Forensic Nursing Chronicles

Methanol poisoning usually results from ingestion of contaminated alcoholic beverages. Common carrier mechanisms for methanol are gas line antifreeze, glass cleaner and windshield wiper fluid. Methanol is extremely toxic. Two teaspoonsful can be fatal to a child. Two to eight ounces can be fatal to an adult. The signs and symptoms, diagnostic studies and treatment depends on the amount of ingestion.

Methanol causes multiple symptoms. Usually symptoms are present between one to 72 hours post-ingestion. Generalized weakness, fatigue, leg cramps and convulsions may be present. Rapid, shallow breathing may be present. Range of visual complaints may start from blurred vision and may progress to blindness. Cyanotic lips and fingernails may be seen. Nausea, vomiting and abd pain are common. Headaches and dizziness may progress to a coma-like state.

Comprehensive lab study (metabolic panel) will give information about the anion and osmolar gaps. This is diagnostic information and exclusive to overdoses, no matter how subtle. A pH of less than 7.0 is not uncommon, but must be treated aggressively.

Ethanol infusion is the traditional therapy for such overdoses. Large doses of ethanol competes for the same sites as methanol, therefore causing the methanol to be excreted from the body and not metabolized.

Case in point: 15-year-old female accidently ingested minute amount (approximately 1 oz.) of windshield washer fluid that had been put into a child’s juice bottle. The color of the fluid resembled the juice that her nephew had been drinking and felt nothing wrong about drinking after him.

Mom had been having trouble with the windshield washers and was manually squirting washer fluid onto the windshield. Due to the sweet taste of the drink, did not realize that it was not juice until mother happened to see the girl drinking from the bottle.

The female was rushed to the emergency department. Immediately, the emergency doctor began an ethanol infusion. The ethanol infusion was based on weight, amount of consumption and by poison controls recommendations.

The end result in this case was positive as the events happened in a short amount of time and treatment was started immediately after ingestion.

Other treatments for methanol poisoning are similar to ethylene glycol poisoning. Primary therapeutics include gastric lavage. Secondary therapeutics include hemodialysis to remove the toxic metabolites from the blood stratm. In addition, an alcohol dehydrogenase inhbitor, fomepizole (Antizol), may be used in persons greater than 12 years of age.

References

Henderson, W. R., & Brubacher, J. (2001, October 27). Methanol and ethylene glycol poisoning: A case study and review of current literature. Retrieved October 16, 2005, from http://www.caep.ca/004.cjem-jcmu/004-00.cjem/vol-4.2002/v41-034.htm

Likosky, D., Rutchik, J. S., Talavera, F., & Galvez-Jimenez, N. (2005, March 9). Methanol. Retrieved October 16, 2005, from http://www.emedicine.com/neuro/topic27.htm

Questions;
1. As a forensic nursing student or nurse with a forensic nursing certification, how would you approach the problem of diagnosing methanol poisoning?

2. If you were in the ER when someone came in and there was suspected methanol poisoning, what could you do to confirm or disaffirm that diagnosis?

Excerpted from:
http://www.bedfordbulletin.com/articles/2005/10/05/news/news01.txt

Following some three hours of testimony that described in graphic detail what rescue and medical personnel found at a Bedford caregiver’s home in June, General District Court Judge Harold Black found probable cause to certify elder abuse and malicious wounding charges against that caregiver, Dorothy Thompson Leonard, to the grand jury.

In presenting evidence at the preliminary hearing, Krantz used emergency responders from the Bedford Lifesaving Crew, emergency room personnel and doctors from Bedford Memorial Hospital, law enforcement officers and a neighbor to convince Black to certify the charges.

Krantz had also hoped to have Leonard’s husband, Alvin, testify. But he chose to invoke spousal privilege.

“The Commonwealth was willing to give Mr. Leonard the benefit of the doubt,” Krantz said. “He had indicated he wanted to be cooperative; he wanted the truth to come out.”

In fact, Krantz said Alvin Leonard had indicated just minutes before Monday’s hearing that he would testify, but changed his mind. That, Krantz said, will force the Commonwealth to evaluate whether Alvin Leonard has any culpability as a codefendant or co-conspirator in the case.

Krantz said exceptions to the spousal privilege include incidents when the victim is a child.

“My feeling in this case is that these women were certainly child-like and were being cared for by Mrs. Leonard in her household. I dare say Mr. Leonard was at least assisting with that care,” he said. “I can’t force Mr. Leonard to testify. It’s frustrating when you have a potential eye witness to the criminal act who has the knowledge that in an analogous situation could have been required to testify.”

The initial 911 call that came from the Leonards’ home at 750 Peaks St. on June 15 of this year was played early during Monday’s hearing. In that call Dorothy Leonard said that a woman had fallen and she was not able to get her up. “I can’t get a pulse,” Leonard states during the call. When asked by the 911 dispatcher if the woman was breathing she replied, “I don’t think so.”

Jeff Johnson of the Bedford Lifesaving Crew testified that the crew responding found Minnie Thompson lying on the floor at about 11 p.m., adding that she was not responsive or breathing. He said he noticed, while performing emergency procedures, that Minnie Thompson had dried blood on her nose, which also displayed deformity, and bruising on parts of her body.

Another Lifesaving Crew member, Janet Blankenship, testified she noticed bruising on Minnie Thompson’s chest, face and abdominal area. She also said another woman, who would later be identified as Nellie Thompson, was laying still on a bed in the room, covered up to her neck with a blanket.

Freda Easterly, another crew member who responded to the scene, said the home was dark when they arrived at the scene. “It was very hot in there,” she said of the room where the two sisters were found. “The room was very dirty. There was a strong smell of urine. It hit me in the face as soon as I walked in.”

She added that she noticed bruising on Minnie Thompson, of varying colors. “I noticed more bruising in the ambulance when there was more light,” she added. “I noticed she was very, very dirty.”

She said Nellie Thompson, whom the crew later went back to see following the transport of her sister, had severe bruising all over her body, including a significant bruise on the side of her face. She testified the diaper Nellie Thompson was wearing “looked like she had been wearing it for days.”

“It appeared to have been old. It appeared to have been soiled multiple times.”

She also said Nellie Thompson had dark, brown stains on her hands, that looked and smelled like feces. “She was very dirty, very pitiful,” Easterly testified.

Theresa Kern, a registered nurse at Bedford Memorial Hospital who also was accepted as an expert witness for the hearing in forensic nursing, was on duty at the emergency room when Minnie Thompson was brought in to the hospital.

Kern testified she photographed Minnie Thompson’s condition and saw bruises that had resulted from trauma that had occurred over various time periods – some recent, others not.

She testified to various stages of bruising under Minnie Thompson’s chin, on her chest, face, rib area, abdomen, umbilical area, arms and legs, and back. She testified there appeared to be feces on her feet. When asked if the bruising could be explained by just falls, she testified it wouldn’t be consistent with that claim.

She testified to a linear bruise on Minnie’s back, which she said would be inconsistent with a fall.

Kern also said there was skin breakdown on Minnie’s back, along with the evidence of dried feces. In addition, she said there was a laceration to the back of Minnie Thompson’s head, bruises on the outside of her hand and arms that she said would be consistent with defensive wounds.

She presented similar testimony on the state of Nellie Thompson, pointing out by photographs bruising and abrasions over much of Thompson’s body

She testified that Minnie and Nellie Thompson had received inadequate care, in her opinion.

Leonard’s attorney, William Quillian, questioned Kern on the manner the bruising may have occurred and whether the elderly bruise easier. “You noted a lot of bruising on the ladies. You have no idea where the bruises came from do you?” he asked.

“Correct,” Kern replied.

Two doctors, Dr. Bruce Bradfield, a family physician, and Dr. William Weddle, who was working in the emergency room at BMH June 15, also testified.

Bradfield said Nellie Thompson had both of her forearms in splints when he visited with her later that evening in her room at BMH. He said both her forearms had been fractured just above the wrists. He also said he noted signs of dehydration.

When asked if Nellie Thompson was receiving adequate care prior to being brought to the hospital, he responded: “It’s hard to believe that she was.”

A neighbor of the Leonards, Michael Nicholas who lives at 748 Peaks St., also testified, stating that he had witnessed an incident occur between Nellie Thompson and Dorothy Leonard. In that incident he said he heard Leonard yelling at Nellie Thompson as she struggled to take the trash outside.

“What the hell are you doing? You know where that goes,” he testified he heard Leonard yell at Nellie Thompson as she took out the trash. He testified Leonard was standing in the doorway to the house and that when Nellie Thompson came to the door Leonard struck her in the head, pushing Thompson’s head into the door jam.

He also testified that, on numerous occasions, he heard Leonard cussing at the Thompsons and also heard “a couple of thumps and thuds” on one occasion.

“It kind of made the hair stand up on me,” he said. “I called my wife and let her know.”

On cross, Quillian was asked why he hadn’t called the authorities.

He later testified that he had told Alvin Leonard that if what he was hearing didn’t stop, he was going to have to take action. He said he never heard anything after that.

Dr. Weddle, who was working in the emergency room on the night of June 15, testified that Minnie Thompson, when she was admitted, was covered in bruises of varying ages over her body. “I do not believe the injuries she had could be explained by repetitive falls,” he testified.

But when he saw Nellie Thompson, he said her appearance was even “more shocking.”

“She was alive but she was severely battered,” he testified.

Investigator Eddie Harmony of the Bedford Police Department testified Leonard told her that the Thompsons would fall repeatedly, but that she didn’t seek medic
al attention because “she didn’t trust any of the doctors around here.”

He said she later admitted in the interview that she “would tap them lightly” because they wouldn’t listen to what she would say. She later admitted to him she would use a fly swatter, ruler or paint stick to strike the women, he said.

Harmony testified Leonard said in her interview that she never struck the Thompsons in anger. “She tapped them because she loved them,” he testified Leonard had told him.

Leonard remains free on bond. Nellie Thompson is currently living in a long-term care unit of Bedford Memorial Hospital.

Questions:

1. If you were called to present expert testimony for this case as a forensic nurse; how would you prepare?

2. What sorts of evidence would you personally review as an expert witness?

3. In your opinion, is there anything that local law enforcement could have done to prevent the deaths of this victim?

Does this sort of case interest you? It may be time to sign up for online forensic nursing certification.

Death occurring while in the custody of the police are more common than I thought. I also found it interesting that in general, there is not standardization for many terms and conditions particular to the area of forensic medicine. In regards to death in custody, it seems unlikely that there is not a universal definition for what this is, yet there is not.

The forensic nurse is in a vital role in the initial and ongoing examination of the detainee. The nurse may be the first contact the prisoner has whether it be in the local emergency department of the hospital or in the prison.

In Minnesota nurses staffed the county jail, but I don’t believe it is customary for most jails to have a nurse on duty. Irregardless of the site of examination, it is the nurses’ obligation to ensure the health and safety of the prisoner is being attended to.

The assessment and ongoing care of each person who are detained by the police can prevent miscarriages of justice as well as harm to the detainee. Communication and documentation is imperative in order to prevent potential harm to the prisoner, and in the case of infectious diseases, to the police and staff who have contact with that prisoner.

Early intervention by a trained healthcare professional to determine fitness for detention and questioning may provide the diagnosis for any natural disease processes present, drug or alcohol use, and any trauma visible or covert.

I believe the professional nurse advocates for his/her profession and the population being cared for. Forensic nurses should be active in the formation of public policy. In this area of nursing it is vital for nurses to better define and advocate their role to the benefit of themselves, the population served, and the general public.

I had many occasions to be involved with child protection services (CPS) and adult protection services (APS) while working as a community health nurse and in hospice. My dealings were by no means something I was formally taught, however it was quite apparent that careful, concurrent, and accurate documentation was of most importance.

The documentation of behaviors, diagnostics ordered and provided, any wounds or injuries, and verbal interactions was painstakingly undertaken. In essence, I created a paper trail so each interaction was documented by date and time.

Public health nurses and other nurses who work in the community deal with many who are vulnerable and at risk. Forensic nursing can be of great assistance and should be a course covered by these nurses in order to assist them in dealing with situations involving harm. Using unambiguous language, documenting all interactions with any involved in the case, and obtaining clinical data to present a clear picture of the problem/incident assists in the pursuit of an desirable outcome.

The use of unnecessary force is not unheard of in the penal system, nor is the use of coercion, psychological torture, and neglect. I begin to see the importance of the nurse in trying to safeguard the health and safety of prisoners, regardless of their crime.

The forensic nurse in the penal system is in an ideal position to assess and evaluate the prisoner, the people who work in the system, and the protocols to maintain the system. Poor assessment and treatment and or misdiagnosis was made real to me. The fitness of a prisoner and their ability to safeguard themselves is of utmost importance when dealing with mental health, metabolic conditions, injuries, and cognitive ability.

There is also the matter of the real threat of disease. One of my misguided preconceptions was that the penal system posed a very real and dangerous threat to the safety of the healthcare professional. While this is true, my misconception resided in the belief that these diseases were “rampant”. It is through forensic science that well defined protocols are in place for the interactions and handling of persons and items which may be infected, decreasing the risk of transmitting any biologicals to self and others.

I’m not sure how much of my thoughts and beliefs are influenced by television and movies, but I think documenting and reporting as a neutral party is difficult when heinous crimes are involved, but nursing in general is ideally non judgmental. In forensic nursing it becomes the task of the nurse to maintain this objectivity, regardless of the outcome. The ability of the forensic nurse to be an advocate for the alleged, or convicted accuser is one I admire.

While the history of forensic medicine is interesting and provides a good overall view of the duties relegated to that field, the fundamental principles lay the strong foundation for the rights of all peoples, regardless of their role of victim or perpetrator.

The rights, or rather the misuse of rights, of victims has always made headlines. Torture of prisoners in detention facilities or of peoples being held captive point to the breakdown of basic human rights and protections. I see the role of the nurse in forensic nursing to be one of ensuring that the rights of victims and alleged perpetrators are kept intact to the benefit of all, and to the greater whole which is the society in which we live.

I have recently read about a medical case regarding a 34-year-old black female that was flying from one side of the US to the other. After being up in the air for several hours, she began to complain about abdominal cramping.

She proceeded to spend a significant amount of time in the bathroom. Upon returning to her seat, an elderly women offered a solution to black female’s abdominal problems. The elderly women thought that her seat partner must be constipated and gave her a dose of mineral oil to help her move her bowels.

Before landing at their destination, the black female began to feel worse. Her heart was racing, abdomen was rigid and causing excruciating pain, and began to vomit profusely. After landing, she was taken immediately to a nearby medical center. She died shortly after her arrival at the emergency center.

The autopsy showed a massive overdose from crack cocaine. Apparently, she had swallowed multiple condoms filled with crack cocaine prior to her departure. She was transporting them to her arrival destination. Her abdominal cramping started from the massive influx. By offering the mineral oil, the elderly women actually caused a life-threatening condition. Condoms cannot withstand any type of oil based substances. The mineral oil caused the condoms to rupture, thus, a toxic dosage of crack cocaine was introduced into the females body. Ultimately, the toxic dose resulted in her death.

This case raised my awareness of a problem that I had never thought about. As a forensic nurse, the ingestion of drugs to avoid being charged with possession may be fatal. Problem-solving to retrieve the drugs takes knowledge of the body system and potential hazards that may result by actions that we impose.