Code Orange

Part of learning the new job is learning the new lingo. I was scanning the computer census and something unfamiliar caught my eye.

“This patient has a chief complaint of ‘Code Orange.’ What’s that all about?” I asked.

The charge nurse answered without looking up from her pile of charts “Rape. We are a sex assault center.”

Crap. I didn’t know that when I took this job. The city of Philadelphia designates certain hospitals as centers where women (and some men) that have been sexually assaulted are brought for evaluation and evidence collection. I was required to perform many post-rape exams when I was a resident and in the Navy and when I resigned my commission I swore that I would never do one of those horrible exams again. Hospitals train nurses to specialize in evidence collection from rape victims; they are called Sexual Assault Nurse Examiners (SANE) and I learned that my new hospital, since we are a sexual assault center, hires and trains SANE nurses to be on staff 24/7.

What a relief.

The sexual assault exams that I performed took hours, in some cases. Part of the problem was the complexity of the evidence collection. Many exams require collection of clothing from the victim – in some cases leaving the victim with nothing to wear except their hospital gown when they leave the ER. There are arcane rules surrounding ultraviolet light examination (semen glows under UV light), clipping hair and fingernails, yanking out pubic hair from the root with pliers, gynecologic and anal exams with cultures and photographs and just about every other humiliating thing you can ask a recently raped woman to undergo.

In my experience, the aspect of the exam that took the longest was sitting and talking with the victim and explaining to her the procedures through her tears and sobs and emotional fragility. I always had a female chaperone in the room with me and some chaperones were more patient than others. How do you rush through that kind of an exam with a woman that has just been violated and in some cases beaten badly?

In hospitals that aren’t sexual assault centers, the responsibility of the ER doctor is merely to examine and treat the victim for lacerations, broken bones, burns or other injuries that require immediate attention, not contaminating the crime scene and getting the patient to the local sexual assault hospital safely. Despite that relatively limited task, things can go wrong.

Years ago the police brought a young woman to my ER after she had been raped at gunpoint. She had been pistol-whipped and smacked around in addition to the sexual violation, but none of her injuries required extensive treatment so I gently cleaned her wounds and softly spoke to her and reassured her that everything will be alright and the police would transport her to the sexual assault center in a few minutes. The nurse had left the room to make the necessary phone calls and I patted her shoulder and turned to leave when she stopped crying for a moment and said “He put something in me.”

I stopped. “He what?”

She began crying again, uncontrollably “He put something inside me and it’s burning me. Oh God, it’s burning me!”

Oh Jesus. I needed to perform a gynecological exam and potentially ruin the evidence collection and any chance she might have at prosecution, but my patient was curled up in fetal position crying loudly “It’s burning, it’s burning.”

“Shhh. It’s OK. I’ll help you.”

My exam revealed a large amount of some kind of brown material shoved up inside the vaginal canal. As I cleaned out the brown stuff from the vagina and tried to collect it in an evidence specimen bag, I seemed to be making some progress toward making her comfortable and my patient calmed down. What was this brown stuff?

Then I found the crushed up white filter tucked behind the cervix. He had shoved a cigarette in her vagina after the rape.

I asked the special victims officer if she thought the rapist was trying to somehow use the cigarette to interfere with or destroy evidence to avoid prosecution.

“Nah," she said. "He was just being cruel.”