Transcript to the presentation slides.

The “ABC’s” of Forensics in
Emergency Nursing
Mary Leblond
MSN, RN, CEN, CA-SANE, CP-SANE, FAEN
Copyright Texas ENA 2006
Disclosure and Limitations
This continuing education activity was approved by
the Emergency Nurses Association, an accredited
approver of continuing nursing education by the
American Nurses Credentialing Center’s Commission
on Accreditation.
The original content was developed by the Texas
Emergency Nurses Association to meet the forensic
requirement. The speaker is responsible for the
updates and content.
Objectives
Discuss the definition of forensics, including
examples and applicable laws governing the
definition.
Describe components of the primary and
focused secondary survey in a forensic
patient.
Apply information on evidence collection and
chain of custody to selected forensic
situations
Discuss documentation principles
Contributors
•
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Donna Wright, RN, MSN, CPNP, CA/CP SANE
– CARE Team Clinical Manager Cook Children’s, Fort Worth
Sally K. Snow, RN, BSN
– Trauma Program Manager, Cook Children’s, Fort Worth
Cam Brandt, RN, MS, CPN, CEN
– Clinical Educator, Emergency Services Cook Children’s, Fort Worth
Wally Fears, RN, CEN
– ED/Trauma Education Program Coordinator CHRISTUS Spohn Health System, Corpus
Christi
Melissa Bradley RN, CMLDI
– Emergency Services, Methodist Medical Center, Dallas
Sheryl Turner, RN, BSN, CEN
– Educator, Emergency Services, Methodist Med. Center, Dallas
Jamie Ferrell BSN, RN, DABFN, CA/CP-SANE, SANE-A/P, CMI-III, CFN
– Forensic Nurse Examiner/Educator, Memorial Hermann Hospital, Houston
Carrie Edwards, RN, MSN, CA/CP SANE
– TTUHSC School of Nursing, Lubbock
Forensic
Broadest definition:
The use of science and technology to investigate
and establish facts in criminal or civil courts of
law. (American Heritage Dictionary)
In the clinical setting:
Every injury, illness, or death can have forensic
implications.
Forensic Nursing
“…the application of the forensic aspects of
healthcare combined with the
bio/psycho/social/spiritual education of the
registered nurse in the scientific investigation
and treatment of trauma and/or death of
victims and perpetrators of violence, criminal
activity and traumatic accidents.”
Lynch, 2006
Forensic Nursing (cont.)
“The forensic nurse provides direct services to
individual clients, consultation services to
nursing, medical and law-related agencies, as
well as providing expert court testimony in
areas dealing with questioned death
investigative processes, adequacy of services
delivery and specialized diagnoses of specific
conditions as related to nursing.”
Obstacles
Lack of communication and coordination
between clinical practitioners and law
enforcement.
Failure to recognize the legal issues.
Clinicians lack of skill in the documentation and
preservation of evidence.
Categories of Clinical Forensic Cases
Victim or a suspected offender!
Police/corrections custody abuse
Sexual Assault
Substance abuse
Child maltreatment
Occupational related injuries
Domestic/Intimate Partner violence
Elder abuse
Suicide attempts
Violent crimes
Workplace Violence
Categories of Clinical Forensic Cases
Physiological and psychological
abuse
Motor Vehicle crash
Food and drug tampering
Transcultural medical practices
Human Trafficking
Suspicious trauma or death
Medical/nursing malpractice
Environmental hazards & disasters
Forensic Procedures
Component of emergency nursing practice
Accurate documentation
Part of the scientific investigation, evidence
collection and preservation, and treatment of
medico-legal related issues
Legal Standards
Penal Code
Mandatory Reporting
Patient’s legal rights
– Recognition
– Collection and preservation of evidence
Professional Standards
• International Association of Forensic Nurses
– Scope and Standards of Forensic Nursing Practice
• Emergency Nurses Association Scope of Emergency
Nursing Practice
• Emergency Nurses Association Position Statements
– Care of Sexual Assault Victims
– Domestic Violence-Maltreatment and Neglect
– Forensic Evidence Collection
Professional Standards (cont.)
• American Nurses Association
– Violence Against Women Position Statement
• (Texas) Nurse Practice Act
– Sec 301.306 Forensic Evidence Collection
Component in Continuing Education
• Senate Bill 1191 passed during the 83rd
Regular Session of the Texas Legislature
Effective September 1, 2013
Texas law affecting “the duties of health care facilities,
health care providers, and the Department of State
Health Services with respect to the care provided to
a sexual assault survivor in the emergency
department of a health care facility.”
http://openstates.org/tx/bills/83/SB1191/
Amendments provided by SB 1191
Any health care facility that has an emergency
department (no matter the size or trauma
designation) shall comply with Section 323.004
Definition of a SANE
A Sexual Assault Nurse Examiner is a registered
nurse who has been specially educated to
provide comprehensive care to sexual assault
patients, who demonstrates competency in
conducting a forensic exam and the ability to
be an expert witness.
Training and Certification Program
Sexual Assault Prevention and Crisis Services
Program of the Texas Attorney General’s
Office
Program provides training and certification of
Registered Nurses in communities with
signed cooperative working agreements
between community members and the Office
of the Attorney General
Purpose of Certification
Sets an educational standard
Validates a current body of knowledge
Provides a framework for credentialing SANEs
in hospitals
Currency of practice maintained with recertification
Responsibilities to Sexual Assault
Patient
S/A medical and evidentiary exam
STI risk evaluation and prevention
Pregnancy risk evaluation and interception
History of event and collection of forensic
evidence
Emotional support and crisis intervention
Testifying in court
http://www.dshs.state.tx.us/hfp/PDF/Sex
AssaultPatientEng.pdf.
Accessed 10/21/2016
Primary Survey
Taking care of the patient’s immediate medical
and psycho-social needs is always the highest
priority.
Primary survey: ABCDE’s are the priority of
care, preservation of evidence follows.
Airway
Airway (patency, foreign objects, obvious
injuries…
– Consider C-spine with patients of possible
trauma or assault
– Preserve unusual foreign objects
Breathing
Breathing (effectiveness, integrity of the chest
wall, JVD or tracheal deviation, especially
with victims of assault)
– Do not cut through bullet or knife tracks in
clothes
– Label and retain any unusual objects, scrapings,
etc.
Circulation
Circulation/perfusion (pulse rate and quality, skin
color and temperature and capillary refill.
Alterations in assessment may indicate blood loss
with patients of assault)
– Assess for signs of uncontrolled bleeding
– Assess for occult bleeding such as abdominal distension,
bruising, signs of head injury
– Elevated heart rate could be due to emotional response
to the event, medications, street drugs OR volume loss
– Do not clean injury sites at this time
Disability
Disability (alteration in level of consciousness may
indicate head injury, physical or emotional shock,
presence of medications or street drugs)
– Does the patient appear to be disassociating?
– Are there occult or obvious head wounds?
– Do you see identification bracelets that might indicate a
seizure disorder, diabetes, or other finding that might be
a cause for the decreased level of consciousness?
Exposure
Exposure (carefully remove clothing and
preserve as evidence, documentation of
injuries)
– Remove clothing intact if possible and place in
separate paper bags
– Carefully and thoroughly document injuries
– Keep patient covered to prevent heat loss
Full Set of Vitals and Family Presence
Obtain a full set of vital signs
Facilitate family presence
Get Resuscitation Adjuncts (LMNOP)
Laboratory analysis
Blood-typing, blood gases, lactate and KleihauerBetke
Cardiac Monitor and/or cardiotocography monitor
Consider naso-or orogastric tube
Using appropriate pain scale assess pain
Non-pharmacologic comfort measures
Analgesic pain medication
FAST exam if uncontrolled internal hemorrhage
suspected
Secondary Survey
Identify all the injuries
Secure the scene
Collect baseline laboratory specimens
Obtain thorough history
– Only ask for details necessary to perform medical
and evidence collection tasks
Preserve clinical data
Collect any potential evidence
Wear gloves and change often
Common Injuries
• Grab or restraining
marks
– Neck
– Arms
– Wrists
– Legs
• Ligature marks
– Choke vs. strangulation
• Note injuries to
– Breasts
– Upper portion of the
inner thighs
– Injuries or soreness
• Scalp
• Back
• Buttocks
Commonly, there is no physical injury with
sexual assault.
.
Physical Assault
Sexual Assault
Locard’s Exchange Principle
(Basis for Trace Analysis)
‘With contact between 2 items there will be an
exchange.’
Crime Scene
Suspect
Victim
Thornton 1997
Evidence Collection
Evidence is used to establish the facts of the
crime:
– Was a crime been committed?
– What person(s) committed the crime?
– What is the modus operandi of a crime (how a
crime was committed)?
Forensic Evidence Collection and
Preservation-Concepts
The patient is a crime scene whether dead or
alive
The crime scene has been moved to the
emergency department
Law enforcement is dependent on nursing to
process the human body when the patient is
in the hospital
Forensic Evidence Collection and
Preservation-Concepts (cont.)
This includes physical and objective data
obtained from the patient.
The human body is the most intricate crime
scene ever documented.
Evidence Collection is inclusive of
documentation (including body diagrams),
photography (if available) and trace evidence
gathered from the scene of a crime.
Types of Evidence
Physical evidence
– Physical findings, including surface trauma
– Body fluids
– Clothing
– Missiles and other debris
General Rules for Collection
There is only one chance for collection
When in doubt, collect
Never use plastic to store evidence: Plastic causes
mold
Package in clean unused paper bags
Wet evidence should be air-dried, without heat,
before packaging
Separate all items to avoid cross contamination
IMPORTANT!
Every item submitted to the forensics lab
for analysis must be labeled as to site
(vaginal, oral, anal, penile, surface
areas), name of patient, date and
examiner’s initials.
Evidence Collection Kits
An evidence collection kit must contain the following
items:
– items to collect and preserve evidence of a sexual assault
or other sex offense;
– other items recommended by the Evidence Collection
Protocol Advisory Committee of the Attorney General’s
office and determined necessary for the kit by the
Attorney General.
Check with your local/county law enforcement agency
Prefabricated kits
– Sirchie TX 100
Required Kit Contents
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•
•
•
•
Crush-proof box
White envelopes
3 frosted-ended glass slides with
new/unused pap smear mailers
2 small narrow tooth combs
Purple-top blood tubes; 1 red-10cc
blood tube
Nail file or pick
4 swabs for each (Total swabs:20)
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Vaginal
Oral
Anal
2 body surface areas
2 plain envelopes for other evidence
that needs to be included
Sirchie TX 100
Texas Attorney General’s Evidence Collection Protocol, 1998 edition
Evidence Collection Box
SIRCHIE Kit Envelopes
Evidence Collection Principles
Label all bags with
– Patient name and hospital number (or case number)
– Date
– Time
– Your initials
Fold top of bag 2 times
– Seal with tape all the way across
– Time, date, and initial seal
Forensic Evidence Collection-Process
Evidence collection from the human body
– If possible, have the patient remove clothing and
comb hair over a clean, white sheet. Carefully
fold sheet, place in paper bag and label.
– Use disposable tools and clean them between
each sample
– Do not sneeze, cough or talk in a manner that
might contaminate the evidence
– Do not use stables or lick envelopes to seal
Collection of Clothing
Clothing may contain blood, semen, sweat, saliva,
skin, hairs and fibers as well as debris from the
crime scene.
Drainage of ejaculate from the vaginal or anal cavities
may collect on panties/underwear.
Damaged or torn clothing may be significant. Any
item of clothing worn during the assault or prior to
the exam may need to be collected.
Collection of Body Fluids
Four swabs should be used for each body orifice
Collect as soon as possible after arrival of the patient
If a concern of alcohol or drugs, a sample of
nasogastric contents should be saved
Label slides with a pencil
Blood or urine may be collected
Label slides with a pencil
Common collection sites for Sexual
Assault Exam
• Oral
– Between upper and lower lip
– Gum and along gingiva
• Vaginal
– Vaginal vault
– Cervical cuff
– Check for contraceptive or sanitary device and retain for evidence
• Penile
• Anal
• Injured/bleeding sites
Bite Characteristics
Bites generally present with an ovoid or circular
bruise pattern that consists of 2 opposing Ushaped arches separated at their bases by
open space. Do not write “appears to be bite
mark”, but rather describe what you see.
Frequently a central area of bruise or contusion
Individual tooth patterns may be present
Hair Evidence: Collection Procedures
Combings: Head hair
– Comb over a piece of paper to collect all loose
hair and fibers.
– Combings and comb are folded into the paper
– Placed in an envelope
Combings: Pubic hair
– Second comb used
Label as “head hair” or “pubic hair”
Fingernail Scrapings/Swabbings
Ask patient if they could have left a mark or scratch on
the offender’s face, body or clothing
May use orange stick or plastic pick
May use small cotton swab lightly moistened with
sterile water
Scrapings should be separated for each hand and
obtained over separate pieces of paper
Label as “right hand” or “left hand”
Whole Blood and Saliva Specimens
Used to determine which DNA markers belong
to patient/victim
Blood: Purple top tube included in
prefabricated kits
– Obtain 5-7 ml of blood from adult patients
Saliva: Two swabs, moistened with saliva
– Patient should not smoke, eat or drink for at
least 30 minutes prior to procedure
Evidence Collection in Physical Abuse
Diagrams
Photography
Documentation –
– Red flags: History inconsistent with physical findings or
(pediatric) inconsistent with the child’s growth and
development
Collection of swabs from the skin
Screening
SAFE
– S – do you feel safe in your home: Are you under stress?
– A – are you afraid of anyone? Or are you being abused?
– F – does your family know about this? Have you told your
friends?
– E – have you any money set aside so that you can escape
from the situation? Do you have an emergency plan?
Forensic Evidence Preservation
Evidence Preservation
– What is or is not evidence?
– How do we know what to preserve?
– When did the even occur – acute in 96 hours
Forensic Evidence Preservation (cont.)
Other circumstances
– Weapons found on the patient should be bagged, labeled
and secured with the law enforcement entity.
– GSW
• Patients should have their hands bagged with paper until the law
enforcement entity releases that patient.
– Stabbings and/or suspicious injuries are
reportable to law enforcement
Gunshot Wounds/Firearms Injuries
Forensic Ballistics
Firearm discharges a missile
Loss of Substance
Presence of two wounds
Possible presence of particles
Beveling occurs in flat bones
Penetrating Wounds
Stab Wounds
• Forensic Importance
Reflects sharp edge, not weapon type
No trace evidence
Bleeds Profusely
Forensic Evidence Collection and
Preservation
Consider every possible evidence preservation
technique
When all evidence has been collected:
– Complete information on the top of the kit
– Immediately seal with red or orange evidence tape
– Paper bags are placed next to, but not inside the
completed kit
– Completed kit and clothing bags should
be kept together and stored in a safe area
Chain of Custody
Proper collection and handling of evidence by
healthcare professionals are equally essential.
Chain of custody is the responsibility of the medical
professional collecting the forensic evidence until a
“duly authorized agent” takes responsibility and
signs the collection kit with time of transfer.
Chain of Custody – “unbroken history of a piece of
evidence from the time it is collected until the time
it is used in court”
McCracken, 2001
Chain of Custody (cont.)
Documentation of all individuals possessing the
evidence is critical to the integrity of the
chain of custody process.
Document:
– Date
– Time
– Name of person handling evidence
Evidence Collection: Photography
Photography is a useful adjunct for documentation of
wounds and trauma. It does not take the place of
specific, concise documentation of wound
characteristics.
A measuring device or size standard should be used in
all photographs.
If possible, photograph patient & each specific injured
area prior to medical treatment.
Try to avoid cleaning the area prior to photography.
Photographs should be taken at repeated
intervals to show progression of injuries.
Photography Evidence
Photography: Rule of Three’s
– Full body, including the patient’s face, showing the body
part and wound
– Mid-distance with and without a size standard showing
the body part and wound only
– Close up with and without a size standard showing
wound only
Different venues to store photos:
Photography policies should be in place
Size Standard
Principles of use of a size standard
ABFO No. 2 Ruler
If ABFO ruler unavailable:
– Consider coin or other standardization method
Documentation
Documentation needs to be complete and accurate;
surgery or procedures may alter evidence.
Documentation should include:
– Objective and subjective symptoms of
trauma;
– Date and time of injury and time of arrival;
– Mechanism of injury
• The first step of proper evidence collection is
thorough documentation!
Documentation Principles
• Verbal findings
• Physical findings
• Care given
• Chain of custody
Blunt Force Injury
• Four main subdivisions:
– Lacerations
• Blunt force injuries resulting from tearing, ripping, crushing,
overstretching, pulling apart, bending, and shearing soft tissues.
• May be contaminated with foreign material or trace evidence
– Abrasions
• Scratches and grazes
• Removal of the outermost layer of skin by a compressive or
sliding force
– Lynch, 2006; Assid, 2005
Blunt Force Injury (cont.)
 Contusions
– Bruise
– Leakage of blood from the vessels into tissues
after sufficient force has been applied
– Cannot predict the age of the bruise
 Fractures
– Bones fracture in different ways according to the
amount of force and fashion in which it was applied
Sharp Force Injuries
Cuts
– Sharp force injury, caused when a sharp object comes
against the skin with sufficient pressure to divide it.
– Clean-cut edges, usually without abrasion or bruising
Stab Wounds
– Sufficiently sharp and narrow object is forced inward
– Depth exceeds width
Adjuncts
Body diagrams
– Adult
– Pediatric
Documentation: Anatomical Charts &
Diagrams
To record all marks on the body
Description of each mark must include type of
injury, size, shape, & color.
Diagrams
Available in many forms….
The Office of the Attorney General
provides diagrams in “Texas Evidence
Collection Protocol” (2007):
Male
Full body (adult and infant)
Genitalia
Female
Full body (adult and infant)
Genitalia
http://www.oag.state.tx.us/AG_Publicati
ons/pdfs/evidence_collection.pdf
(Accessed 10/21/2013)
Courtesy, Cook Children’s Medical Center
Obligation to Report
Must report suspected abuse or neglect of a child or
elderly person.
Report must be made within 48 hours
CPS Statewide intake:1-800-252-5400
Website – https://reportabuse.ws
– Users will then be prompted for a user name & password,
may sign in as guest
Police Department in city where the abuse occurred
Jane Doe is non-reporting to law enforcement
CAMH
Comprehensive Accreditation Manual for
Hospitals
2013
JC
Joint Commission
In 2004, JC instituted new standards for
hospitals on how to respond to domestic
abuse, neglect and exploitation.
Two Standards for Victims of Abuse
Standard PC.3.10
Patients who may be victims of abuse or neglect are
assessed:
a. (See standard RI.2.150. Ethics, Rights &
Responsibilities)
b. (See standard PC.3.10 Provision of Care,
Treatment & Services)
Rationale for PC.3.10
Victims of abuse or neglect may come to a
hospital in a variety of ways. The patient may
be unable or may be reluctant to speak of the
abuse, and it may not be obvious to the
casual observer. Staff needs to be able to
identify abuse or neglect as well as the extent
and circumstances of the abuse or neglect to
give the patient appropriate care.
Elements of Performance for PC.3.10
The hospital develops or adopts criteria† for
identifying victims in each of the following
situations:
● Physical assault
● Rape
● Sexual molestation
● Domestic/Intimate partner abuse
● Elder neglect or abuse
● Child neglect or abuse
Elements of Performance for PC.3.10
(cont.)
Appropriate staff is educated about abuse or
neglect and how to refer as appropriate.
A list of private and public community agencies
that provide or arrange for assessment and
care of abuse victims is maintained to
facilitate appropriate referrals
Elements of Performance for PC.3.10
(cont.)
Victims of abuse or neglect are identified using
the criteria developed or adopted by the
hospital at entry into the system and on an
ongoing basis.
The hospital’s staff refers appropriately or
conducts the assessment of victims of abuse
or neglect.
Elements of Performance for PC.3.10
(cont.)
All cases of possible abuse or neglect are
reported to appropriate agencies according
to hospital policy and law and regulation.
All cases of possible abuse or neglect are
immediately reported in the hospital.
American College of Emergency Physicians Guidelines. (1998).
Evaluation and Management of the Sexually Assault or
Sexually Abused Patient.
Assid, PA (2006). Evidence Collection: Are you Prepared to be a
Medical Detective? Topics in Emergency Medicine. Jan-Mar;
27(1): 15-26.
Emergency Nursing Pediatric Course (2004/2013). Emergency
Nurses Association: Des Plaines, IL
Lynch, VA (2006). Forensic Nursing. Elsevier Mosby: St. Louis.
Texas Department of State Health Services (2015). Adolescent
Health, A Guide for Providers. September 2015 ed.
Elements of Performance for PC.3.10
(cont.)
O’Brien, CA. (2006). Forensic patients, nursing and
the law. CHART. Apr; 103(2): 21.
Olshaker, J., Jackson, M., & Smock, W. (2007). Forensic
Emergency Medicine (2nd ed.). Philadelphia:
Lippincott Williams & Wilkins.
Sekula, LK (2005). The Advance Practice Forensic
Nurse in the Emergency Department . Topics in
Emergency Medicine. Jan-Mar; 27(1): 5-14.
Stevens, S (2004). Cracking the Case: Your role in
Forensic Nursing. Nursing 2004. Nov; 34(11): 54-6.
Texas Evidence Collection Protocol (1998). The Office
of the Attorney General, Sexual Assault Prevention
and Crisis Services Division. September, 1998.
http://www.oag.state.tx.us/AG_Publications/pdfs/
evidence_collection.pdf. (Accessed 10/16/2016).
Trauma Nursing Core Course (2014). Emergency
Nurses
Association: Des Plaines, IL.
Confronting Commercial Sexual Exploitation and Sex
Trafficking of Minors in United States (2013).
www.iom.edu/sextraficingminors.
• Methodist Specialty and Transplant Hospital –
Phone # 210-575-8168
• Children’s Hospital of San Antonio–
Phone # 210-704-2190
• Center for Miracles – Phone # 210-704-3800
(Children-Assault > 96 hours)
• Rape Crisis Center – Phone # 210-349-7273
• Rainn: National Sexual Assault Hotline –
Phone # 1-800-656-HOPE
Questions?
Presented by Mary Leblond
Email:
[email protected]
Phone:
210-520-4471