Forensic Nursing Chronicles

It takes many years and approximately $1 billion in research and development costs to bring a single drug to market. After a drug is brought to the marketplace, the fourth phase of drug development, also known as post-marketing surveillance begins (Clayton and Stock, 2004).

During this period, drugs are monitored for possible adverse effects. Of the new chemical entities approved by the FDA from 1975 to 1999, 10.2% of them acquired a new “black box warning” (very serious, potentially life-threatening) or were withdrawn from the market because of serious or fatal complications (Clayton and Stock, 2004).

A class of drugs commonly used to treat attention deficit hyperactivity disorder (ADHD) is among the most recent medications being scrutinized for adverse effects. In fact, a federal advisory panel recently recommended that several drugs used for ADHD should carry a “black box warning” cautioning patients of the increased risk of heart attack or stroke associated with the drugs (Stevens, 2006).

These claims are the result of a handful of sudden deaths among children and adults taking the drug. The individuals affected by these medications suffered cardiac events while taking the drugs. Because there haven’t been any long term studies conducted on these medications and their effects on the heart we really are not sure of the extent in which these medications can adversely affect patients (Stevens, 2006).

What can health professionals do to reduce the chances that patients will suffer from unpredicted drug side effects? Health practitioners should monitor their patients and ensure that they’re not suffering from adverse drug effects. If patient side effects are suspected, the practitioner should report all incidents. They should complete a MEDWATCH form whenever adverse effects are suspected (Clayton and Stock, 2004)

Health practitioners should also be sure to ask patients about any heart problems prior to taking medications for ADHD. In fact, I feel that it is prudent for the practitioner to inquire from the patient and/or patient’s guardian specifically if he or she has ever complained of any heart palpitations, shortness of breath or other symptom that could be related to a heart problem. Often times the reason people suffer from a drug’s adverse effects such as a cardiac event is because they do not verbalize the presence of any symptoms they may be experiencing.

Source: Dowshen, Steven, MD. (2006, February 10). FDA Panel Pushes for Warning on ADHD Drugs. Children’s Health News.

Pesticides, by definition, are toxic and biocidal. Even though they have been used for many years to eliminate specific pests, they have also had unintentional impacts on the health of wildlife and humans.

Canada has more than 6000 registered pesticide products and each year more that 50 million kilograms of pesticides are used. Each year, humans and wildlife are coming into increasing contact with them through direct application, inhalation, or ingestion of food products and water. It is estimated that as much as 50% of the chemicals used on lawns, gardens and crops end up in our ground water or surface water.

In 1996, the Quebec Poison Control Centre and the Ministry of Environment and Wildlife reported 1,650 poisoning cases, with 79.4% of the cases occurred in private homes, of these 46.1% were children under 5 years of age. 31% of these cases were due to oral ingestion and 34.9% following a pesticide application.

Although the chronic long term effects (bioaccumulative) are not fully understood, we do know that regular exposure to low doses of pesticides are associated with cancer, birth defects, childhood leukemia, non-Hodgkin’s lymphoma, Parkinson’s Disease, hormone disruption, low sperm counts and sterility. These organochlorines, such as DDT, are attracted to fats, which allows them to accumulate in the tissues of living organisms. Many pesticides are considered “probable” or “possible” human carcinogens based on evidence of cancer in laboratory animals. North Americans and Europeans are known to have residues of at least 6 persistent chemicals in their bodies.

Short-term acute effects can be recognized by their immediate health effects on people who are overexposed. Organophosphates are extremely toxic and work by inhibiting enzymes that are essential for the proper functioning of the central nervous system. Effects can range from disorientation, to spasms, to eventual death.

What are the Symptoms of Acute Pesticide Poisoning?

• External Injuries (via contact)
• Skin: redness, itching, pimples, swelling or blistering
• Mucous Membranes of eyes, nose, mouth and throat: stinging and swelling
• Internal Injuries (via inhalation, ingestion or absorption across skin)
• Lung: shortness of breath, heavy salivation, or rapid breathing
• GI tract: nausea, vomiting, abdominal cramps or diarrhea
• Nervous System: excessive fatigue, sleepiness, headache, muscle twitching, & numbness

Treatment

Treatment should be initiated immediately according to standard first aid poisoning protocol. Forewarn the doctor or medical facility so that they can begin preparations for treatment. Health care providers may not be well informed of the symptoms or treatment of pesticide poisoning. This is generally due to the few cases that they treat, and that pesticide poisoning symptoms are similar to those of other illnesses and poisonings. It is always advisable for clients to bring the printable version of the product label or at least the name of the suspect pesticide to the health care facility or with the emergency response team. The product label should detail what chemicals have been used, symptoms of poisoning, treatment and antidotes. Health care providers should contact the Poison Control Centre at 1-800-222-1222 to obtain accurate, up to date information about the product.

Should the poisoning be of an indeterminate variety, healthcare providers can access the PAN Pesticide Database – Pesticide Poisoning Diagnostic Tool.
This web based tool ( http://www.pesticideinfo.org) has been established to assist in identifying the pesticide or class of pesticide that may have been responsible for the pesticide-related illness. Product identification is based on observed symptoms, type of crop sprayed, pesticide type and/or geographic area of product application.

Remember that in some localities, pesticide poisoning must be reported to the appropriate authorities.

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Teaching an Online Forensic Nursing Certification Course provides me with the opportunity to solicit the opinions of the bright people who are creating the future of Forensic Nursing. Here is one such opinion on how to stop drug misuse among people diagnosed with mental illness.

Approximately 10% of the U.S. population will suffer from a mood disorder at some point in their lifetime. The unipolar and bipolar mood disorders that afflict so many individuals can be incredibly debilitating and difficult to treat.

In fact, major depression currently ranks as the second leading cause of disease burden in the United States (Clayton and Stock). Successful treatment of mood disorders is a multi-faceted approach that usually includes psychotherapy, pharmacologic treatment as well as the presence of a strong familial or friendship support system.

Many of the medications used to treat mood disorders such as CNS depressants and anti-anxiety medications have the potential to be addictive for the patient. Also, patients suffering from mood disorders are more likely to develop addictions to medications. In fact, people who suffer from depressive disorder are four times more likely to suffer from addictions to drugs and or alcohol (http://www.muschealth.com/cdap/psyaddiction.htm).

The integrative approach to treating mood disorders is one way of reducing the risk of patients becoming addicted to or misusing prescription medications. The integrated approach to treating patients with mood disorders provides a system of checks and balances to ensure that medication abuse is not occurring.

Psychotherapy is an important component of treating a patient suffering from a depressive disorder. The patient should include regular sessions with a therapist, counselor or psychiatrist. During these weekly or bimonthly appointments, the health care practitioner can monitor the patient’s behavior, affect, and overall progress.

This patient evaluation is an important component of monitoring the effectiveness and proper use of prescription drug therapy. Another component of an integrated therapeutic approach is the incorporation of family members or close friends in the patient’s treatment program. The inclusion of support persons in the patient’s therapy (monthly group therapy sessions), is another way to help the patient adhere to an appropriate medication regime and avoid the potential for misuse.

Substance abuse, and the impact it may be having on employee health and workplace safety, continues to receive increasing attention in companies across Canada. Much data is now available to Canadian employers especially aimed at the transportation industry, (truck and bus drivers, and railway), as well as oil field and construction workers, machinery operators and automakers. This data can support the development of comprehensive workplace policies to reduce health and safety risks, and address potential legal liabilities.

The Alberta Alcohol and Drug Abuse Commission has been very aggressive in their researching and finding solutions to the problems of substance use. In a 2002 survey of 755 employees, 8% reported that their companies had alcohol or drug testing programs, whereas in the 1992 survey only 1% reported such programs. A provincial review of toxicology data from 290 fatal workplace incidents between 1990 and 2001 found that 11% of the dead had alcohol or illicit drugs in them.

Alcohol and drug screening tests are used for three purposes:

1. Medical purposes – to monitor progress in a treatment program
2. Legal purposes – to determine substance use prior to accident or crime
3. Medicolegal purposes – Employer program aimed at preventing accidents/crimes and treating employees with substance use / abuse problems.

As workplace drug testing becomes more common, the science of “Urine Sample Adulteration” is also becoming more prevalent. Adulteration is defined as the tampering or manipulation of a urine specimen with the intention of altering the test results and can usually be achieved by substitution, dilution or the addition of adulterants called masking agents. Adulterants can cause a false negative result by interfering with the screening test or by destroying the drugs present in the urine. Urine adulteration products such as the Whizzinator, Dr Green’s Agent X, Strip Extreme Cleaner and real, dried urine can be purchased at local stores or via internet. The brisk business in the sale of these products to help drug users pass a urine test have become a serious problem in forensic urine drug testing.

Proper procedural collection and processing of urine samples is vital to the overall process. The following is an outline of guidelines that can be used to reduce or eliminate the opportunity for adulteration of urine samples.

Urine Specimen Collection Procedure:

Collector: a trained person who instructs and assists individuals who receives and makes an initial inspection of the urine specimen and completes and submits all relevant documentation.

Collection site: the place where individuals provide the urine specimen.

Collection supplies: items that must be available at the collection site in order to conduct proper collections.

Individual Identification: individuals must provide appropriate original identification to the collector. Acceptable forms of identification include: photo identification such as driver’s license or other government issued photo identification.

Ideal Qualities of Collector and Collection Site:

1. The collector must be someone in which there is no conflict-of-interest, or in a situation that may preclude any potential appearance of collusion or impropriety.

2. The collection site may be a single-toilet restroom or a multi-stall restroom that will provide visual privacy. Hand washing facility (water faucets & soap dispensers) should be outside the stall or room area so that no water sources are accessible to the individual privately. Water within the toilets should be coloured with a bluing agent and flushing handles and toilet tank lids secured. Only authorized personnel should be in the collection area. Collectors should ensure that individuals do not have access to items that could be used to adulterate or dilute the specimen such as soap, disinfectants, cleaning agents and water.

The collection site must also have a clean surface for the collector to use as a work area and for completing the required documentation.

3. Collection supplies should include the following:

• An approved urine collection kit.
• Appropriate forms for documentation – may be specific to lab, company or agency.
• Bluing agent for toilets.
• Disposable gloves.
• Tamper-evident tape for securing faucets, flusher handles and toilet tank tops.

Steps in Urine Collection

1. Prepare collection site and collect all supplies required.
2. Begin procedure for collection immediately upon individual’s arrival to collection site.
3. Individual supplies appropriate form of photo identification.
4. Collector explains the basic collection procedure to the individual.
5. Ensure all require information is provided for accurate documentation and that the individual’s specimen ID number is present on all forms and specimen containers.
6. All outer clothing such as hats, coats and personal items; briefcases, purses or lunch bags must remain outside the collection site.
7. Individuals are directed to empty pockets and display all items to ensure no adulteration items are present. Collector assesses the need for further investigation of adulteration products on client’s person.
8. Individuals are instructed to wash and dry hands under supervision, and also instructed not to wash hands again until after the specimen has been collected.
9. Individual personally selects the collection container and with both parties present the seal of the container is broken.
10. Individual is directed to go to the room used for urination and provide a specimen of at least 45 ml. within designated time frame not to flush the toilet return with the specimen after completing the void
11. Urine is immediately tested for temperature. (acceptable range 32º to 38ºC) Voiding periods of longer that 4 min. must be repeated under supervision.
12. Specimen should be inspected for unusual colour, presence of foreign objects, or materials, or other signs of tampering. If it is apparent that specimen has been tampered with – collector should then follow procedures outlined in the Problem Collections Section of the collection kit instruction manual.
13. The collector divides the urine sample from the collection container into 2 specimen bottles. Bottle A – 30 ml. and Bottle B – 15 ml. Ensure that lids are secured tightly to prevent leakage.
14. Each bottle must have correct ID labels and tamper-evident tape is applied over the lids and bottoms and extending down the sides so that lid cannot be opened without destroying the seal. The collector dates each seal and the individual should initial each seal.
15. The collector completes all relevant documentation, ensuring that the individual signs where required.
16. The collector transfers specimens to laboratory ensuring that the procedure for chain of custody is followed.

Sexually transmitted diseases (STD’s) are on the rise.
According to the American Social Health Associations ASHA “more than half of all people will have an STD at some point in their lifetime.” http://www.ashastd.org/learn/learn_statistics.cfm.
STD’s range from chlamydia to trichomoniasis.

Many STD’s are asymptomatic, detected only through testing which is only routinely performed a third of the time. One of these asymptomatic STD’S is the genital herpes HPV infection. By the age of 50, according to the ASHA, 80% of women will have acquired this genital HPV infection which can, in high-risk types of HPV, lead to cervical cancer.

Sexual activity does not die when you reach 50, a gross thought for our children. In an age of better health care, better nutrition, and health promotion, we are living into our nineties and so is sex, and unfortunately so are STD’s. According to the Hunterdon Co. Health Department, 10% of all AIDS cases occur in persons over the age of 50.

According to the Atlanta based Center for Disease Control and Prevention “AIDS cases among Americans over 50 have quintupled since 1995, up from 16,300 in 1995 to 90,600 in 2003.” and they estimate seniors with 14% of total AIDS cases with senior women representing 18% of female AIDS cases. http://homepage.mac.com/georgia.nesmith/iblog/C191060534/E1307881895/index.html

The older population is at a great risk. Many don’t know about “safe sex”, or just don’t believe it will happen to them. Physiological changes also contribute to their risk. Immune systems are weakened with age. Menopause and its’ symptoms can mask actual STD symptoms and again, less than 1/3 are routinely checked for STD’s. Remember, AIDS has increased 5 fold in just 8 years for those over 50.

Education will be an uphill battle. Many have already lost friends and spouses and intimate relationships is not in the foreground. But once it happens safe sex is not practiced or “it won’t happen to me” attitude pervades. Unless there is a change in social attitudes and an increase in education, such as pamphlets, and sexual activity discussions during annual physicals, for the golden agers, sex til death maybe more ominous than bargained for.

Insomnia is a problem that affects countless numbers of people. Although the causes vary the treatment for many is the same, sleeping pills. Far too many begin to rely on sleeping pills and find themselves taking them on a regular basis. The question that begs to be answered, are sleeping pills addictive? There is no doubt that they can be habit forming, but can one develop a physiological dependence?

The answer to that question depends on the type of sleeping pill in question. Benzodiazepines can certainly cause life threatening symptoms such as seizures if they are not tapered off slowly. Most of the drugs advertised on television are being marketed as ‘safe’. What exactly does ‘safe’ mean.

Benzodiazepines have been prescribed for treating sleep disorders since the late 60’s early 70’s. The carry a relatively low risk of overdose when taken alone and do not interact with liver metabolism the way that barbiturates do. However they are indeed habit forming and sudden withdrawal can be life-threatening.

Nurses, pharmacists, and physicians need to be educated on the signs and symptoms of the abuse of sleeping pills. Patients need to be carefully examined to rule out possible underlying causes of their sleep disturbance before sleeping pills are prescribed.

Depression can be one cause of sleep disturbance and if properly addressed the patient may find their sleep improved without the use of a sleeping pill. As with all prescription drugs that carry the potential of abuse, there is a strong need for the implementation of a check and balance system to prevent the abuse and exploitation of obtaining prescriptions.

Nurses, physicians and pharmacists need to be fully aware of the potential for sleeping pill abuse regardless of whether or not research has proven them to be addictive. The fact that they are habit forming makes them enough of a danger.

Patients need to be fully informed of the potential to become reliant on them, and with the help of their physician discuss a long term treatment plan to address their sleep disorder since sleeping pills are not meant to be taken for long periods of time.

The issue of acquiring adequate nutrition is one of the most important issues faced by humans every day. Sufficient nutrition, along with exercise, is the key to maintaining true health. Without the nutrients that the body requires for every day living, it will begin to break down.

This is a problem for adults and children all over the world, in all walks of life. The reasons for this lack of healthy nutritional intake range from a financial inability to, a lack of available foods (or variety therein), or a need for nutritional education. Each of these reasons is valid and their consequences can be seen everywhere we look.

The Food Guide Pyramid lays out a general guideline for daily food choices. It is recommended that people eat a variety of foods in order to best achieve the required level of nutrients. In the pyramid, the whole grains group is given the bottom spot with the highest number of daily servings.

Above the whole grains groups is the fruits and vegetables group. Next come the meat, beans, eggs, and nuts group. On the top are the fats, oils, and sweets.

Children who do not get the nutrients they need, become sick with one or more of the many diseases associated with malnutrition.

Kwashiorker, marasmus, and other wasting diseases are more common than we prefer to think. Yet the symptoms of malnutrition can often be harder to pinpoint than a disease. The effects of undernourishment or malnutrition can be seen in the inability of children to focus at school, increased irritability, or even just a generalized weakness.

As nurses it is important to assess for proper nutrition in patients, be it under or over the required amounts. Once malnutrition has been identified, it is important to take the necessary corrective measures in nutrient intake. It is equally important to educate the patient and the necessary family members about nutrition and patient health.

In the field of forensic nursing, it is essential to be familiar with the signs and symptoms of undernourishment. Things like low body weight or fat content can be equally as important to note as the specific symptoms of a disease such as Kwashiorker or marasmus. Understanding nutrition and its effects on the body while it is living can greatly assist someone as a forensic nurse who deals with the patient posthumously.

Substance abuse is inclusive of drugs (both prescribed and illicit), alcohol, and tobacco. Common characteristics with any addiction are denial, rationalization, defocusing, minimization, and enabling behaviors of family members.

There are progressive stages of addiction. First learning, then seeking, dependence, to harmful dependency, finally to addiction.

According to the National Survey on Drug Use and Health, in 2004, 7.9% of the population ages 12 and older were current (30 days) illicit drug users, with and increase of lifetime prevalance in pain reliever usage such as Vicodin, Lortab, Tylox, Oxycodone, and more.

An illicit drug category of taking pain relievers for non-medical use has markedly increased. A 2005 survey shows a decrease in drug use but a continued increase of non-medical use of prescription drugs especially opioid pain killers.

Inhalant use is of great concern too. According to SAMHSA’S 2002-2004 NSDUH “an average of 598,000 youths aged 12-17 per year reported the they initiated inhalant use in the 12 months prior to being surveyed”. Prior to inhaling, 59% used cigarettes, 67.6% alcohol, 42.4% marijuana and 35.9% used all three. There appears to be a progression in use.

Other substances abused are alcohol, with 50.3% ages 12 and older being current drinkers, and 22.8% admitting to binge drinking and tobacco with 70.3 million or 29.2% of the population ages 12 and older.

I mention all this because of the possible suggestion of Kandel et al, 1986 that early use of substances may continue or reappear in the elderly.

There is 3 times the frequency of elderly using prescription drugs. Because of physiological changes they may decrease elimination or increase accumulation. Misuse maybe intentional or unintentional.

The illicit drug use among seniors has risen from 3.5% to 5% just from the previous generation. This study was from 1996 translating into 1.1 million more seniors using drugs.
A report Alcohol and the Elderly “seniors drinking mostly unreported, undiagnosed, or ignored” and “statistically in epidemic proportions”.

In our youth oriented society, seniors are not part of “mainstream society”. No one pays attention to them. If drinking wasn’t initiated in earlier years, then social isolation -depression as a result; loss, grief, or decline of health may lead many seniors to begin.

Our society focuses on prevention on the youth as it should. An ounce of prevention can save lives and alot of money over time but assessment of the elderly must begin with annual physicals, obtaining a complete medical and psychological history and verification of same, drug use history, and family history of addiction.

Perhaps if we listen to those who have experienced a lifetime, or near, of abuse we might gain wisdom on how to reach the young more effectively and prevent the obvious succession towards substance abuse.

Here is another article submitted by one of my students in our Online Forensic Nursing Certification Course.

My first position as a Director of Nursing was in a medium size nursing home. The home was the result of the amalgamation of 2 older nursing homes, and the population was around 130.

The staff was mainly older staff left over from the closure of the old homes. I had been the Director of Nursing only 6 weeks when I received an early morning call informing me that one of our patients had passed away after being taken to the hospital with respiratory problems.

The patient in question was a 78 year old female with a history of throat cancer, and had a tracheostomy in place. All usual precautions were in place, including a suction machine at the bedside, head of bed elevated, and call bell in reach.

The patient was NPO, but was allowed small sips of water with supervision. It was hoped that with time the trach could be removed permanently.

On the night in question, it appears that the patient asphyxiated on a blocked inner trach cannula. She was unable to call for help because she panicked, or the call bell fell to the floor, and the patient subsequently died.

The patient was not found until the change of shift at 7 AM. The patient was cold, and it was later determined that she had been dead for approximately 5 to 6 hours. The nurse, a Licensed Practical Nurse, and the Nursing Assistant, both panicked and initially lied about the time they last saw the patient alive.

The Nursing Assistant was the first to admit that she had not seen the patient since around 1 AM. The nurse, however, insisted that she looked in on the patient around 4 AM, and convinced herself that she was properly tucked in bed with the head of the bed up and the call bell in reach.

This argument fell apart when the autopsy showed that the patient’s trach was blocked by the seed of a watermelon given by the Nursing Assistant at around 1:30 AM.

The Nurse and Nursing Assistant are both now in jail for 2 years, with 1 year suspended. There is no arguing with Forensic Science.

As I currently instruct an online Forensic Nursing Certification Course, I am often told stories about how my students have experienced different facets of their professional lives. This is one of them:

Hip Fracture Surgery

I live and work in an area where there is a growing population of elderly people. In the community hospital where I work, as an operating room nurse, one of the services that we do the most surgery with is orthopedics.

We do many hip fractures in our operating room, more in the winter than in the summer for obvious reasons. People who experience a hip facture can have many causes for weakened bone. The most prevalent reason is low bone density, one because of the age of the client and as is documented in many books inactivity. When talking with one of the orthopedic surgeons in our hospital he states that inactivity is the main reason for the elderly to have low bone density, related to the long winters we have here. The most common fracture of the hip is the femoral neck fracture that we see.

Doing surgery to repair the fracture requires an open reduction with compressions screws. The most important aspect of surgery that the nurse needs to think about with is blood loss. When ever there is surgery involving the hip, as opposed to the knees where a upper leg tourniquet is used which reduces blood loss, there is usually a large blood loss secondary to cutting in to the bone.

When surgery is performed on the elderly many can not afford to have a large blood loss. When a client has a large loss of blood that delays them post operatively in healing and rehabilitating.

Postoperatively the patient is always put on a blood thinner usually coumadin to prevent blood clots, and if not contraindicated, antiembolotic stockings (Ted’s) and compressions stockings. The major concern for the nurse taking care of the post-op is monitoring the patient for signs and symptoms of deep vein thrombosis which can lead to pulmonary embolus and then death, if not monitored closely.

This is one of the common causes of mortality in clients with hip fractures. The signs and symptoms of pulmonary embolus will depend on the location of the thrombus. The most common signs are chest pain, dyspnea, and tachycardia. It is very important for the nurse to monitor the client for DVT’s.