It's enhanced and advanced training that qualified providers need, yet hope they never have to use.

It's also standardized instruction for all military branches, subject matter expert driven, and required by law.

Naval Hospital Bremerton held Sexual Assault Medical Forensic Examiner (SAMFE) training for the week of July 20-24 that was attended by experienced Navy Sexual Assault Forensic Exam providers.

The SAMFE training features enhanced curriculum to augment the command's response ability in preventing and eliminating sexual assault, as well as continuing to provide timely patient-centered care to any victim in need.

"This training is very important to the Navy. It has the attention, alignment and purpose of all the service surgeon generals. Congress has called for the uniform training and this is our beginning. We will deliver patient-centered trauma support and care. The focus of the course is that the victim comes first," said Cmdr. Gregory Freitag, Navy's Bureau of Medicine and Surgery (BUMED) Sexual Assault Medical Program manager.

Freitag is part of the BUMED team directing the advanced and enhanced training, with an emphasis on policy, headquarters oversight, and being able to address questions and provide insight to how the training relates to Navy Medicine.

NHB is the initial stop on the training itinerary that is the culmination of months of behind the scenes work by the three services - Navy, Army, and Air Force - to have uniformed standard training to expand provider knowledge and comprehension of medical-forensic care to sexual assault patients.

The SAMFE curriculum has multiple disciplines sharing that include Fleet Family Support Center, SAPR, Victim Advocates, Pastoral Care, Mental Health, law enforcement, Naval Criminal Investigative Service, and Navy Judge Advocate General Corps' victim legal counsel.

Freitag attests that the biggest difference between the civilian sector and the military is that in the armed forces, sexual assault is a more broadly defined concept. Any type of unwanted sexual contact, from breast to genitals, can be considered a crime and will be investigated as such.

"Our nation's military works sexual assault differently. Every report is investigated. Every allegation is taken seriously," Freitag stressed.

The military focused training is addressing overlapping areas of training requirements.

"We have subject matter experts here to share best practices and up to date information. This is a valuable experience for us all because we can learn from each other, network, and help to further the science of sexual assault medical forensic work," said Lt. Cmdr. Lacy L Gee, Nurse Corps, Certified Nurse Operating Room, Main Operating Room division officer, Sexual Assault Nurse Examiner and organizer of the SAMFE training at NHB.

Gee notes that the SAMFE course is not focusing on teaching about performing medical forensic exams. The ability to perform such is a service that the providers enrolled in the course already are able to handle to beneficiaries, whether stateside, at sea, or forward deployed down range. They already know a forensic exam is not the same as a physical exam and the principles behind proper evidence collection and forensic photography. The 26 course modules for this week are increasing their ability to interact with patients that have experienced sexual assault trauma.

"By training examiners and assistants here, we provide them the opportunity to carry this skill with them throughout the Navy, regardless of their assignment. We're committed to providing exceptional care to all our patients," Gee said.

Guest lecturers in their recognized fields such as toxicology experts and professionals on behavioral healthcare for sexual assault patients are on the schedule for such topics as,'Victim Advocacy and Sexual Assault,' 'Intimate Partner Sexual Assault,' 'Healthcare Implications of Sexual Violence,' 'Informed Consent,' 'Patient Centered Care,' 'Military Criminal Investigative Officers (and) Investigative Aspects of Sexual Assault,' 'Legal Considerations/Reporting Options/Payment Under the Violence Against Women Act,' 'Sexual Assault Medical-Forensic Exam,' 'Forensic Evidence Processing and Analysis in Sexual Assault Cases,' 'Alcohol and Drug Facilitated Sexual Assault,' 'Medical-Forensic Documentation,' 'The Male Sexual Assault Patient,' 'Sexually Transmitted Diseases Evaluation and Treatment,' 'Pregnancy Risk Evaluation and Care,' 'Discharge Planning and Follow-up Care,' 'Suspect Examinations,' 'Sexual Assault and Contingency Operations,' and 'Compassion Fatigue.'

"I think one of the best aspects of this entire course is that we all get to share our experience, knowledge and use that better ourselves and each other in this discipline," said Lt. Sarah Huley, NHB SAFE examiner and Critical Care Nursing division officer, who is teaching several modules in the week-long course.

The training will wrap up on Friday with the emphasis on the military justice process and the role of the SAMFE at trial.
Freitag notes that historically, the sexual assault forensic examiner role has been seen as an arm of law enforcement.

"When a provider presented themselves as a law-enforcement proxy, their testimony a lot of the time would be discounted. We'll go over cross examination skills needed and refine how to be objective witnesses," Freitag said.

"I used to work in trial settings taking notes as part of my job so I was used to being in court. But once I got called up to testify and that was entirely new. I almost couldn't help but be nervous. It can happen to anyone. This training will definitely help," added Peter Medina, NHB Paralegal Specialist.

With the SAPR providers already trained in forensic exam protocol, the added insight from the course syllabus will enable them to deliver a high standard of compassion, care and concern to any sexually assaulted victim. Just understanding the physiological reactions of sexual assault will help the providers in turn help their victims.

Using the 'fight or flight' analogy for someone to respond to trauma, Freitag pointed out that there's also a third option - 'freeze' - with which a person can react to a shock to the system like being sexually assaulted. Recall can be delayed. Memory of events can be disorganized.

"Victims often appear unable to comprehend and remember. As a result, in the past, there was been case attrition with snap decisions being made because an attorney or law enforcement officer didn't think there was any chance for a case. It's not a question of contact; it's a question of consent. In every case, the victims will need compassionate patient centered care which is vital for their recovery and resiliency," Freitag said.
According to the Department of Defense Sexual Assault Prevention and Response 2014 Annual Report, the estimated number of service member sexual assault victims in Fiscal Year 2014 was 18,900, compared to an estimated 26,000 in FY 2012. There were 6,131 reports of sexual assaults in FY 2014.

"We did 342 total exams in the Navy for Fiscal Year 2014, with 11 taking place on a ship. Getting a DNA swab during the forensic exam is part of the process but it isn't the real importance. Providing the best medical care that we can to the patient is our best way to provide for them, assist in their healing and in getting them back to where they need to be," said Freitag.

BUMED directed the establishment of a multidisciplinary team three years ago - made up of doctors, nurses, physician's assistant, independent duty corpsmen - to be able to handle any such need at a military treatment facility like NHB with staff trained and available to ensure timely and appropriate medical care is available to sexual assault victims as soon as possible.

The release of the FY15 National Defense Authorization Act (NDAA) increased the training requirement for SAFE, now SAFME, trainers stating that they needed to hold either a Sexual Assault Nurse Examiner Adult/Adolescent certification or equivalent, or have training and clinical/forensic experience in sexual assault forensic examinations similar to that required for certification.

NHB's SAMFE, as well as Sexual Assault Prevention and Response (SAPR), are both comprehensive programs staffed by trained personnel to reinforce a culture of prevention, response, and accountability for the safety, dignity, and well-being of Sailors and Marines. The Department of the Navy does not tolerate sexual assault.

"We in the military have to be good stewards of public trust. In our diverse community we have to be adaptable and responsive to the needs for patient centered care. Having a structured program in place that includes such core responsibilities as Victim Care Protocols are important to every command with SAMFE and tailored to each military treatment facility," Freitag said.

Victim Care Protocols are MTF specific. At NHB they include a safe (exam) room in the Urgent Care Center, victim advocate availability, as well as having professionally trained staff member(s) to guide through the entire forensic exam process.
Under the leadership of Lt. Angela Sadosky, Occupational Therapist and SAPR Program Coordinator, NHB ensures that sexual assault education is provided to every Sailor on a regular basis. Drills and awareness events are held. There is an informational photo board on the first floor displaying the command's victim advocates, so staff as well as beneficiaries are aware of who they can turn to in case they have questions or need help. Additionally throughout the entire hospital, DoD Safe Helpline posters are affixed so everyone knows where to turn for increased professional help if needed.

"To have the senior leadership and surgeon general's concurrence and endorsement is very gratifying. As we continue to practice in the fleet, we will ensure robust delivery of care is in alignment with the Chief of Naval Operations, Adm. Jonathan Greenert goal for the program," Freitag said.

For more news from Naval Hospital Bremerton, visit www.navy.mil/.