness, whether they have insomnia, angst, maybe headaches or nightmares. As in any medical record, then I will document past medical, past surgical, any medications, and in the case of women, their gynecological history. So this is basically the format and how I would write any medical documentation, the format that I would use, past medical, surgical, and so forth. So I admit this is a very traditional way of approaching it. It's not a soap note. Then I move on to the physical exam. The physical exam starts, especially in these forensic affidavits with the mental status examination. And if you'll see here, just looking quickly over this, XX was cooperative, composed, polite throughout the interview. She knew where she was, explained the timeline in logical order and so forth. Basically, in the mental status exam, I am setting the stage to interpret the stated history and mechanism of injury. I am commenting on a level of consciousness, her attitude, orientation, speech, mood, affect, ability to think, memory, intellectual function. These are very important points and help with understanding the rest of the report. After I've documented the mental status examination, I go into the physical exam. The next three slides include the complete physical exam. As I mentioned, this is not a soap note. It is a very complete, and I admit, traditional documentation form of the physical exam. Now, there is no one set way to document the findings. I find it helpful to start with the appearance and then the vital signs. And as you can see here, mentioning how the person approaches you in the room. Did they walk in on their own? Or did they come in with a walker or a cane? It's very important to document whatever the general appearance was and any other first impressions that you have. And then the vital signs, followed by the skin exam. Now, the reason that I put the skin exam in its own category right at the top is that it is very important in these examinations, sometimes the only scarring that you have, visible scarring from abuse and torture. And also the skin is not geographically limited as other parts of the head and neck, chest and back. So I put it right up in the front. So general appearance, vital signs, skin. And in the skin exam, very concrete documentation. And I'll discuss a little bit more on that in a minute. Here is the HENT exam. And perhaps you noticed that it's important to describe what you see using non-medical language so that non-medical people like the judge will understand without translating it. So instead of saying respiratory effort, you might say breathing. Or hums instead of murmurs and tapping the space or the belly instead of percussion. It just makes it easier to read. For instance, in describing the tongue, I wrote no jerking movements instead of fasciculations. It just makes it easier for them to understand, I think. The third page is the rest of the physical exam. And again, note the language that it's an attempt at lay people understanding of the body. Of the language of the exam. Also, you'll notice that I documented in the genitourinary exam that it was not done. And that's important that it wasn't relevant or for whatever reason. Sometimes it is. And then you document it. That is the documentation of the physical exam. Just a couple notes on scars. As I mentioned in our work with clients, scars on the skin are all too frequent, reminders of what happened. And it's important to document all scars, whether they are traumatic, surgical, or ritual. Including the size, the shape, any borders, the color, relation to landmarks. And in your report, then, to reference any photographs that you take of the abnormal findings on the skin. So in preparation for, now we've talked about the documentation of the findings, we have to also give a clinical interpretation. Your professional opinion on the findings that you have on physical exam. And Amanda mentioned the Istanbul Protocol, which has been a help to all of us in preparing in terms of setting the stage for writing and documenting these abuses and torture. And these six questions are a backdrop, not that you would sit down and put this in your report, but basically in preparation for considering the findings, now you want to move to the interpretation, you ask yourself, are the physical and psychological findings consistent with the alleged torture? Are there physical conditions that contribute to the clinical picture? Are there psychological findings that are typical of a reaction to extreme stress? And here, the social context is really important. And then a note to the time frame. You ask yourself, how long has it been since this individual escaped or came into this country? What are the other stressful factors in the life of this individual? And for many of the women that I saw, contributing factor is that they left their children or their children were taken from them, as an example. And lastly, the question, does the clinical picture suggest a false allegation of torture? So those are the questions that backdrop the interpretation of what findings we have. And this, here we have also from the Istanbul protocol, the interpretation in terms of language. The lesion is not consistent. For the most part, if you see something, it's consistent with something. So it may be, if you are interpreting that it is consistent with the trauma, that basically means it is possible that it was caused by the purported trauma. It's also possible that there were other reasons. As opposed to highly consistent, the lesion could have been caused by the trauma and there are very few other causes. So you'll see in some of the examples that we use highly consistent often. Or typical of, this is what happens when this kind of trauma. And I showed you some of the pictures for some of the burns and electrocution. Typical of, you would see this to happen. And then as a last category, diagnostic of. And I have one example here in the cases of something that is diagnostic. So we'll go through that. But it's important to have these as a backdrop to how do you frame or interpret the findings that you have relative to the torture. So we're going to move on to several examples. In this first example, we have a client who has had rope restraints on his arms just above the elbows. And I don't know if you can see it on your screen. But basically, there are hyperpigmented areas. And here is the description. Two dark, dotted, curvilinear scars, 7 centimeters long, symmetrical above the elbows. Dark, curvilinear, 7 centimeters, and so forth. Interpretation. These scars are highly consistent with an injury from a wet rope tied tightly on the skin. The dotted lines show where the texture of the rope touched the skin. And the normal skin between show where the rope did not touch the skin, consistent with Mr. X's account. So very clear, precise language. In this case, the client has scars on his hands. And it would be important in describing these to note that the attack happened in a defensive posture. So I think that here is the scarring. And this is consistent with the defensive posture that he spoke about. This man has scarring on his chest. Linear, irregular, with keloid formation here. OK? Described as three linear, irregular, raised scars horizontal on the chest between the nipples, about 5 centimeters above the nipple line. So very specific. It shows that the person has a scar It shows that the person took out a ruler, measured it, 5 centimeters above. Bottom scar consists of two scars side by side, 2.5 cm, each thick, raised on the right side. Again, interpretation. These scars are highly consistent with an injury from a sharp object, such as broken glass, swiped across the body from the front. The irregular texture of the scar imply that the strike started on the right And as the glass edge cut his chest, the victim turned away. This resulted in thicker scar that tapers off, consistent with Mr. S's account. So very specific to this case. So this is a burn on the lower leg. Described as 2 centimeter round, textured, light, mix of light and dark, mix of light and dark, lighter on the bottom half, located on the left inner leg above the ankle. Interpretation. The size and shape of the scar and the uneven texture are highly consistent with a burn from a small, round object, such as a cigarette. Cigarette burns have different textures as different amounts of pressure is applied to extinguish them, consistent with Mr. U's account. In this case, there is a large scar on the thigh. Described as left thigh 6 inches by 2 inches thick, textured, raised, light and dark in color, with one area of star-like shape that was white in the middle of the scar. So there's the star-like shape. Devoid of hair, shaped in a rectangle with rough borders. Interpretation. The large textured scar with areas of light and dark on the left thigh are highly consistent with a scar from a burn. The position and shape of the scar is consistent with an injury from a burn that was started inside a rectangular pants pocket, consistent with Mrs. A's account. The textured nature of the scar is highly consistent with a scar that became infected, also consistent with Mrs. A's account. So in this case, highly consistent with a burn. We're not sure if it related to torture or another event. But it's illustrative of how very specific the language is in describing this scar. All right, and this last case shows a scar in the midline of the neck with the following description. 4 centimeter by 2 centimeter, flesh colored scar at the bottom of the throat, center raised with tethered edges. And the interpretation. This scar's appearance and location are diagnostic of a scar from a tracheostomy, as would be necessary if one were unconscious and required external mechanical ventilation for an extended period, consistent with Mr. A's account of being hospitalized and unconscious for a month. So those are all examples of concrete, very specific descriptors and interpretation. The next two slides, also from Amanda, thank you, give you very concrete language about injuries that you may see, from contusions to incisions and helpful as reference to describing a burn for second, third degree and so forth. And this other one, in terms of scar healing, whether it was a scar from primary intention or secondary intention, primary intention is usually a surgical scar. Whereas oftentimes, someone who has not seen medical personnel may have a secondary intention scar. In terms of describing the wounds, again, a helpful slide to recall how to be all inclusive with your descriptors. And again, in terms of size and shape, always, I usually describe it in centimeters, although inches is acceptable in the United States. And whether it's the texture, the surface area, and the relationship to the surrounding tissue. So these are great resources, these last three slides. Thank you, Amanda. You may choose to use a diagram that can be helpful in showing where each of the scars or findings relate to the body. And a diagram can be very helpful. So I think we've come to the point. I know this was, yeah, I hope there's some questions. And I'd be very happy to, we have plenty of time. So if anyone has questions, feel free to ask. Hello? So far, I'm not seeing any questions. OK. Well, this could be good news and bad news. They fell asleep, or it was so thorough that they have to think about it. I'm sure they didn't fall asleep. That was a lot of information. It's a lot of information, and I'm relieved to know that they will have the slides as a backdrop. Yeah. Anyone at all? OK. Then I guess I will wrap it up. Oh, would you estimate the something of the injury? Would you estimate? Oh, OK. Can you help me with that? The area of the injury? Oh, the age. Oh, the age of the injury. Oh, the age. That's a good question. And it's a little difficult to do, frankly, because we, there are very such differences in how we heal, if you think about just the propensity for some people to develop keloids, for instance. But usually, you will have a surgical scar will be healed within two to three weeks, at least superficially. And then a super-infected wound could go on for months. So that is difficult. I think it's very difficult. Why would you not examine the genital urinary system? I would think it would be needed for a complete physical examination. So it depends on the history. If I have, and also where I'm doing the examination. If I'm thinking specifically about the last several women I saw were in detention, where I didn't even have a medical room, and several other individuals in the room, mostly students, and translators, and so forth. Unless there's a compelling reason to do a genital exam, I don't see any reason. So if I think the woman is, yeah, I don't think it's necessary for a full exam. And if I had any suspicion of pregnancy, I would first do a pregnancy test. I have done a couple of the males did a genital exam because the mechanism of injury involved the testicles. But otherwise, I ask it in the history. But if nothing has been reported in that area, I don't. Do we have any more questions? Amanda, do you want to say anything to that Dr. Spear, who thought it should be part of a physical exam, a genital exam? Often, I've seen people. I saw somebody yesterday in a lawyer's office. So it just isn't feasible to do a genital exam. And it also wasn't necessary for her and many other patients I've seen, where they weren't making allegations of sexual violence at all in their history. And I think a lot of us are used to doing acute sexual assault exams. And we know how quickly those areas heal, too. So unless there's been ongoing symptoms, I don't see the point in re-traumatizing somebody. We're not collecting DNA. Now, however, we'll talk about this in the next webinar. For the FGM cases I've seen, that absolutely is necessary to do a genital exam, where that documentation is just invaluable. But again, it's all related to their asylum claim and what they're alleging. And I see that she has attended her comments. She is a sane nurse along the border. So again, I would say, if the woman has had trauma, including sexual trauma, then I would definitely do an exam. If she says that she has no complaints, I just don't think it's necessary. And on that note, getting medical histories from hospitals, I usually get a comprehensive medical history from folks. And then I try and get their medical records. And I've gotten documentation from folks along the border, where a 12-year-old shows up positive for chlamydia on their screening. And those kinds of things help corroborate the story that they're telling. And that kind of documentation is just so helpful if you're working along the border, even diagnostic tests like that can be really helpful. Right, right. Wow. So I'm sure that Jeanette is seeing a lot of those cases. Well, yeah, the last slide I have, if people want to, the last slide you'll see on here is my email address. And I am very, very willing to take your comments or questions through email and be in touch that way. Anything that could represent the situation clearly and completely, I think, is really our goal here. So, yeah. Excellent. Well, I want to thank you so much for a fabulous presentation. And thanks to everyone for joining us today. Please remember to look for the follow-up email from us in the next few days, where you'll be able to do the evaluation and get CE for that. And if you have any other questions, you can also email me at elearning at IAFN.org. And if there's anything else, I guess everyone should have a fabulous rest of the day. Yes, thank you, everyone, for your attention and great questions. And thank you again, Amanda. Thank you so much, Dr. King. OK, bye-bye.

medical forensic examinations

asylum seekers

physical exam

Istanbul Protocol Diagnostic Guide

forensic nurses

cultural competency

documenting findings

injuries

scars

Istanbul Protocol

Amanda Payne

Dr. Mary Jo Fink

marginalized populations

genital exams

corroborating medical records