Alright, we can go ahead and get started while you're working on that, if that's okay, Brian. Sure thing. Okay. Will do. Well, hello, everyone. My name is Sarah Jimenez-Valdez. I'm a project manager with the International Association of Forensic Nurses. Today's webinar is titled SANE Testimony Part 2, SANE Testimony Practice, which is also known as the Biology of Testimony. This is a second of two-part series, which is made possible with grant funds awarded by the Office of Victims of Crime for the SANE Program, TTA Project. Welcome back to those of you who were able to attend the first part. I am going to ask that you bear with me for a few minutes so I can cover a few items before we get started as we did last time. So I will start with a few disclaimers. Brian, are you able to get that presentation portion up? Yes. I'm going to read them anyway, so you can go ahead and keep working on that part. I did want to share that the presentation was produced by the International Association of Forensic Nurses under the grant number you will see listed on the screen. Oh, there it is. The grant was awarded by the Office for Victims of Crime, Office of Justice Programs, and the U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. We can go to the next slide. Since there are 1.5 continuing education units being offered for today's presentation, we would like to note that the authors, presenters, and planning committee for this webinar have no relevant financial relationship with ineligible companies to disclose. Upon verifying attendance, attending the course in its entirety, and completing the course evaluation for today, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is an accredited provider of continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation. For live attendees, you will receive an evaluation within a week of this presentation. All that said, we do encourage you to please use the Q&A feature and or chat if you have any questions that come up for you throughout this presentation. I will be available throughout the presentation. I will share my contact information in just a second, but I would like to welcome our presenters for today. We are joined again by Valerie Prelier, who has been nationally certified as a SANE-A since 2002, but working in the field since 1998. She has worked as a sexual assault nurse examiner, forensic consultant, educator, and led a full-service forensic nursing program. Valerie has worked as a forensic consultant, expert witness, and educational consultant within the United States Department of Justice and Armed Services. She has also co-authored several articles on healthcare aspects of sexual assault, domestic violence, and strangulation, as well as contributed to several textbooks on forensic nursing. Valerie maintains a clinical forensic practice with the Crisis Center of Tampa Bay in Tampa, Florida. We do also have, again, Brian McDonough, who serves as an Assistant United States Attorney in the Office of the United States Attorney for the Northern District of Ohio. He is currently assigned to the White Collar Crimes Unit, where he supervises investigations and prosecutes a variety of complex financial crimes. He also serves as the Elder Justice Coordinator for the Northern District of Ohio. Brian has served as a Special Assistant to the United States Attorney General in the Western District of Pennsylvania in a complex white-collar crime case involving healthcare fraud and secured the first jury conviction in the United States for illegal human growth distribution. Prior to joining the United States Attorney's Office in 2014, Brian served as an assistant to the Cuyahoga, I wanted to make sure I said that right, Cuyahoga County Prosecutor for 13 years. Both Valerie and Brian's experience are much more extensive than I've shared today, but with that, we would like to welcome back Valerie and Brian. All right. Hi, Sarah. Thank you, everybody, for attending. Again, my name is Brian McDonough, and it's a pleasure to present to you along with Val today. I was the former Assistant Cuyahoga County Prosecutor that's in Cleveland, Ohio, with the suburbs, about 1.3 million folks there. And I was honored to be a former co-chair of the Cuyahoga County Sexual Assault Response Team, which is a wonderful multidisciplinary team, including Staines, and having a chance to work with them throughout my time there. And then also, I had a chance to be part of the Ohio Attorney General's Sexual Assault Response Team as a trainer, going throughout the great state of Ohio, with the multidisciplinary team teaching best practices on it. So I am absolutely thrilled to be here today. Awesome. And I just want to welcome everybody as well. The Ohio Attorney General's Training Team is where Brian and I actually got to know each other and work together pretty frequently. So we are thrilled to be back here to talk to you today. Let me just give you a brief roadmap of what our next 90 minutes is going to look like. There were a few questions that we didn't have a chance to answer because we ran out of time last session. So we're going to take just a few minutes and respond to those questions. Brian is going to talk to us about the biology of testimony, which it just makes me smile thinking about the attorney talking biology to a bunch of health care people. So we're all going to enjoy that. And then we're going to transition into actually getting some practice with testimony. We've had some willing participants, you're hearing some pretty bad weather in my background, I apologize for that. Some willing participants offer after the last session, you should all have a copy of the medical record, the SANE chart that we will be working off of today. And if you would like to put your name up in the chat, we will maybe have an opportunity to do some testimony practice with you as well. So I will just leave that for our teaser for testimony. And Brian, are you ready for us to respond to a couple of questions? Yes, I am, fire away. All right. When you are testifying as an expert, what is your process for reviewing another SANE's chart? Oh, that's a great question. That is a great question. And honestly, looking at that chart, it's the same process I go through when I do a peer review or a chart QA, looking at was the standard of care met logically, you know, from a medical perspective, from a forensic perspective, you know, is the exam head to toe being done the way. Valerie, I think your audio froze, audio and video. Maybe give her a second to come back. She did. I don't know if she mentioned, but both Valerie and Megan are having bad weather where they're at, and so she was a little concerned about the weather. Yeah. Do we want to maybe go on to another one of the questions, Brian? Yeah. I'll jump in as well on that part. No. In terms of the process, obviously, as a SANE, the ability to testify as an expert reviewing something is phenomenal. It's a wonderful opportunity, and often, if you ever get the chance to be called as an expert by the defense, some SANEs get concerned saying, oh, my goodness, that is a wonderful thing, if you get called as an expert witness by the defense, because that way, it really enhances your credibility and the fact that you don't always testify for the government. I mean, you're an expert in your field. But yes, I think as Val said, treating it like a peer review, going through everything, feeling comfortable with your testimony, that you're not reaching for anything, that what you're testifying to is based in science, is based in the literature, that's pretty much the pathway that you'd have in terms of testifying as an expert and reviewing another SANE's charts. I'm back. Oh, my goodness. Mother Nature, bless your heart. Okay. I'm not sure where I froze and disappeared with the Internet outage here. So I'm going to keep going. Are you ready for another question, Brian? Yes. All right. One person noted that they were interested in more pitfalls or traps that defense may utilize that causes SANE to make their testimony less than effective. Yes, that's a good question. Probably some of the traps would include the following. You want when testifying to treat both sides equally. You can be nice to both sides or you can be not nice to both sides. But as long as you're consistent, that's important because a jury will see that if a defense attorney gets angry with you and you respond in anger, you end up losing credibility. So it's normally very difficult for people to still be nice and friendly when someone is attacking or being aggressive. So that's probably one to be wary of on that part in terms of the tone in terms of how you're testifying on that part. Hopefully, there are not any mistakes on the chart. That is part, if there is a mistake, you just have to own it at that part as well. Your prosecutor will have you go ahead and do that because sometimes one tactic is to say, oh, if you didn't cross a T or dot an I, well, then we have to throw out the whole chart. As I say, that's not the case. But more often than not, the charts are always really, really good on that. Then always don't feel free to get pigeonholed into an answer, a yes, no, or something. If you have to qualify it, go right ahead. Because as you practice more and more testifying, you'll see where the defendant is trying to go. If you can figure that out, it takes a little bit of practice, that can be more effective too. So if you freeze and just do yes, no, you'll end up be leaning down a path that you may not want to end up going down. So those are just a couple of suggestions. Great. I'm going to add to that. If you notice an error in your chart, please let the counsel who has called you to testify, let them know as soon as you see that error. Do not cross your fingers and hope that nobody is going to notice. So that would be a proactive way you could help get through some of those issues. With those yes to no answers, some of the things you can actually do and it's quite reasonable, if you cannot truthfully answer a question yes, no. I've often actually said that during testimony. Mrs. Prelier, is the sky black? Well, for me to truthfully answer that, I would need to give you more than a yes, no answer. That would be my suggestion, maybe to think about when you can tactfully use that response as well so you don't get pigeon-holed. Excuse me. Are there other state national expectations for what is expected to be released when subpoenaing records, or does it just depend on the attorney? Toss into you, Brian. Yeah, sure. Expectations. Well, obviously, the jurisdiction is going to control. So whether it's federal or state, there's going to be some different rules applying for that. Normally, when you get the subpoena, it's going to be for your testimony. So whether it's the government, the state prosecutor calling you to testify, or whether the defense is calling you to testify, those are going to vary by state on that. On the federal system, and in most state systems, technically, you're not required to go ahead and talk to an attorney upon being subpoenaed. It's a court order to appear, but there's no rule saying that you have to go ahead and speak and converse with them. More often than not, folks do find that helpful, you know, to say, yes, I've been subpoenaed. You know, what do you intend to me to testify about? And obviously, if you're testifying for the government, we'd obviously encourage you to go ahead and have those conversations and to prepare your testimony. On average, it's about three hours of prep outside the courtroom for every one hour inside the courtroom. But that's generally how it would be regarding expectations of regarding testifying. As regarding the release of the info and what's there, that's going to vary by state or jurisdiction regarding the discovery rules. Typically, if it's going to be an exhibit, the defense is going to have that exhibit prior to trial or prior to testimony. Great. Thank you. Two more questions. How do you avoid cross-contamination or loss of evidence when the patient is under the care of other health professionals? The realistic answer to that is you do the best you can to, you know, collect the samples, preventing, you know, touching as many things as you can. But if the patient is needing the care of other healthcare professionals at this point, then that's going to take priority over sample collection. So I'm thinking of a trauma patient or something like that. We do the best we can. There is always the opportunity if there are more than one donor of DNA in a sample that law enforcement come back and collect samples from the healthcare providers if they need to, to rule those, you know, to identify whose DNA is there. Do you have anything to add to that, Brian? No, same thing. It'd be law enforcement's job to go ahead and collect exclusion samples, because at that point, law enforcement collecting exclusion samples, that's going for a criminal case. It doesn't have to do with the medical care of the patient. Correct. Okay. And last question. When testifying as an expert, is there a difference between a sane RN and a sane RN with a degree in forensic nursing? We actually talked about this question the other day when we were kind of preparing for this. And I'm going to tell you from my perspective, and then Brian's going to tell you from his perspective. If I'm looking at two nurses, one, let's say, is an old timer with a lot of experience versus maybe a new sane with a degree, but little clinical experience, I would probably, I would obviously be interested in both, but that clinical experience has so much weight over the course of a career that I don't think it puts, I don't think the degree itself necessarily puts that nurse at an advantage for testimony. Does that make sense? Yes. Yes, yes, on that. I would say, from the legal perspective in the courtroom, you can divide witnesses. Typically, you're just late witnesses or expert witnesses. So late witnesses, they don't choose to be witnesses. It's something they saw, they heard, they did. Expert witnesses, normally they go out and review something and they go out and they do an opinion based on that. And then you have what's called percipient witnesses. And those are witnesses that based on their occupation, their training, their education, their experience, have more knowledge about a subject area than a late witness would have. And those witnesses go ahead and testify. And as I say, I think in those cases, kind of coming through the kind of the clinical experience and those things like that coming through based on that, typically you have a tendency to carry a bit more weight. As I say, juries kind of look at them and say, you've seen lots of patients versus those who haven't and simply just are reviewing a chart. As I say, it probably adds a bit more there. At the end of the day, it's helpful to realize that that audience, that jury or that judge is not gonna have anywhere near the training, the experience, even those judges who preside over trials involving sexual assault that you have as saints. Awesome, thank you. Just from a timestamp perspective, Brian, we are at 3.53 now Eastern Standard Time. So we've gone a little beyond the 10 minutes or so we allotted that. So I am going to turn this over to you, my friend. Okay, wonderful. Well, let me go ahead and go through on here. On it, let's see if we're able to go ahead and do this. All right, so here is the problem that a lot of saints may have when getting that subpoena to testify in court. You get some nervousness, you get some anxiety, or you get some stress. Oh, goodness, I've gone through the trainings, I've done all that and now lo and behold, now I'm being called to court. And that may happen as the result of the very first exam you did, or maybe it was the 50th or 100th exam that you did. And it might have happened a year ago, or in some cases, it could be 20 years ago. So obviously, a lot of saints feel the nervousness, the anxiety, the stress about having to go to court and testify and what effect that has on the body regarding that. So one thing that I have found is that there's a good solution to this, and that is how to best use your brain, and your body, and your voice to deliver effective testimony. There are some tools that I'd like to go ahead and share with you. And these tools are tools that you can develop them, you can explore them, and it kind of expand upon them, because they're gonna be unique to you. It's a distinctively individual style. In testifying in court as a saint, you cannot simply copy somebody else. You have to be you. You have to be personal or inauthentic. And otherwise, it just doesn't ring true. You kind of have to find your own voice and stride. And it may work, your mentor, or what may work for a colleague, you may find inspiration from that and say, oh my gosh, I love the way that person presented, how they presented, some of those techniques. But it's simply not magical words in terms of testifying on it. And often, if it's something regarding, if you're naturally a soft-spoken person, if naturally you're a nervous person, if you fidget, if you have those, it's gotta be, it's your unique combination of elements involved in the control and the coordination of your brain, your body, and your voice. And we're all different. You are all different learners in how we learn, how we process, how we deliver. And my hope is that you're gonna experiment with some of these tools, try them out, find out what works best for you. And to be persuasive in court, it's not acting. It's not pretending. It's not faking it. You have to look and sound and feel authentic to be believable. And that's what it's all about. A jury believes you, a judge believes you, affords your testimony, that weight, that becomes effective. And it doesn't determine the outcome. We're not here to win. It's a matter of presenting that effective testimony for the jury to go ahead and consider. So what I like to call the paradox of naturalness, someone says, well, you're nervous, you got some anxiety, you got some stress, be natural, be natural. Well, if you do something often, yeah, it's natural. But some of the natural behaviors that you may do may look and feel unnatural when you're testifying in court. And so you have to consciously employ certain unnatural behaviors. And then that way you'll look and feel natural. So that's kind of the paradox of what's going on. So we have a direct examination. You're there, you've got sworn in, you are in the witness stand, you're there, all the kind of the lights are on you. If it's a high profile case you got, you could potentially have a member of the press in the gallery, they could have a court TV case, have a camera on you. And what's going on in your brain when you're listening to the question that's being asked to you on it and trying to focus on those questions as to what is being asked of you on direct examination. And again, on direct examination, typically the attorney who's asking you the questions, they are kind of fading into the work that you are the star, so to speak, of direct examination. The focus is on you. You're there, you're seated. In most courtrooms, you're going to be seated in the chair that will be closest to the jury so the jury can go ahead and observe you. Typically the prosecution table or the government's table is also closer to the jury than the defense table because the burden of persuasion, the burden of production is on the government. And that chair could be comfortable or not. It could swivel or not. There most likely will be the table in front of you along with a microphone and the ability to go ahead and situate yourself so that you're comfortable, so that your voice can be heard and that as your brain is ready, willing and able to listen to the questions, process the questions, and then go ahead and answer them on it. Your body, how are you positioned? In terms of unnatural behavior, is it something, if you're nervous, do you adjust your glasses constantly? Or if you've got long hair or bangs or you're constantly adjusting your hair, do you ever touch your face? Do you ever fidget while in the chair, swiveling from back and forth? For those of you that have those fidget spinners or you're jiggling change, or if you have a pen and you're clicking on the pen, all those are, excuse me, all those are behaviors that you may be doing all the time and may feel natural, may feel comfortable, but quickly a jury will tune you out and they will then just focus on that behavior itself, the clicking of the pen, the swiveling in the chair. So one technique we like to do is if you're sitting in a chair, to make sure you're seated in the chair, that you're sitting up tall, imagine from the crown of your head going up, you're sitting up tall. And then what you can do is if you lean forward with your forearms and you can put your forearms, clasp your hands and actually put them in front of you on the table and it's called really anchoring you. If you feel anchored at that point in the witness chair, then you won't go ahead and swivel. And by anchoring and kind of being solid there, the jury will be able to go ahead and simply focus on you and not any of the other behaviors on that point. Normally, when you're being asked the question, you're gonna look at the person who's questioning you, but the most important person in the room is actually the jury. So over time, as you become more comfortable with it, when you get asked the question, when you go to answer, you can actually look at the jury and provide your answer there too. So that is very helpful on that. How about your voice? Not everyone is blessed with a FM quality radio voice. Some of us are naturally soft spoken. So this can be a problem. I would say that for 98% of the time that people encounter a microphone, they are fearful of it. When we think of loud volume, when we think of shouting, we are often thinking of someone's angry, upset, they're yelling, they're raising their voice. But you wanna be able to speak loud enough that your voice projects and carries. And more often than not, that's about having the microphone about two to three inches from your mouth when you're speaking. By having it that loud, what you're able to do is carry your voice and the jury will be hearing it. If they cannot hear your voice, they'll tune you out. If they cannot hear your testimony, they will just simply tune you out at that part. So to be effective, you wanna go ahead and do that. Can you be too loud while testifying? Yes, it actually is possible. One aspect of being too loud will be if the microphone is too close, you'll actually hear a popping sound. So anything like with a B or a B, normally there's a little microphone cover, there's a little guard on the microphone. And what it does is it prevents those Bs from popping or those Bs from popping. It's your breath that as you're exhaling actually gets goes over the microphone the microphone picks that up so if that does happen you can simply adjust it but if you asked a jury what were their major concerns about not being able to hear someone it's it's the volume you know rarely would they say oh that witness was too loud it's normally not couldn't hear them loud enough on that side on it at times if you have a friendly judge of a judge may ask you to speak up or perhaps a court reporter will will go ahead and ask you to speak up the other thing is the tempo of when you're speaking the nervousness that you have that nervousness typically has you speaking a little more quickly than normal so when you're nervous and testifying you typically speak more quickly and you normally speak more softly so two things to do would be to speak louder and to go ahead and slow down and then that way that the jury will be able to hear you and better understand you and then lastly it's the tone how long will you be testifying on average it could be an hour hour and a half two hours depending direct cross-examination what part of your testimony is important that jury is kind of conditioned to just focus on highlights right when you watch the evening news or you watch a program you'll get a little highlight a little overview a snapshot there'll be some graphics and the average attention span 20-30 seconds like that pops up in a Facebook ad or Instagram ad where it's a quick view of it and that's about it so for the jury to constantly focus and listen to every word of your testimony on occasion changing your tone changing your emphasis changing your volume are good cues to the jury that this is a significant point this is something that's important about it and typically the attorney through the questioning they're gonna go ahead and do that they're gonna adjust the tone the volume especially a pause because silence in the courtroom does carry a lot of weight and that's a nice auditory clue to the jury about hey this is important so let's talk about adrenaline a natural hormone from your adrenal glands it flows when instinct signals a need for some extra energy perhaps if you're gonna defend yourself right we got that old fight-or-flight response to run away or respond to pressure performance on it adrenaline you feel pumped we say we're pumped very excited you're the anticipation of it but oh goodness the negative side of adrenaline and for about 20 years I experienced the negative side of adrenaline and I never knew it it was really through studying some biology that I thought oh this is what it's about this is why I feel that way so for me it was butterflies in the stomach on the first day of every trial I'm taking a shower in the morning and I would have butterflies in the stomach I would always feel nauseated and that's not a good feeling before every trial thinking I'm gonna vomit before this before going to court and it would always always happen on it now knock on wood it never happened in 20 years I never threw up before like to work but that's how it felt and it took once I learned that that was the natural hormone that adrenaline that was causing me on an empty stomach to go ahead and do that I you know I wouldn't have anything to eat I mean I get offered I hear some scrambled eggs or something like no I can't eat anything on it that was it butterflies in the stomach we're looking about the respiration muscles in the diaphragm and your inner costals and the ribs are pulling against each other it's a push-pull and that's causing the butterflies there can it manifest itself in other ways you betcha your arms for some folks your arms start to tremble and it's the release of the adrenaline into those muscle fibers preparing your muscles to fight how about the knees are knocking the knees are knocking again adrenaline pumping extra energy to your thighs to your quadriceps to run and that's gonna cause some knees to knocking on that one and then how about on speech what effect does adrenaline have well you can have a trembling you can have some excessive muscular tension that's gonna rob you of your breath support the ability to go ahead if you want to speak loud if you want to speak clearly you have to have breath support you got to have a full face to go ahead and do that and it's when you're speaking with it their phrase you breathe in and speak out okay it's impossible to scream if you don't have in order to go ahead and scream on that you can try it exhale and then try to scream you can't you need that you inhale and you're able to scream or what I say inhale breathe in and then speak out and that's gonna be allow you to go ahead and project your voice carry your voice and do that but just as I say being aware of adrenaline so with with that in mind let's go ahead and let's go ahead and see some some exercises so on that part of it well thank you for listening the chat yes your your district attorney was afraid that you were gonna vomit said well just go ahead and bring a bucket and I'll see you at court at 9 yeah that would be that would be something but here now you know now you know if you're going if you're experiencing any of those problems distress anxiety and those things there is a biological reason for that that is completely normal okay so we're gonna go back on some of our exercises here on it let's we start off with the brain okay brain what is going on with your brain and here's some some exercises on that we'd like to call this like a time warp okay so beef think about if you've ever been involved in a car crash okay how does your brain process and remember that so as you're going along your heart may be beating for example at 60 beats per minute resting heart rate right now all of a sudden you're in a car crash and boom your heart rate will go ahead and double now you're at let's say 120 and so your your brain is registering twice the amount of beats per second on that so the perception of time okay the perception of time all of a sudden it now it seems like it slows down on that part so for some sayings when they're testifying in court they feel a little bit of a time warp because the heart rate increases the effect biologically on the brain is the brain is off on timing and now everything seems like it's coming through in slow motion just like it would be in that car crash and you're thinking of the car crash in the way you go ahead and processing on that part again the silence in the courtroom it may feel unnatural but having that silence having that break often it's unnatural the format of the questions question pause answer pause question pause answer pause that in the reason that is for the court reporter to take everything down that silence may feel unnatural it's a good thing a silence or a pause allows the jury to comprehend the info or reporter to take it down and the the questioner to be able to go ahead and get that answer likewise on cross-examination it's always good to listen understand the question and then go ahead and answer and then echo memory we often call this looping and that is you want to engage in active listening and so often to be able typically it's on the role of the questioner where they're able to go ahead and and ask the question and start off the question with repeating the last couple of words that were part of the answer as a saying you can actually do that in your answers and that can be very effective and that is repeat the last couple of words that the questioner had and use that to go ahead and frame your answer and for juries that echo effect on that memory it creates it's a nice dialogue there's a nice synergy there that also happens to be effective you want to go ahead and practice that have a conversation with someone it can be a loved one it can be a significant other and in that conversation before you answer repeat the last couple of words and the other person in the conversation they will feel that you are really listening to them because they're able to hear what they just said along with your answer and it can increase communication and be a very good technique in court as well the other thing that's valuable with that that silence and that pause that gives the same the opportunity to move from looking at the attorney for the question to transitioning to the jury to respond so there can be that that kind of physical attention change as well during that time yeah that's it's a great a great point Val again we have limited attention spans and anytime you're able to break that off so in that flow of that dialogue to be able to do that is terrific and again that leaving that little pause a little micro pause to be able to turn to the jury the jury gets oriented to that and they're able to respond and listen that's that's very good that I find is a skill you can go ahead and practice it it gets a little trickier to go ahead and do but over time as you do this more and more and practice more and more that becomes easier and easier to do so we're gonna go ahead and if you can if you can I'm gonna have you those folks that have been sitting a while go ahead and stand up the hand up a little bit here this is gonna be fun so stretch this is gonna be a little stretch here you're gonna stand up a little bit on it and we're gonna do a little little anesthetic exercise here and that is you know when you think of the body it's like a little you know you hear like a head-to-toe assessment but we're gonna go the other way we're gonna go toe-to-head assessment toe-to-head okay so go ahead and stand up and I want you to if you can when you stand up notice your stance okay if you had to stand while you testified okay what would be biologically the best stance to have okay for those say nurses that testify in Canada for the crown all their testimony they do standing up for the crown and courts in Canada so what would your what would your stance be most I would say if you probably look down you'd say hey I would probably be about 50-50 right it would be a very equal weighted equal balanced stance and I would suggest to you that that is actually not the ideal stance on it okay you number one you don't want it to be too narrow you wouldn't want to have your if your shoes your feet touching together while you're standing and you wouldn't want to have your stance who wide as though you were a you know riding a horse okay but what would be the better stance would be to have one foot about half a foot in front of the other on that so you could have your left leg and you gave your left leg forward about six inches or you could have your right leg forward about six inches on that one and by doing that that allows for a flexible stance on it which is good you don't nearly have the 50-50 you can actually just have them offset you can take a natural stance and just simply put one foot forward that would be good and that's what that's what you're trying to do now once you do that I want you to feel your feet feel your feet on the floor you want to feel ground you don't want to go ahead and walk you never want to walk and talk in a courtroom you either walk stop and then talk but you don't walk and talk at the same time whether you're testifying or whether you're a questioner and there may be a time when you have to come off the witness stand you know let's say for a demonstration or to point something out depending on the configuration of the courtroom so this part I think is incredibly helpful then you want to have flexible knees right we do not want to lock the knees biologically we don't want to cut off any blood flow we don't want to increase tension okay hips hips we want our hips centered okay not too far forward not too far back and then as we're kind of working our way up here on our arms we want to have our arms in in a natural position and the natural position would be to have your elbows bent okay and you want to have your hands together and you want your hands just about a waist high and you can have one palm simply on top of the other palm and that is fine on it you do not want to have your hands below your waist you know in a tension a position you do not want to have a reverse attention position with your hands clasped behind you you know with your hands behind your back you want to have your hands just about elbow height elbows bent in front of you that's a natural position for you on that so your breath we want to talk about tactical breathing you want to be able to take a full breath you want to breathe in to be able to go ahead and speak out when it comes to that when it comes to your face how to feel your face we don't want to have a scrunched up face or a tightened face on it you just try to relax try to imagine just relaxing your face relaxing your features to the best that you can have in terms of our lips you want to have your lips slightly parted not first close not clenching your teeth you want to relax with your lips about a quarter inch apart lightly parted and then also for your eyebrows to be able to go ahead and to lift your eyebrows a little bit that actually helps relax your face and then when it comes down to your eyes where are you looking probably the best way to do it is when you're looking at that jury that jury box typically a rectangular box is you're gonna have your eyes of well around the perimeter when I look at the perimeter of the jury box thinking of it like you have a garden you're gonna water your garden that's what you'd be doing your water in the garden you have brief eye contact with each jury as you're kind of going along doing that perimeter on that part in that by having that position set up we found that that is probably the most effective testimony for you now going back to say well what about most of the time I'm sitting down how will that work on it some of those things apply you still want to have your you want to feel relaxed there you go ahead and as you say you want to still have probably the most important thing to feel comfortable you're not going to be slouching you're going to feel like your crown extended and be able to go ahead and still have that breath support same thing facial features to still feel relaxed lips parted breathe in speak out lift those eyebrows and that is the best for effective effective testimony on that all right my fire director you sound like my director and it could be there hey there's something when it comes to choir there's something there's something good about yoga to some of this it it does it helps for effective body control and effective testimony on that as well and that for the diaphragm we talked a little bit about the biologically how does the diaphragm function and breathing we talked about the inhalation and exhalation or what's going on in inhalation we've got that there you know breath coming in your diaphragm pulls down right we're going ahead we're filling the lungs and then when you're exhaling we intercostal muscles diaphragm relaxes and you're exhaling there so we have your diaphragm going from pulling down to relaxing you have your intercostals pulling up and then intercostals relax we have that adrenaline we talked about you can go ahead and and it affects that breath support by causing a little bit of a yin-yang going on there that's part of what we're talking about by having that breath support breathing in speaking out you remember that and that will cure you well whenever you're when you're testifying when you're here I need to reject your voice you know at the clinic at the hospital wherever that all works works out quite well when it comes to that and then let's talk about your voice too these are just some techniques when you warm up a little bit think of the folks on radio or on TV or performers what are some of the tricks that you can do to be more effective I thought this would be this could be very helpful for teenagers when you're mumbling I can't understand you what are you saying here are some drills that you can go ahead and practice the nimony pimony nimony pimony or but a gutter but a gutter but a gutter girl gargoyle guy gargoyle say five times real fast repeat repeat you're doing a couple things you're activating activating the voice you're being able to go ahead and in doing those to be able to kind of warm you up so you can have these on a card you could practice a little bit you know a minute to before you testify in that in that room while you're preparing it helps you out a little bit by activating those muscles on it there's a couple other Swiss wristwatches statistically significant Swiss wristwatches statistically significant you can say those two things or say any of these things as you practice with your voice the ability to enunciate and have those will be able to go ahead and highlight again the jury can't understand you they tune out same as for the judge on there so these are just a couple of other techniques to go ahead and use you add them all together and end up with some effective testimony on that delivery between brain body and voice and with that in mind we I think we're ready for some direct examination so let's see can you guys hear me yes we can hear you now. Can anyone hear? Okay, I'm back. I keep kind of going in and out with the power. So I do have a list of participants and I have no visual screen here. So I'm just gonna talk in the, there you are, Brian. There we are, yes. Monica Diaz, is Monica Diaz in the courtroom? While we're finding Monica, I have limited zoom capacity here. We were thinking that we would break down testimony into a few parts, looking at qualifications, qualifying the witness, the medical history, the forensic history, the head to toe assessment with sample collection, and then what was the last one? Branching to custody and some other issues? Yes, yeah. Head to toe assessment, physical findings, sure. Physical findings, that's what it was. So do we have Monica in the room? I see you. We do. Thank you for your bravery. We're very thankful for you. Do you have a copy of the chart in front of you? Yes, I do. Okay, so I am going to turn this over to Brian for some direct, we'll have some feedback. And if you wanna, when you wanna switch roles, Brian, you let us know which hat you're wearing there. Yeah, absolutely, sure thing, sure thing. I think that this report took place in the state of any town. So the state of any town calls Monica Diaz. Monica Diaz, we called you, we're gonna say that you're sworn in. And now we'll start with direct examination. Could you please state your name and spell your name for the benefit of our court reporter? Yes, my name is Monica Diaz, M-O-N-I-C-A, last name Diaz, D-I-A-Z. By whom are you employed? I'm employed by William Beaumont Army Medical Center in El Paso, Texas. In what capacity? I am a trauma program manager and a forensic nurse. And how long have you been a forensic nurse? I have been a forensic nurse for five years. Can you tell us a little bit about your education to become a forensic nurse? Yes, I attended the SAMHSA course through the United States Army in San Antonio, Texas. And I also attended the SANE-A and the SANE-P course at the Texas A&M University. And I hold a master's in forensic nursing. What is a SANE? A SANE nurse is a sexual assault nurse examiner, or in some areas that's also known as a sexual assault forensic nurse examiner. And we are one of the steps in the process when a patient comes into the emergency room or to the hospital. And we are there to provide care for both the patient and in some instances also the suspect. And we interview the patient. We make sure we do a good assessment, always making sure we put their mental health and their health needs first. We collect evidence. We take a patient statement. We also make sure that we properly bag all of the evidence and we also can teach classes and educate others on what we do. All right, my next question, Monica, is normally what are the duties and responsibilities of a forensic nurse or SANE? But boy, I believe, I think you covered that. That was one of the, a great answer, a great answer when it came to that. So those are all kind of the basic ones. I would call that that lead in those initial questions about the name and the spelling is for the court reporter, education, background, experience, all those, those can be practiced at any time. I mean, those are kind of like a little bit the elevator, the elevator pitch, because obviously you're given an example here and the audience has, right, a hundred and a hundred plus attendees listening to you. When you think about that jury box, typically for a sexual assault case, there will not be anyone in the jury box with any medical knowledge training or as an occupation. Typically in cases involving medical records, there's not gonna be anybody in any healthcare field regarding that. So it's interesting. I always like to say to try to keep it simple and break it down. And I thought you did a real nice job with that. Val, anything for Monica on some of the background questions? I thought you really did answer very, you know, very completely what that is. I think overall, my suggestion would be answer that, just answer, and it not the specific question, but the question that you're asked, you know, what is a SANE nurse? You know, we've got, we're a nurse. We've got specialized education and knowledge to effectively take care of acute, you know, people who have experienced acute sexual assaults. We can meet those legal needs and the healthcare needs. So you kind of got that all in your answer. So that, yeah, I thought it was very comprehensive. Okay, thank you, thank you. Excellent on that part. For, let's see, I just mentioned for a cross-examination just on the qualifications, probably the one we see most often is you are not a doctor, correct? No. You've never gone to medical school, correct? No, sir. And you do not have the ability to make diagnoses, correct? Correct. And you do not have the power independent of yourself to go ahead and prescribe medication, correct? Correct, we do not. Correct. So, I mean, those are all some of the things they do on it. Again, you're gonna prepare with your prosecutor, hey, these are the standards. They're gonna hit these all the time. And in truth, your prosecutor is gonna get back up there on redirect and say, cross-examination, you were asked if you were a doctor or a physician and attended medical school, can you tell us about the training that you've had? And typically that allows you to explain, hey, the training we've had can be more than what you'd have as a doctor worthy, more than what you have at medical school at that point, or as I say, just based on that knowledge part on it, so. Those are some of the things on that. Okay, do you have the chart there? Oh yeah, sure. She's getting a chart. One of the other comments about that and I, that diagnosis piece, even all these years, it just, it's like, okay, how does a nurse, we do nursing diagnoses, right? We do nursing process with all of our patients, but it's just not something that's easily explained. So I found personally, one of the things I do is I talk about the healthcare needs. I don't talk about medical diagnosis, but I found it's easy to talk to a jury about the healthcare needs of a patient. And that's just regardless of how that attorney asks me the question, I'm gonna turn my answer around into a way that lets me educate the jury accurately about what we do. Okay, all right. Monica, would you like to stay on for the next section here, part two? I can, or I can give somebody else a chance. I don't mind. Let's see. Let's stay on with part two and then we'll bring Stephanie in for part three. Terrific, all right. I'm gonna ask you some questions about an exam of a patient by the name of Priya Moore that was done on November 11th, 2023 at four o'clock p.m. in case number 14327. Are you familiar with the patient Priya Moore? Yes, sir. Can you tell us a little bit about the consent form and the consent process that was done during her examination? Yes, sir, I can. When Ms. Moore came in, the first thing we do is establish consent with the patient. I have a blank copy that I have laminated that I keep for myself and then I provide a copy to the patient. I read verbatim. I explain to the patient the processes. I go ahead and read verbatim from the consent form, also giving the patient an opportunity to read over it. And then we go through it together and then she initials along the way as we go along. And then, of course, signing at the bottom. And showing you government's exhibit page two, do you recognize the handwriting on government's exhibit two, page two? Yes, sir, I do. And are the initials PM? Did you notice who wrote in those initials by each checked X-box? Yes, I do, the patient. Yes, and are your initials at the bottom with the date? Yes, sir, they are. Okay, great. And turning to government's exhibit one, page three, do you recognize the printed names and signatures on page three? I do, sir. And whose are those? Those are the patient printed name and signature as well as my own. All right. Wonderful, nice job, Monica. There's the consent piece on that, yeah. Typically the rule is anytime you're gonna go ahead and have an exhibit would be to go ahead and be able to see that exhibit beforehand. You never wanna be in a position where you're seeing something on the fly. So in preparing for your testimony with the prosecutor would be to say, listen, what exhibits would you like to go through and be able to go ahead and familiarize yourself with those? Okay, thank you so much. Yeah. One of the other comments about consent, and it has nothing to do with testimony, but just keep in mind that we're keeping this all aligned with healthcare. So this is an informed consent process just like any other healthcare consent that a patient would sign. The nice thing about our medical forensic exam consent forms is that it's kind of like an a la carte menu where the patient has control over the bits and pieces of the exam that they give consent to. So that informed consent is an opportunity for us to really bring home that healthcare aspect. Thank you. Thank you for this opportunity. Brian, are you ready to go on? Absolutely, absolutely. All right. The government would call, is it Stephanie Babbier as our next witness? Yep, hello. Hi. All right, we'll just go ahead and continue here. Can you tell us a little bit about the medical history that Ms. Moore provided to you during the examination? Yes, we discussed her past medical history and there was nothing in her medical history that she had a medical, so I guess that would be one of my questions. Like what, would that be an opportunity to pause and there's nothing that is pertinent to her exam today? Sure, sure. No, good question. Good question. I appreciate you jumping in because we're kind of doing this on the fly on this part. But one thing I think that's helpful for the jury, and again, typically no one with a medical healthcare history at all, but it's kind of nice to say, to kind of paint the picture, right? To be able to have that juror be actually in the room and just explain the process. For that medical history, describe the room, this is where I was and this is where the patient was and it had a chance, we have a form here and going through, asking questions about the history, what was the purpose of it? We always like to go ahead and I think Val made a great point. They're meeting the healthcare needs of the patient and in order to meet those needs, it is critical to be able to take a history, an accurate history to be able to go ahead and to document that so that you go ahead and have that so you can meet those needs on it. So it can be kind of very generic, jury general, going through there on it, on that part. And again, it's not a, typically you have the exhibit. So I'd say, here's government exhibit, page four, you'd be able to go through it. You're not gonna have to remember her height, weight and what the vital signs were, nothing like that on that part of it, but in terms of going through that on it. And then the, maybe pointing something out. I mean, obviously, here she was on that part. You know, was there anything significant regarding that? They were even describing the process of taking on those comments, you know, and directing your attention to page five of the exhibit. Did you write down any of the comments that you had? How was she, was she dressed appropriately for the weather? Did you observe anything regarding her hands? What was she doing there? And that would kind of be a cue, you know, to what was she doing with her hands? She was, you know, frequently tearing tissues in her hands, you know, is it someone who's nervous or something like that on that part. And then depending on that, probably going into that reproductive health, that bottom section of the form on here, as part of that history that he had inquired regarding questions regarding her history on that part. And then probably the next thing, the key part would be going into the actual, the history of the assault. So it's, again, taking the history, just kind of a preview, just kind of leads you up to that. And then all of a sudden here, it'll be going into the assault, you know, the history of the assault. I guess my question would be like, I mean, you had asked specifically about her past medical history. Looking at the form, it talks about anxiety, depression, even the tonsillectomy, that was, I mean, none of those. So would it be appropriate to say, yes, we review, we do a thorough medical review and there was nothing pertinent to her visit today that needed addressing because we don't need to announce like her history correct? Right, right. Well, again, as you say, the exhibit would probably be coming in as evidence. Anything on there would be for game on that part, but it just kind of paints a picture of who that patient was, what the patient had on that part, but you're absolutely right. May not be pertinent, but it just says, hey, you're meeting her healthcare needs. And how do we do that? By obviously finding out about the patient and every juror's gonna have that. You know, why when I go to that doctor's office for a visit, why do they keep asking me the same questions? Every single time I go, they ask me the same questions. Don't they keep record of it? It's not gonna change, right? Well, that's part of the process. And I think jurors can go out and relate to that saying, hey, we're gonna take that accurate history. If we go to, did it answer your question? Yes, I think so. On that part a little bit. Okay. All right, can you tell us- I think it's really important to keep in mind that we are healthcare providers here and that history, the medical history, the history of the assault we'll get to in a minute, but that medical history really is important for how we're gonna treat the patient. You know, she may be there, her presenting complaint may be sexual assault, but she may be having an anxiety attack. She may be allergic to a medication that's gonna impact how you medicate her. She may have an orthopedic issue that's gonna impact how she can position for the exam. So I really want the nurses to think about this patient coming in as a different healthcare complaint. We're gonna go through the same process and that history is gonna probably bring information in that's gonna be helpful, maybe not for the samples you're gonna collect, but for the overall healthcare needs of the patient. So you do, as the nurse, need that information. I would probably not summarize it as being not pertinent for the reason she came in today. Just because that's drawing a conclusion that, you know, she didn't really need me as the nurse there. You know, she needed my swab technique. She didn't need my critical thinking and knowledge as a nurse. That's just kind of my response. Okay, we got 15 minutes left, Brian. We got roll this trial forward. Roll the trial forward, all right. Did Ms. Moore describe to you the assault? Yes, she did. Can you describe how you captured what Ms. Moore, her description of the assault? Can I describe how I did it? Well, I wrote down her description of the assault. Okay. And can you tell us how did the patient describe the assault? And I'm allowed to reference my papers? Correct, yes. So the patient stated that she met Bobby at a bar. He brought her a couple of drinks. She became very tired. She said that things were starting to feel fuzzy for what I had to drink. I started to feel really sleepy. She recalls no memory of leaving the bar. She, something, her memory is waking up in an unknown location. She was on a scratchy couch in a place. I don't know. I was so cold. Her pants and underwear were off. I don't know what happened. Faint memory of Bobby climbing on top of me. I think I remember his dick in my mouth too. I didn't see him anywhere when I woke up. I felt wet between my legs. I went to the bathroom and vomited. I peed and wiped off really good. And then she left. On that part, yes. And did you use quotation marks during the, in your charting of the patient's description of the assault? I did. And what did the quotations mark indicate? They were fragments of the conversation, things that she directly stated. Okay, on that part. All right. After obtaining that history, can you tell us what was the next portion of the, her examination? And the next part was we did a, we went to an exam room to do a head-to-toe assessment. We went to another, we went to the exam room to do a head-to-toe assessment. And what was the purpose of the head-to-toe assessment? To, my job or my role is first and foremost as a nurse. So I, we're just checking her over to make sure that her, she is healthy and there was no additional injuries or no injuries that she has. Okay. Did you have an opportunity to observe any physical findings? Need to look at my paperwork. Brian, we have one more volunteer. I am so sorry. Yep. Oh, no worries on it. It's going to be page 5 of 11 directing your attention. Yeah, page 5. There were no visible. Oh, sorry, page 7. I misspoke there. I think page 7, page 7 of 11 there. Yep. There were no visible injuries on our head-to-toe assessment, but there were some injuries when we did her genital exam. OK. Could you describe those injuries? Yes. If you were to imagine the patient laying down and examining her genitalia, we kind of think of it as like a clock. So we talk about it as a clock. So she looked as though she had a laceration around 6 o'clock, so at the bottom. It was tender to touch and palpation. There was noted that there was thin white fluid throughout her vaginal vault. And that was it. All right. Very nice. Very nice on that. I think the explanation, again, the 12 o'clock, 6 o'clock, we'll chart on that. Typically in court, you might actually have the diagram itself to be able to go ahead and have the jury follow along. It could be highlighted. Cross-examination, when it comes to this, would be something along the lines of, just because there is a linear laceration, that does not mean that that's an assault, correct? It's not my role to make a diagnosis. I'm just charting my findings. Sure. The laceration that you found there and charting it in your findings, that could be consistent with consensual physical or sexual intercourse, correct? It's also consistent with the patient's story. Okay. And thin whitish fluid noted in vaginal vault, that can be consistent with consensual sexual intercourse as well, correct? Correct. Yeah. So, I mean, kind of that's where they're going, but, hey, they're there. They're there. And it's going to be the government's job to go ahead and highlight those to say, yes, just like you mentioned. It would be consistent with the patient's story and those things on that part there. Okay. Nice job, Stephanie. All right. Great job. How about anything, Val? One more. We have any more volunteers? Marie. Marie is ready to testify. And while she's getting up and connected here, I just want to refer everybody back to a comment that Karen Carroll posted at 431. And I totally agree with her. We obtain a history of the event. We don't take statements. We don't write down the patient's story. Use your verbiage as you would in your mainstream clinical job. So, keeping things very much healthcare rooted. Thank you for putting that in there, Karen. I agree. That's a nice add on that part. The law enforcement takes statements. Nurses, as they say, do not on that part. All right. All right, Marie, we'll go ahead and jump right in. Did you have an opportunity to participate in a sample collection with Ms. Moore? And you're muted, Marie. If you can. There you go. Oh, turn your volume up, maybe. If you turn your volume just a little bit up so we can hear you. A little bit of a challenge there. I hate technology. Sorry, Marie, we can't. Yeah, we can't hear you on there. You're not muted. You're on there, but we can't hear you. I think it's a mic issue. Yeah, that's a bummer. That's a bummer. So just for the sake of time and because this is being taped, Marie, thank you so much. I'm sorry. We'll try maybe another time. So maybe do you want to throw some questions about that to me, Brian, and I can, since we don't have any other volunteers, I can maybe answer your question. Yes, can you tell me about the swabs and samples that you collected in this case as part of your examination of Ms. Moore? Of course, I collected buccal swabs, two swabs from the inside of her cheek for her DNA standard. I did collect two swabs of Ms. Moore's buccal cavity or her oral cavity, excuse me, swabs around the gum line and the base of the cheek. I did collect fingernail swabs from each hand. I collected pubic hair or mom's pubis swabs because there was no pubic hair present at the time of the exam, so I collected two moist swabs there. I collected two external genitalia swabs, basically from the labia minora, the clitoral area, the hymen, the fossa, the vicularis, and then down to the posterior foreshadow. I collected two perianal swabs around the outside of the anal sphincter, not putting any swabs inside. I collected two swabs of her left breast and of her right breast, and then with the speculum exam, I did collect samples from her vaginal walls and from the face of her cervix. What is an SAE kit and what's a DFSA kit? So the SAE kit, Sexual Assault Evidence Collection Kit, that is the kit that is provided to us by the state for completing the medical forensic examination with sample collection. DFSA indicates drug-facilitated sexual assault, and that would be the toxicology kits that would be processed as part of the investigation. All right. After collecting the swabs and the evidence, what did you do with it? Well, I dried the swabs in the swab stand while I was completing my documentation, never leaving them. I sealed them into the envelopes that go into the kit. I sealed the kit, and then I placed, I think, let me check. I think I released this kit to Officer... Are you familiar with Officer Doug Krupke? It was Officer Krupke. Yes, it was, of the Inningtown Police Department. All right. Terrific. And that would cover chain of custody on that part. Cross-examination, normally when it comes to evidence collection, would be somewhere along the lines of you collected swabs from the patient, Ms. Moore, correct? Yes, sir. And you collected it and turned it over to law enforcement, correct? Correct. And the purpose of it was for law enforcement to collect it as part of a, and use it as part of a criminal investigation, correct? They could, yes. So somewhere along the lines of that, of just being that the idea that the SANE is just a tool, an arm of law enforcement, that's pretty much how it is. But you can tell even by Val's complete answers in some of those, keeping it with the lens of the healthcare focus. And that's why everything it's done in terms of meeting the healthcare needs of the patient, keeping it in that world, that medical arena there, that normally is able to go ahead and vitiate that idea of, you know, you're just an assistant. You're just a evidence collector for law enforcement at that part. So, yeah. I have called worse. Yes, yes, yes on that. We are actually down to five minutes and I know Sarah needs a couple minutes at the end. Are there any questions that have been put up in the chat box that I just haven't been able to monitor? I don't see any scrolling there. There was one about, does anyone ever answer yes about nursing diagnosis? I'm not sure if you already answered that. Does anyone answer yes about nursing diagnosis? So, Jamie, I see that comment now. Is that question about, does a nurse ever talk about nurse diagnoses on the stand? I suppose they probably could. I see Jamie popping up here. I think it might have been in the context. I never have personally. In my context of doctors, you know, nurse is not a doctor. Doctor makes the diagnoses on it. Nurse would not be making a diagnosis on that in terms of position on that part. But I think you had mentioned earlier, Val, that, you know, having a plan, having a plan for treatment. I know in some jurisdictions when it comes to discharge, you know, why is it important for a nurse to know the identity of the purported assailant, you know, the name or the relationship? Because that goes towards the planning for discharge. Is there gonna be a, you know, for the patient's health care needs, is that gonna be an issue on that part? So, yeah. That, just keep in mind, if you need it to provide health care to the patient, like the relationship of the assailant for safety and discharge planning, if it relates to the health care of the patient, it belongs in the chart. If it relates specifically and only to an investigation like the color of a car or something like that, it doesn't need to be in your documentation to keep you as firmly rooted in health care as possible for, and if we, you know, throw that term medical exception to hearsay out there just to stay rooted. I wish we had more time. We are gonna turn this, I think, back over to Sarah because she's the, she's like the boss of us here today, keeping us on track. Thank you all so very much. Thank you, Valerie and Brian, both for joining us today. This was incredibly informative and helpful. This two-part series, both the first part and the second part. For those of you that missed it, I did drop the first part in the chat. They will both be available on the safetyaid.org website if you would like to access them. A special thanks to our volunteers, Monica and Stephanie, and we appreciate you trying, Marie. I know it can be nerve wracking, but we thank you for being willing to participate. But on behalf of the International Association of Forensic Nurses, we thank you for joining us today, and we look forward to seeing you all on a future webinar.

SANE Testimony Part 2

biology of testimony

SANEs

body posture

voice projection

facial expressions

strategic breathing

vocal warm-ups

balanced stance

eye contact

pacing

active listening