Dr. Tiffany Kuehl strides through the emergency department at Deaconess Medical Center, past rows of glowing computers and high-tech monitors aimed at healing trauma of every type.
Around a corner and down a short hall, however, the doctor stops, pausing for a moment before showing visitors the decidedly low-tech equipment used to treat victims of rape and sexual assault.
Tucked in a recess of the busy ER, a wooden cart is stacked with evidence envelopes, empty vials and nine sealed rape kits – enough for an average month.
“It’s kind of old-school,” admits Kuehl, 33, dressed in gray scrubs and sneakers. “We’re working on that.”
But upgrading the cart – the hospital’s only dedicated space for the supplies – is just one of many tasks facing Kuehl and a group of community activists struggling to start the first Sexual Assault Nurse Examiner – SANE – program in Spokane.
In September, they brought staff from Seattle’s Harborview Medical Center to conduct 40-hour training sessions for 17 nurses from the emergency rooms of the region’s four largest hospitals. But Kuehl and other organizers say that’s only the first step to providing compassionate care and vital evidence collection for nearly 600 rape and assault victims who show up in the ERs each year – and an estimated 3,000 more who don’t.
“We’re starting from scratch to treat sexual assault,” Kuehl said.
It’s been almost 30 years since nurses in Minnesota, Tennessee and Texas first started SANE programs based on the idea that victims of rape and sexual assault require specialized treatment.
And it’s been at least a dozen years since SANE programs began sprouting nationwide in cities much larger – and much smaller – than Spokane. Today, some 472 programs are logged in a database kept by the International Association of Forensic Nurses in Arnold, Md.
So common are SANE programs, in fact, that when Kuehl arrived in Spokane in 2003, she was stunned to learn there wasn’t one here.
“I thought for sure Spokane would have a well-developed program,” said Kuehl, a Montana native whose residency in New Mexico offered the training. “Other ER docs come here and they say, ‘What? You don’t have a SANE program?’ ”
It’s not for lack of interest, say police and social service workers. During the past decade or more, efforts to begin SANE programs have started – and sputtered, said Detective Jan Pogachar of the Spokane Police Department.
“I’m not the first one that’s tried to push this through,” said Pogachar, who makes no secret of her frustration at the long delay. “That’s an embarrassing thing for Spokane.”
Kootenai Medical Center in Coeur d’Alene once had several SANE nurses on its staff and equipment to conduct detailed evidence exams. Those nurses have since left, said Lisa Johnson, a hospital spokeswoman. There is at least one SANE-trained nurse at Bonner General Hospital in Sandpoint.
In Spokane, competition among the region’s hospitals, concern about funding and questions about where such a program would be housed and how it would be sustained have slowed nearly every effort, organizers say. In addition, there’s a widespread community reluctance to acknowledge that sexual assault is a problem.
“I think we’re still a conservative town, aren’t we?” Pogachar said. “Head in the sand? The idea that this doesn’t happen here?”
In fact, Spokane’s rate of rapes exceeds state, regional and national averages, according to information from the Uniform Crime Reporting program forwarded to the FBI. Ninety-one rapes were reported by Spokane police in 2006, and 54 were logged through July of this year.
Last year, Spokane’s rape rate was 45.5 per 100,000 people, higher than Washington’s rate of 42.9 per 100,000 and a national rate of 30.9 per 100,000, UCR data showed.
Because of pending investigations, it’s unclear how many rapes are prosecuted in Spokane each year, but Ed Hay, a deputy with the local prosecutor’s office, estimates that his office cleared 60 cases in 2006.
In Spokane, as elsewhere, most rapes and assaults are never reported. Many are cases of third-degree rape, in which victims know the perpetrators, Pogachar said.
“We see a lot of date-rape,” she said. “It’s a he-said, she-said situation.”
Kuehl treats at least two victims of rape or sexual assault each week. The same goes for Jim Lyons, an emergency room nurse at Deaconess who has made it a personal resolution to start a SANE program in Spokane. Lyons, 49, who suffered abuse as a child, said it’s vital for victims – he calls them survivors – to have compassionate care.
“Our nurses are honestly doing the best they can with what they have, which in most cases is no specialized training,” said Lyons. “I want people to do the exam that have some level of empathy. That never happens now.”
Without trained SANE nurses, victims of sex crimes in Spokane experience problems reduced or eliminated in other communities. Long waits are common here, for instance. Because most sexual assault victims don’t have life-threatening injuries, medical crews often prioritize other patients.
“I’ve had them wait five to six hours,” Pogachar said. “The average is two or three hours.”
Victims aren’t allowed to eat, drink, urinate or shower during that time to preserve evidence.
A 16-year-old Shadle Park High School girl waited nearly four hours for care in August after an 18-year-old acquaintance forced her to have sex. She’d dated the boy for a few weeks when he assaulted her at her home.
Deciding to go to the hospital was difficult, she said. But the process that followed was worse.
“It was slow. It was just so slow,” said the girl, who showed up in the Deaconess ER at 2 a.m.
The Spokesman-Review does not identify victims of sex crimes.
An advocate from Lutheran Community Services was called to comfort the girl, but without a trained SANE nurse available, she had to wait for a doctor to arrive to conduct an exam and collect evidence. The girl almost bolted several times during the ordeal.
“I started getting antsy. I said I don’t like being here. I was getting pushy because I wanted to leave,” she recalls.
Many victims do leave, said Hay, the prosecutor, depriving themselves of treatment and justice – and leaving perpetrators free in the community.
Even when they are seen, some victims are further traumatized by the treatment they receive from untrained medical staff, Pogachar said.
“Doctors, some of them, aren’t real sympathetic,” she said. “They don’t believe the victim. And some nurses in the ER don’t want to deal with the rape victims.”
The 16-year-old said the male doctor who examined her quizzed her about the details of the assault in the midst of the exam.
“I was like, are you joking me?” she said. “Couldn’t you ask someone I’ve already told that to?”
It’s not that the doctors and nurses are insensitive or unkind, Kuehl said. Without specific training, medical workers don’t realize that how victims are treated can determine whether – and how well – they recover from the ordeal.
“There are few opportunities in the ER when we have such an opportunity to impact somebody’s life at a critical moment,” Kuehl said. “This can be either the first step to healing or a cycle of negative outcomes.”
That’s been proven during years of research into the effectiveness of SANE programs, said Rebecca Campbell, an associate professor of psychology at Michigan State University who specializes in the subject. Studies show SANE-trained staff provide not only psychological comfort, but also better evidence collection that leads to higher rates of arrests and convictions.
“When you treat victims with dignity and respect and calmness, they become better witnesses,” said Campbell.
SANE programs also help decrease the stigma surrounding rape and sexual abuse, which persists despite decades of activism, Campbell said.
“It’s based on that old assumption that women lie about rape,” she said. “There are false rape reports, but those are very rare.”
Starting a SANE program in a community like Spokane is a good first step, said Dr. Naomi Sugar, medical director of Seattle’s Harborview Center for Sexual Assault and Trauma Stress.
That program, one of nine in Washington, sees 400 to 450 victims a year. About 70 percent of those are treated by on-call, SANE-trained staff, Sugar said. (SANE nurses aren’t available for all shifts and some victims decline the services, Sugar said.)
It may take three or four years for the impact of a new SANE program to be seen in reports, arrests and convictions, but it will come, experts say.
“You begin how you can begin,” Sugar said.
It’s still too early to tell the impact on victims treated by the newly trained SANE nurses, said Marcia Black-Gallucci, an advocate with Lutheran Community Services in Spokane. Last year, the agency logged 3,125 face-to-face crisis visits with victims of assault, records show.
But there’s no question that it will improve a hospital system that can traumatize victims again.
“If they’re blamed, shamed and judged, it’s compounded, the harm they suffer,” Black-Gallucci said. “It’s bad enough to be hurt, but then to have a professional come down on you – it can be devastating.”
With some work, Spokane soon could have a system that allows healing to begin immediately, a benefit not just to the victim, but to the larger community, organizers say.
“Sexual abuse is a very, very wounding happenstance to people,” Black-Gallucci said. “It can determine what kind of a marriage partner they’ll be, what kind of a parent, even what kind of a citizen.”