Professional Documents
Culture Documents
July 2015
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Pre-Service Training (PST). At the PST medical interview and at all subsequent patient
encounters, PCMOs will strive to understand Volunteers perspective on health and mental
healthcare along with their personalities, health and emotional strengths, needs, and
preferences. PCMOs skilled use of evidence-based assessment methods (see below,
Assessment of mental health needs) will augment knowledge developed in the doctorpatient relationship, and facilitate evidence-based treatment planning.
To support PCMOs effective doctor-patient relationships with Volunteers, the COU staff
provide cross-cultural and communication skills trainings at CME and MOST conferences,
through webinars, and ad-hoc in consultations by phone and Lync. Examples in 2014 include
Trauma-Informed Care (MOST; CME), and Basics of Supportive Counseling (MOST).
3.3. Resources: Each Posts PCMOs have a unique set of clinical expertise and skills. At some
Posts around the world, this expertise is enhanced by the presence of Regional Medical
staff. For mild adjustment problems, Volunteer/Peer Support Network (V/PSN) programs
may also be helpful. Awareness of Medical Units strengths and limitations is critical when
determining a viable course of care for a Volunteer with mental health concerns.
3.4. Environmental and organizational context: For the US Peace Corps, context includes a
system of medical and mental health oversight from Headquarters (OHS) and Regional
Medical Officers as outlined in Technical Medical Guidelines, the availability and quality of
local medical and mental health resources (i.e., psychiatry, psycho-social therapy services),
national and regional phenomena such as proximity of Volunteer sites to care facilities,
transportation infrastructure, political stability or unrest, and other health or safety issues.
Because the US Peace Corps is a federal agency, the potential exists for US Congressional
input and inquiries of sentinel Volunteer health or mental health events.
Figure 1. Key elements of evidence-based care. (Spring, B. & Hitchcock, K., 2009)
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3.5. Providing evidence-based patient care: Evidence-based care begins with developing a
plan with the patient that considers each aspect of the model (Figure 1).
The importance of each elements of the evidence-based model will differ at different times
in the care process, or depending on ones perspective. In developing an evidence-based
plan of care, providers consider patients needs together with other factors in the evidencebased model. Patients input is a crucial to the entire process.
The Five As of Evidence-Based Care outlines how to translate evidence-based theory into
practice. PCMOs should consider the following when creating a plan of care for Volunteers
seeking help.
1. ASK enough questions about to the Volunteers problems, concerns, preferences, and
other factors affecting well-being so that you are clear about:
o the Volunteers definition of the problem and its impact on aspects of life
o the Volunteers ideas about the kind of help they want/anticipate
o other relevant information about need, kind, location, and timing of care
2. ACQUIRE additional, necessary information:
o Best available research findings on etiology and treatment of the specific
problem
o Resources (e.g., Medical unit resources/expertise; VSN)
o Contextual factors (e.g., OHS practices/policies relevant to specific problems;
availability of competent local professional care; country factors such as political
status, ease and safety of transportation between Volunteers site and Post)
3. APPRAISE evidence and information in terms of its applicability for the specific
Volunteer problem, and make the best choice that considers all the information:
o Please note: Care decisions at times may not equally honor each element of the
evidence-based practice model. It is important to help Volunteers understand
that care plans are continuously evaluated and adjusted accordingly.
4. APPLY elements based on steps 13, by doing the following, in this order:
o Outline care options
o Answer the Volunteers questions
o Make a collaborative decision for care that best accommodates
Volunteer concerns
best evidence,
resources, including PCMO expertise
care context (i.e., specific Peace Corps environment)
o Initiate treatment
5. ANALYZE and ADJUST:
o Evaluate treatment impact and changes in the Volunteers needs or priorities
o Alter aspects of care as needed.
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4.3. Management of psychiatric emergencies and other urgent mental health problems
The management of emergent and urgent mental health problems, such as psychiatric
emergencies, events that fall under Kate Puzey Act (KPA) jurisdiction (i.e., sexual assault) as
well as sequelae of other traumatic experiences, substance abuse-related problems, and
emotional issues related to acute medical issues are discussed in detail in separate
guidelines.
Referral procedures for psychiatric emergencies, legislated (i.e., KPA) and unique mental
health events as well as non-urgent psychological issues are outlined in the 2014 Proposed
Criteria for Mental Health Referrals to COU (below, Figure 2).
Because of the life threatening nature of psychiatric emergencies, steps for Volunteer care
are briefly outlined in Section 4.4. However, PCMOs are strongly encouraged to become
familiar with the detailed guidance provided in TG 530.
Detailed information for emergent, legislated events that involve unique mental health
issues can be found in the following Technical Guidelines:
Psychiatric Emergencies (TG 530)
Sexual Assault (TG 545)
Substance Abuse (TG 520)
Pregnancy (TG 170)
4.4. Psychiatric emergencies: In the case of psychiatric emergencies, PCMOs should
Provide medication to stabilize the Volunteer,
Provide continuous, close supervision until a licensed and appropriate mental health
professional assumes responsibility for the Volunteers care
Promptly contact OHS/COU for guidance.
5. EVIDENCE-BASED ASSESSMENT OF MENTAL HEALTH ISSUES
When conducted in a personalized and collaborative manner, mental health assessment is a
potentially therapeutic intervention (Katon et al. 2010; Riddle et al., 2002). Collaboratively and
carefully exploring the sources and meaning of a persons emotional distress oftentimes results
in symptom reductions (Clair & Prendergast, 1994; Levenson & Evans, 2000). Poston and
Hanson (2010) determined the assessment process itself has clinically meaningful and
measurable effects on the overall treatment process and outcomes.
Evidence-based assessment (EBA) emphasizes the use of research and theory to inform the
assessment process (Hunsley & Mash, 2007), and is necessary to prevent common assessment
errors (Garb, 2010; Wilkinson, T., 2014). Measurement-based care specifically enhances care in
several ways (Scott & Lewis 2015):
Provides important information about treatment needs and targets (i.e., focus of mental
health services)
Streamlines assessment process
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The electronic pamphlet, A Few Minor Adjustments, (listed among the references at the end
of this TG) provides additional material concerning Volunteer adjustment issues in Peace Corps
service.
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PCMOs may also consider the DSM-5 criteria for Adjustment Disorders to distinguish common
adjustment problems from this gateway psychiatric disorder.
Criteria for Adjustment Disorders, in brief, are:
1. Identifiable stressor;
2. Timing: Distress begins within 3 months of stressor, but not more than 6 months after
stressor, or the consequences of the stressor, have ended;
3. Clinically significant distress: Distress is defined as out of proportion to the severity or
intensity of the stressor and/or significant impairment in important areas of
functioning most notably, social and/or work-life
4. Not caused by bereavement.
In summary, considering onset, severity, and nature of a Volunteers problem, obtaining a
profile of wellbeing using PROMIS-28, and comparing this information with criteria for DSM-5
Adjustment Disorders (see Attachment D) will help PCMO decide whether or not supportive
counseling could help, or if it may be more expeditious to prepare a mental health referral.
7.2.PCMO-provided supportive counseling for Volunteer adjustment issues
Supportive counseling expected of PCMOs is distinct from counseling or therapy provided
by a professional mental health therapist as follows:
Professional mental health treatment by licensed professionals is a prescribed course of
psychotherapeutic care based on psychiatric assessment including diagnosis, assessment of
risk, and conceptualization of maladaptive mechanisms contributing to and/or maintaining
symptoms and problem behaviors. A course of professional mental health treatment is
intended to resolve symptoms consistent with identified psychiatric diagnosis and facilitate the
Volunteers adoption of more adaptive responses to problem-triggering situations.
Professional mental health treatment for Peace Corps is often a relatively short course of care
(e.g., 46 sessions). However, a longer course of care (e.g., 1520 sessions) may be indicated.
Length-of-care decisions are based on the Volunteers needs, diagnosis, and clinical practice
guidelines regarding the evidence-based treatment for a specific mental health condition. This
determination is made by a licensed mental health professional.
Please note: Although in-country licensed mental health professional may determine a longer
course of care is warranted, in-country mental health services is limited to a maximum of 46
therapy sessions per Volunteer tour of Peace Corps service.
Supportive counseling that PCMOs are expected to provide is short-term, one to four sessions.
In brief supportive counseling PCMOs are expected to help Volunteers to identify and alleviate
temporary emotional problems related to adjusting to Peace Corps (e.g., worries,
misunderstandings, frustration, mild problems with low mood or lack of motivation.) The
PCMO is expected to do this in a supportive and empathetic manner.
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The temporary nature of common adjustment problems and mild severity of distress is
important to consider. Such defining characteristics (i.e., temporary, mild) enable a brief course
of supportive counseling to be effective. Problems that exceed that time frame, or problems
and distress that do not respond to supportive, empathetic care may indicate the need for
professional mental health intervention.
7.3. Integrating supportive counseling with evidence-based assessment and prevention of
mental health problems
Supportive counseling consists of active listening and basic, problem-solving methods. Together
these strategies are intended to help the PCMO help the Volunteer identify the problem and
potential solutions.
After identifying the problem, the PCMO should discuss with the Volunteer:
How the Volunteer addressed this issue on the Personal Health Action Plan (PHAP)?
What coping strategies the Volunteer is using?
Available social supports
As solutions or alternative coping methods are identified, the PCMO and Volunteer should
incorporate this into the Volunteers PHAP.
Initial and follow-up administration of the PROMIS-28 (e.g., after 23 counseling sessions) can
augment short-term supportive counseling efforts by:
1. Normalizing distress
2. Focusing supportive counseling efforts: PCMO and Volunteer may agree to explore domains
of functioning identified on PROMIS-28 that are worse than the norm
3. Quantifying distress for purposes of determining if supportive counseling or suggestions for
stress management are helping
4. Determining when a referral to professional mental health is needed (see section 7.4).
Detailed information about the PROMIS-28 is in section 5 of this document.
7.4. When short-term supportive counseling by the PCMO is not enough
A short course of supportive counseling should be sufficient to address most common
Volunteer problems. The following two situations are indicators professional psychological care
may be needed are:
1. Failure to resolve worries, frustrations, and mild problems with low mood or motivation
after a few (one to four) supportive counseling sessions over a few weeks time as
evidenced by, for example:
a. PROMIS-28 scores remain elevated and unchanged
b. Subjective assessment by PCMO and Volunteer that problems are unchanged
c. The impact of problems on social and work functioning is worsening
2. Volunteer is unable to participate effectively in supportive counseling:
a. Volunteer has a bias against discussing emotional problems with an HCN,
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C.
The Vol unteer i s a vi ctim of a sexual assault as defined in IPS 3-13 and ANY ONE of the following:
a . In the i mmediate aftermath of a n assault:
i . The PCMO wa nts assistance assessing the s everity of emotional distress and mental
hea lth needs of the Volunteer;
ii . The Vol unteer requests contact with a licensed professional to discuss reactions to the
i nci dent a nd/or to discuss options for mental health ca re;
iii. The Vol unteer requests mental health counseling to help manage distress related to
the i ncident;
b. Duri ng the one-month follow-up medical consultation with a Volunteer/sexual a ssault s urvivor
a grees to a consult by COU a fter he/she:
i . Screens positive for PTSD using the PC-PTSD;
ii . Reports ongoing a nd/or i ncreasing distress since the i ncident i nterfering with
functi oning;
iii. Acknowledges poor coping (e.g., a dmits to increasing alcohol use, social isolation, etc.)
ei ther s pontaneously or i n response to questions
c. At a ny ti me a sexual assault survivor/Volunteer discloses emotional distress or dysfunction that
ma y be related to the assault a nd wishes to s peak with a licensed mental health professional.
D.
After s upportive counseling by the PCMO, the Volunteer continues to be distressed and AT LEAST TWO (2)
of the following:
a . As s essment of s ymptoms AND results on PROMIS 28:
i . Symptoms of emotional distress in one psychiatric domain a re of moderate severity
(i .e., more than 1 SD di fferent from norm);
ii . Symptoms of emotional distress in two or more domains a re mild (wi thin 1 SD of
norm) on PROMIS 28, at least one of which perta ins to psychological i ssues;
b. Dys function:
i . Symptoms i nterfere with Volunteers ability to work, get along s ocially, or ca re for s elf;
ii . Di s ordered eating or s ubstance a buse that interferes with functioning;
c. Pre-s ervice history of mental i llness:
i . Vol unteer has a pre-service history of mental illness a nd treatment, AND current
probl ems may represent a new episode, or worsening, of a pre-existing problem;
d. Di a gnostic uncertainty by the PCMO;
e. Two (2) of the following:
i . The PCMO ha s l ow confidence regarding a bility to treat or manage the Volunteer i n
country;
ii . The Vol unteer will not a ccept continued mental health ca re from PCMO, or from a n incountry/HCN mental health professional;
iii. The Vol unteers i nterpersonal behaviors interfere with, or otherwise undermine,
trea tment available from PCMOs or i n-country provi ders.
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PCMOs should take care to advise in-country provider regarding Peace Corps requirements
with regard to documentation and the limits of patient-provider confidentiality. Specifically,
PCMOs should ensure the provider agrees with:
Peace Corps requirement that providers inform Peace Corps in the case of suicidal,
homicidal or self-harm intention, plans or attempts, and in the case where a Volunteer
discloses he/she was a victim of sexual assault
Peace Corps documentation requirements
PCMOs should make a viable plan for obtaining treatment notes from in-country providers.
Provision of treatment notes is not negotiable. It is a requirement of the contract between incountry mental health providers and the US Peace Corps. In-country providers who do not
fulfill this provision of the contract for care will lose status as contractual providers for the US
Peace Corps.
PCMOs should plan follow-up discussions with Volunteers referred to in-country providers to
obtain Volunteer feedback both in the form of anecdotal reports of quality of care, but also
patient-reported outcomes information (i.e., PROMIS-28 results). Feedback allows PCMOs to
track quality and standards of care of the in-country mental health services to which Volunteer
are referred.
9.2. Psychotropic medication management:
Psychotropic medications are commonly prescribed to treat a variety of psychiatric s ymptoms
and have been proven to be both safe and effective in many circumstances. One must always
balance the potential risks associated with these medication with the potential benefits. Peace
Corps service is full of challenges, and Peace Corps Volunteers often experience temporary
difficulties adjusting to new challenges. Psychotropic medications are rarely indicated for these
types of temporary symptoms. Many volunteers enter Peace Corps service on a psychotropic
medication regimen. Medical accommodation for these PVS is based on a history of stability on
a specific medication regimen and the role of the PCMO or Peace Corps consultant is to monitor
the PCV and their medication regimen during their service. Changes in these medication
regimens should only be done after consultation with OMS and COU.
PCVs may ask for psychotropic medications during their service. Please follow the guidelines
below for the use and management of psychotropic medications in PCVs.
Prior history of use of psychotropics: If a PCV has a documented past history of effective
treatment and tolerability on a specific agent, psychotropic medication may be started and
titrated for uncomplicated mood and anxiety symptoms utilizing an approved SSRI
(sertraline, fluoxetine, escitalopram, etc.), SNRI (venlafaxine) or buproprion. Medication
dose may be titrated up to 75% of FDA recommended maximum dose, or up to 100% of
maximum dose if the pre-service records show that dose was tolerated and effective.
PCMO should notify OMS and COU for informational purposes.
No prior history of use of psychotropics: In a PCV who does not have a past history of
treatment with psychotropic medication, psychotropic medication may be started and
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titrated for new onset uncomplicated mood and anxiety symptoms only after a consultation
with OMS and COU utilizing an approved SSRI, SNRI or buproprion when clinically indicated.
Acute anxiety: Short term use of benzodiazepines for acute anxiety may be initiated as
indicated In TG 530 Psych Emergencies. (TG 530, Sec 6 Acute Anxiety A short course of a
minor tranquilizer may alleviate the problem. This treatment should not be extended for
more than a week, at which time the dosage should be tapered by giving the night-time
dose only for several days. If there is no improvement or there is an ongoing need for
anxiolytics, discuss the patients condition with OMS/ RMO and COU). Research shows
that use of benzodiazepines for greater than two weeks for post traumatic anxiety increases
the risk for development of Post-Traumatic Stress Disorder (Guina, J, et al, 2015).
Alprazolam should be avoided as it is associated with more inter-dose anxiety, as effects can
wear off rapidly in some patients, causing more anxiety before the next dose (Cloos JM &
Ferreira V, Curr Opinion Psychiatry, 2009). When alprazolams faster onset of action is
combined with its short half-life, these effects can strongly reinforce pill-taking to alleviate
anxiety, can enhance potential for abuse, and may reduce self-efficacy (i.e., patients
confidence that they can manage their anxiety on their own) (Herman JB, Rosenbaum JF,
Brotman AW, 1987). Benzodiazepines should be avoided in individuals engaging in Cognitive
Behavioral Therapy as they have been shown to reduce the efficacy of CBT (Westra HA,
Stewart SH, Teehan M, Johl K, Dozois DJA, Hill, 2004.)
Sleep difficulties:
o Short term use (one to two weeks) of sedative/hypnotics for insomnia may be
initiated when clinically indicated after a consultation with OMS and COU. Nonbenzodiazepine medications are preferred due to less risk for tolerance and
dependence (Buscemi N, et al, 2007.)(CITATION).
o Long term use (greater than two weeks) of sedative/hypnotics for insomnia should
be avoided (Kripke, DF, et al, 2012.) (CITATION) and if symptoms persist consult
with OMS and COU.
o
Adding psychotropics to an established regimen: Augmentation with a second
psychotropic medication should only be initiated after consultation with OMS and COU.
Mood stabilizers: Mood stabilizers should be reserved for the stabilization of acute mood
symptoms with thorough evaluation and clear clinical indication. This should only be
considered after a consultation with OMS and COU if a PCV is under direct psychiatric care
and needs stabilization for medical evacuation. Mood stabilizers are used primarily
indicated for the treatment of Bipolar Spectrum Disorders and the diagnosis and treatment
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of these disorders should not be undertaken with PCVs while at Post. Initiation of longer
term maintenance use or off label use of mood stabilizing medications is not supported.
Stimulants :
o Stimulant medication for the treatment of ADHD may be initiated and titrated for a
PCV who has a history of ADHD documented in their preservice medical record.
Starting dose should be the FDA recommended starting dose of the ADHD
medication in question. Dose may be titrated to the maximum dose used in the past
as documented in the preservice record. PCMO should notify OMS and COU for
informational purposes. If the PCV requests treatment with a higher medication
dose or a different medication a consultation with OMS and COU is indicated.
o Stimulant medication for the treatment of ADHD may not be initiated for a PCV who
does not have a documented history of ADHD. If requested by a PCV a consultation
with OMS and COU is indicated. For OMS to consider starting ADHD meds on a PVC
without a disclosed history of ADHD treatment, we would need clear clinical
evidence that they were experiencing ADHD symptoms as well as recent preservice
documentation (within the past 3 years) from a licensed mental health provider,
usually a psychiatrist or psychologist, that included a thorough evaluation and clear
diagnosis of ADHD.
o Stimulant medication may be effective in the treatment of ADHD, but has a high
potential for abuse and dependence. Treatment of ADHD may provide benefit but
does not constitute an emergency situation.
However, PCMOs should take note that at all times OHS and COU staff are available to assist
with evaluation and support in mental health cases. And, OHS and COU ask that PCMOs work
closely and consult with OHS/COU in all cases of psychiatric emergency, but also when shortterm counseling is not successful in relieving the Volunteers distress.
9.4 Mental healthcare and the medical record
A copy of any field consult/mental health referral from the PCMOs is maintained in the Health
Record.
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REFERENCES
American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006).
Evidence-based practice in psychology. American Psychologist, 61, 2712815.
Buscemi, N., Vandermeer, B., Friesen, C., Bialy, L., Tubman, M., Ospina, M., Klassen, T.P. &
Witmans, M. (2007). The efficacy and safety of drug treatments for chronic insomnia in adults:
a meta-analysis of RCTs. Journal of General Internal Medicine. 22(9):1335-50.
Clair, D., & Predergast, D. (1994). Brief psychotherapy and psychological assessments: Entering
a relationship, establishing a focus, and providing feedback. Professional Psychology: Research
and Practice, 25, 4649.
Cloos, J. M., & Ferreira, V. (2009). Current use of benzodiazepines in anxiety disorders. Current
Opinions in Psychiatry; 22(1):9095.
Counseling and Outreach Unit. Trauma-informed care. Presentations at Peace Corps
Continuing Medical Education Conferences, and at Medical Officer Staff Trainings, 2013 and
2014.
Garb, H. N. (2010). Clinical judgment and the influence of screening on decision making. In, A. J.
Mitchell and J. C. Coyne (Eds.) Screening for Depression in Clinical Practice: An Evidence-Based
Guide. Oxford, Cambridge, UK: Oxford University Press.
Greiner, A. C., & Knebel, E., Eds. (2003). Health Professions Education: A Bridge to Quality
(Institute of Medicine Quality Chasm series). Washington, DC: National Academies Press,
retrieved from http://www.ebbp.org
Guna, J., Rossetter, S. R., DeRhodes, B. J., Nahhas, R.W. & Welton, R. S. (2015). Benzodiazepines
for PTSD: A systematic Review and Meta-Analysis. Journal of Psychiatric Practice. 21(4). 281303.
Herman, J. B., Rosenbaum, J. F. & Brotman, A. W. (1987). The alprazolam to clonazepam switch
for the treatment of panic disorder. Journal of Clinical Psychopharmacology. 7(3):175.
Hunsley, J., & Mash, E. J. (2007). Evidence-based assessment. Annual Review of Clinical
Psychology, 3, 2851.
Katon, W. J., Lin, E. H. B., von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B. et al. (2010).
Collaborative care for patients with depression and chronic illnesses. New England Journal of
Medicine, 363, 26112620.
Kripke , D. F., Langer, R. D. & Kine, L. E. (2012) Hypnotics' association with mortality or cancer: A
matched cohort study. BMJ Open 2(1):e000850.
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Levenson, H., & Evans. S. A. (2000). The current state of brief therapy training in American
Psychological Association-accredited graduate and internship programs. Professional
Psychology: Research and Practice, 31, 446452.
Poston, J. M., & Hanson, W. E. (2010). Meta-analysis of psychological assessment as a
therapeutic intervention. Psychological Assessment, 22, 203212.
Storti, C. (1992) A Few Minor Adjustments: A Handbook for Volunteers. Washington, D.C.:
Peace Corps Office of Special Services. Updated as an electronic version on Peace Corps
Intranet (2011).
Kohls, L.R. (1984) Survival Kit for Overseas Living, Second Edition. Yarmouth, Maine:
Intercultural Press, Inc.
Riddle, B. C., Byers, C. C, & Grimesey, J. L. (2002). Literature review of research and practice in
collaborative assessment. Humanistic Psychologist, 30, 3348.
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996).
Evidence based medicine: What is is and what it isnt. British Medical Journal, 312, 7171.
Scott, K., & Lewis, C. C. (2015). Using measurement-based care to enhance any treatment.
Cognitive and Behavioral Practice, 22, 4959.
Spring, B. & Hitchcock, K. (2009) Evidence-based practice in psychology. In I.B. Weiner & W.E.
Craighead (Eds.) Corsinis Encyclopedia of Psychology, 4th edition (pp. 603-607). New York:
Wiley & Sons.
Westra, H. A., Stewart, S. H., Teehan, M., Johl, K., Dozois, D. J. A. & Hill, T. (2004).
Benzodiazepine use associated with decreased memory for psychoeducational material in
cognitive behavioral therapy for panic disorder. Cognitive Therapy and Research. 28, 193208.
Wilkinson, T. (2014). Cognitive errors in medicine. Presentation at Peace Corps Continuing
Medical Education Conferences, August/September 2014. Pre-Service Volunteer Health
Trainings
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TG 510/530 ATTACHMENT A
neat/groomed/appropriate dress
underweight
overweight
casual
sloppy
poor hygiene
poorly nourished
other
Behavior:
cooperative
guarded
relaxed
agitated
preoccupied
uncooperative
withdrawn
evasive
aggressive
suspicious
bizarre
other
Speech:
normal
soft
mumbled
loud
slurred
hostile
pressured
other
Mood: (ask patient how she/he has been feeling lately)
Affect:
restricted
anxious
cold
flat
superficial
labile
silly
worried
afraid
panicked
apprehensive
euphoric
irritable
sad
depressed
hopeless
apathetic
angry
ambivalent
tense
enraged
ecstatic
worthless
other
Suicidal
Homicidal
Thought processes:
goal-directed
tangential
flight of ideas
poverty of speech
vague
repeats self
illogical
loose associations
neologisms
Thought content:
Hallucinations:
olfactory
Delusions:
control
Perceptions:
tactile
visual
persecution
magical thinking
auditory
sexual
grandeur
depersonalization
obsessive thoughts
place
gustatory
religious
somatic
phobias
compulsive behaviors
Orientation:
person
time
Consciousness:
clear
Memory:
immediate events
Attention span:
normal
Insight:
good
adequate
poor
Judgment:
good
adequate
poor
General knowledge:
intact
impaired
clouded
delirious
comatose
recent events
drowsy
intoxicated
remote events
DOB:
Id #:
Instructions: Please respond to each question or statement by marking ONE box per row
No
difficulty
A little
difficulty
Some
difficulty
With much
difficulty
Unable
to do
Never
Rarely
Sometimes
Often
Always
5. I felt fearful
7. My worries overwhelmed me
8. I felt uneasy
Depression
Never
Rarely
Sometimes
Often
Always
9. I felt worthless
Not at all
A little bit
Somewhat
Quite a bit
Very
much
Very poor
Poor
Fair
Good
Very
good
Physical functioning
Currently
Anxiety
In the past 7 days.
Fatigue
During the past 7 days.
Sleep disturbance
In the past 7 days.
17. My sleep quality was
*PROMIS-28 is a redacted version of PROMIS29. Redaction adds raw score values into domain cells, and adds a scoring
table. It omits item 29 Pain intensity. The last change does not affect comparability of PROMIS 28 T-scores w/ population norms
for the Pain domain; item #29 was not included in original PROMIS29 profile calculations.
DOB:
Id #:
Not at all
A little bit
Somewhat
Quite a bit
Very
much
Never
Rarely
Sometimes
Usually
Always
Not at all
A little bit
Somewhat
Quite a bit
Very
much
Pain interference
In the past 7 days
Domain
Raw
score
T -score
Interpretation
Doing worse or better than average American
Physical functioning**
Anxiety*
Depression*
Fatigue*
Sleep disturbance*
Ability to participate in
social roles & activities**
Pain interference*
*T-scores more than 1 SD above the mean (M =50) represent worse functioning (of clinical concern)
**T-scores more than 1 SD below the mean (M = 50) represent worse functioning (of clinical concern)
*PROMIS-28 is a redacted version of PROMIS29. Redaction adds raw score values into domain cells, and adds a scoring
table. It omits item 29 Pain intensity. The last change does not affect comparability of PROMIS 28 T-scores w/ population norms
for the Pain domain; item #29 was not included in original PROMIS29 profile calculations.
Raw score
T-score
Interpretation
Doing worse or better than average American?
Physical functioning**
Anxiety*
Depression*
Fatigue*
Sleep disturbance*
Ability to participate in
social roles & activities**
Pain interference*
*Domains in which T-scores more than 1 SD above 50 = worse functioning compared to US norms
** Domains in which T-scores more than 1 SD below 50 = worse functioning compared to US norms
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4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Physical
functioning
T-score SE*
T-score
SE*
T-score
SE*
22.9
26.9
28.1
30.7
32.1
33.3
34.4
35.6
36.7
37.9
39.1
40.4
41.8
43.4
45.3
48.0
56.9
40.3
48.0
51.2
53.7
55.8
57.7
59.5
61.4
63.4
65.3
67.3
69.3
71.2
73.3
75.4
77.9
81.6
6.1
3.6
3.1
2.8
2.7
2.6
2.6
2.6
2.6
2.7
2.7
2.7
2.7
2.7
2.7
2.9
3.7
41.0
49.0
51.8
53.9
55.7
57.3
58.9
60.5
62.2
63.9
65.7
67.5
69.4
71.2
73.3
75.7
79.4
6.2
3.2
2.7
2.4
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.3
2.4
2.4
2.6
3.6
3.9
2.7
2.4
2.2
2.2
2.1
2.1
2.1
2.1
2.2
2.2
2.2
2.3
2.4
2.6
3.1
6.7
Anxiety
Depression
Fatigue
Tscore
33.7
39.7
43.1
46.0
48.6
51.0
53.1
55.1
57.0
58.8
60.7
62.7
64.6
66.7
69.0
71.6
75.8
SE*
Sleep
disturbance
T-score SE*
Participation in
social roles
T-score SE*
Pain
interference
T-score SE*
4.9
3.1
2.7
2.6
2.5
2.5
2.4
2.4
2.3
2.3
2.3
2.4
2.4
2.4
2.5
2.7
3.9
32.0
37.5
41.1
43.8
46.2
48.4
50.5
52.4
54.3
56.1
57.9
59.8
61.7
63.8
66.0
68.8
73.3
28.0
33.6
35.7
37.3
38.8
40.3
41.7
43.2
44.8
46.4
48.1
49.8
51.6
53.5
55.6
58.1
64.1
41.6
49.6
52.0
53.9
55.6
57.1
58.5
59.9
61.2
62.5
63.8
65.2
66.6
68.0
69.7
71.6
75.6
5.2
4.0
3.7
3.5
3.5
3.4
3.4
3.4
3.4
3.4
3.3
3.3
3.3
3.4
3.4
3.7
4.6
4.2
2.5
2.2
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.2
2.2
2.2
2.3
2.7
5.1
6.1
2.5
2.0
1.9
1.9
1.9
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.8
1.9
2.1
3.7
T-scores were developed to facilitate interpretation of tests results by enabling a comparison of a persons scores
against norms for a relevant population. A T-score is a standardized score that is calculated from the total
distribution of scores within a relevant community (norming) sample. For PROMIS 28, this was a representative
sample of the US adult population.
T-scores are obtained from raw scores. T-scores have a mean of 50 and a standard deviation (SD) of 10. T-scores
within one standard deviation of the mean of 50 (i.e., a T-score of 55) on any domain is regarded as being within
the normal range (WNL) for that domain, and therefore not a clinical concern.
A T-score that differs more than one standard deviation, either higher or lower depending on the domain
(explained above), shows elevated symptom or distress/problem. A one SD difference indicates sub-clinical
problems.
PROMIS 28 are NOT diagnostic. Identification of sub-clinical problems in any domain warrants follow-up and reassessment; this does not necessarily indicate a need for referral for psychiatric evaluation or treatment, but
indicates the need to explore the persons view of the problem, attempts resolution, and coping strategies.
When to make a mental health referral to OHS/COU:
A T-score that differs much more than one standard deviation, or at least two SDs, either higher or lower
depending on the domain (explained above) in any domain may be viewed as a good indicator of the need for
referral to a licensed mental health professional.
When an individuals PROMIS 28 profile shows multiple domains of substantially worse than average
functioning (i.e., T-scores are more than one SD from the norm).
Page 2 of 2
TG 510-Attachment D
July 2015
Peace Corps
Technical Guideline 520
ALCOHOL MISUSE AND ABUSE
1.
PURPOSE
2.
BACKGROUND
2.1
Definitions
Per DSM-5, Alcohol Use Disorder (AUD) is a problematic pattern of alcohol use
leading to clinically significant impairment or distress, as manifested by 2-3
(mild), 4-5 (moderate) to 6 or more (severe) of the following symptoms within a
12-month period:
Alcohol is taken in larger amounts or for longer periods than was intended
There is a persistent desire or unsuccessful efforts to control alcohol use
A great deal of time is spent in activities needed to obtain, use or recover
from alcohol
Craving, a strong desire to use alcohol
Recurrent use resulting in a failure to fulfill major role obligations at
work, school or home
Continued use despite having recurrent interpersonal or social problems
caused by alcohol
Important social, occupational or recreational activities are given up or
reduced
Recurrent use in situations where it is physically dangerous
Use is continued despite knowledge of a persistent / recurrent physical or
psychological problems, caused by or exacerbated by alcohol
Tolerance (need for markedly increased amounts or markedly decreased
effects
Withdrawal
Alcoholism is not a clinical diagnosis. It is sometimes used to describe any single
type (mild, moderate or severe) of Alcohol Use Disorder (AUD). Persons who are
in remission from alcohol use may use recovering alcoholic; to describe their
abstinence. Diagnostically, the term Alcohol Use Disorder in remission or in
early remission is used. If none of the above 11 criteria is met for 3 months (but
not yet 12) the AUD is considered to be in early remission.
December 2015
Page 1
2.2
December 2015
Page 2
Myth
Fact
Myth
Fact
Myth
Fact
Myth
Fact
Myth
Fact
December 2015
Page 3
3.
PREVENTION
Peace Corps staff should actively prevent alcohol abuse among volunteers by:
4.
Becoming familiar with and educating on other substances of abuse (e.g., coca
leaf, locally fermented beverages, marijuana, and other illicit drugs) in the country
of practice as well as their effects alone or in combination with alcohol
5.
All PCMO contacts with volunteers suspected of alcohol or drug abuse must be made in
person. Contact may take place through a site visit, or the volunteer may be brought to
the health unit.
December 2015
Page 4
The Substance Abuse Evaluation Interview (outlined below) can be used to guide the
history taking, examination, assessment, and development of a management plan.
The PCMO should remain friendly and helpful throughout the evaluation interview
and, at the same time, firmly remind the Volunteer that strong evidence of a problem
exists.
OBJECTIVE
Physical Examination
General condition, abrasions, bruises?
Spider veins?
Enlarged liver?
Abdominal tenderness? (ulcer, gastritis, pancreatitis)
Unsteady gait? Tremor?
Needle track marks?
Rectal exam for stool guaiac? (ulcer, gastritis)
Mental Status
Complete a mental status exam (TG 510)
Laboratory Tests
CBC (with MCV)
Liver enzymes (increased transaminases may indicate alcoholic hepatitis, esp. GGT)
Blood alcohol
Blood and/or urine toxicology screen
ASSESSMENT
Utilize the AUDIT screening questionnaire
December 2015
Page 5
5.2
6.
Those results vary by country in rank, but most countries AVS scores responses to this question
have each of these responses in the four among the five that are most often cited. Attempts at
decreasing excessive drinking at the Post level may logically begin with interventions to address
one or more of the above factors.
The management of alcohol misuse at post is not solely the PCMOs responsibility.
Collaboration with the Country Director and other members of the staff as well as Volunteers in
leadership positions (VAC; PCVLs; PSN) is critical. Post is encouraged to consult a 2015
publication of the National Institute of Alcoholism and Alcohol Abuse (NIAAA) titled College
AIM. Interventions at both individual and environmental levels are all evidence supported and
are scored on effectiveness and cost. Though prepared for university settings (where most of the
cited research is centered), the applicability to Peace Corps is clear.
Beginning with interventions focused on the four factors Volunteers report as causal in their
drinking habits would likely prove to be most beneficial.
College-age PCVs may come from an environment where binge-drinking (>4-5 drinks in one
setting) is highly prevalent, causing health and safety risks. The safety risks in Peace Corps are
often much more severe than those in a university setting.
Some research has shown that an important step in stopping alcohol abuse is to change the
culture which is the drinking habits of fellow Volunteers. Recommendations for developing a
culture of responsible alcohol use may include:
developing a country alcohol policy
not serving alcohol at Peace Corps-sponsored events
preventive training
prompt management of PCVs with binge drinking problems through PCMO/CD/staff
collaboration.
Office of Health Services
December 2015
Page 6
MANAGEMENT AGREEMENTS
When counseling a volunteer who has a problem with alcohol, it is often useful to have the
Volunteer agree to certain commitments. Written agreements are preferable. The objective is to
have the volunteer set the terms of the agreement rather than have terms imposed. The terms of
the agreement should be voluntary, realistic, and specific to the areas of concern for the
volunteer. Generic agreements prepared in advance are not generally appropriate.
SAMPLE MANAGEMENT AGREEMENT
I agree to carry out the following: Have the volunteer propose the terms of the agreement
1)
2)
3)
4)
5)
In agreeing to these terms, I also understand that failure to comply with them may result in
(consultation with OMS, other action)
Signature of Volunteer
Signature of PCMO
Signature of CD
7. ALCOHOL WITHDRAWAL
Individuals who are physically dependent on alcohol will experience withdrawal symptoms if
they abruptly stop using the alcohol or significantly reduce its intake.
Alcohol dependent Volunteers may first present in withdrawal or may stop using the
alcohol during assessment and then go into withdrawal.
Volunteers requiring supervision for alcohol-related problems must be supervised by the
PCMO or by another Peace Corps staff member and may not be supervised by another
Volunteer.
When caring for a Volunteer who is or has been abusing alcohol, the following questions
must be answered:
December 2015
Page 7
It is not always possible to predict who will develop seizures or DTs during alcohol
withdrawal. However, they are more likely if:
Drinking has been heavy or prolonged
A past history of seizures or DTs exist
Other medical problems or complications are present
7.2 Managing Alcohol Withdrawal
Management of mild withdrawal symptoms involves supervising and reassuring the patient,
maintaining hydration, and possibly using low to moderate doses of pharmacologic
detoxification (see chart below).
Management of severe withdrawal symptoms involves continuous supervision of the patient,
obtaining expert advice from OMS and/or the RMO, and pharmacologic detoxification in doses
adequate to control symptoms. Persons at risk for severe withdrawal as defined in section 7.1
Office of Health Services
December 2015
Page 8
should be closely monitored and pharmacologic detoxification given if any signs of withdrawal
are seen. Medications may be started before symptoms are seen if the patient has experienced
withdrawal in the past.
Pharmacologic Detoxification
Benzodiazepines are used in the management of alcohol withdrawal to:
Control the symptoms of withdrawal
Reduce the likelihood of seizures
Reduce the chance of other medical complications
Relieve physical and psychological discomfort
Benzodiazepines are NEVER used if alcohol has been consumed in the past 24
hours.
Drug Regimens for Pharmacologic Detoxification from Alcohol
Oral: Initial dose: 50-100 mg; dose may be
Chlordiazepoxide (Librium)
repeated as necessary to a maximum of 300
mg per 24 hours. Once agitation is under
control, maintain therapy at lowest
or
effective dose.
Diazepam (Valium)
or
Lorazepam (Ativan)
December 2015
Page 9
Bibliography
Barbor, T. E., La Fuente, J. R., Saunders, J., & Grant, M. (1992). AUDITThe alcohol use
disorders identification test: guidelines for use in primary health care. Geneva: World Health
Organization.
College AIM NIAAA's Alcohol Intervention Matrix. (2015). Retrieved from
http://www.collegedrinkingprevention.gov/CollegeAIM/Default.aspx
DSM-5 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders. Arlington: American Psychiatric Publishing.
Kaplan, H.I. and Sadock, B.J. (1990). Pocket Handbook of Clinical Psychiatry. Lippincott
Williams & Wilkins
National Survey on Drug Use and Health. (2015). SAMHSA/HHS Publication, (15-4927)
US Department of Health and Human Services. (2005). Helping patients who drink too much: a
clinicians guide. National Institutes of Health. National Institute on Alcohol Abuse and
Alcoholism. NIH Publication, (07-3769).
December 2015
Page 10
Alcohol Abuse
TG 520 Attachment A
ATTACHMENT A
THE CAGE QUESTIONNAIRE
C
A
G
E
Have you ever felt the need to Cut down on your drinking?
December 2005
Page 1
Alcohol Abuse
TG 520 Attachment B
ATTACHMENT B
THE AUDIT QUESTIONNAIRE
Place an X in one box that best describes your answer to each question or circle the
number that comes closest to the patients answer.
Questions
1. How often do you have a drink
containing alcohol?
0
Never
1
Monthly
or less
1 or 2
3 or 4
Never
Never
Never
Never
Never
Never
No
No
2
2 to 4
times a
month
3
2 to 3
times a week
4
4 or more
times a week
5 or 6
7 to 9
10 or more
Less
than
monthly
Less
than
monthly
Less
than
monthly
Less
than
monthly
Monthly
Weekly
Daily or
almost daily
Monthly
Weekly
Daily or
almost daily
Monthly
Weekly
Daily or
almost daily
Monthly
Weekly
Daily or
almost daily
Less
than
monthly
Less
than
monthly
Monthly
Weekly
Daily or
almost daily
Monthly
Weekly
Daily or
almost daily
Yes, but
not in the
last year
Yes, but
not in the
last year
Yes, during
the last year
Yes, during
the last year
Total
December 2005
Page 1
Peace Corps
Technical Guideline 530
PSYCHIATRIC EMERGENCIES
1. PURPOSE
The purpose of this guideline is to provide the PCMO with information on the assessment, diagnosis
and management of psychiatric problems, including severe depression, suicide risk, acute anxiety,
and acute psychosis.
2. PREVENTION
PST and IST are opportunities to assist Volunteers with emotional adjustment, including the phases
of adjustment to Peace Corps service and critical periods in the life of a Peace Corps Volunteer.
Self awareness, acceptance of attitudes and values, and the development of effective coping
strategies and stress management techniques can be taught. Refer to the Pre-Service Health
Training on mental health.
PCMOs must be prepared to deal with psychiatric emergencies. Such preparation includes:
Identification of local health care providers and facilities to assist with psychiatric emergencies.
24-hour access to medication required for the treatment of psychiatric emergencies. These
medications must be stocked in the Peace Corps Health Unit and in the Go Bag.
Arrangements with Peace Corps staff, security guards, and other medical personnel for
assistance in managing a violent or agitated patient.
Alterations in mental status can be due to infection (e.g., malaria), disease (e.g., vitamin
deficiency), drugs (e.g., amphetamines), adverse reactions to medication, head injury or other
intracranial lesion, or a psychiatric illness.
A complete history (medical and psychiatric) and physical exam (including a mental status exam)
and appropriate laboratory studies are necessary to correctly diagnose the cause of alteration in
mood, thought, or behavior.
Always provide a safe environment for a Volunteer experiencing an acute psychiatric disorder.
Provide accompaniment or supervision in all cases, and medicate when appropriate (as
described below.) Do not permit acutely suicidal or psychotic individuals to be alone, even if
they desire to work it out by themselves.
June 2014
Page 1
Psychiatric Emergencies
TG 530
MANAGEMENT OF PSYCHIATRIC EMERGENCIES
SUBJECTIVE
OBJECTIVE
Examination
Perform a mental status examination (ATTACHMENT A)
Perform a physical examination (as much as possible) with special regard to:
- vital signs and temperature
- evidence of head injury
- evidence of drug use or intoxication
If unable to complete the examination, document the reason(s)
Laboratory screening tests
If an underlying medical illness is suspected, some of the following tests may be indicated:
A rapid blood glucose determination and pulse oximetry should be obtained in all
combative patients
CBC with differential white blood count
Urinalysis
Electrolytes
Malarial smear
Blood glucose
Liver and renal function tests
Pregnancy Test
Thyroid function
Toxicology screen
June 2014
Page 2
Psychiatric Emergencies
TG 530
4. ACUTE PSYCHOSIS
A patient with acute psychosis has an impaired sense of reality and may talk and act in a bizarre
fashion. He or she may be confused and agitated, but may remain oriented. Other features of
psychosis include:
Thought disorganization: sudden and incomprehensible changes of subject and obvious flaws
in reasoning
Hallucinations: the perception (visual, auditory) of objects or events which do not exist (e.g.,
hearing voices, seeing things which are not present)
4.1
Classification of Psychosis
Psychosis is classified as having either a physical (organic) or functional cause.
4.1.1 Physical (organic) psychosis (Psychosis secondary to a medical condition)
requires urgent medical intervention. Contact OMS/RMO/COU.
4.2
June 2014
Page 3
Psychiatric Emergencies
TG 530
The PCMO should inquire about previous treatment with antipsychotic medication. If such
treatment has been given and was successful, that particular antipsychotic medication (if
available) is the drug of choice for that patient.
Antipsychotic use
Haloperidol (Haldol):
In the United States, haloperidol is the drug of choice for the rapid control of acute psychosis.
Oral dosing is appropriate unless very rapid onset is necessary.
Recommended dose of haloperidol (oral)
Initially 2 to 5 mg orally two to three times a day*
Adjust dose according to response. Most patients will respond to a total of 10-15 mg per day.
Give diphenhydramine (Benadryl) 50mg every 6-8 hours to prevent acute side effects and to
provide additional sedation.
Agitated patients should receive a benzodiazepine in addition to haloperidol as long as they are
not intoxicated (see below.)
* Note: Dosage will vary depending on the severity of the symptoms and the individuals
response to the medication. Significantly higher or lower doses may be necessary.
Recommended dose of haloperidol (intramuscular)
Initially 2 to 5 mg* intramuscularly
May repeat hourly or at 2-8 hour intervals until able to administer orally. Begin oral course
with total daily dose equivalent to amount given IM in first 24 hours (give as divided doses two
or three times a day.)
Give diphenhydramine (Benadryl) 50mg every 6-8 hours to prevent acute side effects and to
provide additional sedation.
Agitated patients should receive a benzodiazepine in addition to haloperidol as long as they are
not intoxicated (see below.)
* Note: Dosage will vary depending on the severity of the symptoms and the individuals
response to the medication. Significantly higher or lower doses may be necessary.
Risperidone (Risperdal)
Risperidone is a second generation psychotropic agent with fewer extrapyramydal side effects
in lower doses.
Recommended dose of Risperidone (oral)
Initially 1-2 mg every 30 minutes to 2 hours, to a maximum of 4 mg per day
June 2014
Page 4
Psychiatric Emergencies
TG 530
Side-effects of anti-psychotics
The side effects of anti-psychotic medications include drowsiness, sedation, hypotension,
extrapyramidal symptoms (e.g., tremors, rigidity, and akathisia), photosensitivity and
hepatotoxicity. Such symptoms are more commonly seen with haloperidol than with
risperidone.
Extrapyramidal side effects can be managed with diphenhydramine (Benadryl) 50 mg IM or
PO. It is as effective as benzotropine (Cogentin) 1mg or trihexphenidyl (Artane) 1mg for acute
extrapyramidal side effects and has the additional benefit of providing sedation.
Benzodiazepine use
Antipsychotic medications at standard doses do not provide adequate sedation for many
patients. Agitation or anxiety which persists despite use of an antipsychotic medication requires
the addition of a benzodiazepine. In addition, sedation with a benzodiazepine is helpful during
travel to help prevent agitation or a psychotic relapse.
**Benzodiazepines should NEVER be used with intoxicated patients
Lorazepam (Ativan) 2-4 mg, PO offers rapid onset of action and a long half-life (14 hours) to
prevent rapid fluctuation in level of sedation. If administering IM, a lower initial dose (0.5 mg) is
indicated.
If Lorazepam is unavailable, alternative benzodiazepines can be used. Check medication
information for appropriate dose.
June 2014
Page 5
Psychiatric Emergencies
TG 530
5. DEPRESSION
5.1
Background
The following criteria to classify depression appear in the Diagnostic and Statistical Manual
(DSM-V) published by the American Psychiatric Association.
DIAGNOSTIC CRITERIA FOR A MAJOR DEPRESSIVE EPISODE
At least five of the following symptoms have been present in the same two-week period and
represent a change from previous functioning. At least one of the symptoms must be the first
or second in the list.
(1) Depressed mood most of the day, nearly every day, as indicated either by subjective
account or observation by others.
(2) Markedly diminished interest or pleasure in all, or almost all, activities of the day, nearly
every day (as indicated by subjective account or observation of others.)
(3) Significant weight loss (when not dieting) or weight gain (a change of more than 5% of
body weight in a month) or decrease or increase in appetite nearly every day.
(4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation or retardation nearly every day (observed by others.)
(6) Fatigue or loss of energy nearly every day.
(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self reproach or guilt about being sick).
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day.
(9) Recurrent thoughts about death, recurrent suicidal ideation without a specific plan, or
suicide attempts or a specific plan for committing suicide.
Also, the symptoms must cause clinically significant distress or impairment in s ocial,
occupational, or other important areas of functioning, and must not be caused by the effects of
a substance or by a general medical condition. Note that bereavement (grief) may meet these
criteria, especially within the first 2 months.
5.2
Suicide Risk
A depressed patient may be contemplating suicide. It is important to explore the possibility of
suicide in any depressed patient so that preventive action can be taken, if necessary. Factors
which increase the risk of suicide include:
June 2014
Page 6
Psychiatric Emergencies
TG 530
Removal of stressful situations. It may be beneficial for the Volunteer to remain at the
Health Unit (or in the capital) until clinical improvement is observed.
6. ACUTE ANXIETY
Background
Anxiety is the apprehension of danger and dread and is often accompanied by restlessness and
tension. Anxiety may exist as an isolated condition or may be associated with other medical or
psychiatric conditions.
Underlying causes of anxiety include:
Office of Health Services
June 2014
Page 7
Psychiatric Emergencies
TG 530
Depression
Management of acute anxiety (without underlying medical or psychiatric condition)
A short course of a minor tranquilizer may alleviate the problem. This treatment should not be
extended for more than a week, at which time the dosage should be tapered by giving the night-time
dose only for several days. If there is no improvement or there is an ongoing need for anxiolytics,
discuss the patients condition with OMS/the RMO and COU. Use of an SSRI may be indicated.
Evaluation by a psychiatrist is useful, if available. Assure that the patient is not consuming alcohol.
Short acting benzodiazepine:
Lorazepam (Ativan) 1mg orally three times daily* for no more than 1 week
OR
Alprazolam (Xanax) 0.5 - 2mg orally three times daily* for no more than 1 week
Reduce to a night-time dose only for days 8-10 (i.e., for three days after completing a course)
*The lowest effective dose should be used. Dosage will vary depending on the severity of the
symptoms and the individuals response to the medication. Significantly higher or lower doses
may be necessary.
The safety watch is arranged and supervised by the PCMO. The patient is assessed each day
to determine the ongoing risk. The patient is discussed daily with OMS, the RMO and/or
COU.
Watchers work in shifts (at least 3) and must remain alert, awake and never let the person out
of their sight for any reason. Arrangements to continue the safety watch even during bathroom
visits are necessary for actively suicidal or psychotic persons. A PCMO alone cannot perform
continuous shifts.
Peace Corps staff members, Embassy staff, and other medical professionals may be asked to
assist. PCMOs should never take on this responsibility without the active involvement of other
June 2014
Page 8
Psychiatric Emergencies
TG 530
Peace Corps staff. Volunteers must not be permitted to serve on a watch shift alone, but may
assist non-Volunteer watchers.
The location selected must be safe with all potentially harmful objects removed
(e.g.,
sharps like razors, knives, glass, hand mirrors, weapons, any pills or medicines of any kind,
open windows.)
Watchers need to be:
8. MEDEVAC
In general, medical evacuation (by commercial carrier) can only be performed when the Volunteers
symptoms are sufficiently under control that travel without incident is anticipated. Remember that a
Volunteer may become claustrophobic or agitated on an airplane or in the airport (especially during
customs and immigration procedures.)
In preparing the medevac, staff should be honest with the Volunteer. It should be stressed that the
medevac is for further diagnostic procedures and treatment is in the patients best interest. The
PCMO or other staff should not deceive the patient regarding purpose or destination.
If the PCMO is not a US citizen, please ask the Country Director to contact the US ambassador in
country to assist in expediting US Immigration and Customs procedures and assure that the PCMO
and Volunteer are not in separate immigration lines at the first point of entry into the US.
The Volunteer must be accompanied by a medically trained escort capable of administering and
monitoring medications required during travel. In some cases, two escorts may be required. In
unusual circumstances, the additional escort may be another Volunteer.
The escort must:
Document all of the above actions in chronological notes for insertion in the Medical Record.
Hand-carry and safeguard the Volunteers Health Record. The Health Record must not be
given to anyone other than Peace Corps Health Services staff. The PCMO should prepare a
summary of history, current status, and lab results to be given to the receiving physician.
Stay with the Volunteer until the Volunteer is either admitted to a hospital, turned over to a
consultant, or turned over to OHS staff. The PCMO escort responsibilities end at this point.
June 2014
Page 9
Psychiatric Emergencies
TG 530
Ideally, the escort should be the same sex as the patient to facilitate supervision during bathroom
visits. If two escorts are required, one should be the same sex as the patient. A same sex
escort is essential for actively suicidal patients.
Outside office hours, contact the medical duty officer. The escort should leave full name and a
return phone number. If there is no response in 15 minutes, call again.
The escort should give a verbal report and the Health Record to the IHC covering the country
on the next business day.
They will be met by a COU clinician who will conduct a brief mental status exam at the airport
and try to reach a shared decision about whether the patient will be admitted to a local hospital
or be escorted to the medevac hotel.
If hospital admission is elected (or required) the IHC, if not already at the airport, will meet the
patient at the hospital admissions area.
June 2014
Page 10
Peace Corps
Technical Guideline 542
Purpose
PCMO Responsibilities
PCMO Preparations For Sexual Assault Forensic Exam (SAFE)
Clinical Management
a. Managing the Initial Report of a Rape
b. Preparing the Volunteer for a Sexual Assault Examination by the PCMO
c. Taking the History
d. Performing the Exam
e. Documenting the Exam
5. Collecting Evidence
a. Before the PCMO Collects Forensic Evidence
b. Forensic Evidence to Collect
c. Basic Rules of Evidence Collection
d. Evidence Collection Procedure
e. Photographing Evidence
f. Summary Chronologic Note
g. Drug Facilitated Sexual Assault (DFSA)
h. Drug Testing Guidance
i. Ordering and Maintaining Sexual Assault Kits (SAK)
6. Registered Nurse PCMO Privileges for Sexual Assault
7. Attachments
Attachment A: VEC#100 Consent Form
Attachment B: Summary Chronologic Note Outline
January 2015
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1. PURPOSE
To establish procedures for Peace Corps Medical Officers (PCMOs) to perform a sexual
assault forensic exam (SAFE), if requested by the PCV victim and either (1) the perpetrator
is another Volunteer or a Peace Corps staff member or (2) the assault took place in a building
or on land used by the U.S. government or in a residence used by a Volunteer, a U.S.
government employee or other U.S. government personnel.
2. BACKGROUND
The purpose of the SAFE is to collect forensic evidence to help the Volunteer pursue legal
action after a sexual assault. The SAFE is comprised of a comprehensive history and
examination with special attention to physical injuries, emotional distress, and the collection
of evidence for future legal proceedings as prescribed jurisdictional law. Forensic evidence
is used to:
Support a victims history
Confirm recent sexual contact
Show that force or coercion was used
Possibly assist in identifying the attacker
PCMOs are not authorized to perform SAFE exams in general. In the event that a sexual
assault is perpetrated against a Volunteer who wants to pursue legal action that may result in
the case adjudicated in the United States, the PCMO may collect forensic evidence of the
Volunteer. For Volunteer on Volunteer or Staff on Volunteer Sexual Assaults, the incident
may be prosecutable under U.S. law. In order for the PCMO to offer to conduct the SAFE,
the following requirements must be met and the Volunteer must want to have a SAFE
conducted by the PCMO. The requirements are:
This incident is a rape or aggravated sexual assault;
The perpetrator is another Volunteer, a U.S. direct-hire Peace Corps staff member, a
U.S. citizen Peace Corps contractor (including a personal services contractor), or a
U.S. citizen embassy employee;
The assault took place in the Volunteers residence, or the residence of the perpetrator
or in a U.S. government building.
The Volunteer has declined to file a complaint with host country law enforcement,
but has expressed interest in reporting to law enforcement in the U.S.; and
The Volunteer has declined to have a SAFE in accordance with host country law.
Examination can occur only if the Volunteer has given consent. The clinical components and
approaches to collecting evidence through a SAFE outlined in this Technical Guideline are
based on A National Protocol for Sexual Assault Medical Forensic Examinations:
Adults/Adolescents (DOJOVAW, 2004), Clinical Management of Rape Survivors (WHO,
2005) and Sexual Assault Nurse Examiner protocols.
Note: For purposes of this document, the female pronoun will be used, but Peace Corps
recognizes that males can also be sexually-assaulted.
A. Resources
To effectively respond to the sexual assault of a Volunteer who requires a SAFE
performed by the PCMO, PCMOs should follow this Medical Technical Guideline and
Medical Technical Guideline 540 Guide for Clinical Management of Sexual Violence
Office of Health Services
January 2015
Page 2
and TG 545 Sexual Assault: Mental Health Assessment and Care. Other resources
include:
IPS 3-13 Responding to Sexual Assault Policy
IPS 3-13 Procedures for Responding to Sexual Assault;
Legal Environment Survey (LES) for the country in which the assault occurred;
B. Peace Corps Medical Officer (PCMO) Responsibilities
The responsibilities of a PCMO when performing a SAFE are to:
Assure the Volunteers physical safety, privacy, and comfort during the exam
Maintain the supplies required for a SAFE
Document the Volunteers pertinent history and injuries
Maintain chain of custody of the SAFE contents/evidence
January 2015
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Depending on the circumstances of the incident, ask the Volunteer not to urinate,
douche, shower, bathe, rinse her mouth, brush teeth, or clean under her fingernails
before examination, if possible and as appropriate.
3. The Volunteer should not wash or dispose of the clothing worn at the time of the
assault. If the Volunteer chooses to change into fresh clothes before she is examined,
instruct the Volunteer to put all clothing worn at the time of the assault in a bag or
pillow case to bring with her.
4. Inform the Volunteer to bring an extra set of clothes in order to be able to change into
a fresh set of clothing to change into after the exam.
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January 2015
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January 2015
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9. Open a sealed Sirchie #VEC100 Sexual Assault Victims Evidence Collection Kit (aka
SAK). Note the date and time as this is the date and initial time that should be on ALL
the specimens. Document on the top of the SAK box.
10. Review the SAFE consent form (inside the SAK) with the Volunteer. Let her know that
she can refuse any aspect of the examination and that she can delete references to these
aspects on the consent form. Once the PCMO is confident that the Volunteer understands
the consent form, ask the Volunteer to sign the consent. Do not perform the exam without
consent.
B. Obtains the History of Events from the Volunteer
1. Interview the fully-dressed Volunteer in the examination room using a calm tone and
maintaining eye contact.
2. Refer to TG 540, Section 5. D on how to obtain the history and document on the
Female or Male Sexual Assault Clinical Exam Form (TG 540 Attachments D or E).
3. Document what the Volunteer says exactly in quotation marks. Do not sanitize or
remove remarks such as slang, offensive, or derogatory statements.
4. Document steps taken by the Volunteer since the event. Have you bathed, urinated,
defecated, vomited, douched, brushed your teeth, consumed food or beverages, or
changed your clothes since the incident?
C. PCMO Collects Evidence Through the SAFE
1. Start with a visual inspection of the overall appearance and behaviors of the Volunteer
prior to the exam.
2. Assess the Vital Signs including pain level. Tell me where you hurt.
3. Initial primary assessment may reveal severe medical complications that need to be
treated urgently. These take precedence over evidence collection or the remaining part of
the exam. Such complications might include: extensive trauma to genitals, head, chest or
abdomen, neurological deficits, and/or respiratory distress.
4. Never ask the Volunteer to undress or uncover completely. Examine the upper body first,
then lower body providing a gown and cover throughout the exam.
5. Systematically examine the patients body. Look for findings that are consistent with the
history. Collect evidence as you go through the exam.
a. If available and at the discretion of the PCMO, Toluidine Blue Dye may be used for
better visualization of lacerations/abrasions. Toluidine Blue Dye 1% assists
examiners to detect lacerations/abraisons difficult to detect with the naked eye. Use of
Toluidine Blue Dye should be after swabs for DNA/evidence have been collected, but
during the genital examination.
January 2015
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How to Use: Apply Toluidine Blue Dye by swabbing sparingly to the external
genitalia and perianal area with a cotton guaze pad or swab. After a few seconds,
gently wipe the stained area of skin with lubricating jelly. The lacerated or abraised
skin areas will attract the dye making it easier to visualize these wounds. Do not use
the dye on mucous membranes as it will not stain these areas.
Let the Volunteer know prior to application that the dye produces a mild sting.
Residual stain on wounds may cause stains on under garments subsequent to the
exam.
Deep blue stain is positive for injury. No stain or diffuse stain is negative for injury.
Photograph the stained area with permission of the Volunteer.
Ima ges from Sexual Assault: Victimization Across the Life Span. A Color Atlas.(2003).
b. Female Examination
After vital signs, examine her body in this order and describe any of the following
specific findings, collect swabs from mouth, vagina, and/or anus if pertinent to
history, and take photographs of findings with the Volunteers permission:
Hands and wrists: circular wounds or bruising, defense wounds, broken nails
Eyes and nose: petechial hemorrhaging
Mouth: inner aspects of lips, gums and palate (frenulum and hard palate often
areas of trauma). Collect swabs from buccal space.
Ears: behind pinna for bruising, breached ear drums (from slapping/punching)
Neck: signs of bruising, patterns of bruising or injury around the neck
Scalp: areas of hair missing, lacerations, bruising, or other tender areas
Torso: bruising (in different stages of healing?), lacerations, bite marks, other
injuries. Inspect areas of the body that would have been in contact with the
surface on which the assault occurred.
Outer thighs and lower legs: circular wounds around ankles, bruising
Feet: heel abrasions from being dragged
Genital area, anus, and rectum (in this order)All areas are subject to Tears,
Ecchymosis/bruising/contusion, Abrasions, Redness, Swelling (TEARS),
bitemarks, burns, and pain.
a) Mons pubis
b) Inside thighs: bruising from being held open or apart
c) Perineum
d) Labia majora and minora
e) Clitoris
Office of Health Services
January 2015
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f) Urethra
g) Introitus and hymen (Examine by holding the labia at posterior edge between
index finger and thumb and gently pull outwards and downwards.) Describe
areas of bruising and tears as on the face of a clock (e.g. partial hymnal tear
at 3 oclock)
h) Vaginal vestibule/navicular fossa: hymenal tears can extend to the vaginal
vestibule /fossa navicularis
i) Posterior forchette: the most common site of injury showing bruising, tears,
and abrasions
j) Cervix: gently introduce a speculum lubricated with sterile water. Check the
cervix, vaginal walls, and posterior fornix for trauma, bleeding, and signs of
infection.
k) Aspirate or collect vaginal secretions on swabs. Sperm remain motile for
about three hours after ejaculation. Non-motile sperm has been found up to
19 days in the vagina.
l) Bimanual exam: only if indicated from the history and exam findings to assess
for abdominal trauma, pregnancy, or infection
m) Anus and rectum (inspect while she lies on her back with thighs pulled
towards her abdomen and arms around the back of her legs): note the shape
and immediate dilatation of the anus (>than 2cm gaping is significant for
recurrent anal penetration). Check for fissures, tears, bleeding, fecal matter
present on skin.
n) Rectovaginal exam: only if indicated to assess for trauma, recto-vaginal tears,
bleeding. Use an anoscope if possible.
c. Post-menopausal women have decreased hormone levels that can cause reduced
vaginal lubrication and friable vaginal walls. This population is at increased risk for
tears, injury and transmission of STIs and HIV. Ensure a well-lubricated speculum is
introduced into the vagina using sterile water to lubricate speculum. If she cannot
tolerate without better lubrication of the speculum, water-based lubricant may be
used as long as it is documented on the exam form.
d. Male Examination
After vital signs, examine his body in this order and describe any of the following
specific findings, collect swabs from mouth, genital area and/or anus if pertinent to
history, and take photographs of findings with the Volunteers permission:
All areas are subject to Tears, Ecchymosis/bruising/contusions, Abrasions, Redness,
Swelling (TEARS), bite marks, burns, and pain.
Scrotum: swelling, bruising, bite marks, pain
Testicle: assess for testicular torsion as this an emergency and requires
immediate surgical consultation
Penis (bitemarks, lacerations)
Periurethral tissue
Urethral meatus
Anus and rectum (inspect while he lies on his back with thighs pulled towards
his abdomen and arms around the back of his legs): note the shape and
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January 2015
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e. During the exam, use a Woods lamp or alternate light source (ALS) in a darkened room
to inspect for semen or saliva (illuminates white in a dark room). Examine the perineal,
inner thigh, abdomen, face and back with a Woods lamp to detect semen or saliva stains.
Swab any fluorescent areas with saline-soaked cotton swabs. Try to photograph the
illuminated areas and document on the pictograph.
f.
OMIT DRAWING DNA BLOOD SAMPLES ASKED FOR IN THE KIT. These
samples require refrigeration of the SAK which can be unreliable in many of Peace Corps
overseas environments. DNA blood samples may be drawn at a later date if needed.
Label the blood tube envelope with OMITTED due to lack of reliable refrigeration
g. If the Volunteer refuses parts of the exam (e.g. hair pulling), write Volunteer unable to
provide a specimen at this time on the respective envelope.
h. Label each piece of evidence as you go including individual swabs, envelopes, etc. Each
label should include the PCVs name, date, initial time, area where collected and PCMO
initials.
i.
Seal individual bags or envelopes by putting a piece of paper tape across the seams of the
paper envelopes or bags in which the evidence is being held. Write the Volunteers name,
date, initial time, area where collected and PCMO initials.
D. SAFE Documentation
1. Document the interview and exam findings in a clear, complete, objective, and nonjudgemental way.
Document history and findings on documents contained in the SAK.
2. Document findings without stating conclusions about the nature of the incident. It is
not the PCMOs responsibility to determine the legal finding of rape or sexual assault.
Document exactly what you see as a clinician (not what you think may have caused
the injury).
3. Use appropriate and standardized terms to document the history and findings:
Inappropriate Clinical Findings
Documentation
Rape; Sexual Assault
Victim
Alleged
Page 9
Seminal fluids
Standardized Term
Laceration/Tear
Incision
Bruise/Contusion
Ecchymosis
Petechiae
Puncture
Wound
Lesion
Bulls Eye Injury
Patterned
Classification
Site
Size
Shape
Surrounds
Color
Office of Health Services
Definition
Blunt force trauma to tissue that occurs from crushing impact
resulting in an open wound with irregular edges or margins.
Disruption of skin with clear and clean demarcated edges.
Skin is not broken with possible discoloration, swelling, &
pain.
Irregularly formed hemorrhagic area of the skin. Color is blueblack changing to greenish brown-yellow.
Small purplish hemorrhagic spots on the skin or mucous
membranes; may be singular or multiple.
A wound deeper than it is wide and caused by a foreign object.
Disruption of the skin.
Pathological in nature; usually not caused by trauma.
Patterned injury assuming the shape of the offending object;
pale center with a hypervascular or petechial surrounding area.
Shows specific repetition, patterned appearance or site of
wounds.
Use accepted terminology wherever possible (see chart below)
Record the anatomical position of the wound(s).
Measure the dimensions of the wound(s).
Describe the shape of the wounds(s). (Linear, curved, irregular,
crescent, patterned, circular)
Note the condition of the surrounding or nearby tissues
(swollen, bruised, ecchymotic, petechial)
Observation of color is particularly relevant when documenting
January 2015
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Course
Contents
Age
Borders
Depth
Tenderness/Pain
January 2015
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There is a high likelihood that DFSA drugs metabolize quickly and are not found
in the specimen.
There is no chain of custody for the specimen; therefore, the specimen is not
admissible.
Kit Sealed by: Write the PCMOs name or the individuals name who sealed it.
January 2015
Page 12
minimum number of staff - preferably only the PCMO that collected the evidence.
Preferred secure areas can include: a locked desk drawer or locked file cabinet in the
office of the PCMO that collected the evidence and that same PCMO is the only one with
the key. (The PCMO may have to give testimony that the SAK was not tampered with
while stored at the medical office).
Instructions for Handling a Sexual Assault Kit
From: TG 542 Attachment A-1
Standard Report
1. Obtain a unique alphanumeric identifier for the Volunteers SAK from the Office of
Victim Advocacy (OVA) and document unique alphanumeric identifier in Volunteers
medical file.
2. Attach a Standard Report Chain of Posession label (TG 542 Attachment A-1) to the outer
package. Fill out the form using the unique alphanumeric identifier. Do not use the
Volunteers name on the outside Chain of Possession label.
3. Contact OIG (202-692-2900, oig@peacecorps.gov) to determine the method for returning
the SAK to OIG at Headquarters. OIG will advise whether an investigator will pick up
the SAK from post, if it should be turned over to the RSO, or if the PCMO should send
the SAK to OIG via another avenue.
4. In the CIRS database associated with the Volunteer, record the date and time that the
SAK was either transferred directly to the OIG or RSO or sent from field to
Headquarters.
Send the package as soon as possible to OIG. Label the package as follows:
Evidence Custodian
Peace Corps - Office of Inspector General
1111 20th Street NW, 5th Floor
Washington, DC 20526
January 2015
Page 13
4. The package must be sent through an avenue in which there is a tracking number. The
order of preference for sending the SAK to OIG at Headquarters is:
a. Diplomatic pouch with pouch registry number
b. APO/FPO with tracking number
c. DHL/FedEx/UPS express courier service with tracking number
5. Notify OIG by email at oig@peacecorps.gov, providing the date, avenue (diplomatic
pouch, APO, etc.), and tracking number of the SAK. Copy the Lead Security Specialist
and the Director of the Office of Victim Advocacy on the notification email.
6. In the CIRS database associated with the Restricted Report, record the date and time that
the SAK was sent from field to Headquarters.
I. PCMO REGISTERED NURSE PRIVILEGES MEDICAL AND SAFE EXAM
Registered Nurse PCMOs who have successfully completed training on Technical Guideline
540 at Medical Overseas Staff Training(MOST) and who have been granted gynecological
exam privileges through the OHS Credentialing Committee as outlined in TG 605, may be
granted, at the discretion of the Chief Clinical Programs, standing order TG 540. If
granted TG 540 privileges, the RN PCMO may perform the medical exam to determine
medical care needs of the victim and perform the SAFE exam only if required by the Office
of Inspector General and Office of Health Services.
REFERENCES
Fuagno, Diana (MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN. Director, End Violence
Against Women International. http://www.evawintl.org/about.aspx
Giardin, B.W., Faugno, D.K., Spencer, M.J. & Giardino, A.P. (2003). Sexual Assault:
Victimization Across the Life Span. A Color Atlas. St. Louis, MO: G.W Medical
Publishing.
Giardin, B.W., Faugno, D.K., Seneski, P.C., Slaughter, L. & Whelan, M. (1997). Sexual
Assault: Victimization Across the Life Span. A Color Atlas. St. Louis, MO: G.W Medical
Publishing.
Legal Environment Survey (LES), Office of Safety & Security. Please note that each country has
its own.
Office on Violence Against Women. (2004, September) A National Protocol for Sexual Assault
Medical Forensic Examination; Adults/Adolescents. US Department of Justice. NCJ
206554 http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf
Rape, Abuse, and Incest National network (RAINN). (2009). Statistics. http://www.rainn.org/
January 2015
Page 14
Sirchie. (n.d.). VEC#100 Exam and Consent forms and Sexual Assault Forensic Evidence
Collection Kits. http://www. sirchie.com
Washington DC Sexual Assault Nurse Examiners (SANE) Protocols. 2011.
World Health Organization (WHO). (2005). Clinical management of rape survivors: Developing
protocols for use with refugees and internally displaced persons (revised edition).
Geneva, Switzerland. http://www.who.int/reproductive-health/index.htm
January 2015
Page 15
CHAIN OF POSSESSION
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Chain of Possession
September 2014
CHAIN OF POSSESSION
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Received From:
Received By:
Date:
Time:
Chain of Possession
September 2014
Time:
Time:
Time:
Time:
STEP 1
(HOSPITAL)
1,_ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , freely consent to
allow
assistants and associates to conduct an examination to collect evidence concerning an alleged sexual
assault. This procedure has been fully explained to me, and I understand that this examination will include
tests for the presence of sperm and venereal disease, as well as clinical observation for physical evidence
of penetration of or injury to my person or both, and the collection of other specimens and blood samples
for laboratory analysis.
I fully understand the nature of the examination and the fact that medical information gathered by this
means may be used as evidence in a court of law or in connection with enforcement of public health
rules and law.
I do D
do not D authorize the hospital and its agents to release the laboratory specimens, medical
records , and related information pertinent to this incident, inclduing any photographs, to the appropriate
law enforcement officials, and I herewith release and hold harmless the hospital and its agents from any
and all liability and claims of injury whatsoever which may in any manner result from the authorized
release of such information.
SIGNED: _ _ _ _ _ _ _ _ _ _ _ _ _ __
WITNESS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE: _ _ _ _ _ _ TIME:
ADDRESS:
STEP 13
ANATOMICAL DRAWINGS
VICTIM'S NAME
~\
Photographs taken?
0 Yes
0 No
0 No
PELVIC EXAMINATION-Note all signs of trauma. Use a non-lubricated speculum when possible.
VULVA: __________________________________________
INTROITUS: - - - - - - - - - - - VAGINA: ___________________
CERVIX: __________________________,_____________
UTERUS: ----------------------------------ADNEXA: -------------------------------------HYMEN: ---------------------------------RECTUM: ______________________________
ANUS: _________
Photographs taken?
o Yes
No
0 No
EXTERNAL GENITALIA EXAMINATION- Note all signs of trauma. i.e., bruises, petachiae, discharges, sphincter tone.
Also note any traces of lubricants or rectal soiling.
PENIS: ------- ---------------------------------SCROTUM:
MEATUS: - - - - - - - - - - --------------------------GLANS: _____________________________________
TESTICLES: ______________________,_____________
PERINEUM: _____________________________________
RECTUM : _______________ ______________________
ANUS: __________________________________________
Physician's Signature
Date
STEP2
D Single
D Married
D Separated
D Divorced
D Widowed
_ _!_ _!__
7.
_ _! _ _! _ _ _ _:_ _am/pm
8. Examining physician: _ _ __ _ _ __ _ _ _ __
__: _ _ am/pm
9. Nurse: _ _ _ _ _ _ _ _ _ _ _ _ _ __
D Bathed/Showered
D Used Mouthwash
D Defecated
D Douched
D Changed Clothes
D Vomited
D Brushed Teeth
D Urinated
D Drunk
Attempted
Successful Ejaculation
Yes
No
Unsure
Vagina
Anus
Mouth
D Lubricant
DCondom
YES
NO
If Yes, Date:
and Time: _ _ _ __
D Stranger D Acquaintance D Relative (specify): - -- - - - - - - - - - - - - -- - -21. Any injuries to the assailant(s) resulting in bleeding?
D Yes
D No
D Unsure
If Yes, describe:
22. Was any medication taken by the victim prior to or after the assault?
D Yes
D No
D Knife
D Gun
D Yes
D No
D Choke
D Fists
D Verbal Threats
DOther: - - - - - - - - - - - - - -- - - - -- - - - - - - - - - - - - - - - 24. Emotional demeanor of the victim; i.e., crying, angry, agitated, lethargic, frightened, shocked , depressed, etc.
25.
Description of the victims outward appearance; i.e., clothes torn, shoe(s) missing , etc. : _ __ _ _ _ __
26.
Date
Peace Corps
Technical Guideline 545
September 1, 2013
Page 1
The Volunteer
should be encouraged to speak with a licensed mental health professional with specific
evidence-supported trauma treatment expertise.
Many Volunteers are worried about what to say and how to handle the reactions of people
who know about their experience. The utmost care must be taken in observing medical
confidentiality and in respecting the privacy of the Volunteer. PCMOs play a role in
providing education to all non-medical staff involved of the confidentiality requirements.
3. PCMO RESPONSIBILITIES
The PCMOs responsibility is to attend to the immediate emotional and physical needs of
the Volunteer. The PCMO should:
Assure the Volunteers physical safety and help her gain a sense of control.
Offer calm acceptance of the Volunteers range of feelings, and provide psychoeducation
about post-trauma reactions, including reassurance that whatever the reactions are, the
Volunteer will be supported and helped.
Help the Volunteer identify people and things that she would find supportive and
comforting.
After any SAFE is performed, evaluate the Volunteers psychological and physical
condition. Refer to Technical Guideline 540 Clinical Management of Sexual Violence.
Maintain clinical notes regarding emotional support and counseling in a separate Sexual
Assault Medical record to attach to the regular Volunteer health record (See TG 540).
Identify locally trained counselors willing to complete specific online training (course
information provided by Peace Corps) in trauma-focused treatment; this will enable
them to meet Peace Corps standard for managing sexual assault survivors mental
health care (i.e., provide evidence-supported trauma-informed treatment);
Follow-up with the locally trained providers to identify those who have completed
recommended training, and are therefore ready to manage mental health care for
cases of sexual assault;
September 1, 2013
Page 2
Familiarize yourself with TG-545, especially the symptoms and assessment tools of
Acute Stress Disorder and PTSD.
Attend Peace Corps-sponsored and other continuing medical education avenues to
keep general counseling skills relevant, and to update knowledge and skills regarding
best practices for responding to sexual assault and other survivors;
Maintain psychoeducational material in the office on traumatic stress reactions, what
facilitates recovery, and services available to the Volunteer.
screening after a sexual assault is to normalize post-trauma reactions and to identify individuals
most at risk for developing PTSD (Gartlehner, et al., 2013)). It is normal for individuals to have
strong reactions in the immediate aftermath of an assault. More severe reactions are predictive of
post-trauma difficulties (Rothbaum, et al., 1992; Steenkamp, et al., 2012) .
The screening assessment begins to determine severity of reactions. It is a means for quantifying
traumatic stress reactions, and one way to attempt to identify potential problems in emotional
recovery post-assault. The screening process begins one of several opportunities to discuss and
educate the Volunteer on several topics: stress reactions, what facilitates recovery, and services
available to the Volunteer to support recovery.
Proactive discussion of emotional responses after an assault normalizes reactions, and gives
permission to the Volunteer to share concerns about her reactions. This also promotes recovery:
it discourages avoidance of memories, thoughts and feelings about the rape and denial of
psychological reactions; at the same time, it communicates acceptance of the Volunteer, her
experience, and her struggle to recover from the assault (Ehlers, Mayou & Bryant, 2003; Halligan,
Michael, Clark, & Ehlers, 2003; Koopman, Classen & Spiegel, 1994; Resick, Monson, & Chard, 2010; Ullman &
Filipas, 2001; Ullman, Townsend, Filipas & Starzynski, 2007).
Please Note: Most survivors immediately post assault will screen positive (i.e. have symptoms of
PTSD); only a few will be at risk for PTSD long term (Gartlehner, et al., 2013). In the immediate
aftermath (from 24 hours to one month post assault) a positive screen means further mental
health assessment, including assessment of Acute Stress Disorder (ASD) is warranted.
First, perform an overall mental health assessment.
A. Mental Health Assessment
The Mental Health Assessment and ASD/PTSD Screening requires a PCMOs
observations and the Volunteers responses to a series of questions.
o Volunteers appearance (can choose all that apply): Neat/groomed; appropriate dress;
poor hygiene; under/overweight; poorly nourished
o Volunteers behavior (can choose all that apply): Un/Cooperative, relaxed, agitated,
aggressive, suspicious, guarded, preoccupied, withdrawn, evasive, bizarre, tearful,
nervous
o Volunteers speech: Normal, soft, mumbled, loud, slurred, hostile, pressured
Office of Health Services
September 1, 2013
Page 3
o Affect (can choose all that apply): Restricted, cold, flat, superficial, labile, giggly,
apathetic, ambivalent, tense, anxious, apprehensive, worried, afraid, panicked angry,
enraged, ecstatic, euphoric, irritable, sad, depressed, hopeless, worthless
o Mood: Ask, How are you feeling? Document the PCVs reponse in their exact
words with quotation marks.
o Suicidal: Ask, Do you have feelings of wanting to hurt yourself?
If yes, ask, Do you have a plan on how you would hurt yourself?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, rope, etc.)?
o Homicidal: Ask, Do you have feelings of wanting to hurt someone (e.g. assailant)?
If yes, ask, Do you have a plan on how you would hurt someone?
If yes, ask, What is the plan and do you have access to the method (weapon,
drugs, etc.)?
o Thought Processes: goal-directed, goes off topic easily, vague, repeats self, illogical,
flight of ideas, gives minimal answers, cant find words, loose associations
o Hallucinations: olfactory, tactile, visual, auditory, gustatory
o Delusions: Control, persecution, sexual, grandeur, religious, somatic
o Perceptions: Magical thinking, phobias, obsessive thoughts, impulse to perform
repetitive behaviors
o Orientation to person, place and time (do they know who they are, where they are,
and the date/time).
o Consciousness: clear, clouded, delirious, comatose, drowsy, lethargic/intoxicated
Second, assess for acute traumatic stress symptoms, acute stress disorder, and post traumatic
stress disorder in this order as assessment results indicate. Use the following assessment tools for
this purpose.
B. Assessing for General Acute Stress Symptoms, Acute Stress Disorder, and Post
Traumatic Stress Disorder
The PC-PTSD screening instrument (PC-PTSD; Prins, et al., 2003) is a good tool to use
in the INITIAL screening for posttraumatic stress reactions because it is short, it covers
the basic groups of posttraumatic stress reactions, and works well as a springboard for
discussion of the Volunteers emotional response to the assault. As you ask the questions
on the PC-PTSD screen, help the Volunteer understand these reactions, provide psychoeducation about stress reactions, and explore her experience of each symptom she
endorses.
1) Administer the Primary Care PTSD Screen (PC-PTSD)
a. Use the PC-PTSD to determine if the Volunteers reactions are in response to the
assault for which they are seeking care.
b. If the assault is recent, then alter the timeframe on the screening instrument (e.g.
if the assault happened last week, ask the Volunteer, In the past week, have you
had.(symptoms)?
c. Tell the PCV that you are going to administer a few questions that will help
determine the severity of the Volunteers reactions to the assault. This screening
tool is used by primary care clinicians to assess if a person may need extra
emotional support after a traumatic event.
d. You may either ask the questions by phone or in person or ask the Volunteer to
complete the instrument herself.
September 1, 2013
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Yes or No
Yes or No
Yes or No
Yes or No
September 1, 2013
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Provide concrete help (e.g. food, warmth, and shelter) (US Department of Veterans
Affairs, 2010).
Soothe and reduce states of extreme emotion (US Department of Veterans Affairs, 2010).
Increase controllability (US Department of Veterans Affairs, 2010).
September 1, 2013
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o Support the Volunteer as being in charge of when, to whom, where she talks
about the incident and other aspects of her personal history. The Volunteer should
be in charge of her history and tell it as she is able.
o Provide good information and psycho-education can help survivors make the
decisions they need to make. She needs to regain control of her life, starting with
the small decisions, such as what to take with her to the capital and where to stay
o Assist the Volunteer in making her own decisions regarding whether she wishes
to work within her own support network on her recovery, or her interest and
readiness to accept professional help from a trauma expert.
o Offer medical evacuation to Washington or home of record for counseling,
recuperation, and management of the trauma in a safe and familiar environment
o Discuss options with her:
Does she want to go to Washington for additional medical or psychological
support?
Does she want her family or friends notified?
Is there another Volunteer in the country who is able to provide companionship
and support?
As she is able, discuss any concerns about returning to her site. Should other
sites be considered?
She may be considering using annual leave or early termination instead of
medical evacuation. Reassure her that she is in control of these decisions, and
that medevac may be the best way for her to get help after an assault.
Assist survivors to help manage distress (US Department of Veterans Affairs, 2010).
o Provide psycho-education about trauma reactions, recovery post-trauma, and what
is known about what facilitates recovery (i.e., talking through the experience,
allowing feelings, talking about ones thoughts about why it occurred, etc).
o Provide psycho-education about the availability of highly effective treatments for
Volunteers who may struggle with post-trauma recovery, and that these
treatments may be available by phone in-country from COU staff, or in person
with COU staff via medevac to DC.
o Offer emotional support, and professional counseling (locally or with COU) as
appropriate.
o Consult COU if distress symptoms warrant consideration of medication
o See section 10 of this TG for further information about managing post traumatic
stress during a clinical examination.
Assist survivors on how to manage the repetitive, compulsive need to understand why it
happened or to attribute fault. (US Department of Veterans Affairs, 2010).
o Do not label the incident anything other than what the Volunteer calls it. If she
does not think a rape took place, but her history reveals that it does meet the
definition, do not use the term rape unless the Volunteer does. You may help her
to consider how not calling it an assault affects her thoughts and feelings and help
her understand that what one calls an upsetting event can affect ones recovery.
September 1, 2013
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Offer support to other Volunteers who may be experiencing guilt, anger, or anxiety in
relation to the assault.
Recognize that the sense of belonging to the Peace Corps community can be therapeutic.
Peace Corps affiliation is healing because it offers a group identity at a time when the
victims identity is temporarily shaken.
With the Volunteers permission, perform the PC-PTSD screening at these intervals to
assess for recovery status and to coincide with medical follow up testing:
Recommended Follow-up Services (if checked):
At 72 hours post assault:
PEP evaluation and tolerance (if PEP given)
Review of laboratory results (serum and cultures)
Assess mental and physical health
Perform a PC-PTSD
Give Hepatitis B booster
September 1, 2013
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At 2 weeks:
Repeat Pregnancy Test
Repeat Gonorrhea and Chlamydia test if symptomatic
CBC (if PEP given)
LFT (if PEP given)
Assess mental and physical health
At 4 weeks:
Perform a PC-PTSD.
HIV Test
At 8 weeks:
Repeat CBC and/or LFT if abnormal at 2weeks
Assess mental and physical health
Perform a PC-PTSD ( Can be done by phone if PCV not coming
into the office for medical testing.)
At 3 Months:
Serum test for Syphilis (VDRL or RPR)
HIV Test
Assess mental and physical health
Perform a PC-PTSD
At 6 Months:
HIV test
Hepatitis C Test
Assess mental and physical health
Perform a PC-PTSD
Research does not support encouraging the victim to repeatedly explain what happened
outside of the strict constructs of evidence-supported trauma treatment (Gartlehner, et al.,
2013) pp. 89, 96). Should the Volunteer express a desire to tell you, a trusted other or
writing about what happened may aid recovery. Volunteers should be encouraged to not
avoid thoughts, feelings and memories of the trauma.
Respect her wishes regarding the quality and quantity of communication with you.
Trauma experiences are often accompanied by feelings of grief and a sense of loss. The
Volunteer may have lost her sense of safety and security and may sense that shes lost her
way of life.
Encourage her to express all feelings regarding the assault, the assailant, and the
situation. Most reactions are understandable as related to traumatic assaults.
Recognize any fear, and respect it. Help her identify what is causing the fear, and
address any situations that still pose a threat. If fears are pervasive yet the Volunteer can
acknowledge she is not currently in danger, help her understand how fight/flight reactions
can fuel feelings of fear, and that this is normal and may persist for some time when
remembering the assault.
Recognize any feelings of anger and help her to identify its direction or target. Anger at
being helpless to prevent or stop the assault should be directed toward the assailant.
Volunteers who are distressed by their reactions may be offered a phone consult with a
therapist/trauma expert from COU. Explore this option the Volunteer at any timepoint in
the process.
September 1, 2013
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Increased use of alcohol and/or drugs or other means to decrease intrusive thoughts of the
trauma.
September 1, 2013
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Feelings of paranoia that other people are talking about her or laughing at her.
Speak in a calm, matter of fact voice and avoid any sudden movements
Reassure the Volunteer that she is in a safe environment, and although she is having a
reaction, she will be okay.
Explain that you are examining her asking permission to continue the examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold
washcloth for her face.
If possible, go with her into a different room to provide a change of environment..
Understand the differences in how the PCMOs culture and American culture define and
legally manage rape and sexual assault. Knowing ones own cultural biasesand keeping
them to oneselfis very important when working with traumatized individuals.
Common inappropriate responses are denial, downplaying the trauma, and telling the
Volunteer that things really arent so bad.
September 1, 2013
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Volunteer that people who respond in such a way probably do not mean to judge as much
as they need to deal with their own anxiety about the event.
Some may respond with criticism or judgment of the Volunteer. In particular, some men
may be dealing with their own anxiety about the aggressive use of sexuality by members
of their own sex. Men who are able to respond with sensitivity and understanding may
have a particularly helpful effect in providing support.
When working with a Volunteer, if the PCMO senses culture is interfering with
understanding of the situation or the ability to comfort the Volunteer, the PCMO should
feel free to (and be encouraged to) connect the Volunteer to COU for a consult. High
distress can exacerbate cultural and language differences straining communication and
the patient-provider relationship.
Take care of yourself. Recognize how hard it is to provide this kind of support and care.
Be sure to allow yourself some space, distance and support when managing a sexual
assault. Be informed about the effects of vicarious trauma.
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Peace Corps
Technical Guideline 540
July 2015
Page 1
TG 540
Management of Sexual Violence
1. PURPOSE
To establish procedures to provide trauma informed clinical care to Volunteers who have been
sexually assaulted. For guidance in meeting the emotional needs of Volunteers who have been
sexually assaulted, refer to Medical Technical Guideline 545 Sexual Assault: Counseling.
2. BACKGROUND
Sexual assault is a traumatic event that can be physically and psychologically devastating. Peace
Corps Medical Officers (PCMOs) are designated staff at post, and are generally first responders
to Volunteers who are victims of sexual assault. PCMOs are part of a Peace Corps system that is
prepared to respond immediately, effectively, and compassionately to victims. The clinical
components and approaches to examining and providing care to victims of sexual assault outlined
in this Technical Guideline are based on A National Protocol for Sexual Assault Medical Forensic
Examinations: Adults/Adolescents (DOJOVAW, 2004), Clinical Management of Rape Survivors
(WHO, 2005), Sexual Assault Nurse Examiner protocols, and Peace Corps Restricted Reporting
policy.
A. Classifications and Definitions
Peace Corps Sexual Assault Classifications according to CIRG, 2013:
Rape: The penetration, no matter how slight, of the vagina or anus with any body part or object,
or oral penetration by a sex organ of another person, without the consent of the Volunteer.
Aggravated sexual assault: Another person, without the consent of the Volunteer, intentionally or
knowingly:
(a) touches or contacts, either directly or through clothing, the Volunteers genitalia, anus,
groin, breast, inner thigh, or buttocks;
(b) kisses the Volunteer;
(c) disrobes the Volunteer; or
(d) causes the Volunteer to touch or contact, either directly or through clothing, another
persons genitalia, anus, groin, breast, inner thigh, or buttocks, or attempts to carry out any
of those acts, AND:
The offender uses, or threatens to use, a weapon OR
The offender uses, or threatens to use, force or other intimidating actions OR
The Volunteer is incapacitated or otherwise incapable of giving consent.
Sexual assault: Another person, without the consent* of the Volunteer, intentionally or
knowingly:
(a) touches or contacts, either directly or through clothing, the Volunteers genitalia, anus,
groin, breast, inner thigh, or buttocks,
or
(b) kisses the Volunteer on the mouth,
or
(c) attempts to carry out any of those acts.
Office of Health Services
June 2015
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TG 540
Management of Sexual Violence
*Consent means words or actions that show a knowing and voluntary agreement to engage in
mutually agreed-upon activity. Consent is absent if force has been used against the
Volunteer, the Volunteer has been threatened or placed in fear, or the Volunteer is
incapable of appraising the nature of the conduct or is physically incapable of declining
participation in, or communicating unwillingness to engage in, that conduct.
The Peace Corps defines restricted reporting to mean a confidential report made to designated
staff by a Volunteer who is sexually assaulted during service in order to receive restricted
report services without further disclosure of the Volunteers PII or details of the sexual
assault except to the extent necessary and without automatically triggering an official
investigation (IPS3-13).
Designated Staff refers to PCMOs, Sexual Assault Response Liaisons (SARLs), Safety and
Security Coordinators (SSCs), a Victim Advocate in the Office of Victim Advocacy, and
Assigned Security Specialist for the Office of Safety and Security. Medical and
counseling staff at Headquarters may be provided with the Volunteers PII and details of
the assault for the procurement of victim services (IPS 3-13 Restricted Reporting).
Many of the procedures in this Medical Technical Guideline will be relevant for all types of
sexual assaults. However, certain procedures are determined by the nature of the event. In all
cases of sexual assault, the emotional needs of the victim should be cared for in accordance
with Technical Guideline 545 Sexual Assault: Counseling.
Note: For purposes of this document, the word Volunteer will be used to encompass both
trainees and Volunteers and the female pronoun will be used, although Peace Corps recognizes
that males can also be sexually-assaulted.
B. Resources
To effectively respond to the sexual assault of a Volunteer, PCMOs should follow this
Medical Technical Guideline and adhere to policies and procedures outlined in the
following documents:
C. Statistics
It is estimated that one in every six women in the United States has been the victim of an
attempted or completed rape during her lifetime (RAINN, 2009). About 1 in 33 men have
experienced attempted or completed rape in their lifetime (RAINN, 2009).
Office of Health Services
June 2015
Page 3
It is the host countrys local judicial or legal systems responsibility to decide if the legal
definition of rape or sexual assault applies in a particular case. Regardless of how the law treats a
particular incident, if a Volunteer says that she has been sexually assaulted, she should be treated
as a victim of sexual assault for purposes of the Medical Technical Guideline.
Victims of sexual assault do not always present at the time of the incident, but may present at a
later date with incident-related symptoms (e.g., acute stress disorders, pregnancy, STD).
Individuals (men and women) who report that they have been sexually assaulted must be treated
in a compassionate, non-judgmental manner (see Technical Guideline 545 Sexual Assault:
Counseling.)
Typically, only 20 percent of assaulted victims have physical signs of abuse and less than 50
percent exhibit signs of trauma in the first 24 hours. Forty percent may never show signs of
trauma, but this does not mean that an assault did not occur. Victims of sexual assault are 3 times
more likely to suffer from depression, 6 times more likely to suffer from post-traumatic stress
disorder, 13 more times likely to abuse alcohol, 26 more times likely to abuse drugs and 4 times
more likely to contemplate suicide (RAINN, 2009).
D. Peace Corps Commitment to Sexual Assault Victims
The Peace Corps is committed to providing a compassionate and supportive response to
all Volunteers who have been sexually assaulted. To that end, the Peace Corps makes the
following commitment to our Volunteers who are victims of sexual assault.
1. Compassion. We will treat you with dignity and respect. No one deserves to be the
victim of a sexual assault.
2. Safety. We will take appropriate steps to provide for your ongoing safety.
3. Support. We will provide you with the support you need to aid in your recovery.
4. Legal. We will help you understand the relevant legal processes and your legal
options.
5. Open Communication. We will keep you informed of the progress of the case,
should you choose to pursue prosecution.
6. Continuation of Service. We will work closely with you to make decisions
regarding your continued service.
7. Privacy. We will respect your privacy and will not, without your consent, disclose
your identity or share the details of the incident with anyone who does not have a
legitimate need to know.
Peace Corps staff worldwide will demonstrate this commitment to the Volunteer through
our words and actions.
3. PCMO RESPONSIBILITIES
The general responsibilities of a PCMO when to prepare for and manage rape and sexual
assault are to:
July 2015
Page 4
Maintain hard copy information of host country sexual assault medico-legal resources for
quick reference and to provide for temporary duty medical officers providing clinical care
coverage on a short term basis.
Identify and maintain professional relationships with facilities or host country providers
recognized in the host country to perform SAFE exams.
Provide orientation to community back-up providers to Attachment L, A Step-by-Step
Guide to a Sexual Assault Report By a Volunteer to the Medical Duty Phone.
Fulfill the duties as a designated staff member as outlined in IPS3-13, Volunteer
Reporting of Sexual Assault and The Guidelines for Responding to Rape and Sexual
Assault
Assess the Volunteers physical safety, which is a shared responsibility among
designated staff.
Maintain medical confidentiality.
Explain to the Volunteer the policies and procedures for Restricted Reporting of Sexual
Assaults, the option to make either a Restricted Report or a Standard Report, and the
services that are available to the Volunteer, as well as IPS 1-11 Immunity from Peace
Corps Disciplinary Action for Victims of Sexual Assault. Use The Volunteer Reporting
Preference Form
If the Volunteer wants to report to local law enforcement, explain the local procedures
regarding a Sexual Assault Forensic Examination (SAFE) and the potential for such an
exam to lead to a standard report.
Ascertain how the Volunteer wants to report an incident (Restricted or Standard).
If necessary, contact the OMS Sexual Assault Nurse Examiner (SANE), International
Health Coordinator (IHC), or Counseling and Outreach Unit staff for clinical consults.
Perform a mental status exam and Acute Stress Disorder/Post Trauma Stress Disorder
screening and arrange for appropriate psychological support (see Technical Guideline
545 Sexual Assault Mental Health Assessment and Support)
Document the Volunteers pertinent history, injuries, and care in a separate file labeled
SA (Sexual Assault) attached to the Volunteers general medical file.
Provides a choice of medical and mental health providers to the extent practicable including a
Health Care Provider/Consultant Satisfaction Survey to evaluate the providers
Develop a treatment plan in conjunction with OMS and the Volunteer according to the
mental and medical health needs of the Volunteer.
Arrange for a medevac upon the Volunteers request or if the PCMO determines a clinical
need for medevac (MS 264).
If the Volunteer is going to be medevacd ensure that the Volunteer understands that she may
request an escort. Normally the PCMO should serve as the escort unless this will create a
hardship for post. In this case the SARL or another staff member may serve as an escort.
Offer a clinical exam to ascertain medical and mental health needs for a treatment plan.
Treat physical injuries.
Provide medication for the prevention of sexually transmitted infections including HIV.
Note: **PCMOs should know local resistant strains of sexually transmitted infections
and identify appropriate alternative therapies in-country with OMS approval.**
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Notify the Country Director to coordinate a response plan with the CD serving as the
team lead.
Determine if the Volunteer wants to undergo a SAFE and explain its purpose, the process
for conducting an examination, who is authorized to conduct the exam in country, and
where it will be conducted. A SAFE may require notification to local law enforcement.
When legally permissible and when requested by the Volunteer, the PCMO should
accompany the Volunteer to and during a SAFE exam. If Volunteer declines a SAFE
exam, offer a clinical exam and medical treatment as for a restricted report.
If a SAFE is to be performed by an authorized local authority, the PCMO should refrain
from providing medical treatment to the Volunteer unless waiting for the SAFE may
compromise health care outcomes of the Volunteer (e.g. providing PEP, Plan B, or STI
prevention, frank wounds that need immediate attention). After the SAFE, the PCMO
should then develop the treatment plan to include STI and pregnancy prevention, medical
treatment of injuries, counseling, and medevac options.
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4.
PCMOs must plan ahead to be able to clinically support a Volunteer who has been sexually
assaulted. Administrative preparations to assist PCMOs in preparing for management of
sexual assault are listed below. The PCMO must:
Participate in the facilitation of the required Pre Service Training Modules that outline:
o Services available to Volunteers including medevac options and health provider
surveys
o Where to go if assaulted
o Benefits from seeking medical care and emotional support, both immediate and longterm
o Trust in the PCMO and management system
o Peace Corps protocols and policies regarding support to Volunteers who have been
victims of sexual assault
Know basic host country laws and policies regarding sexual assault:
o Participate in the development of the Legal Environment Survey especially portions
that pertain to the SAFE
o Complete the SAFE Consultant Information Form (Attachment K) and update
annually.
o Have a basic understanding of the legal requirements for reporting and for a SAFE
exam for evidence collection. Be able to explain the SAFEs purpose, the process
for conducting the SAFE, who is authorized to conduct the exam in country, and
where it will be conducted.
o Know if the PCMO can accompany and support a Volunteer during the SAFE exam
Identify and maintain relationships with local sexual assault health care resources:
o Official facilities and/or clinicians in country that perform SAFE exams
o Official arrangement with the local SAFE facility or official provider if possible
(recommended)
o Health care facilities for gynecological and general trauma
o Mental health care providers that work with sexual assault or trauma victims
o Laboratory services that can provide basic required laboratory analysis (e.g., CBC,
STI screening, and pregnancy testing) as well as laboratories that provide drug
screening.
o Infectious Disease specialists to know STI drug resistances in country
Maintain a readily accessible sexual assault resource binder in the medical office that
contains written protocols, guidance, and information regarding host country laws,
facilities, and resources. Post-specific information should be updated at least yearly.
o TG 540 Sexual Assault Management and attachments
o TG 542 SAFE and Forensic Evidence Collection
o TG 545 Sexual Assault Mental Health Assessment and Support
o Guidelines for Responding to Rape and Sexual Assault
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MS 461
Official or unofficial agreements with forensic examiners in-country
Information regarding host country laws, facilities, and resources
Post Incident Assessment Tool
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2. Explain what is going to happen during each step of the exam. If the Volunteer asks,
explain why it is important, what it will tell the examiner and how the PCMO will use
the information obtained during the exam to determine treatment.
3. Reassure the Volunteer that she is in control of the pace, timing, and components of the
exam.
4. Reassure the Volunteer that the clinical exam findings will be kept confidential unless
she decides to revert to a standard report and pursue legal action.
5. Ask if she has any questions about the examination. Ask the Volunteer what she
imagines will be the most difficult parts of the examination. Listen carefully to any
concerns. Ask her what might help reduce her stress during the procedures. Provide the
Volunteer with as much choice as possible.
6. Ask the Volunteer who she would like to be in the room serving as a chaperone. A
chaperone is required to provide support to the Volunteer and is bound by
confidentiality. A chaperone can be the SARL, medical assistant/secretary, or any other
person the Volunteer would prefer to have in the room for support.
7. Discuss the exam consent form (Attachment C) with the Volunteer. Let her know that
she can refuse any aspect of the examination and that she can delete references to these
aspects on the consent form. When the Volunteer states she understands the consent
form, have her initial and sign.
8. Provide a secure, private location for the examination. During the exam, the only people
who should be in the room are the PCMO, the chaperone and/or SARL with the
Volunteer.
9. Perform the examination as soon as possible but only at the time agreed by the
Volunteer.
10. Do not force or pressure the Volunteer to do anything against her will. Explain that she
can refuse steps of the examination at any time but can still continue with other steps of
the exam.
D. Taking the History Using the Peace Corps Sexual Assault Clinical Exam Form
(Attachment D (Female) or E (Male))
1. Interview the fully-dressed Volunteer in the examination room.
2.
Use a calm tone of voice and maintain eye contact. Speak clearly and directly to the
Volunteer. Do not stand over the Volunteer. Sit equal or lower than the level of the
Volunteer and begin gathering the medical history.
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3. Start by letting the Volunteer tell the history of events the way she wants to. Do not
interrupt. Explain that she does not have to tell you anything that she is not
comfortable with. Examples of appropriate interview questions:
a. Tell me what happened. Please tell me everything you remember about what
happened. Describe to me what happened in the best way that you can. I know
these are hard questions, but in order for me to understand the care you will need, I
need to ask you more details about this. I will go as fast as I can.
b. Please explain any involvement of your body (e.g. mouth, vagina, anus, and
breast).
c. Can you tell about what happened here (PCMO points to wound)?
d. Are there any parts of the incident that you have difficulty remembering?
e. Is there anything that I did not ask you that you would like to tell me?
f. Can you describe what you were thinking or feeling during the incident?
4. The patient may omit or avoid describing details that are particularly painful.
However, it is important for the PCMO to understand what happened in order to
guide the exam and care to be provided. Reassure the patient that the information is
for this purpose and will be kept confidential, and that you believe her account of the
incident. Take a break during the exam if necessary.
5. After the Volunteer relates the incident to the PCMO, the PCMO may question to
clarify information in a careful manner so as not to imply blame or lead to answers.
An example of a good way to clarify information:
I did not quite understand what you said about your mouth and ejaculation. Can you
tell me that again?
6. Do not ask questions that begin with why as they imply blame. Typical questions
that should be avoided:
a. What were you doing there?
b. Why did you go there?
c. Remember in PST when we discussed that letting a man into your home gave him
permission to have sex with you? Im sure he was confused with your
signals.
d. Were you wearing something that could have led the man on?
7. Asking about alcohol is sensitive and it is important not to imply blame. Tell the Volunteer
that the history of alcohol consumption is important especially when providing prophylactic
medications that may react adversely with alcohol. If the Volunteer shows signs of being
uncomfortable with the response to this question, reassure her that alcohol consumption will not
be used to accuse or blame her for the assault. Appropriate questions to ask:
a. When was the last time you had an alcoholic drink as this might affect the drugs or
treatment that I may offer you?
8. Take sufficient time to gather the information needed to focus the clinical exam.
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9. Except to help clarify information, avoid asking questions repeatedly or asking the
Volunteer to repeat her story unnecessarily.
10. Avoid distractions or interruptions during the history and exam.
11. Write precisely in the Volunteers own words including the history of events, threats
made against her and name(s) of assailant(s). Use qualifying statements such as:
Volunteer states or Volunteer reports Document what the Volunteer says
exactly in quotation marks. Do not sanitize or remove remarks such as slang,
offensive, or derogatory statements.
12. Review health record and confirm on-going health concerns, medications, vaccine
status, urological issues, and current STIs.
13. Evaluate for possible pregnancy by asking for details of current contraceptive use
(consistently and correctly), last menstrual period, last date of consensual sex and
contraceptive used at that time.
D. Perform and Document the Sexual Assault Clinical Exam (Attachments D:
Female, E: Male, and F: Strangulation)
1. Prepare equipment and supplies before the Volunteer enters the exam room.
2. Use the Sexual Assault Clinical Exam For (Attachment D: Female or E: Male) to
document the history and examination.
3. Explain everything you will do in advance and as you do it.
4. Listen carefully to any concerns voiced by the Volunteer.
5. Check regularly throughout the exam about the patients level of anxiety.
6. Engage in dialog during the exam.
7. Consider talking to her about her work or family because in some cases this kind of
distraction may help sexual assault survivors cope with distress of the post-assault
examination.
8. Utilize the Strangulation Documentation Form (Attachment F) if appropriate.
9. Help to minimize PTSD reactions during the examination. (Sharkansky (2011).
Despite providers best efforts, sometimes posttraumatic stress symptoms occur during
an exam. If this happens, dont panic. Use grounding techniques with the patient:
Speak in a calm, matter of fact voice and avoid any sudden movem ents
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Reassure the Volunteer that she is in a safe environment, and although she is
having a reaction, she will be okay.
Explain that you are examining her asking permission to continue the
examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold
washcloth for her face.
If possible, go with her into a different room to provide a change of environment.
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HIV
The risk of acquiring HIV infection as a result of rape depends on the likelihood of the
assailant having HIV, the sexual acts performed, and other factors (associated trauma,
presence of other STDs, etc.) According to the CDC, HIV sero-conversion has
occurred in persons whose only known risk factor was sexual assault or sexual abuse,
but the frequency of this occurrence is probably low. In consensual sex, the risk for
HIV transmission from vaginal intercourse is 0.1%0.2% and for receptive rectal
intercourse, 0.5%3%. The risk for HIV transmission from oral sex is substantially
lower. Specific circumstances of an assault (e.g., bleeding, which often accompanies
trauma) might increase risk for HIV transmission in cases involving vaginal, anal, or
oral penetration. Site of exposure to ejaculate, viral load in ejaculate, and the presence
of an STD or genital lesions in the assailant or survivor also might increase the risk for
HIV. Refer to TG 712, HIV Prevention and Treatment for further guidance.
Recommended HIV Post Exposure Prophylaxis:
Truvada (Tenofovir 300mg + Emtricitabine 200mg) 1 tablet orally QD for 28 days,
AND
Isentress (Raltegravir 400mg) 1 tablet orally BID for 28 days
Truvada carries a Black Box Warning indicating risk of hepatotoxicity and exacerbation of
Hepatitis B therefore it is imperative that HbsAg is drawn prior to prescribing Truvada.
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There is a high likelihood that DFSA drugs metabolize quickly and are not found
in the specimen.
There is no chain of custody for the specimen; therefore, the specimen is not
admissible.
7. DISCHARGE INSTRUCTIONS
A Volunteer who has been a victim of sexual assault will need follow- up clinical care and
emotional support. The following documents should be provided to the Volunteer to educate,
reinforce, and promote compliance with post exposure prophylaxis care and follow- up.
A. Sexual Assault Discharge Information & Instructions for Volunteers Form
The Sexual Assault Discharge Information & Instructions for Volunteers Form
(Attachment I) should be used for follow-up care and instructions to inform Volunteers of
the treatment they have received and follow up clinical requirements.
B. 127-C Forms at Close of Service
Upon Close of Service, all Volunteers who have been treated or are currently undergoing
treatment for sexual assault must receive 127-Cs for counseling and any outstanding followup clinical care and testing.
The PCMO should issue a 127-C for any outstanding sexually-transmitted infection testing or
pregnancy per instructions in this guideline and as appropriate.
For psychological support and counseling, the 127-C must be for a PhD psychologist or
psychiatrist with these instructions:
Provide three initial counseling sessions to provide support and evaluate for further
counseling needs. Call the Post Service Unit for additional sessions at 202-692-1540
opt.7.
C. SUMMARY CHRONOLOGICAL NOTE
The summary note (example in Attachment J) is a chronologic note in SOAP
documentation format to recap the clinical examination, the PCMOs assessment and the
plan for the Volunteers continued care. The summary note should be put in the separate
sexual assault medical file attached to the medical record.
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REFERENCES
Centers for Disease Control (2015). Sexually Transmitted Diseases Treatment Guidelines, 2015.
http://www.cdc.gov/mmwr/pdf/rr/rr6403.pdf
Eisenhower Medical Center. (n.d.) Forensic Medical Report: Acute Adult/Adolescent Sexual
Assault Examination Form, Sexual Assault Exam Instructions, Strangulation Addendum.
Faugno, Diana (MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN. Director, End Violence
Against Women International. http://www.evawintl.org/about.aspx
Guidelines for Responding to Rape and Sexual Assault. (2013). Office of Safety & Security,
U.S. Peace Corps.
Giardin, B.W., Faugno, D.K., Spencer, M.J. & Giardino, A.P. (2003). Sexual Assault:
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http://www.womenshealth.gov/publications/our-publications/fact-sheet/emergencycontraception.cfm#b
Office on Violence Against Women. (2004, September) A National Protocol for Sexual Assault
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Rape, Abuse, and Incest National network (RAINN). (2009). Statistics. http://www.rainn.org/
Sharkansky, E. (2011). Sexual trauma: Information for womens medical providers. National
Center for PTSD. Retrieved from: http://www.ptsd.va.gov/professional/pages/ptsdwomens-providers.asp
Sirchie. (n.d.). VEC#100 Exam and Consent forms and Sexual Assault Forensic Evidence
Collection Kits. http://www. sirchie.com
Washington DC Sexual Assault Nurse Examiners (SANE) Protocols. 2011.
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Weathers, F. W., Litz, B. T., Herman, D., Huska, J., & Keane, T. (1994). The PTSD checklist
civilian version (PCL-C). Boston, MA: National Center for PTSD.
Weaver, Michael L. MD, FACEP, FCC. System VP Clinical Diversity and System Medical
Director, Forensic Care Program. Saint Lukes Hospital of Kansas City. mweaver@saintlukes.org
World Health Organization (WHO). (2005). Clinical management of rape survivors: Developing
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