Nurse as sleuth

By IN-SUNG YOO

For those who can see it, it's everywhere.

It may be lining the inside of a baseball cap, or smeared on a scrap of fabric. Or maybe it's in the distinct pattern of a bruise.

It's evidence -- and it's the key to conviction of criminals and justice for victims.

But evidence isn't collected only by detectives and crime scene investigators on the street or in a home. A lot of evidence can be found in the hospital -- on the victims and suspects themselves. And forensic nurses do the finding.

Examining abused or assaulted patients and assembling rape exam kits used to fall to whichever nurses or physicians were available. But without specialized training, they often overlooked or even discarded crucial evidence. Today, forensic nurses -- and similar professionals called legal nurse consultants -- are helping to bridge the medical and legal worlds by providing expert knowledge in a variety of roles.

The International Association of Forensic Nurses has more than 2,800 members, up from 1,400 in 2000, and it continues to grow. Meanwhile, forensic nursing is becoming a more nuanced field. Last year, Johns Hopkins University, in Baltimore, graduated its first class from the forensic clinical nurse specialist master's program, joining 12 other schools that offer graduate level training in the field. Earlier this month, Christiana Care Health System expanded its forensic nursing program to include trauma patients in addition to sexual assault and abuse patients.

Improved technologies have led to greater reliance on medical data within the legal system. DNA collection is now possible in instances where it wasn't just 15 years ago. But for all the attention paid to technological advances, they are worthless if good samples aren't retrieved, said Daniel Katz, DNA technical leader at the Office of the Chief Medical Examiner in Delaware.

"Forensic DNA gets a lot of exposure, and it's a constantly evolving field," he said. "But the forensic nurses are the front line, and if they don't do the proper collection and documentation, then we don't have anything to work with. They have a very challenging job, since they've got the double challenge of caring for a person and their injuries and emotions as well as collecting evidence."

Between law and medicine

Unlike the forensic pathologists and investigators prominent in popular TV shows like "C.S.I.," most forensic nurses do little crime scene and death investigation. Most are employed as sexual assault nurse examiners at hospitals. Others work as nurse coroners, correctional nurses, researchers and consultants. Legal nurse consultants perform similar advisory roles, but usually have less patient contact.

As both an attorney and a forensic nurse, Lisa Schwind is in a unique position to assess the interaction of medicine and the law.

Schwind is the forensic services and education coordinator for the Delaware Office of the Public Defender and president of the northern Delaware chapter of the forensic nurses association. She works closely with forensic science specialist Gerard Spadaccini and forensic nurse Linda A. Fernandes, one of the first graduates of Hopkins' master's program.

Together they assist attorneys by educating them on medical issues and screening cases. Identifying possible sources of forensic evidence early on allows attorneys to plan their course of action more thoroughly. Schwind and Fernandes also can review medical records, which sometimes reveal medical conditions relevant to the case.

"The attorneys focus on the legal aspects of a case," Fernandes said. "Sometimes they may not completely understand the medical terminology or the medical records. By having me here, I can basically break it down to them."

Schwind was involved in the case of George McCray, who was cleared of first-degree robbery after being charged with stealing a woman's purse. She recommended DNA testing on a hat left by the attacker, even though no hairs were found, because she knew epithelial cells on the hat could still yield DNA. The charges were dropped after four epithelial samples taken from the hat could not be matched to McCray.

Forensic nurses have helped make defense attorneys more familiar with important medical issues, said Delaware Public Defender Lawrence M. Sullivan, who won an award from the forensic nurses association in 2005 for his work in establishing the office's forensic unit. Their support also helps lighten the workload for attorneys, who handle 37,000 cases every year.

Forensic nurses are just as useful to the prosecution, said Delaware Deputy Attorney General Stuart Sklut.

"Before, we were basically just relying on the reports of the victim and if the investigating officer had the forethought to photograph injuries," he said. "Now those types of injuries are routinely being documented, as well as the internal examination."

Assessing injuries goes beyond what can be seen

When assessing a patient's injuries, seeing isn't always believing, said Dan Sheridan, director of the forensic clinical nurse specialist program at the Johns Hopkins School of Nursing and past president of the International Association of Forensic Nurses. Sometimes an injury isn't consistent with a patient's retelling of how it incurred.

Sexual assault victims are more likely than domestic violence victims to report their incidents, said Anita Symonds, forensic nurse examiner program coordinator at Christiana Care Health System.

"Sometimes we need to recognize the injuries," she said. "They may say, 'I fell,' yet they have multiple injuries at different stages of healing. With those people, you may take them aside and say, 'I'm concerned. Is someone harming you?' "

In the past, sexual assault exams were sometimes assigned to rookie nurses as a rite of passage, said Debra Holbrook, forensic nursing director at Nanticoke Memorial Hospital in Seaford. But a good exam means more than collecting a few swabs of bodily fluids. Injuries need to be fully detailed -- not just location and size, but color and pattern as well. A forensic nurse knows what questions to ask to uncover less obvious sources of evidence. Saliva, sometimes invisible, can be swabbed for DNA, even after it has dried.

"There's a standard kit that they process, and the kit ensures that they collect everything we need, but you're starting to see the forensic nurses becoming more creative when the situation isn't standard," Katz said.

All evidence is properly maintained until it's needed by the police, Symonds said. Delaware isn't a mandatory reporting state for instances of domestic abuse and adult sexual assault, so evidence is turned over to police only if charges are filed.

Patient care takes precedence in cases of traumatic injury like stabbings and gunshot wounds, so it's understandable that clothing may be tossed aside or an injury site may be altered in the rush to provide treatment. However, once a piece of evidence is thrown away, it's compromised.

So-called "dumpster diving" for discarded items may yield tainted evidence that's not as strong in court, Sheridan said. But it's a practice that's still necessary at most hospitals in the country, which do not have forensic nurses on staff.

"It's being destroyed out of ignorance," he said. "It's a missed opportunity, and it still happens on a regular basis."

At Christiana Hospital, forensic nurses are based out of the emergency department, where most victims of abuse and assault begin receiving care. As a staff ER nurse, Symonds is familiar with the procedures of the often hectic department. So, in order to document what injuries looked like before treatment began, she can shoot photos while care is being delivered by another nurse or doctor. She also can swab for bodily fluids and gunshot residue, remove bullets, collect clothing and even do bite impressions.

"As ER nurses, we know how to get that done without being in the way," she said. "And the response time is virtually zero."

Growth of the field

Even as forensic nurses find new ways to apply their skills, growth of such services is limited by the willingness of institutions to pay for it, Holbrook said.

Many hospitals, even in major metropolitan cities, neglect forensic nursing services, most likely due to the cost of starting up such a program, she said. Holbrook estimates it can cost at least $100,000 to start a forensic program.

Christiana Care -- a "model program," according to Schwind -- started its forensic nursing program in 1996 with 10 forensic nurses. Today it employs 20 such nurses, with one on-site at Christiana Hospital 24 hours a day. The recent addition of forensic trauma nurses expands the team's capabilities from sexual assault, domestic violence, and child and elder abuse, to patients with injuries such as gunshot and stab wounds.

Nanticoke started its forensic nurse program in 1997. Bayhealth and Beebe Medical Center have had a sexual assault nurse program since 2001 and 1997, respectively. Alfred I. duPont Hospital for Children works with the Children's Advocacy Center of Delaware to coordinate care for suspected cases of abuse and refers some cases to Christiana. St. Francis Hospital does not employ forensic nurses.

The American Nurses Association recognized forensic nursing as a subspecialty in 1995, but certification through the International Association of Forensic Nurses exists only for nurse examiners for adult and adolescent sexual abuse. Meanwhile, only a handful of states require licensure to practice forensic nursing; Delaware is not one of them.

Improving coordination between national nursing organizations and state boards would be a huge step forward for the profession, said Holbrook. "It would maintain standardization throughout all states," she said. "What I see right now is that anybody can make their own rules."

Educational options also have expanded and some nursing undergraduate programs have added forensics classes to their curriculums. Most established forensic nurses learned their skills through on-the-job training, but nursing students can now pursue such specialization from the start. Master's programs like the one at Hopkins offer more in-depth work with research, but there may be another side benefit, Sheridan said.

"In court, the alphabet soup after your name can help," he said.

Recently, a case in which Holbrook testified as an expert witness was appealed to the state Supreme Court and upheld, setting the precedent that forensic nurses could serve in that capacity. It's indicative of the growing respect for the profession, she said.

"It's growing in a lot of different ways and people are seeing the usefulness," Schwind said. "We're still in the beginning stages so we can't really see where the end is."