Chapter 38: Six Hours to Go

July 13, 1990, McKinley, Ohio

"Detective Nicki Castle," she said.

"Doctor Mike Loucks. With me are Nurse Kellie Martin and medical student Marta Schäfer. This is Carrie Walker, who reported she was sexually assaulted. We're about to perform a rape kit."

"Good morning, Miss Walker," Detective Castle said. "I'll want to ask you questions afterwards."

Carrie nodded, and Detective Castle began writing in her notebook.

"Kellie," I requested, "would you get a rape kit from the secure locker, please?"

"Right away, Mike!"

She left and returned about two minutes later with the sealed kit, which she showed to Detective Castle to verify. Detective Castle recorded the identifying serial number, and then Kellie broke the seal. While they were doing that, I washed my hands and put on gloves.

"This is going to be somewhat embarrassing," Kellie said. "You'll end up completely naked, standing on white butcher paper. As Doctor Mike said, you have the option of waiting for a female doctor."

"It's fine," Carrie sighed.

She was, in my opinion, showing early signs of PTSD, which was common following sexual assault. We'd call for a psych consult as soon as we finished the rape kit, but I also made a mental note to ask for Mary to be trained.

Kellie asked Marta to help, and they unfolded a large sheet of butcher paper and had Carrie stand in the middle of it.

"First, we're going to brush your hair with a special brush," Kellie said.

She removed a sealed bag with a brush, broke the seal, and proceeded to brush Carrie's shoulder-length hair, then put the brush back into the bag and set it on the instrument tray.

"Next, we're going to scrape under your fingernails," Kellie said. "Marta, I'll need you to hold the bag, please."

Kellie scraped under each fingernail, then put the tool into the bag that had caught the scrapings.

"Mike?" Kellie prompted, handing me a sealed tube with three swabs.

"Carrie, I'm going to swab your mouth and nostrils," I said. "OK?"

"Yes."

I used one swab per nostril and one for her mouth, then put them into the tube, which I set on the instrument tray.

"Carrie, we're going to undress you," Kellie said. "Just allow us to do it, please."

"OK," Carrie said dully.

The exam was embarrassing, humiliating, and degrading, but there really wasn't any other way. I focused on a spot on the wall, rather than watch Kellie and Marta remove and bag each piece of Carrie's clothing until she stood naked on the butcher paper.

"Carrie," Kellie said, "I'm going to comb your pubic hair. Mike, I see some bruising."

Kellie completed her task, then, per protocol, Detective Castle took a pair of close-up Polaroids of the visible bruises, framing the shot to avoid Carrie's genitals.

"Carrie, I'll need you to get on the exam table," I said. "I need to swab your labia, vagina, and anus."

"Uhm, why my butt?" she asked.

"It's standard procedure," I replied. "Given you were unconscious during the incident, we need to collect as many samples as possible."

Marta helped Carrie get onto the exam table, and Kellie set up the stirrups for an exam. I asked for the speculum and swabs and proceeded to collect the samples.

"I see abrasions consistent with forcible penetration," I announced. "Marta, call for an OB/GYN consult, please."

"How do I do that, Doctor Mike?" Marta asked.

"Next to the phone is a list of numbers. Dial the one for OB/GYN, say that you're calling from the ED, and we need a consult for a sexual assault in Exam 1."

She went to the phone to make the call, and I collected the final sample from Carrie's anus. Once that was complete, I used a damp collection cloth to wipe the insides of Carrie's thighs of what I suspected was dried semen. Finally, for completeness, I did the same with her breasts.

"Kellie, she can get dressed," I said.

Kellie helped Carrie into scrubs, as she obviously couldn't put on her own clothes, which were now evidence.

"OK, Detective," I said. "You can ask your questions."

"Thanks, Doc."

She began asking questions, and I went to the phone and dialed Psych.

"Is Maureen Bishop available?" I asked after identifying myself.

"She is."

"I'd like her to consult on a sexual assault, please."

"I'll let her know, Doctor."

"Thank you."

There was a knock at the door, and per protocol for rapes, I went to the door and opened it a short way, and saw a new OB/GYN Resident.

"Christine Crenshaw," she said. "My med student is Nancy Kyper."

I admitted them, and Detective Castle stopped her interview to write down their names.

"I saw minor vaginal abrasions consistent with forcible penetration, as well as bruising on the inner thighs. No other obvious external signs. Her pulse was 100, BP 120/70, and no anomalies on auscultation."

"Thanks," she said, then moved to the side of the exam table. "Detective, I need to do an exam. It'll take less than ten minutes."

"OK. I'm going to go speak to her brother."

Detective Castle left, and Nancy assisted Doctor Crenshaw performed a complete gynecological exam, including STD swabs.

"Carrie," Doctor Crenshaw said when she finished, "I can prescribe drugs which can prevent you from becoming pregnant, and I strongly advise you to agree to take them."

"Uh, yeah," Carrie said.

"We'll give you two doses of two drugs — levonorgestrel and ethinyl estradiol. Together, taken twice, twelve hours apart, they are very effective at preventing pregnancy."

"OK," Carrie acknowledged.

"Mike, we'll use the Yuzpe regimen. Can you keep her for the second dose and another hour after that, so I don't have to admit her?"

"Thirteen hours from first administration, right?" I inquired.

"Yes."

"We can do that," I replied.

"Nancy, we need an emergency contraception kit, please," Doctor Crenshaw said to her student.

"Right away, Doctor."

"Carrie, you'll need to follow up with your gynecologist," Doctor Crenshaw said. "You may have some spotting, but your period should start next week, based on what you said. If not, you can have your gynecologist run a pregnancy test or use an EPT kit you can buy at the drugstore. What we're giving you is very effective, but it's not 100%."

Carrie nodded, and there was another knock at the door, so I went to check and saw Maureen Bishop and a medical student. I stepped out to speak to them.

"Hi, Mike. This is Kenton Washington, Third Year."

"Hi, Maureen; Hi Kenton."

"What do you have for me?" she asked.

"Carrie Walker. Sixteen-year-old rape victim; she has bruises and vaginal abrasions consistent with forcible penetration. She reports drinking six or seven bottles of beer in a two-hour period, and admits she might have had more. I estimate her EtOH was at least 0.25, given her sex, weight, and age. She was unconscious during the assault. Her brother brought her in this morning.

"Detective Castle is interviewing him, and we just completed the rape kit and gynecological exam. Doctor Crenshaw recommended emergency contraception, and the patient agreed. We're about to begin the Yuzpe regimen, and I agreed with Doctor Crenshaw that I'd keep the patient for the second dose plus an hour, given our protocol is to administer both doses here."

"Is she sober?"

"Yes. Her EtOH was 0.02 on intake, and I expect it is 0.0 now. I'd say she's in the early stages of PTSD — dull, monotone, one-word answers and resignation about the exam. I believe she was competent to decide to use emergency contraception."

"Before I go in, can I ask you about that?"

I nodded, "I am adamantly opposed to abortion except when absolutely necessary to save the life of the mother. But I am also a physician, and I cannot allow my personal morals to interfere with what is in the patient's best interest. I won't prescribe or administer the drug personally, but I also won't stand in the way of anyone counseling her to take it or administering it."

"Pretty enlightened."

"For a religious zealot?" I asked with a grin.

Maureen laughed, "That is what they call you upstairs."

"Oh, I know. And a whole bunch of other things. As the saying goes 'sticks and stones may break my bones, but names will never hurt me'. Or, more pithily, it's water off a duck's back. Let's go see our patient."

Just then, Detective Castle came back from the waiting room, and I introduced Doctor Bishop and her medical student. Detective Castle wrote down the information, and the four of us went into the room. A minute later Nancy arrived with the doses of emergency contraception. Doctor Crenshaw administered the first dose, then she and her student left.

"Carrie, this is Doctor Bishop," I said, "She'd like to talk to you."

"Pshrink?" Carrie asked.

"Yes. We always have either a psychiatrist or a social worker speak to victims of sexual assault. I'm going to leave now, but Marta will stay with you. I'll come check on you regularly, as will the nurses. If you need anything at all, just ask."

"Thank you, Doctor."

"You're welcome. All yours, Maureen."

"Thanks, Mike."

I filled out and signed the chart, then left the exam room and went to find Doctor Wernher, who was in his office. He waved me in.