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Forensic Nursing — Real-Life CSI

Special training prepares these nurses to collect evidence and care for patients after a crime. But the TV shows just don’t do them justice.

Monday January 1, 2007
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An unidentified male is brought to the hospital ED via ambulance. He has a gunshot wound to his chest, and he is unconscious. The forensic nurse cuts off his clothes, being careful to avoid the hole where the bullet pierced his shirt. The nurse allows his bloody clothes to air dry, and then places each article of clothing in a separate bag. She places paper bags over the patient’s hands to preserve any evidence that might be on them, and she searches his pockets for anything that will help identify the young man.*

Nurses first

Forensic nurses can be found in many different settings, such as law offices, prisons, and institutions for the criminally insane. They often choose to work in hospital EDs. These nurses, who are specially trained to care for patients with injuries resulting from a criminal act, know how to preserve evidence and document care for use in future legal proceedings.
In any case requiring a forensic nurse’s expertise, the nurse would establish whether life-saving interventions were needed before identifying, collecting, or preserving any evidence, says Sue Leonard (pictured), RN, BSN, clinical manager of the ED at AtlantiCare Regional Medical Center City Campus in Atlantic City, N.J. “Patient care comes first. We treat the injuries that are involved first,” says Leonard, who is also a forensic nurse.

Preserving the evidence

It is often necessary for ED staff to cut off a trauma patient’s clothing to administer proper care. The forensic nurse knows how to preserve clothing for a police crime lab to analyze, says Leonard, who previously was a nurse investigator in New Jersey’s Cape May and Cumberland county medical examiner’s offices. It is important to avoid cutting through any clothing that is pierced. Doing so makes it more difficult for the crime lab to analyze the hole and establish how the bullet or knife may have entered the body, Leonard says.

To make it easier for the police lab to test for gunpowder residue, the nurse places paper bags over the patient’s hands to preserve evidence. Clothes must be carefully folded to avoid transferring blood or evidence from one side of clothing to the other, and each piece of clothing must be bagged individually and marked. Paper bags are used because plastic bags promote moisture that can degrade evidence, says Kathy Connell, RN, CEN, FN-CSA, also a nurse in the ED at AtlantiCare.

Cooperating with the law

Atlantic City attracts many tourists and international visitors, and it is not uncommon for the busy city ED to care for patients who come in without any identification. “Sometimes we have limited or no information to use on how the patient came to be injured,” says Leonard. “It could be hours or even a day before we can get details or identify the person.”

This is where the cooperation between community and public safety agencies can be critical, she says. Sometimes the patients are fingerprinted so that if they’re known to law enforcement, they can be identified more quickly.

Sexual assault cases

Sexual assault is another crime for which forensic nurses are specially trained. Leonard and Connell are both trained sexual assault nurse examiners (SANE). In fact, Leonard participated in one of the nation’s first SANE training programs, held in Texas in 1990.

But at Doylestown Hospital, Doylestown, Pa., the seven SANE nurses prefer to call themselves forensic nurse examiners (FNEs) because it’s a more accurate title for what they do, says Mary-Helen Scales, RN, CEN, FNE, staff nurse and coordinator of the hospital’s Sexual Assault Response Program (SARP).

“We selected FNE as our designation because it encompasses more than just sexual assault,” Scales says. “We examine victims of suspected child abuse, elder abuse, domestic violence, and any other patients [whose conditions] have legal ramifications.” The nurses also photograph and document injuries resulting from physical assaults.

Special training needed

Scales and one of her colleagues received SANE training in cooperation with the Virginia Division of Forensic Science. Most of the other FNEs at Doylestown Hospital participated in a weeklong session taught by Ann Burgess, RN, DNSc, FAAN, and Kathleen Brown, RN, CRNP, PhD, faculty members at the University of Pennsylvania School of Nursing in Philadelphia.

Many years ago, a grant from the Pennsylvania Coalition Against Rape provided Brown with the resources to develop sexual assault response teams (SARTs) at the county level in Pennsylvania. She helped to develop them in 43 of the state’s 67 counties. Although the grant has expired, Brown still hopes to train nurses in the remaining counties. She also helped establish SARTs in New Jersey and Delaware.

A SART at the county level usually includes representatives from law enforcement, victims’ advocate services, the mental health system, the judicial system, social workers, the medical community, crime lab, the corrections system, the department of public health, and the community. SANE nurses must approach sexual assault victims according to a set of procedures written by the SART.

The procedures are intended to be victim-focused and may vary in terms of the initial response to a victim. “We’re nurses, and nothing changes about that. The health and safety of the patient comes first,” Brown says. Hospital staff nurses already know how to care for these patients, “and then we help them learn how to do the forensic piece,” says Brown.

Collecting evidence

When patients present to AtlantiCare reporting that they are victims of sexual assault, the patients are given the opportunity to call the county SART team via a dedicated hotline. The SART team is composed of a victim’s advocate, a SANE nurse, and a police officer from the city where the assault occurred. By working together, the team minimizes the number of times victims must tell their stories. More than once can “retraumatize” victims, Leonard says: “They relive [the assault], and it can be brutal to be asked the same questions over and over.”

To law enforcement officers, the location where the crime took place is considered the crime scene. But to forensic nurses, the patient is viewed as the crime scene.

A forensic exam might yield evidence to connect a victim to the offender. For example, gravel found in a patient’s hair could be used to corroborate the victim’s story that she was attacked on the gravel road behind the neighborhood convenience store, Brown says.

Collecting evidence from sexual assault victims is made less difficult by technology. Ultraviolet or black lights help SANE nurses find dried secretions, which literally glow in the dark. The nurses collect dried sperm or saliva by rubbing the clothing or skin with a moistened swab. They also use a digital camera to photograph a patient’s injuries.

A colposcopy light (used only for magnification, not biopsies) is attached to a camera, so tiny vaginal tears can be documented with high-quality photos. “Colposcopy technology allows us to electronically capture — and store — images of the victims’ injuries,” Connell says.

In New Jersey, standardized evidence collection kits are issued by the state’s Office of the Attorney General. A 15-page document accompanies a set of envelopes labeled for specific specimens, such as hair, secretions, blood, and fingernail scrapings. The medical exam and evidence collection can take between two and six hours.

In Pennsylvania, victims undress over a clean sheet so that any evidence that falls off them can be collected. “Almost 100% of the time, the police want us to keep the panties to identify seminal fluid and epithelial cells from the offender,” Scales says. Once the exam begins, the door to the exam room must remain closed and no interruptions are allowed. “No one can walk in or out of the room while the exam is in progress because we can’t take a chance that evidence is tampered with in any way,” Scales says.

Reality vs. TV Drama

Forensic nursing bears little resemblance to the crime investigation shows on television. Brown says the students in her courses on victimology and forensic mental health learn quickly that cases aren’t solved in an hour. “And the roles [of the actors] are all mixed up. Sometimes it looks like the answer [to the crime] just comes to those who are sitting around in chairs,” she says. “There’s really more science to it than that!”

TV shows such as ER, Law and Order, and CSI sometimes give the impression that law enforcement takes precedence over a patient’s medical condition. “That is not true in real life. [Law enforcement officials] know when they can enter a room. They know when to keep their distance,” Leonard says. “They’re very respectful of the staff and know the importance of what’s going on with the patient medically.”

Maintaining Objectivity

But real-life forensic nurses must be more reserved than their fictional counterparts. When caring for a crime victim, it is important that they keep their personal opinions in check.

“A forensic nurse needs to leave bias outside the door whenever he or she is working with a patient,” says Daniel J. Sheridan, RN, PhD, FAAN, president of the International Association of Forensic Nurses.

Scales agrees that forensic nurses must maintain their objectivity and not take sides. She believes it’s possible to be a skilled evidence collector as well as a compassionate caregiver. “We’re not the jury,” Scales says. “We do a great physical exam so that if it does get to trial, there is good evidence that can be presented.”

*Hypothetical case

Karla A. Knight, RN, MSN, is a freelance writer.

Photo by David DeBalko Photography.

For more information

The International Association of Forensic Nurses (IAFN) is the only international professional association of registered nurses formed exclusively to develop, promote, and disseminate information about forensic nursing. Members will convene September 27 to October 1, 2006, for the 14th Annual Scientific Assembly in Vancouver, BC. For more information, visit http://www.iafn.org/or call (856) 256-2425.