JOHN DAY — Being sexually assaulted is a devastating experience, but for the victim, the ordeal doesn’t end there.

Next comes the rape exam, a combination medical and forensic procedure that involves treating the victim’s injuries while also gathering evidence that can be used to arrest and prosecute the assailant.

For a survivor of sexual assault, it requires an act of courage to go to their local hospital and ask to have a rape exam performed. So imagine how it would feel to be told the hospital doesn’t have anyone with the training to do the exam.

That’s currently the case at John Day’s Blue Mountain Hospital, the only hospital in Grant County, which has not had a trained sexual assault examiner on staff since the beginning of 2021. The nearest facility that can do the exam is St. Charles Medical Center in Bend, which means a three-hour drive — each way.

“What happens sometimes is the victim just says, ‘I’ve had enough. I want to go home,’ ” said Debbie Morris, director of nursing at Blue Mountain Hospital. “So what happens if they don’t press charges is the criminal just gets away with it.”

Grant County is certainly not alone. Sexual assault nurse examiners — known as SANE nurses, or simply as SANEs — are in short supply throughout the state, particularly in rural areas. At the moment, there are only 16 in all of Northeast Oregon, and only three of those are certified by the state. Three counties in the region — Grant, Morrow and Baker — currently have no one available to do rape exams.

Blue Mountain Hospital has two nurses who are in the process of training to become certified SANEs, and other hospitals in Northeast Oregon are looking for candidates to do the same. But finding them isn’t easy. Hospitals are already grappling with a nursing shortage, and recruiting nurses willing to take on the added burden of performing rape exams is challenging at best.

And in the meantime, people who have been sexually assaulted — usually women, but not always — may find themselves having to travel long distances in the aftermath of the most traumatic experience of their lives to get the medical care they need in pursuit of justice.

“It’s a need,” Morris said. “We would just like to take care of our residents here and not have to have them go through that. … It’s traumatic enough.”

Support is available

Resources are available to help survivors of sexual assault. Every county in Northeast Oregon has a nonprofit rape crisis center that can provide a wide range of services, such as a 24-hour hotline, emergency shelter, safety planning, legal advocacy, support groups and referral to other services.

Heart of Grant County, located in John Day, is a typical example. And like similar organizations elsewhere, the group guarantees confidentiality for survivors.

“We are not mandatory reporters, so everything is confidential,” said Beth Simonsen, the nonprofit’s executive director.

“Sometimes we have people who just need to come in and tell us their story. They need to talk to somebody but can’t talk to their family, can’t talk to their friends because they feel somebody’s going to blab.”

In addition to Simonsen, Heart of Grant County has two advocates on staff: Rayme Lacey and Elisha Nightingale. At least one of them is always available to help survivors of sexual assault. That includes accompanying them to a rape exam, even if that means driving them to Bend, staying by their side throughout the procedure and driving them back home — or wherever they feel safe.

“They don’t have to go through it alone,” Lacey said. “We’ll give you some of our strength.”

Survivors of sexual assault may need that strength to get through a rape exam — especially if they have to travel a long distance to get it.

“By not having services in our county, it requires about a 12- or 14-hour day,” said Nightingale.

From John Day, it’s a three-hour drive to St. Charles Bend, which is currently the nearest facility with SANE nurses reliably available. But that doesn’t mean the nurse is waiting when the patient gets there. Typically, Nightingale said, the hospital doesn’t call the SANE nurse in until the assault victim checks in.

“At night, they may or may not be available,” she said. “It can take time.”

The exam itself typically takes four to six hours, sometimes longer. And in order to preserve evidence that can be used to prosecute the attacker, survivors are told not to eat, drink, shower or use the bathroom until after the examination is complete.

Sometimes the exam can continue late into the night or early morning hours.

“On my most recent accompaniment, we arrived at the hospital in Bend, after a three-hour drive, at 3 p.m.,” Nightingale wrote in an impact statement quantifying the need for SANE services in Grant County.

“The exam continued until 10 p.m. My client was exhausted and we were still hours from home. Heart of Grant County paid for a hotel for this client to be able to go take a hot shower and have a good night’s rest before driving three hours home the following day.”

Earlier this year, Lacey worked with a client who had been sexually assaulted but decided not to get the exam after learning she’d have to travel to Bend — even though Lacey offered to drive her there.

Some stories are even more heartbreaking.

Last winter, Lacey said, a Grant County woman who had been sexually assaulted and wanted to get an exam decided to drive herself to a hospital in another county for the procedure. On the way, her car broke down on a remote stretch of highway. With no cell service, she waited in the dark on the side of the road until she could flag down a passing motorist and get a ride home. She never had a sexual assault exam done.

“It is something that affects all of rural Eastern Oregon,” Nightingale said. “All of rural Eastern Oregon is faced with a shortage of those nurses to do exams.”

Extent of the problem

The Oregon Attorney General’s Sexual Assault Task Force runs the state’s certification program for sexual assault nurse examiners. And while medical practitioners who are not certified can still perform rape exams, certification ensures that the provider has the latest training in compassionate and trauma-informed care and is doing enough exams to keep current on the skills involved.

And according to Mei Pomegranate, SANE coordinator for the task force, there aren’t nearly enough certified practitioners to go around.

“We have somewhere in the neighborhood of 100 certified SANEs (statewide),” Pomegranate said. In the six counties that make up Northeast Oregon, “there is a total of three certified SANEs, which is pretty bleak.”

“I’ve heard of patients going across state lines … because that’s their nearest or most practical option,” Pomegranate said. “I’ve heard of people commuting long distances, four or five hours, to get that kind of care.”

Around the region

There are seven hospitals scattered around the six counties that make up Northeast Oregon, an area of 18,000 square miles. None is licensed for more than 25 beds, and most staff to a lower level because of limited patient volume.

Baker County is a prime example of the need for more SANE nurses.

Millie Joseph recently returned to the position of executive director at MayDay Inc., the nonprofit rape crisis center in Baker City, after being away for six years.

“When I was doing it before, we had an excellent group of sexual assault nurses,” she said. “So I never had to take anyone out of town.”

But the situation has changed. At the moment, there are no trained sexual assault nurse examiners on staff at Saint Alphonsus Medical Center in Baker City, the only hospital in Baker County, and just one at Saint Alphonsus in Ontario, in neighboring Malheur County 70 miles from Baker City. The next-nearest options are in La Grande, 43 miles, and Pendleton, 95 miles.

“If we have to go clear to Pendleton, we’re talking about an hour and a half to two hours, depending on the roads,” Joseph said. “None of them are close, and in the winter it can take even longer because of the weather.”

Shelly Cutler, a spokeswoman for Saint Alphonsus, said the health care system is trying to improve the situation at its Baker City hospital.

“We are actively trying to recruit another (SANE) from our staff of nurses,” Cutler said. “It’s tough to retain a nurse because it’s so emotionally draining.”

Saint Alphonsus is also trying to recruit a second SANE nurse for its Ontario hospital, and unlike some health care systems, Cutler said, it does pay nurses to be on call for the duty. Still, she acknowledges, it’s a difficult position to recruit for.

“When you’re the only SANE nurse available, it’s like you’re always on call,” Cutler said. “They’re doing it because they’re passionate about supporting people, but they also need to have that work-life balance.”

Pioneer Memorial in Heppner, Morrow County’s only hospital, has no sexual assault nurse examiners on staff.

“We’re a very, very small hospital here,” said Emily Roberts, chief executive officer of the Morrow County Health District, which runs Pioneer Memorial. “We only have two RNs on at a time.”

Better, but not always enough

Sexual assault survivors in Morrow County are referred to Good Shepherd Medical Center in Hermiston, 45 minutes away in Umatilla County. When they get there, they find the best-staffed hospital in the region for sexual assault nurse examiners.

“Good Shepherd Health Care System has seven SANE nurses on staff,” hospital spokesperson Caitlin Cozad said. “All seven of our SANE nurses are trained and maintain competencies, while one is certified.”

Even with seven trained examiners on staff, though, there’s no guarantee that one will always be available to do an exam. And in a rural region like Northeast Oregon, that can still mean a long drive to get care.

“We are committed to ensuring our patients receive the care they need,” Cozad said, “and in the few cases that a SANE nurse has not been available, we have called surrounding hospitals, sometimes even Portland hospitals when needed to facilitate a transfer of the patient so they can get the forensic exam.”

Umatilla County’s other hospital, CHI St. Anthony’s in Pendleton, has three SANEs: two nurses, neither certified, and a nurse-practitioner who is certified to perform pediatric exams.

Robbin Ferguison, executive director of Domestic Violence Services, a nonprofit that helps sexual assault victims in Morrow and Umatilla counties, said even though both Good Shepherd and CHI St. Anthony’s have SANEs on staff, it isn’t always enough — and when that happens, the rape survivor suffers.

“If there isn’t a SANE nurse available, (the survivor) is asked to come back or they’re asked to go to another hospital, where they have to retell their story — so they’re revictimized,” said Ferguison. “They may not have the funds or the means to get to Hermiston or Walla Walla or the Tri-Cities.”

Steve Hardin, emergency room manager at CHI St. Anthony’s, agreed that he needs more than three SANEs to serve the need in the Pendleton area.

“I should probably have six or seven, but I only have 17 nurses (total),” Hardin said. “It’s not something a lot of nurses want to do.”

There are a number of reasons for that, said Hardin, who was a SANE nurse himself earlier in his career.

They may already feel overworked without taking on an additional responsibility. They may feel uncomfortable doing the exam. They may have their own history of trauma. They may have family or other obligations in their off time.

And even if they’re willing to make the commitment, the hospital they work for may not have the budget to pay them extra.

“None of the little hospitals can pay somebody to be on call for this,” Hardin said.

Tracy Pozar is one of the SANEs for St. Anthony’s. She is internationally certified to do pediatric cases and worked seven years as Umatilla County’s medical examiner for child sexual abuse cases.

In large metro areas, multiple hospitals can pool resources to maintain a pool of on-call SANE nurses, Pozar said, but that just won’t work in a sparsely populated region like Northeast Oregon.

“We just don’t have that capacity here because we’re so spread out,” Pozar said. “And we don’t get exams very often, so a lot of nurses feel it’s hard to keep up on their skills.”

A different approach

Union County follows a different model when it comes to rape exams.

“We actually have a SANE nurse that works with our organization personally,” said Jordan Kaufman, executive director of Shelter From the Storm, a nonprofit rape and domestic violence crisis center based in Island City.

“Grande Ronde Hospital will call and let us know someone wants an exam done, and we will set it up and do the exam at our office.”

Jamie Jo Haddock, a nurse practitioner who works out of Grande Ronde Hospital’s clinic in Elgin, has been performing sexual assault exams at Shelter From the Storm for years.

“Union County is unique in that we actually have an exam room where we do that (at Shelter From the Storm),” she said, adding that it’s a more suitable setting than a hospital emergency room.

“The ER is a very high-pressure environment,” she said. “It’s not set up for a SANE exam, it’s set up as an emergency room.”

While Haddock is one of five SANEs currently available in Union County — there are three on staff at the hospital in La Grande and one at the county health department — she said she’s the only one who’s certified, which means she’s essentially always on call.

“There’s a difference between those who are certified and (other medical practitioners) who do exams,” she said.

“The RNs have to have medical oversight. They would only be able to do them at the hospital if I was not available.”

With a shortage of SANE nurses throughout much of the region, Haddock is sometimes called on to do exams for rape survivors from neighboring counties. This year alone, she has had referrals from Pendleton, Enterprise and Baker County.

“I am technically on call all the time,” Haddock said. “I would like to share that responsibility with others.”

When Haddock is not available, rape survivors in Union County will sometimes be referred to Wallowa Memorial Hospital in Enterprise, which has one sexual assault nurse examiner on staff.

Like other advocates around the region, Kaufman said it’s important that survivors of sexual assault be able to get the care they need at their local hospital in the immediate aftermath of an attack.

“This person has already gone through a very traumatic experience,” Kaufman said. “Sometimes they could feel like it’s too much, or they can’t go (elsewhere) because they don’t have the means.”

April Brock, nurse manager for the emergency department at Grande Ronde Hospital, said she understands the need for more trained nurse examiners, but for a small hospital in a sparsely populated area, low patient volume creates a challenge.

“We continue to offer training opportunities to staff who are interested,” Brock said. “However, the total number of adult SANE cases are currently covered with the number of staff we have. Maintaining competency and providing coverage is an important balance for this vulnerable population.”

Getting the exam

A forensic exam can be conducted anytime within five days of the assault, but for purposes of evidence collection it should be done within 84 hours — and for purposes of caring for the survivor’s injuries, it should be done as soon as possible.

In most cases, the cost of the exam and related testing and medication is covered by the state. Survivors are allowed to have a personal representative of their choice with them throughout the exam, and part of the protocol involves calling the local rape crisis center to send an advocate who can provide that service as soon as the survivor arrives at the hospital.

According to guidance from the Attorney General’s Sexual Assault Task Force, the exam should begin with an assessment and stabilization of the patient’s medical condition and treatment of any pressing injuries.

The exam also routinely includes testing for pregnancy, sexually transmitted diseases, HIV, human papilloma virus, hepatitis and tetanus, as well as medication when appropriate.

Evidence collection for a potential prosecution is also an important part of the exam. It includes photographic documentation of the survivor’s appearance and physical condition, including any injuries. Clothing worn at the time of the attack is collected, as well as hair samples, and swabs are taken to collect traces of the attacker’s DNA.

All of the evidence is numbered, labeled and bagged for proper identification and safe storage.

That doesn’t necessarily mean law enforcement authorities will be called. In Oregon, reporting of sexual assault is mandatory for minors, people 65 or over and others deemed especially vulnerable under the law. But for most adults, the decision is theirs alone.

If they choose not to report, their evidence will be stored anonymously at the Oregon State Police crime lab for up to 60 years. If they eventually decide to report the assault to law enforcement, the evidence will still be there.

The power of evidence

Sometimes, when survivors of sexual assault don’t report the crime to law enforcement, additional attacks may follow.

“You may have this perpetrator, and if nobody comes forward he may still be out there doing the same thing,” said Blue Mountain Hospital’s Morris.

But the reverse is also true: When a sexual assault survivor does get their evidence collected and agrees to press charges, it can help encourage others to break their silence.

“It’s not usually just one victim,” said Simonsen, executive director of Heart of Grant County.

“If that first victim comes forward, then other victims feel more comfortable to come forward. And even if their evidence has not been collected, they can still testify in court.”

That’s exactly what happened in the case of Brogan McKrola, a notorious Grant County rapist.

McKrola was initially arrested in late 2020 on charges of rape and other crimes involving a single victim.

At the time, Blue Mountain Hospital still had a SANE nurse on staff who was able to perform a rape exam.

Additional charges were filed after other young women came forward. Eventually McKrola was charged with a total of 30 crimes involving 11 different victims. Now, after cutting a plea deal to avoid a trial, McKrola is serving a 15-year prison sentence and will be required to register as a sex offender after his release.

The case hinged, in part, on evidence collected during a sexual assault exam performed at Blue Mountain Hospital in John Day.

“We don’t know what would have happened if (the victim) had had to leave town,” Morris said. “But because she came forward, then other people came forward.”

Jim Carpenter, Grant County’s district attorney, says it’s been a struggle to maintain the capacity to perform sexual assault examinations locally.

“Over the years we’ve had a few SANE nurses, but mostly not,” he said.

“If we don’t have a SANE nurse, we try to have a physician look at them,” Carpenter said. “But we struggle with getting local physicians to do those examinations.”

While a lack of local SANE nurses has sometimes meant his office has not had access to important forensic evidence in sexual assault cases, Carpenter insists that has not kept him from prosecuting those cases.

“Sometimes we have to move forward with the statements we have and the witnesses we have,” Carpenter said.

On the other hand, he acknowledged, having access to a trained sexual assault nurse examiner can definitely strengthen the prosecution’s hand in court.

“They help us educate juries — there are a great number of misconceptions about sexual assault that prevail in people’s minds,” Carpenter said.

“A SANE nurse who’s done the exam acts almost as an expert witness and a fact witness.”

Answering the call

Amber Auty and Joelle George are the two registered nurses who have stepped up to become certified sexual assault nurse examiners at Blue Mountain Hospital. The training process is time-consuming and has to be worked in around their full-time jobs.

George completed the SANE program’s 40 hours of online instruction in early January, and Auty expects to finish the class by the end of the month. Next, they’ll need to perform simulated SANE exams and partner with a certified practitioner on some actual exams before getting their own certification.

According to Morris, the hospital’s nursing director, Blue Mountain could be ready to start providing SANE exams within the next few months.

“I’m hoping by late spring, early summer,” Morris said. “We hope we can get this done as soon as possible.”

For George and Auty, getting trained to perform sexual assault exams seemed like the right thing to do.

“John Day’s definitely in need of it,” George said. “There are too many cases that have to get sent to Bend or Boise, and cases get dropped.”

Working on the problem

Shannon Rose, executive director of the Oregon Sexual Assault Task Force, said her organization is doing all it can to address the statewide shortage of sexual assault nurse examiners.

In addition to providing training and technical assistance for SANEs, the task force is trying to build stronger partnerships with the medical community, which Rose said could do more to support staff members who want to become certified sexual assault examiners. She’d also like to see more government funding.

“Oregon historically has had one of the highest rates of sexual assault in the country,” Rose said. “We need our state to step up and say, ‘We’re going to provide the funding and resources needed.’”

If you’ve been sexually assaulted, you can call the nonprofit rape crisis center in your area. Crisis hotlines are staffed 24 hours a day. A counselor can speak with you confidentially about your experience, explain your options for medical care and reporting, and offer information on additional resources that may help.

GRANT COUNTY

Heart of Grant County

Crisis line: 541-620-1342

Office: 541-575-4335

BAKER COUNTY

MayDay Inc.

Crisis line: 541-523-4134

Toll free: 888-213-4134

Office: 541-523-9472

MORROW COUNTY

Domestic Violence Services Inc.

Crisis line: 800-833-1161

UMATILLA COUNTY

Domestic Violence Services Inc.

Crisis line: 800-833-1161

Hermiston office: 541-567-0424

Pendleton office: 541-276-3322

UNION COUNTY

Shelter from the Storm

Crisis line: 541-963-9261

Office: 541-963-7226

WALLOWA COUNTY

Safe Harbors

Crisis line: 541-426-6565

Office: 541-426-4004