Chapter One Who Is a Forensic Nurse? Saturday night. The bars are full. So is the emergency room. The usual suspects jam the cubicles, overflowing into the halls: a brawl victim with a broken hand; a baby with a high fever; a truck driver who complains of dizziness; a man, claiming to hear voices, who has stabbed his sister; the police are on their way in with the second of two rape victims and a DOA (dead on arrival). Gunshot wounds, stabbings, and drug overdoses are common here, in this large metropolitan hospital. One victim, a walk-in patient, is a young woman in a blood-spattered dress, bruises covering her face and body. She says she fell down a staircase in her home. The admitting physician, an intern, interviews her briefly. Assisted by a nurse, he examines her and orders X-rays. He finds no life-threatening injuries but does observe evidence of earlier abrasions and contusions. Visibly upset and nervous, the patient explains them away, saying they were from tripping over her child's toy, and other household accidents. With at least a dozen patients waiting for him and ambulances bringing in more, the intern treats the woman's cuts and discharges her. Is it possible that, under the pressure of a crushing caseload, he inadvertently released a victim of domestic violence without taking time for the appropriate follow-up? Had the assisting nurse been a forensic nurse, there would have been little chance of that. In fact, many patients in the emergency room have one thing in common: They are cases for the forensic nurse. Any time a nurse treats a victim of a criminal act or someone suspected of committing one, the survivor of a catastrophic accident, or any other victim of a bodily injury, living or dead, where liability may be involved, she* is involved in a forensic case, one that requires investigation beyond the medical. The forensic nurse (FN) is the new detective on the block. She is law enforcement's secret weapon. The expertise of a forensic nurse--a unique combination of medical skill, legal knowledge, and criminology--makes her input increasingly more valuable in the investigation of crimes. "Forensic nursing" is a relatively new term and has been formally accepted as a specific area of the nursing profession only recently, after it was recognized by the American Association of Nurses in 1996. Forensic nursing has quickly become one of the newest medical specialties, although nurses have been contributing to forensics for centuries. Forensic nurses are the link between the health-care profession and the criminal-justice system. In most cases, their expertise is available at the point of first contact--the door to the emergency room. Forensic nurses have been trained to identify the weapon consistent with the patient's injury; to interview victims in order to get the fullest and most accurate story; and to recognize, collect, and preserve evidence. They have developed the healthy skepticism that enables them to assess the validity of accounts from both victim and suspect. Such specialists are valuable liaisons between the law enforcement and the medical profession, and, unlike many medical professionals, they have the training and experience to testify effectively as expert or actual witnesses. Like Molière's bourgeois gentleman surprised to learn that he has been speaking prose all his life, many in the profession have often served as forensic nurses in the course of their duties without being aware that they were doing just that. From the moment they first entered nursing school, they were warned that anything they did or said to or about the patient could wind up in court. (Back then, not many students looked forward to being relied on as expert witnesses. In fact, a nurse with a crime-related case was usually petrified at the prospect of being called to the witness stand and questioned about his or her abilities and competence.) However, at that time, because there was no training in forensic care, nurses knew neither what it involved nor how they might contribute to lessening the crime and violence they encounter every day. One of the definitions of "forensic" is "employed in or pertaining to the legal profession." Yet the term "forensic nurse" is still not understood by many. Growing up with TV's popular Quincy, who played the part of a forensic pathologist, many assumed the word meant "death" or "working with death." But forensic cases include the living as well as the dead. Anything that is a factor in a legal case can be called "forensic." This includes insurance cases and others where the law might be involved. Victims of rape, abuse, and trauma occupy one in every eight hospital beds. Every day six thousand violent crimes are committed or attempted in the United States (Reiss, 1993). What I saw in the course of my usual nursing duties made me want to learn more about what a nurse could do when she or he encounters a possibly criminal situation. Stumbling across an e-mail address "SleuthRN," I contacted the person behind it to learn what that meant. SleuthRN, aka Sandra Goldstein, is a sexual assault nurse examiner (SANE) in Santa Cruz, California. When I reached her, she directed me to the International Association of Forensic Nurses (IAFN). That was when my working life took a fascinating turn. Attending the organization's Third Scientific Assembly in Louisville, Kentucky, I learned what "forensic" meant as it applied to nursing. Forensic nurses are specialized nurses who fill a void in emergency rooms, where most doctors have little or no forensic training, which can often be a serious handicap. To counter it, the IAFN works to bring forensic nurses together with pathologists, criminologists, and others who can help them perfect their skills and widen their abilities. This organization is only a few years old, but it already has over a thousand members and is growing daily. IAFN was founded in 1992 by seventy-four pioneers, spearheaded by Linda Ledray, Ph.D., who had started the Minneapolis sexual assault response team (SART). It was a step into an unknown territory. Linda had been writing about sexual assault examinations for the Journal of Emergency Nursing. She wanted to find out who else was out there performing sexual assault exams and how they were doing it. She wanted to know what successes they had, what failures, and why. The only way to grow was to learn from one another as a community. So, in the summer of 1992, she organized a meeting of nurses in Minneapolis. Most of those attending considered themselves SANE, since among their other duties they performed rape exams of both the victims and the perpetrators--when those were known. Nurses who attended found out that they were not alone in their quest for justice and their desire to see the victims properly taken care of and guided through the judicial system. One nurse described the experience as akin to "finding your long-lost best friend." During this meeting, the nurses found out that although different groups had various routines for examining victims of rape and other trauma, they were unanimous in believing that there was a better way to help victims and survivors than the present practice. SANEs began to organize. There were bumps in the road, but they moved on. They braved the "old-boy network," stumbling and pushing forward with the courage of Florence Nightingale. They entered the realm of death investigation as nurse coroners or deputy coroners and earned the respect of their male colleagues. In Wisconsin and in Texas, nurses fought to use their medical and legal skills to assist the survivors of trauma as well as to carry out their forensic investigations. A large group took on the bar associations to become accepted as nurse-attorneys or nurse-legal consultants. Yet no matter what they added to their nursing degrees, all of them remained nurses. The unique perspective provided by their nursing skills gave them a leg up in solving problems. Their training and abilities could help the victims in ways law enforcement had never contemplated. Their attitude towards the body as the crime scene took them places and provided them with key questions that no one without their training would ever think to ask. Many crime victims are able to get to the emergency room on their own; consequently, when they arrive, they haven't even talked to the police yet. A high percentage of ER patients who need urgent care are forensic cases. Victims of rape, of felonious assault, and, of course, of homicide are obvious examples. But workman's compensation cases, accident liability, domestic violence, child abuse, elder abuse, food and drug tampering, automobile accidents, attempted suicide, and hazardous environmental contamination all come under the umbrella of the dictionary definition of "forensic." Virginia Lynch, the former president of IAFN, says: "There are puzzles involved; it's up to the forensic nurse to identify what is going on, to listen to the silent language and put the pieces of that puzzle together. "I went to the local crime lab," she says, "to find out what we could do to better protect the patient's legal rights and properly preserve evidence. Inside the lab, the door of forensic science opened. I realized that tremendous void exists between the health and justice systems. I saw that victims were often treated less than empathically by both law officials and health care professionals. They felt uncomfortable with the emotional trauma surrounding crime victims as well as their families, much of which, due to time constraints and lack of necessary skills, could not be addressed properly." Lynch was determined to incorporate crisis intervention and grief counseling into these cases. This was a road to recovery that only a qualified nurse could help with. And hand in hand with the training for this went the special skill of forensic investigation. Because of Virginia's efforts, word of the new specialty spread around the globe--to Canada, England, Japan, Singapore, Russia, and South Africa, where the murder rate is one of the highest in the world. Some Caribbean and Central American countries also joined the forensic nursing family. Law enforcement took notice but not enough. The nurses' services and resources were still underused. Battles had to be fought. Turf wars broke out. But slowly--too slowly for us--things began to change. More hospitals began employing forensic nurses, and the nurses at more hospitals had at least some of the necessary training. Despite that training, very few were awarded full-time positions for their efforts. Weeks would pass without a single day off. In the trauma center, where the usual procedure was "a shot, a Band-Aid, and thank-you-ma'am," the rest of the staff resented the SANEs and left them without support to do four- to six-hour forensic exams and evidence collection for rape victims. And they were further irritated when the SANE then had to be absent from work in order to appear in court. Who was supposed to pay for those hours? Who was going to fund a SART station or stations? Hospitals? Law enforcement? Some centers obtained funding from projects such as Violence Against Women. Some received grants from the Department of Justice. But the money available was seldom enough for the state-of-the-art equipment needed and the cost of the nurses' time. And then there were the doctors, too many of whom felt that the nurses were encroaching on their area. They were angered by the nurses' audacity to do pelvic exams or use the colposcope on their own. The colposcope, an instrument originally used for magnification of cells to identify vulval cancer, was later found to be an excellent aid in getting helpful photographs of such trauma as child abuse injuries. But the medical establishment seldom adopted its use on adult victims of sexual assault as a standard practice, even though there is no better way to differentiate forced sexual contact from consensual. Doctors have the medical knowledge needed to recognize the signs and symptoms of many diseases. They know how to tell physical abnormalities from the norm. But medical school never taught them to identify patterned injuries or to distinguish blunt from sharp-force trauma. That kind of information, however, is a significant factor in discovering what, and consequently who, is responsible for an injury. It is information that forensic nurses can provide and the doctors cannot. It is assumed that doctors can treat trauma. They can. But very few of them understand the different treatment that forensic trauma requires. Their education does not include identifying wound patterns or some sexual injuries. They don't know how to collect evidence so that it will not be challenged in court. Some doctors, knowing that they lack the necessary proficiency to back up their evidence, often shy away from being called into court to be questioned by a hostile defense attorney. Many refuse to perform the medical-evidence exam. And many doctors, while flattered at being called expert witnesses, are not. Doctors became upset when nurses who were not part of the hospital staff started being called in to do rape exams. Yet they were relieved not to have to deal with the courts. The average ER doctor has no training (or willingness), when it comes to doing a forensic exam or collecting evidence. In fact, doctors and untrained nurses frequently throw away or destroy evidence without recognizing its high importance. Overwhelmed by the sheer number of cases, especially in major trauma centers, they often simply do not have time to stop, to collect and preserve clothing, body fluids, and trace materials, all of which could be important evidence. Very few medical and nursing schools in the United States and elsewhere teach forensic medicine. The few that do teach it only as an elective. Frequently, even though the doctor or ER nurse knows what should be done, he or she will fear inadvertently violating the patient's confidentiality or constitutional rights and end up with a lawsuit on their hands. The kind of investigation a forensic nurse is trained to do is also indispensable in cases of questionable death. Pathologists can make great coroners and medical examiners, but there are too few around. Fewer than four hundred certified forensic pathologists practice in the United States and only a fraction of these are willing to do the work of the medical examiner. To fill the positions, many agencies have turned to nurses. Because nurses are trained to understand how the body functions, they can determine more quickly whether a death is natural or unnatural. They can tell if the medications the person had taken had hastened their death or did not affect it. They know when something looks suspicious and when it does not. Dr. John Butts, chief medical examiner of the Canadian province of Alberta, adopted the practice of hiring forensic nurses as death investigators. He carried the practice with him to Nova Scotia when he relocated there. But this intelligent solution to the shortage of medical examiners has not been adopted in enough places in either Canada or the United States. Within the United States, only a handful of chief medical examiners have made the same discovery. Many police, district attorneys, prosecutors, and judges do not know how to use this new weapon. In court, they still look to and expect expertise from the doctors rather than the nurses, in spite of the nurses' additional training and special skills in forensic exams. Bypassing nurses who have actually seen the wounds and can correctly identify them, law enforcement turned to the nearest doctor who may never before have encountered the entrance or exit wound a bullet makes. The mistaken answer the doctor may give often alters the whole course of a trial. Seeing only the stereotype of women in starched white carrying a bedpan, the courts forget that the nurse, who has always been the liaison between the doctor and the public, is a skilled translator of medicalese. Teaching is one of the basic nursing skills. As a by-product of their nursing education, they are expert in educating and persuading a jury, not in medical jargon but in language the lay listener can understand. Moreover, the public itself, unaware of these specially trained nurses and their potential in helping fight crime, does not seek them out or know that their advice could help make recovery from the grief and trauma much easier. Taught to use their knowledge and skills to treat the whole individual and to see the whole picture, forensic nurses often play the role of resource person--someone who can arrange the various disciplines or puzzle pieces into a recognizable whole that will help trauma victims to heal. It is the nurses who are at the forefront of trauma treatment and death investigation. Nurses are almost always the first to see the victims as they are brought into the emergency room. But there are also nurses who work as an adjunct to the medical examiner. They investigate unnatural deaths, join the paramedics in triage, serve as consultants to lawyers and district attorneys in both criminal and civil cases. Some are nurse-attorneys themselves. Often it is a nurse who photographs the evidence and notes the wound patterns, who works as a police liaison, and is the first to pick up signs of child abuse and domestic violence. Forensic nurses who are part of a disaster medical emergency team (DMET) assist not only in providing medical resources to overwhelming numbers of victims in mass tragedies, but a disaster mortuary operations team (DMORT) can help to identify parts of bodies after lethal crashes and hurricanes. Forensic nurses have served as expert witnesses in court, helping to get convictions by uncovering fraud and providing evidence, investigating work-related and vehicular accidents, and, in teamwork with the police, contributing to the solution of many cases of unnatural or suspected deaths. Armed with the knowledge needed to trace by ballistics, the source of gun wounds, to find out the details of a rape by examining the victim, and more, nurses in forensics have increased the odds that rapists and killers will be captured--and that the falsely accused will be exonerated. The forensic nurse is someone who cares enough to be aware of both the medical and legal side of the exam; someone with a passion for justice, someone who wants to make a difference in people's lives. Rampant violence and its consequences is a public health problem that needs addressing. Finding an effective answer to violence in America and the world at large requires cooperation among many disciplines. Forensic nursing is contributing its particular skills to the solution of this worldwide problem. IAFN's motto is "Nursing Beyond Tradition." "We nurses are no longer the bedpan pushers our mother Florence Nightingale was," says Diana. "While we still hold the patient's hand, and are concerned about the physical and emotional trauma the victims of forensic cases are suffering, we can also find ways to go beyond tradition and put a stop to the violence. Working together, nurses, doctors, law enforcement, science, and the public can make a difference in our lives and in our society." Diana is one of the unsung heroines of IAFN. She helped with the original development of the group. "I get surprised when people tell me that I am one of the pioneers. It feels good that my name is known, but I didn't start doing this to break new ground." Like most of us who have become hooked on forensic nursing, Diana read the early Cherry Ames novels* and realized that there was more to helping people than passing bedpans. "Everyone has their own niche. I could never be a CCU nurse, but forensics is my field." As many other nurses, Diana credits forensics with turning her whole nursing career around. "It became more of a challenge to me," she says. Diana works with the American Academy of Forensic Science and is also active in establishing nationwide standards for the SANE, often volunteering her time to chair various committees on ethics and protocol. Originally a head nurse in a pediatric unit, she had helped put the child abuse program together in her home area. The local police were so pleased with the results and with how much easier the prosecution of their cases went that they asked if the hospital could put something together for adults who had been sexually assaulted. "We're tired of getting the runaround and of waiting for hours upon hours in the emergency room for a spot in the triage line," one cop told her. And so the SART program was born in 1990 at Pomerado Hospital in San Diego. One of the earlier groups, they were lucky to have Dr. Laura Slaughter, who pioneered some work on rape victims and evidence-collection, and Sherry Ardnt as their trainers. "If you don't know something exists, you won't be looking for it. Now we see evidence in places we never would have thought of before," Diana says. "Until I was educated about the role of nursing in forensics, I was clueless about all the implications. Now I see clues everywhere, and it helps the police and the DA with the case investigation and prosecution." Diana credits Virginia Lynch with the original article that defined forensic nursing. "I never would have put all that together the way she did. She included death, legal, child abuse, domestic violence, forensic psychiatry, trauma, workman's comp . . . all these areas that I wouldn't have thought of." She admits that there are still a lot of obstacles for the forensic nurse to overcome. "One of the biggest issues is credibility," she says, "and helping the jury and judges to understand that we are nurses, not doctors, yet still recognize our advanced skills and experience. Most doctors have no training in courtroom testimony and really do not want to go to court. Forensic nurses are trained to do just that." John became convinced of the value of medical-legal training when he heard Virginia Lynch, whom he had known in school years before, speak. He realized that forensic nursing was his calling. "I want to do something to help people. I get a lot of satisfaction out of it. "Clinical forensics, which encompasses sexual assault, domestic violence, child abuse, work injuries, MVAs (motor vehicle accidents), has just about everything. I took sexual assault training, a medical-legal death investigation course, and I even did an internship at the coroner's office in Reno, Nevada. "I watched Henry Lee testifying in court and I knew I wanted him to teach me blood-splatter analysis. One thing led to another, and soon I was giving lectures about forensic nursing, just like Virginia. I want to light fires under people and let them assist us with seeking justice." John now teaches others how to recognize evidence and then how to preserve it. "Once we know that, we transport it correctly and use it to testify. All that makes law enforcement a lot easier." A large number of police and law enforcement personnel come to his classes, as well as nurses. And then there's Jennifer. Nurses like Jennifer have a hard time getting established as forensic nurses because even though we do forensics in the emergency room daily, most people, even the nurse managers, and especially the doctors, don't see it as necessary. She was forced to pay for the SANE training and other training that she has since taken on wounds and ballistics out of her own pocket, as have most of the nurses referred to in this book. Only after the hospital administration saw how cost-effective it was to have a forensic nurse on duty, because, among other reasons, they no longer had to give doctors time off to go to court as often, and how her training gave the hospital bonus points with the community, did the hospital pay for other nurses to attend the courses. "But it wasn't easy with police, either," Jennifer says. "We each had to feel our way. Building trust between the police, the doctors, and myself was a painstaking, often frustrating process. I couldn't just go up to them and say, 'Hi, I'm your new forensic nurse.' " The police, Jennifer reported, were more receptive than the doctors because they stood to benefit the most--more perps arrested and easier collars for them. The doctors were a different breed altogether. "On some level," she says, "they still remain a bit distant, despite the fact that they hate going to court, they hate getting called at two a.m. I love it." The presentation of observations has to be made at a more diplomatic level. "Doctor, did those bruises look suspicious to you? Do you think they were at different stages in healing?" Or "We often collect blood so we can rule out------. Shall I collect that for you?" Diplomacy is essential, because most SANE programs have a policy requiring a patient with specific injuries or preexisting histories--such as genital bleeding, pregnancy, insertion of a foreign object, difficulty breathing, loss of consciousness, or being under fourteen years of age--to be seen by a physician before the nurse can do the SANE exam. It is only when a patient is not severely injured that the triage desk is bypassed. The SANE must always consult the attending physician regarding prophylactic antibiotics, pregnancy prevention, and other orders, before she develops a specific patient plan of care. Despite the frustrations, Jennifer and the others who work ER trauma forensics report that when a case is won, "it's the best possible high." Not only that, when a case is won, and the proper credit is given to the nurses and the hospital, the media attention focuses more favorably on forensics and allows the hospital to feel better about paying for the nurses to take these classes. Lately, forensic nursing has been fraught with misunderstandings. Our scope of practice has been questioned more than it ever has in the twenty-five years since the sexual assault response teams, for example, were founded. It is necessary that the law enforcement officers and courts be aware of what we are equipped to do so that they can use our skills to win their cases and clear our streets of criminals. In order to do this effectively, we need to be represented on all State Boards of Nursing by a forensic nurse, so that our evaluation of victims, our freedom to use the needed equipment and to find evidence is not hampered. Our work as forensic nurses focuses on a variety of issues: domestic violence, sexual assault, homicide, death investigations, child abuse, workman's comp, vehicular injuries, elder abuse and neglect . . . and more. This book is also for you, the public. Should you or someone you know suffer sexual assault, death, or other trauma, we want you to be aware of what the forensic nurse can do to ease your suffering and work toward getting justice. Forensic nurses work hard, but the hardest part is seeing the victims failed by the system. Join us, help us in defeating the violence. Let us make this a society we can be proud of. This book is written not only for other nurses who might want to pursue forensics as their careers, not only for the doctors and other medical professionals who need to understand who we are and what we do and the advantage to be gained by working together. This book is also written for the public, to whom we offer our forensic skills to better meet their needs. As Kathy Bell, an IAFN past president, stated, nurses reach out to the police and the law so that we can function as a team; educate others in the medical profession on what a medico-legal case is and how we can work on it together; and do more research into understanding violence and solving problems for crime victims. Like the police, we need to study the victims and their histories, to understand ways and reasons they are chosen as victims. We need to study domestic violence and its effect not only on the victims, but the children as well. We need to understand grief and the way it relates to death investigations and what we, as nurses, can do to help the survivors through the night. We can dive into the police pool and they, in turn, can swim with us, so that all the victims dragged from the waters will be resuscitated by both. Many of my friends and colleagues in forensic nursing have contributed cases to this book. While the facts are true, because of legal and ethical considerations, names, locations, and minor details have been changed, and it might read like fiction, but it's not. The most important facts are there. The passion with which these nurses work has not and never will change. To further the efforts of forensic nursing, a portion of the proceeds from this book will be given to the IAFN for research and scholarship. Copyright © 2004 by Serita Stevens. All rights reserved. Excerpted from Forensic Nurse: The New Role of the Nurse in Law Enforcement by Serita Stevens All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.