Forensic Nursing Chronicles

With the number of news items that have been recorded as of late regarding Avian Flu, the responsibilities of nurses to detect and aid in the diagnosis of such a pandemic seems inevitable.

After reviewing some of the stories from the Google New Feed that is linked above, I decided to answer a few questions to provide some answers regarding the detection, diagnosis, and treatment of Avian Flu as it relates to the role of nursing within any medical or social setting.

Q. What sort of symptoms may lead you to believe that Avian Flu is one possible cause of an affliction that is presenting?

A. Symptoms of avian influenza in humans are vague and not easily discernable from normal flu-like symptoms. They include fever, cough, sore throat, and muscle aches. Symptoms can progress to pneumonia, severe respiratory diseases and other severe and life-threatening complications. A laboratory test is required for confirmation of the avian flu virus.

Q. How likely do you believe it is that a vaccine can be applied to chickens and other birds that will actually slow the spread of these types of viruses? Why?

A. I feel that the likely-hood of mass immunizing all domestic birds is minimal. Other birds such as ducks and turkeys are also susceptible to this virus. Effective immunization would be near impossible.

Q. Although there have only been 152 cases of Avian Flu transmitted to humans as of yet according to WHO, what are the chances in your opinion that the virus could mutate into an easily transmissible between humans strain?

A. My feeling is that we will not have a pandemic avian flu. I believe, possible naively that our systems are in place and we are prepared to quarantine infected persons effectively. I may be jaded by the fact that I was acutely involved in Smallpox and SARS preparedness preparations within my local community. Neither of these issues came to fruition despite dire warnings.

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As the need to document and catalogue evidence within emergency medicine settings has risen, programs have also arisen in order to train nurses and doctors to manage this crucial aspect of their responsibilities.

Forensic Nursing students and those trained in Forensic Medicine have been familiar with the SANE Initiative and Program for documenting sexual abuse evidence. Now a specific set of skills and procedures has started that documents domestic violence evidence.

This article details how seven nurses have completed training in the National DOVE Program that just completed it’s pilot year in 2005.

According to Deborah Piercy writing for Nursing Spectrum Online,
“The program has expanded to include the Domestic Violence Nurse Examiner program and the Perpetrator Collection Program. The name for the combination of the SANE unit, DVNE unit, and PCP has been changed to the DOVE (Developing Options for Violent Emergencies) Program, and it focuses on care of survivors of interpersonal violence.”

This evolution of Forensic Nursing Curriculums and Training seems a natural progression that is continually required in a society that is becoming increasingly violent.

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This article details the various types of microscope use within the fields of Forensic Medicine and Nursing. Here is a brief Q and A Session regarding this:

Q At what times as a Forensic Nurse would you have the opportunity to use a microscope if any?

A Forensic nurses use microscopes to identify sperm during a post-rape examination.

Q What sorts of protocols would you use as a Forensic Nurse or Examiner in order to preserve the integrity of microscopic evidence?

A First is is imperative that consent be obtained. Then the protocols indicated below shoul dbe followed every time.

Protocols for Collection of evidence:
The nurses preserve vital fragments of trace evidence by careful handling of the patient’s clothing and personal property. Gloves – universal precautions, must wear all times.(When handling any specimens, clothing, anything that could potentially be evidence).

Avoid cross-contamination, particularly of clothing and fluids.

Each evidence item must be individually packaged, sealed and labeled.

Blood work should be drawn as soon as possible
“It is better if the genital exam is done prior to the patient using the bathroom. If there has been oral contact the mouth exam should be done before the patient eats, drinks or brushes her teeth. In most cases a forensic exam is not valuable for evidence collection over 72 hours from the time of the assault but the patient may still require medical treatment.”
Sexual Assault Needs Assessment Project: SAFE nurse, (Oct 14 2002) http://www.everything2.com/index.pl?node_id=1372922

According to “Guidelines for the Preservation of Physical Evidence in Living Patients” Linda McCracken RN (2003), http://www.forensic-ed.com/guidelines.htm

Body Fluid: Collect fluids around wounds or wet body contents, seminal fluid, fluid stains by absorbing stain into a clean 4×4 or cotton swab. Allow swab to air-dry and place in a labeled bag, then seal in a PAPER envelope. Large amounts of fluids will not be collected unless specifically requested by law enforcement.

Seminal stains- allow to air dry, wrap in paper, and package evidence in paper bag.
If on clothing, wrap the item in clean paper, place the article in a brown paper bag, seal and label.

Hair & Fibers: Collect, fold in a piece of paper and place in a separate paper envelope, seal, and label. If hair is attached, such as in dry blood or caught in metal, or glass, leave hair intact on the object, mark it, wrap it, and seal it in an envelope

Debris: Collect and place in separate paper envelopes. Collection of large quantities of small glass fragments can be accomplished with use of hand-held vacuum.

Collect clothing or other material showing evidence of gun powder residue or shot holes. The clothing should be carefully wrapped in clean paper and folded as little as possible to prevent dislodging powder particles.

If there is any indication that the victim’s hands may contain trace evidence gunshot residue, hair, fibers, or residue under the fingernails, and sampling is delayed due to patient treatment, place a small paper bag over each hand and secure with tape

Fabrics, clothing: Remove carefully in as few pieces as possible. Avoid cutting through bullet holes, stab wounds, tears, rips or other defects.

Cut along seam lines, away from site of injury. Cutting along seam lines may also preserve blood spatter evidence.

If clothing is wet, inform the law enforcement officer receiving the evidence. If wet clothing is not given to the police within two hours, hang each item separately to air dry with a clean sheet underneath each item.

NEVER MIX ITEMS OF CLOTHING if items are heavily saturated, place them in the appropriate paper bag, seal, and label the bag, and then place the item in a clear plastic bag. This will avoid leakage, cross contamination of evidence and contamination to staff. Dry garments, fabric etc.- place each item on a piece of paper, before placing in a paper bag. Leave flat if possible; insert a clean piece of paper between layers if the item must be folded.

In the trauma setting, placing a clean sheet on the trauma room floor, and depositing each item of clothing in separate piles, allows law enforcement the opportunity to confiscate whatever evidence they deem essential in that specific case.

Once patient is transferred off of the trauma stretcher, bag the sheet the patient was lying on for trace evidence.

Clothing or any other items which may become evidence should NEVER be released to the family or anyone other than law enforcement.

Document the name and badge # of the officer authorizing release of any item. If items of evidence cannot be given to police in a timely manner, lock them in a secure place, or give to hospital security (documenting security officer identification) and document all in nurses’ notes.

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After reviewing this article that indicates the rise in the number of deaths associated with Taser Use by Law Enforcement Authorities a question and answer session came to mind that may help to shed some light on this phenomena from a Forensic Nursing perspective:

Question:If you were a forensic nurse on duty in the ER, how would you determine and present evidence that indeed a cause of death or injury was due to Taser Use?

Answer:If Taser gun is misused or overused, it overrides the subject’s central nervous system, causing uncontrollable contraction of the muscle tissue and instant collapse. The Taser is a conducted-electrical weapon that incapacitates its target through involuntary muscle contraction. (Electro-muscular disruption device)

Tasers can cause fibrillation. Most people who die from being Tasered die immediately, or very shortly thereafter. It is important to determine the length of time between the application of the Taser and the time of death. The taser gun increased the risk of cardiac arrest in people with heart conditions.

Question: What sort of indications may alert you as a forensic nurse to the possiblity that Taser Use was the cause of death or injury?

Answer: The Taser delivers a substantial electrical shock, so immediate abnormal heart rhythm would be a symptom. The patient will have Taser wounds; contusions, abrasions, lacerations, mild rhabdomyolysis, and testicular torsion. Most victims have many or all of these, and some have complications due to a preexisting injury or toxic or psychiatric problem.

Question: If you are already employed as a nurse on staff, have you ever seen a case that may have indicated Taser Use as a contributory factor in injury or death? Please elaborate why you think this.

Answer: I have never seen a Taser used on a victim. The Taser gun is advertised “TASER devices are among the safest and most effective use of force choices available”. The Taser may be safer than using guns; however it is a bit misleading to hear the Taser pronounced “safest”.

There have been recent lawsuits and concern for safety, and many law enforcement agencies have held off ordering more Taser guns until their safety concerns have been abated. The taser guns can be lethal if not used properly.

On the other hand, the Taser’s weapons are still widely used by U.S. police departments. Taser weapons actually save lives when used by police officers as an alternative to guns, so they make sense when used correctly in the right situations.

A Taser gun can be appropriate in limited circumstances. However, a proper evaluation will need to be done on all Taser gun users. Many casualty deaths are in conjunction with drug use. Further research needs to be done for more understanding of the use of Taser guns and sensitive drug interaction.