Understanding SANE

At this stage, no serious observer of events in Durham could deny the magnitude of D.A. Mike Nifong’s procedural improprieties. Medical procedures, on the other hand, have received far less attention. It seems almost inconceivable to believe that the DNA test would yield no matches, given the specific type of attack alleged and the short time thereafter until the accuser’s arrival at the hospital. I’m not alone in this skepticism, of course; the D.A.’s office itself assured the court on March 23 that “the DNA evidence requested will immediately rule out any innocent persons.”

Beyond the DNA, those of us without medical knowledge must rely on the experts. Fortunately, a new and comprehensive site has recently appeared. Forensics Talk is the work of Kathleen Eckelt, a certified Forensic Nurse Examiner with over 30 years of clinical nursing experience. She’s also president of Harford Medlegal Consulting, which specializes on issues relating to forensic nurses.

The site provides a wealth of material, but three items particularly jumped out at me.

1.) The accuser’s injuries are inconsistent with the attack that she described.

The accuser alleged a violent, 30-minute, gang rape, in which she was kicked and hit; and in which she scratched her attackers. Eckelt observes that as "kicking is usually done with shoes on,” there “may be an imprint bruise from the tread of the shoe,” or a “swinging kick may result in a curved imprint,” with injuries most likely to occur to the face, neck, groin, back, and chest. No such injuries appear to have been documented in this case.

Likewise, recent prosecution claims that the accuser experienced blunt force trauma seem dubious; Eckelt describes the condition as characterized by contusions, lacerations, abrasions, and bites—all injuries that the accuser didn’t possess. According to the SANE nurse-in-training, Tara Levicy, the accuser did show diffuse edema on the vaginal walls—which Eckelt argues often isn’t even classified “as consistent with sexual assault.” She can say definitely, however, that she has "not seen simple edema (alone) as a classification of blunt force trauma. If it's not a classification of blunt force trauma, then how could it be consistent with it?”

Finally, Eckelt all but dismisses insinuations that the accuser might have been given a date rape drug. She reports, “Although each person can react differently to any drug, the amnesia produced by these drugs is pretty acute. It’s not usually a matter of a person's memory just being a bit fuzzy. It’s usually a matter of not remembering anything at all past that first drink.” The accuser, of course, alleged no such thing.

I wonder how many experienced SANE nurses New York Times reporter Duff Wilson spoke to before publishing a front-page article implying that diffuse edema is consistent with blunt force trauma and a date rape drug could have been used?

It’s worth noting that the Department of Justice’s SANE Development and Operation Guide reinforces Eckelt’s observations. The guide goes to great lengths to contend that the absence of evidence ought not be determinative, but also (page 69 of this link) lists a variety of injuries to be expected in a violent rape. The accuser, in this case, had none of these injuries.

Take, for instance, injuries associated with choking—the part of the attack that Nifong personally demonstrated on national television. "Since most assailants choke using their dominant hand,” reports the DOJ guide, “the fingertip pattern can identify the assailant’s handed-ness. A righthanded assailant can usually . . . leave a single thumb bruise at the right lateral neck and several finger tipbruises to the left lateral neck.” The SANE nurse-in-training’s report recorded no such evidence of fingertip bruises.

2.) Sgt. Mark Gottlieb’s “notes” lack procedural credibility.

The Times has reported that Gottlieb produced a typed set of notes, many months after the fact, that were not corroborated by any contemporaneous handwritten notes. The many inconsistencies between Gottlieb’s document and the pre-existing case file included his recapitulation of an alleged conversation with Levicy on March 21, in which Levicy allegedly described the accuser’s injuries in terms far more severe than she documented in her report.

According to Eckelt, if Gottlieb’s notes are true, then Levicy was negligent. “Everything is supposed to be documented,” she notes, “at the time of the exam. Now I've had detectives call me up and ask questions. However, it’s usually been during, or right after, the exam and the answers to questions about any evidence or trauma is already in the chart. I always document it as I observe it.” Indeed, “in the medical field, whether written by physicians, nurses, physical therapists, or nursing technicians, the standard protocols for our documentation are all the same. We’ve all been taught that, according to the courts, ‘If it’s not written, it’s not done.”

Eckelt has other reasons for suspecting that Gottlieb’s reminisces are fictional. Indeed, the sergeant has a reputation in Durham for going overboard with his tales, as he seems to have done in this case. In addition to the new description of “blunt force trauma,” Gottlieb’s notes claim that Levicy told him the accuser uncontrollably screamed after a male nurse unexpectedly entered the examination room. The SANE nurse-in-training, alleges Gottlieb, had to race back down the corridor to calm the accuser.

After reading of Gottlieb’s version of events, Eckelt writes,

I was just floored with that statement and really question it. The standard protocol for sexual assault victims is to provide a private room, preferably locked, in which to do the exam . . . We do not have hospital personnel walking in and out of the room during an examination. That simply isn’t done. We maintain strict privacy for our patients and control over all evidence. Once an exam is finished, we call security and have the evidence locked up until the detective can pick it up. Never would we allow someone, especially a male, to just walk in to get supplies or anything else and I can’t imagine any other SANE nurse allowing it either.

Once again, the DOJ guidelines reinforce Eckelt’s arguments. Page 68 of the above link observes “physicians need not be concerned that injuries will be missed by the SANE if they understand that she will err on the side of caution when evaluating and referring sexual assault victims to them.” Yet in this case, Gottlieb implies that Levicy showed more restraint when dealing with other medical professionals and in her medical report than she showed five days later in a private, undocumented talk with him?

3.) Duke Hospital appears to have violated protocol.

Eckelt observes that “experienced SANE nurses can make a conclusion as to whether any injuries are ‘consistent with’ sexual assault,” but the “key word here is experienced.” Such experience, Eckelt believes, is necessary to testify as an expert witness, although she concedes that the standards in North Carolina might be looser on this score.

In any case, Eckelt argues that “standard protocol” dictates a SANE nurse-in-training—like Tara Levicy in this instance—“must have another experienced SANE nurse, or a physician, in the room with her during the whole exam, so that she can be evaluated and later certified to perform exams on her own.” Moreover, this observation must be documented: “the supervising SANE nurse’s (or physician’s) name should have been written on the standardized examination form. If there is no name written there, then that means there was no one supervising the new SANE nurse ‘in training.’”

Who supervised Levicy during an examination that Gottlieb’s notes describe as having lasted several hours?

At this stage, I suppose no one should be surprised that the procedural irregularities in this case dated from its inception.