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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 • • • • • • • • 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 • • • • • • • 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) – – – – • 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