When a distressed patient came to the emergency department of Methodist Dallas Medical Center in April 2018, Janaki Subramanian sensed that something was off. The patient had walked through the doors with a friend. Their relationship seemed odd.
Subramanian was the SANE nurse on call at the time, the sexual assault nurse examiner. Born and raised in India, she had moved to Texas in 2006, at the age of 26, eventually landing a job in the human resources department at IT service management company ComCreation. In her off time, she began volunteering at Methodist Dallas’ emergency room, helping out however she could. She saw it as a gateway to a career that would allow her to work with the community’s most vulnerable populations. Methodist Dallas rewarded her by sponsoring her through nursing school. Now she oversees a team of nine SANE-certified nurses, all of whom work primarily as trauma nurses in the same building and serve about five shifts a month in the SANE unit.
Now Subramanian had a patient complaining of abdominal pain, but everything about the interaction was setting off alarm bells. It wouldn’t be in her nature to assess the situation emotionally, or at least show that emotion in any way. She’s deliberate with her decisions and speaks with a matter-of-factness that would never be confused with insensitivity. She’s there for her patients. This one had a friend who kept correcting the patient, saying that she was simply suffering from anxiety and nausea. “The energy was off,” Subramanian says. The patient avoided eye contact. “The lady who was with her was talking over her. That’s a classic sign for us.” The staff managed to get the patient separated from her friend and into her own room. It would turn out to be a crucial move.
Once alone in a room with SANE staff, the patient confided that she was a victim in a human trafficking ring that operated out of a nearby Oak Cliff house, with about 20 other victims. She also revealed that a patient who had recently been brought to the hospital’s trauma floor with a gunshot wound was living in the house. Carefully navigating the patient’s trauma and fear, Subramanian was able to get more information. The friend who’d brought her in turned out to be a woman named Peaches Hurtado, one of the madams for the operation. SANE collaborated with police and Homeland Security, which helped lead to the arrest and prosecution of the operation’s ring leaders.
Methodist Dallas has one of just three SANE programs in Dallas, along with Parkland and Texas Health Presbyterian. Methodist’s is the only one south of the Trinity River. SANE is more than just a resource for victims; it’s the only program that attempts to help patients 14 years or older through both the medical and legal phases of their assault. SANE nurses in Texas have to go through a certification process that typically takes eight months to a year.
In Subramanian’s previous life at ComCreation, Sundays could have been a time for quiet reflection or lazy brunches. Not any longer. “Sundays we get ready,” Subramanian says. Sexual assaults are committed at higher rates on Thursdays, Fridays, and Saturdays. Victims who choose to come forward or even just seek medical attention often wait a few days, perhaps because they were drugged and need to piece together what happened to them or because they’re scared.
“They may just take a couple of days to think about if they want to do this or not,” Subramanian says. “What are going to be the repercussions? Are their parents going to know? Who’s going to think what? What if the place they work at finds out? There’s a lot of stigma.”
The reluctance of sexual assault survivors to seek help or justice has always been a problem. The danger in coming forward is real, and the stigma is so ingrained that society can be lulled into thinking it’s a smaller problem than it is. As you’re reading this, you may be under the impression that you don’t know anyone who has been sexually assaulted. That is almost certainly incorrect. One in five women in the United States will be raped at some point in their lives, according to the National Sexual Violence Resource Center. Sixty-three percent of sexual assaults are not reported to police.
SANE’s protocol is built on a foundation of safety and respect. Before any forensic or legal steps are taken, the patient must be cleared medically. “Forensic help comes second because it’s not a life-saving measure,” Subramanian says. Once deemed medically safe, the patient is taken to a forensic room by a SANE nurse chaperoned by a victim advocate, who does not work for Methodist Dallas. If the patient consents, a rape kit is performed. From that point, a chain of custody is strictly maintained. The SANE nurse puts the rape kit in a drop box that she does not have access to. Then the Southwestern Institute of Forensic Sciences collects the drop box and collaborates with law enforcement if necessary. The SANE nurse is called to testify in the event that a case goes to court.
Still, protocol can provide only a framework for how to help vulnerable patients. The decisions made by Subramanian’s nurses are a reflection of what she prioritizes in difficult circumstances. If Subramanian isn’t talking to patients herself, she is in the room monitoring the exchange or coaching her nurses through hypotheticals. She wants feedback. “A lot of times, I call patients afterward to ask them how it was,” she says.
When Subramanian says that the forensic science isn’t a “life-saving measure,” she means that only in the sense of a patient’s immediate danger, her staff’s first responsibility. Subramanian’s team has handled sexual assaults that led authorities to international cases linked to Mexico and the United Kingdom. The tact required to make victims feel safe and comfortable enough to provide information about their perpetrators absolutely can save lives.
Still, Subramanian believes that there’s power in choice, and that’s the essential thing SANE provides victims. “A lot of trafficking victims don’t have a choice,” she says. “There is no choice given to them. So we override that.” No patient is ever pushed to speak to police or complete a rape kit. “We take verbal, ongoing consent throughout the exam. They call the shots.”
From her office on the first floor of Methodist Dallas’ emergency department, Subramanian spoke to me with a straightforwardness that might have you believing her when she says she can compartmentalize the intensity of her job with a personal life. “You have to be a special kind of person to be a SANE nurse,” she says. “You have to be a strong-minded person. Very resilient and can leave work at work and go home and sleep like a baby.”
“A lot of trafficking victims don’t have a choice. There is no choice given to them. So we override that. We take verbal, ongoing consent throughout the exam. They call the shots.”
She speaks of emotional circumstances with little emotion in her voice, a trait that allows her to express the gravity of a patient’s situation while still calmly ending an exam the moment that patient wishes. Subramanian suffers from a rare brain disease known as trigeminal neuralgia, which causes bouts of debilitating pain and can make tasks as simple as brushing your teeth excruciating. She had brain surgery in 2017 and another procedure in October to mitigate the side effects. “I don’t know when the pain is going to recur, but it will,” she says bluntly. “But, honestly, this is life. If you’re busy doing a job, you don’t think much of it.”
Ultimately, though, her ability to maintain that emotional distance is betrayed by those who work with her. Talk to them, and they offer a slightly different portrait of their manager. “She just practices at a level that is beyond compassion,” says Emily Wulf, a SANE nurse at Methodist Dallas. It’s unlikely that she actually does sleep like a baby most nights, as she has given her cellphone number to each of her nurses and patients, encouraging them to call her at any time of the night with a question. SANE provides replacement clothes for patients and comes up with discharge plans if it’s not safe for them to return home. Wulf says Subramanian allows victims to sleep in the SANE waiting room if they’re having trouble finding housing. “She goes above and beyond for every patient who walks through that door,” Wulf says.
The SANE program at Methodist has existed only since 2014. Fifteen years ago, a sexual assault survivor’s only option would be Parkland, Dallas County’s public hospital, where a resident or doctor without a specific certification would perform a rape kit. SANE nurses are trained to assist in the physical, medical, emotional, and, to a certain degree, legal needs of their patients. For 17 years, Gallup polls have concluded that nurses rank highest in honesty and ethics of any profession. Lives have been saved and arrests have been made based on the work done through Methodist Dallas’ SANE program, but Wulf says Subramanian has made it clear to her nurses: “This is not our room. This is the patient’s room.”
“We are not the criminal justice system,” Subramanian told me in a characteristically neutral tone. “We are nurses.”