The Invisible Voice.

Abstract

During my overnight shift in the emergency department, around 0230, I had finished up with another patient when I saw that a sexual assault victim had just been checked in for evaluation. After quickly skimming the patient's chart, I entered the room to find a petite young woman, sitting timidly on the stretcher with an emotional reservation creased into her face. With tight yoga pants and a loose fitting satin top, she seemed inappropriately dressed for the piercing, subzero winter night in New Hampshire. Her companion stood in stark contrast: a tall obese male wearing a down jacket, with distracting facial piercings, disheveled hair, and multiple stenciled tattoos on his hands and neck. In the initial silence, the peculiarity of the dynamics between the two suffocated the room. The man displayed a forced distress, as he clasped the patient's hand and moaned, “Does my size even matter if I cannot protect my wife?!” I gently pulled my chair next to the stretcher, trying to convey compassion and engender the patient's trust. As I started the interview, I became unnerved that whenever I asked the patient a question, her eyes would dart nervously toward her looming companion, and he would answer. Sensing my concern, he preemptively stated, “She had a violent boyfriend previously and so she feels uncomfortable around males.” Nodding gingerly, I requested to do a physical exam: once again, the patient looked to her companion for approval, which he gave. While my role focused on medical concerns, I felt incomplete without more situational context, and so I asked her to elucidate what had happened that night, a role typically left to the sexual assault nurse examiner (SANE). The companion promptly narrated an illogical, essentially implausible story, of a rape that left me feeling flabbergasted; thankfully my face mask and eye-pro hid my facial expressions. I looked at the patient for any engagement, her head had remained bowed during the companion's narration, but she glanced up at me; her eyes spoke volumes for her silence. Excusing myself, I communicated my concern for coercion and possible human trafficking to our SANE nurses. The SANE nurses spent 2 h in the patient's room and returned stating, “I am pretty sure he is prostituting her out.” The man had become increasingly more aggressive: refusing to leave the room for any part of the examination, preventing the collection of serum samples but allowing the collection of a urine sample. In addition, during their physical examination of the patient, the SANE nurses had found multiple “defensive wounds” and had discerned an additional history of strangulation. As a result, we ordered a CTA neck to rule out a dissection, but also to separate the patient from her companion and provide her with resources. When the attending and I entered the room, I sat next to the victim and the attending sat closer to the door. As the attending began to speak about obtaining advanced imaging, the companion interjected with incredulity, stating that they had “been there for hours.” Despite our calm explanation regarding the imaging and offering them food vouchers, the man perpetually interrupted my attending, demanding an antibiotic prescription for the patient for any possible STIs. He fomented increasing hostility in the room and assumed a threatening posture against my attending, a petite woman. “You are not listening to her,” he yelled, referencing his “wife” whom we had not heard from the entire night, “We will walk right out of here. Give us the paperwork!” In the subsequent seconds, I felt an uncomfortable warmth layer the back of my neck, as I mentally prepared myself for a physical confrontation to protect my attending. Thankfully, my attending defused the situation saying that the imaging could be obtained as an outpatient and that they could be discharged. I felt nauseous leaving the room. As she was escorted by her companion into the frigid morning, the patient's silhouette rapidly enveloped into darkness the farther she walked from the gleam of the illuminated red emergency room sign. When she stepped into the pick-up truck some distance away and shut the door, the passenger window fogged up in a staccato of rapid breaths: tearful pleas, her phonation appeared hobbled and pitiful, … but we never heard her voice.