Forensic Nursing Chronicles

While training in nursing school, classes are specific to providing nursing care. Nursing classes include pharmacology, documentation, anatomy, physiology and hands-on care. Nurses receive no formal training on law, involvement with police or how to present yourself in court.

As a relatively new nurse, I received a subpoena to appear in court. I was the nurse who performed a legal blood draw for alcohol on a patient brought in by police. During that time, I worked midnight shift and performed from 3-5 alcohol legal blood draws per week. Because the frequency of blood draws happen during the late-night hours, I was very familiar with these procedures.

Our hospital had a specific protocol for these draws and documentation of such. Prior to witnessing, the prosecuting attorney reviewed my educational and work background with me. While I was sitting on the witness stand, I was asked questions that had been discussed with the prosecuting attorney.

The defense attorney then began questioning. This particular attorney was very demeaning in his questioning. I felt as though he was trying to prove that I didn’t know what I was doing, that I did not have the education to support my practice. It was very difficult to listen to criticism that was not founded. By trying to interject additional information, I may have been tagged as being argumentative.

Due to the lack of education related to court proceedings, I could have been asked to step down from the witness stand. In retrospect, I understand that the defense attorney will try to make the witness frustrated and upset in hopes to elicit contempt or incriminating evidence. I should have only answered yes or no or provided a brief, concise answer to questions that were asked by the attorneys. More information does not make or break a case. Confidence and demeanor of the witness provide a tremendous statement about the issue at hand to the jury.

“A permanent solution to a temporary problem” certainly describes the issue of teen suicide in today’s culture. There are approximately 5,000 teen suicides in the United States annually and is the third leading cause of death among teens.

Teens are under a tremendous amount of pressure these days not only academically, but also from peers. The ability to “perform” at a certain standard is difficult, as well as the feeling to fit in, and the hormonal shifts occurring can cause them to react somewhat irrationally to specific circumstances or situations.

The ratio of male to female suicides is 4:1. Males are generally more successful at committing suicide than females and will choose a more violent manner in which to commit suicide such as using a gun or driving their car at a high rate of speed and crashing into something. It can sometimes be a call for attention, but regardless of whether it is or not, it is important to take a verbal hint or actual gesture of suicide seriously!

Warning signs include giving away of prized possessions, feelings of hopelessness, loss of self-esteem, changes in personality, changes in school performance, and withdraw from family and friends.

Hopefully, these indications will prompt concern and help will be perused early on. It is also important to recognize the significant numbers of teens diagnosed with depression as well as other chemical imbalances.

Ignoring these problems and not treating them with therapy and possible use of medications can be devastating in that they can prompt suicidal gestures..

Regardless of the circumstances behind the hint of possible suicide or an actual gesture, it is crucial to LISTEN!! Take the person seriously and don’t attempt to downplay the situation. Be non-judgmental and show genuine concern for the individual. Do not leave the individual alone until a higher level of care and protection can be provided.

Teen suicide is extremely problematic in our country. Creating an awareness of this in parents as well as teens is very important. Teens need to be informed regarding feelings they may be experiencing and to let an adult know.

In regards to the responsibilities of a forensic nurse in the case of teen
or any other suicide, it would be important to understand patterns seen in
an attempted suicide and recognize that this is what you are actually
dealing with as the person may not volunteer this information.

It is important to protect the individual from further harm and provide care for
any wounds incurred as well as the proper referrals or admission for
observation.

It is important that the individual dealing with this type of circumstance
be empathetic and non-judgemental.

In the case of a successful suicide, it would also be important to recognize
patterns with specifics to the mechanism of injury or other methods used to
committ the suicide (such as an overdose). It may not be clear that the
cause of death and it important for the forensics expert to investigate the
evidence in an attempt to figure out what happened.

Working in a busy emergency department in a city with one of the highest crime rates in Southern California definitely brings in some interesting clientele.

It was a busy Friday night and I received word as the assigned trauma nurse that I would be receiving a critical trauma victim with a gun shot wound to his chest. The patient arrived with paramedics performing CPR as they entered the trauma room. We worked the patient for about 20 minutes until the trauma surgeon pronounced the patient and our efforts were stopped.

The patient had several very distinctive tattoos as well as the clothing we had cut off of him being characteristic of a local gang.

Gang and drug activity was certainly not a new concept to this emergency room. We prepared the patient for the coroner and I was informed that “his family” was in the lobby. I called them into an area that provided privacy for discussing issues with family members that were sure to be emotional.

There were several Hispanic men with the same type of clothing and tattoos in the room when I entered and I proceeded to inform them that I was very sorry, but that their friend had not survived the shooting incident. The gang members proceeded to become very angry and several of them began punching the walls. One of the members had me up against a cabinet wall and was yelling at me.

They were obviously very distraught and were not handling their emotions well. Several of them were threatening retaliation against the opposing gang members responsible for the death of their friend.

I looked the man directly in the eyes and told him very calmly but quite directly to let me go. I was prepared to come up with my knee into his groin if necessary. I was scared but thankfully able to think rationally. Such a necessary trait of an ER nurse I believe!

I obviously put myself into a very bad situation and should of thought about the potential for violence in this situation.

My first clue should have been with the obvious indications of the patient being a gang member and that his injuries were the result of gang activity that I would be potentially dealing with violent individuals.

The police were apparently still on the scene of the shooting and had not yet arrived to the ER. Before taking the family members into the private room I should have waited for a police escort or in the very least had hospital security with me.

I also did not provide myself “an out” in the small, enclosed room. I think the lesson learned here is that my own safety needed to be a priority and that it is important to look for indications that there is a potential for danger. There were many indications that that was the case. I certainly learned a great deal this night about “looking for clues” that there is a potential for violence.

The ER staff was summoned to the ER entrance. Several guys were surrounding the back end of a van. Spread out in the area that usually houses a backseat was a 21-year-old male (OG) who “drank too much”. His friends brought him for evaluation because they were starting to get scared. OG had been drinking all day long. He “passed out” and began breathing very slowly.

The ER staff pulled OG out of the back of the van by a backboard and took him into the ER. IV’s were started, activated charcoal and Narcan were given, and his airway was secured by nasal intubation. After being stabilized, the patient was transferred to a tertiary care center.

The next morning, OG was extubated and was released home. OG had no recollection of how detrimental his actions were. Unfortunately, he may repeat these actions again. Next time, he may never wake up.

It is important to know that when a patient presents with an acute onset of respiratory depression that the amount of alcohol ingested was due to the rapid consumption. Typically, alcohol that is ingested is eliminated within an hour. Respiratory depression may lead to death if not corrected. Those patients who are chronic drinkers are able to tolerate larger amounts of alcohol without having life threatening symptoms.

If you were working in an ER, how would your usual method of contributing to diagnosis change after having read this?

Recently, a 21-year-old male (DT) was brought into the ER while CPR was being performed. He had been swimming with several family members and friends. He apparently went under and never came back up. Dive rescue teams were summoned. DT was not found until one hour after he was discovered to be missing. He did not have a pulse or blood pressure from that time forward.

DT did not have any medical problems. He did not take any medications or have any allergies. He occasionally complained of leg cramps, but otherwise never complained. DT had not acted out of the ordinary prior to this incident. He had not given any reason to be suspicious or concerned. In addition, DT was a strong swimmer. Originally, there was question of whether or not drugs or alcohol were a factor.

Approximately, 1-1/2 weeks after DT’s death, the autopsy revealed a normal 21-year-old male. No congenital anomalies were found. No medical problem or condition was found to explain DT’s death…just “a drowning”.

It was difficult to hear these results. What would cause an otherwise healthy 21-year-old male to die? I am sure that it would be easier for the family and those involved with DT’s care if there was an explanation of what caused this young man to die.

This case was actually a medical examiner case. Because DT had not any medical problems, his death was certainly not expected. According to my reading, a drowning may occur and have no physical findings on the autopsy (which was the case for DT). If there is a medical condition that causes a loss of consciousness, usually it is caused by a syncopal episode, heart-related condition, or a congenital anomaly. Also, a drowning victim can not be pronounced dead until the body temperature has been brought back to normal body temperature and is unable to be resuscitated. When all other causes have been excluded, the diagnosis of “drowning” may prevail.

Until you have witnessed a shaken baby syndrome case, either on a personal level or professional level, you cannot appreciate the devastating effects of these cases.

A 28-day-old baby was rushed to the ER with a sudden change in mental status. Mom’s boyfriend had been babysitting while mom was at work. When mom got home, her boyfriend claimed that the baby had been sleeping a lot and wasn’t acting right. Mom was unable to arouse the baby, this she brought the baby to the ER.

Upon presentation to the ER, the physician and the nurse rushed the baby to the trauma room. They realized the severity of the baby’s symptoms. The baby was lethargic and limp. His respirations were shallow, but present. The baby was intubated and stabilized medically, then prepared for transfer to NICU. The physician in charge included shaken baby syndrome in his differential. The mom and boyfriend were not allowed to be alone with the child pending further investigation.

Apparently, the mother’s boyfriend violently shook the baby when he wouldn’t quit crying. Shortly after the shaking incident, mom came home to discover that the baby wasn’t acting right.

Nearly five years later, this case went to court. The mother’s boyfriend was found guilty of first-degree murder status post shaken baby syndrome. The child lives in foster care. He will live on a ventilator for the rest of his life.

Shaking a child or a newborn can cause life-threatening injuries. The injuries are mostly internal. Head trauma is the most common. With an infant, shaking will cause the head to wobble around. The backwards and forwards movement of the brain within the casing of the cranium causes swelling, increased intracranial pressure and retinal hemorrhages. The first symptom that is seen is a change in level of consciousness. This symptom is worrisome to a parent and prompts treatment. Typically, there are not any marks on the body. If marks are discovered, usually fingerprints of the suspect will be seen on the arms or trunk. It is always best to consider child abuse and be cautious until proven otherwise. Time is of the essence for these cases.

As a forensic nurse, what would be the first symptom presenting that may alert you to Child Abuse in the form of Shaken Baby Syndrome?

A 10-year-old female presented with her mother to the emergency department. The little girl was in no apparent distress. Her mother claimed that the young girl had been staying overnight with a family friend. During her visit, the man was repeatedly sexually abusing her. She brought her to the emergency room as soon as the patient reported what had happened to her mom.

As an ER nurse, sometimes it is difficult to take complaints like this seriously. Typically with cases similar to this, there is no need to do a rape kit or an extensive interview as the case does not fit the criteria.

The young girl was able to give a consistent history to the nurse, to doctor and also to the state trooper who came to take a statement. This young girl talked about repeated acts of penetration by the perpetrator’s fingers as if this were normal behavior and supposed to happen. She stated that at multiple times, the family friend touched, massaged and inserted his finger inside her.

The doctor determined that he was going to do a visual inspection of the external genitalia. With the doctor on one side of the bed and the RN on the other side of the bed, a visual inspection was done.

After one quick look at the introitus, I proceeded to pull out a rape kit. Despite the fact that I may not be able to gather much evidence, this was the real thing. The entrance into the vaginal area was grossly edematous and erythemic. Multiple contusions were noted to the inner thigh areas.

I gathered vaginal swabs and rectal swabs and processed them for the kit. While continuing to do visual inspection, there happened to be one lone dark hair found directly inside the vaginal vault. This hair was clearly not the patients and should not be present where it was found. The hair was collected, placed into an envelope and labeled accordingly. After the genital exam was complete, I finished the evidence collection of oral swabs, oral scrapings, etc.

Because I took this child seriously and took the time to do the rape kit, this perpetrator was caught and convicted. It makes me shudder to think that if the rape kit and extensive genital exam had not be done, this child may continue to be violated by a person that was once considered a friend. In addition, the perpetrator may never have been caught and could have potentially violated other children as well.

A 17-year-old female (L.M.) presented to the Urgent Care Center with complaints of pain with urination. After taking a history from the patient, this young girl confided that she had been forced to have sex by a 32-year-old male. What initially seemed to be pretty cut and dry turned out to be a life sentence.

Because L.M. was 17, she is legally able to present for treatment for STD, pregnancy and contraceptive issues without a parent. To complicate things, L.M. claimed a rape situation that occurred approximately one week prior to seeking treatment. Due to the lapse of time, a rape kit was not indicated. As a minor, this only made the case more interesting.

On L.M.’s physical exam, several large open blisters were noted on the external genitalia. In addition, the internal genital structures were bright red and irritated. The cervix was friable and had multiple pustules noted on the surface. Cultures were obtained and sent to the lab.

My decisions for treatment of this patient had to be made pending the cultures results. I was one of the most impressive GYN physical exams that I have seen. After the exam was complete, I discussed the findings with the patient. I expressed concern that the lesions noted on the external genitalia were herpes simplex

I also voiced concern about the possibility of multiple other STD’s. L.M. seemed to take the news pretty well until we discussed the reality that she had contracted a life altering virus that would plague her for the rest of her life. We discussed the medical liability of having to report the act of forcible sex to the police. She did not wish to report for fear of the consequences. After a lengthy discussion, realization set in that this man could continue to spread the herpes virus to other young girls and could impact their relationships for the rest of their lives.

The end results for L.M. were very difficult. L.M.’s cultures came back positive for bacterial vaginosis, chlamydia, gonorrhea and herpes simplex. She was treated for each ailment, but will always have reminders of the dreaded event of rape. She did report to the police that there was sexual activity, but claimed that it was consensual. Unfortunately, the perpetrator will not be caught for this act and will probably strike again.

It is being reported by the LA Times that two jurors in the recent trial of Michael Jackson are now stating that they believe Jackson is guilty despite the fact that he has been acquitted.

What sorts of forensic evidence that exists in this case may have been ambigous?

What sorts of forensic evidence in this case may be conclusive?

Do you have any ideas about how jurors could be convinced of one’s innocence during a trial and then reverse their conclusions?

If you were assisting the District Attorney in prosecuting this case, what sorts of evidence would you have sought to collect and add to the proceedings?

If you were assisting the Defense, what sorts of evidence would you have sought to collect?

Would you use a different approach depending on which side you were working with? describe the differences.

Do these types of questions interest and intrigue you? Perhaps you are ready to add a forensic nursing certification to your skills set. Online Forensic Nursing Certification Courses are the answer.