Debbie Holbrook says the same thing to every one of her patients when she meets them in the waiting room: “I’m going to take really good care of you today. You are safe with me, and I believe you.”

Holbrook is a sexual assault nurse examiner (SANE) at Mercy Medical Center in Baltimore, Maryland. When a victim of sexual assault comes to a local emergency room, Holbrook is often the person who performs the exam.

Holbrook addresses her patient’s medical needs, caring for any injuries they may have sustained and offering medication to prevent disease or pregnancy. But her work as a nurse examiner is also tied to the legal system. She collects forensic evidence for a rape kit, and she carefully photographs every bruise and laceration. She obtains both a medical history and a precise account of the assault.

Over the course of her career, she has heard some horrendous stories: girls raped by their mothers' boyfriends; victims of repeated domestic abuse and sex trafficking; people who were drugged and woke up naked, with no memory of the night before.

“You never care for a happy case,” she says.

Holbrook is one of about 2,600 sexual assault nurse examiners in the United States registered with the International Association of Forensic Nurses — a very small portion of the more than 4 million registered nurses in the country.

In 2016, the U.S. Government Accountability Office (GAO) studied SANE coverage in six states: Massachusetts, Oregon, Wisconsin, Colorado, Florida, and Nebraska. In every state, the need for nurse examiners was far higher than the supply. Four out of six states had only “few or some” hospitals with SANE care available. Nearly half of the counties in Wisconsin did not have SANE programs. In Nebraska, most counties had none.

As a result of this shortage, sexual assault victims may end up having to travel up to two hours to obtain an exam by a properly trained nurse examiner. A victim may show up to a Level One trauma center, only to be told they should go to another hospital.

Sally Laskey, CEO of the International Association of Forensic Nurses, says that this practice is particularly damaging to survivors of trauma and sexual assault.

“The first person that a trauma survivor reaches out to, and what that interaction ends up being, how that person responds, ultimately shifts the path of what services they may seek out, of who they may tell their story to in the future,” she says.

If a victim doesn’t feel believed or cared for, or if, after going through an intense trauma, they’re told they have to get back in the car for several hours, they may simply give up. According to Laskey, this means they miss out both on medical treatment and on the possibility of collecting a rape kit.

Laskey says research has found that “individuals that receive care from a SANE are more likely to have better evidence collected, their cases are more likely to be prosecuted, and their health care needs met.”

Vicarious trauma and burnout

Sexual assault nurse examiners are constantly exposed to violent stories, and they often encounter something called vicarious trauma — they themselves experience intense emotional distress to the extent that it actually changes brain structure and neural function.

SANE Debbie Holbrook feels she’s experienced this. She’s found herself suddenly crying in the car at a red light, with seemingly no trigger.

“It’s not like watching it on TV or a movie,” she says. “You’ve taken care of that person’s body. You have sat with them when they’re crying in the worst moments of their life telling you something that they may not have ever told anybody before. You know, these things, they build up.”

Oftentimes, it isn’t possible to finish a case and move on. Nurse examiners are regularly called to testify in sexual assault trials, which means they have to repeatedly review the graphic material related to the case. Holbrook estimates that, on top of her daily work in the hospital, she usually has about 40 cases she has to keep revisiting as trial dates get continued or postponed.

Consequently, burnout rate among sexual assault nurse examiners is high; a study done by the International Association of Forensic Nurses found that, out of a pool of 540 newly trained examiners, only 42 were still practicing two years later.

Holbrook, who has been practicing for two decades, fights burnout by regularly practicing meditation. She sits in her car and says a prayer before she enters the hospital at the beginning of every shift. She’s also in therapy for the third time in her career.

Providing nurse examiners with the necessary education — at least 40 hours for certification, followed by additional continued training — can be challenging for some hospitals; the 2016 GAO report listed education and financing education as major impediments to having them on staff. But Laskey says that an investment in SANE education both keeps nurses up to date on best practices and helps battle burnout.

“We know that learning new things is actually one of the key tools to address vicarious trauma and kind of rewire our brain to be able to be more resilient and can help forensic nurses as they continue to do this very critical and important work for a patient population,” she says.

Laskey also stresses the importance of creating SANE programs that foster peer support, and that are structured so that employees can recognize vicarious trauma in their colleagues and offer help. Formal programs like these, currently present in 17 percent of U.S. hospitals, typically have better luck retaining staff and staving off the shortage.