Archive for the ‘Health Assessment’ Category

Documentation

February 24, 2012

Documentation is critically important in obtaining any type of encounter in the ED, but yesterday I had the opportunity to apply what I have learned in the coursework to the fullest. My patient was a fifteen month old who was accompanied by her mother. The child was brought in for head injury. Her behavior was appropriate for a toddler, smiling and interacting with both mom, and me and very active. She was cooperative with the triage. Mom was concerned about the abrasion over her left eye and ecchymotic area under that eye which she stated had happened 2 days prior when the child had fallen off the couch and hit her head on the coffee table. She denied LOC, vomiting or lethargy and stated her activity level had been the usual state. On further exam, I noted a three cm ecchymotic area over the left sphenoid which could be consistent with the fall, but it troubled me that she also had ecchymosis lateral to the right eye, petechial contusions to the inner auricle of the right ear but none on the pinna and also noted pinpoint abrasions to the right occiput. This did not seem consistent with the story. I asked mom about these and she stated that “She is just learning to walk and falls a lot.” A fifteen month old is usually walking fairly well, and running unless developmentally delayed, which she seemed to be bright and happy, so this troubled me. However, since triage was busy and it is not the function of triage to document all findings but just identify them, I marked her as urgent and notated my suspicions of abuse due to the inconsistency. Later, when I got off triage, I took over this patient and got to interact with the police investigator and county child protective worker who had been called. The doctor felt that the findings were consistent with abuse and a report was filed with immediate action taken. I measured all the areas and took photographs and logged them as well as documenting all the individuals and actions we had taken. The child was CT’d which thankfully was negative. The mother had admitted that she had left the child alone with her significant other on a number of occasions. The investigator felt he had enough evidence to make an arrest. The child was released to the custody of the mother and her parents. This story had a happy outcome but I still feel troubled by it. How can a person abuse a sweet innocent toddler? How can the mother allow this? Aside from that, she was so benign about the whole matter and practically lied to me about it in triage. As a mother and patient advocate, this boils my blood. I fear for this child’s safety now and suspect will see more of her in the future. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby.

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President Obama is 50 years old this month, comment

August 12, 2011

From the Forensic Nursing perspective, safety should be included in your list. Safety would address

  1. Seat belts
  2. Boating life jackets
  3. Bullet-proof vests (especially for our president in dangerous situations)
  4. Lighting for seeing clearly
  5. Emergency contact information close at hand
Original Post

President Obama is 50 years old this month

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Mental Health Assessment in Forensic Nursing

March 3, 2011

Chapter 7 of Health Assessment for Nursing Practice discusses mental health and mental status assessment. This chapter correlates with Forensic Nursing in that the Forensic Nurse’s assessment needs to indicate the mental status of the client he/she is subjectively and objectively assessing.

The Forensic Nurse determines the client’s mental status by examining the client’s behavior, appearance, risk factors, interpersonal relationships and cognitive function. Vital signs are indicated as well in order to ascertain whether medical treatment is required. Past medical history, family history, drug and alcohol abuse, and medications that the client is using is also added.

The nurse assesses the client’s behavior and cognitive function in order to ascertain the client’s mental status. Is the client alert and oriented to person, place and time? Does the client appear anxious, withdrawn, or does the client’s mood appear appropriate to the situation? Is the client’s emotional state appropriate to the situation? Is the client displaying signs of paranoia, delusions of grandeur, obsessive compulsive actions, or bipolar episodes?

Is the client appropriately dressed for the weather? What is the client wearing? Is the client wearing outlandish dress and makeup or does the client display a lack of hygiene. Assess the posture of the client – Is the patient slumped in a chair and looking to the ground or is the client sitting upright and smiling? Is the client fidgeting or pacing the room? Does the client’s tone of voice indicate anxiety, anger, or is the client rambling with inappropriate sentences?

Risk factors involved include the client’s age, gender, family history, psychosocial environment and personal characteristics. Has the client had a past history of trauma, sexual or physical abuse, or alcoholism? Does the client display evidence of low self esteem?

Interpersonal relationships are indicated to establish the client’s social surroundings. Is the client in an abusive relationship? Does the client have family and friends that are supportive and that the client is able to discuss with them his/her feelings and problems? Does the client have a social phobia which inhibits him/her to avoid social situations?

Elevated blood pressure and pulse may indicate severe anxiety or panic. Assess respirations for dyspnea, tachypnea, or labored breathing. Decreased respirations may indicate depression with evidence of frequent, deep sighs.

Mental Status assessment is one of many observations that the Forensic Nurse incorporates in her nursing assessment. It can give valuable evidence of victim abuse, sexual assault and mental trauma.

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Alcohol addiction is a disease, comment

December 8, 2010

Assessing patients with potential alcohol abuse for mental illness is difficult. Alcohol abuse can mimic a mental illness so it is important to assess carefully. In some cases with mental illness it is necessary to have a period of abstinence of use of alcohol in order to accurately assess the patient for a mental illness. As stated in the article a visual assessment of the patients ability to take care of themselves can be helpful in diagnosis. When there is a dual diagnoses of alcohol abuse and mental illness an accurate assessment will enable a holistic treatment of both the alcohol abuse and the mental illness.

Original Post
July 9, 2010
Title: Alcohol addiction is a disease, comment
Alcohol impacts the lives of many individuals. Alcohol is a dangerous drug that is widely used and abused. There is evidence everywhere in our society, advertisements, socials events, sporting events, alcohol is everywhere. While there are many who can drink responsibly and not get to the point of alcohol being a problem in their life, there is a large percent of our population that has alcoholism. This is a very difficult disease, since there is no cure, no medicine it is something a patient has to overcome this disease using willpower and other methods requiring mental strength.

The nurse’s assessment plays a role in identifying if alcohol or any other substance may be controlling and having a negative effect on a patient’s life. During the assessment the nurse can identify alcohol dependence, abuse, or addictions. The patient may not even realize they have an alcohol problem the nurse can not only assist the patient in identifying a problem they can provide education to assist the patient in finding and evaluating treatment options. The nurse can also educate the patient during the assessment on how alcohol affects the body and mind short term and long term.

Advanced nursing assessment and forensic nursing may overlap on matters that may be related in some emergency situations caused from alcohol abuse. A forensic nurse may be involved in the care of a patient in the ER from an alcohol related incident. In this circumstance a forensic nurse would be required to utilize her advanced assessment skills to care for the patient as well as fulfill her role as a forensic nurse.

Original Post

September 28, 2009

Title: Alcohol addiction is a disease

Alcohol is the most commonly used and abused psychoactive drug in the United States. Of those seeking treatment 50% will relapse in the first few months of therapy. Everyone around these patients is effected by this disease. Nursing is on the forefront of the battle these individuals undertake. Alcohol use is broken down into two categories abuse and dependence. Alcohol abuse is characterized as a pattern of use leading to one or more manifestations in a period of a year such as a failure to fulfill major roles or obligations at work, school or home. Recurrent alcohol related legal problems or being in physically hazardous situations and continued use despite problems with relationships caused by or exacerbated by alcohol. Alcohol dependence is a pattern of three or more manifestations in a year such as having a tolerance to alcohol, showing signs of withdrawal, consuming larger amounts or over longer periods than had intended. Continued use of alcohol despite desire or failed attempts to cut down consumption. Drinking and recovering from use takes up more and more time. Continued use despite knowing it is doing damage physically or psychologically, as well as those listed above for abuse. Alcohol not only effects those who are abusing or dependent on the drug, but everyone around them. As a child I remember the late night phone call my mother received that her father, only 49 years old, had passed away after having too much to drink, vomited and aspirated his stomach contents. He was an abuser, a weekend social drinker whose life alcohol had very little impact on until that night, then it had the ultimate impact. A patient I took care of many years ago had a similar experience, he was a young man in his early 30’s, he too aspirated after vomiting, he survived this initially only to be left with damage to his brain from a lack of oxygen. He would live the rest of his life in a coma like state, with a grieving wife and child. Alcohol is a treatable disease, when a patient comes to a hospital or clinic, they have chosen to undertake the battle of their lives. They are not able to do this alone, the attitudes of family and nurses as well as others they may come into contact with are crucial. A compassionate nurse can change the life of a patient, as well as an unsympathetic nurse whose attitude may be “they did this to themselves.” Alcohol dependence or abuse should be seen for what it is a real disease that needs real treatment. These patients need all the support they can get from those around them, and education on the subject is paramount to recognizing the signs and symptoms that manifest. Education for healthcare workers so they understand these patients, as well as how to successfully treat them with medications, together with the patient’s desire to enter therapy will hopefully change that 50% to 25% or better 0% relapse in first few months.

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Importance of Skin Assessment in Elderly and Child Abuse, comment

October 18, 2010

Skin assessment is a more valuable tool than we give it credit or time for. There are so many clues to a long list of health issues; from the varience in color, turgor, texture, temperature and thickness, to hair distribution, and condition of the nails.  All of these variances from norm could be linked to some health issue.  Issues like nutritional deficiency, allergy, local or systemic disease; such as melanoma or systemic lupus erythematosus; or they could be signs or the ‘remnants’ of abuse.

Unfortunately, I don’t think the nurse on the floor routinely gives skin assessment the time or attention needed to pick up on these clues.  The most opportune time to find these signs would be on admission, during the initial assessment. What I see on the floor, is short staffing more often than not, trying to care for more patients than can be fully cared for during their shift, and bed shortages, requiring ‘quick’ turnover.  I am also afraid that the gains in my staffing numbers over the past year are in jeopardy with the reforms and cuts in reimbursement that I think are coming. Thorough assessments are an essential part of health care, of preventative medicine, and all of our professional practices; so I truly hope there will be the time and ability going forward to complete this valuable task.

Original Post

May 26, 2009

Title: Importance of Skin Assessment in Elderly and Child Abuse

In studying skin assessment, one cannot help feeling overwhelmed. Without a desire to pursue dermatology, the unlimited amount of skin lesions, pustules, macules and papules can lead one to skim over information out of the pure necessity for mental sanity. The mind can only hold so many pictures at once. However, I do see the need to ensure the memorization and ability to recognize and diagnose normal skin variations. In reading articles and working with children and the elderly, one unfortunately sees the reality firsthand of physical abuse and neglect. This can often be recognized by assessing the skin. Breakdown, malnutrition, physical abuse, bruises, injuries at different stages of healing can all be noted by a thorogh assessment of the skin. As follow up care and the big picture should always be a part of our thought process in nursing assessment, the ability to note whether a skin assessment finding is simply normal or abnormal is vital to our practice.

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Screening for abuse, comment

July 20, 2010

Screening for abuse is a very important element of the nursing assessment.  While screening for abuse should be included in every nursing assessment abuse is seen more frequently within certain patient populations; such as the very young and the very old.  Those patients who are very young or very young are more vulnerable to abuse by their caretakers.  This screening can sometimes be difficult to perform.  There needs to be attention to detail during the interview for any inconsistencies with information given and findings during the assessment.

The nurse assessment of the skin and musculoskeletal systems hold great importance when screening for abuse.  It is during these advanced assessments there may be evidence of abuse may be found.  Any suspicious bruising, welts, or marks that are found should be taken into consideration when screening for abuse.

When a nurse is functioning in the field of forensics their assessments and screenings for abuse may be called into use during a proceeding in court; the nurse may have to testify to their assessment findings.  Forensic nurses will also have to rely on their experience in advanced assessment to accurately screen possible victims for abuse.

Forensic nurse or any other area of nursing this screening for abuse is a vital part of the nursing assessment.  A nurse is responsible for advocating for the patient to their best ability.  Especially in circumstances when the caretaker of the patient is overpowering and does not cooperate with the patient being assessed without them present.

Original Post

September 28, 2009

Title: Screening for abuse, comment

I think that all nurses and doctors should receive additional training in screening for abuse depending on their specialty area. Patients will present differently depending on whom they are being interviewed by. Many times in the situation of children they are with their abuser when they present and it is difficult to separate the two. The abuser does not want you to have words alone with their child. I worked many years as a school nurse and suspected many cases of abuse that were reported to the appropriate authorities only to find that the child was disbelieved and then years later found to be telling the truth. Adults are very savvy at making a child look like a liar but seldom do these children have the capabilities to make up the horrendous story I heard. Unfortunately the investigators seem to want to believe the abuser. These children were also ones with poor grades (not sleeping at night due to the abuse), behavioral issues (they just wanted someone to listen) and many times documented storytellers (the only way to get attention) so it was very easy for the abuser to discredit them. If we are all trained to look for something other than physical marks we may start to diminish abuse against our children. Part of the assessment should not include where the parents reside in society. Several times the investigators simply found out what the parents did for a living and that in itself ended the investigation.

Original Post:
September 8, 2009
Title: Screening for abuse
Thank you for this important message. It is absolutely imperative that ALL providers know the signs and symptoms of physical, emotional and sexual abuse. Furthermore, it is absolutely necessary that ALL providers screen every patient at EVERY patient encounter for abuse. Providers should incorporate screening for abuse into their health assessment. It is very easy to do. Providers can accomplish this important task by 1. Printing the screening question on the pre-assessment paperwork, 2. Asking the patient during the assessment, “Do you feel safe at home?” 3. Knowing the s/sx and incorporating screening into every pt encounter. So very important.

Original Post
September 2, 2009
Title: Abuse
Child and elder abuse continue to be very under reported making it imperative that doctors and nurses have education on signs of abuse. Nursing home abuse is also very under reported since nursing home pts. are lacking in visitors and seen as demented. Nurses also need to know who to contact should abuse be suspected.

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Alcohol addiction is a disease, comment

July 15, 2010

When assessing a patient with potential or actual alcohol abuse it is important to assess their mental health status as well and realize how closely alcohol abuse and mental illness go hand in hand. In obtaining information clients should feel a good level of comfort with the nurse in order to disclose information willingly about alcohol intake. Many patients with mental illnesses such as depression and bipolar disorder that are undiagnosed will self medicate with alcohol. Obtaining a good family mental health history as well as collecting an inventory about emotions and feelings may help the nurse identify patients at risk for alcoholism. A nurse should also be aware at risk factors for depression and anxiety and collect good subjective and objective data during the patient interview. A persons ability to care for themselves and personal hygiene are good examples of objective data collection. Another piece of valuable information is a patients support system and living arrangements. A nurse should document a patients orientation, memory, communication skills and reasoning. The Audit and Cage tests can be used in a more structured assessment for alcohol abuse as additional supportive data. Alcoholism is a complicated disease that has many factors to address when helping a patient to find the resources to overcome it. Treating a patient holistically when considering alcoholism will allow the nurse to identify predisposing or precipitating factors of this disease.

Original Post
July 9, 2010
Title: Alcohol addiction is a disease, comment
Alcohol impacts the lives of many individuals. Alcohol is a dangerous drug that is widely used and abused. There is evidence everywhere in our society, advertisements, socials events, sporting events, alcohol is everywhere. While there are many who can drink responsibly and not get to the point of alcohol being a problem in their life, there is a large percent of our population that has alcoholism. This is a very difficult disease, since there is no cure, no medicine it is something a patient has to overcome this disease using willpower and other methods requiring mental strength.

The nurse’s assessment plays a role in identifying if alcohol or any other substance may be controlling and having a negative effect on a patient’s life. During the assessment the nurse can identify alcohol dependence, abuse, or addictions. The patient may not even realize they have an alcohol problem the nurse can not only assist the patient in identifying a problem they can provide education to assist the patient in finding and evaluating treatment options. The nurse can also educate the patient during the assessment on how alcohol affects the body and mind short term and long term.

Advanced nursing assessment and forensic nursing may overlap on matters that may be related in some emergency situations caused from alcohol abuse. A forensic nurse may be involved in the care of a patient in the ER from an alcohol related incident. In this circumstance a forensic nurse would be required to utilize her advanced assessment skills to care for the patient as well as fulfill her role as a forensic nurse.

Original Post

September 28, 2009

Title: Alcohol addiction is a disease

Alcohol is the most commonly used and abused psychoactive drug in the United States. Of those seeking treatment 50% will relapse in the first few months of therapy. Everyone around these patients is effected by this disease. Nursing is on the forefront of the battle these individuals undertake. Alcohol use is broken down into two categories abuse and dependence. Alcohol abuse is characterized as a pattern of use leading to one or more manifestations in a period of a year such as a failure to fulfill major roles or obligations at work, school or home. Recurrent alcohol related legal problems or being in physically hazardous situations and continued use despite problems with relationships caused by or exacerbated by alcohol. Alcohol dependence is a pattern of three or more manifestations in a year such as having a tolerance to alcohol, showing signs of withdrawal, consuming larger amounts or over longer periods than had intended. Continued use of alcohol despite desire or failed attempts to cut down consumption. Drinking and recovering from use takes up more and more time. Continued use despite knowing it is doing damage physically or psychologically, as well as those listed above for abuse. Alcohol not only effects those who are abusing or dependent on the drug, but everyone around them. As a child I remember the late night phone call my mother received that her father, only 49 years old, had passed away after having too much to drink, vomited and aspirated his stomach contents. He was an abuser, a weekend social drinker whose life alcohol had very little impact on until that night, then it had the ultimate impact. A patient I took care of many years ago had a similar experience, he was a young man in his early 30’s, he too aspirated after vomiting, he survived this initially only to be left with damage to his brain from a lack of oxygen. He would live the rest of his life in a coma like state, with a grieving wife and child. Alcohol is a treatable disease, when a patient comes to a hospital or clinic, they have chosen to undertake the battle of their lives. They are not able to do this alone, the attitudes of family and nurses as well as others they may come into contact with are crucial. A compassionate nurse can change the life of a patient, as well as an unsympathetic nurse whose attitude may be “they did this to themselves.” Alcohol dependence or abuse should be seen for what it is a real disease that needs real treatment. These patients need all the support they can get from those around them, and education on the subject is paramount to recognizing the signs and symptoms that manifest. Education for healthcare workers so they understand these patients, as well as how to successfully treat them with medications, together with the patient’s desire to enter therapy will hopefully change that 50% to 25% or better 0% relapse in first few months.

Legal Services for Alcohol Abuse Addiction

Patient Education & Counseling online course

Public Health Nursing online certificate program

Forensic Nursing Online Certificate Program

Forensic Nursing Online Introduction Course

Online Advanced Nursing Health Assessment Course

Alcohol addiction is a disease, comment

July 9, 2010

Alcohol impacts the lives of many individuals.  Alcohol is a dangerous drug that is widely used and abused.  There is evidence everywhere in our society, advertisements, socials events, sporting events, alcohol is everywhere.  While there are many who can drink responsibly and not get to the point of alcohol being a problem in their life, there is a large percent of our population that has alcoholism.  This is a very difficult disease, since there is no cure, no medicine it is something a patient has to overcome this disease using willpower and other methods requiring mental strength.

The nurse’s assessment plays a role in identifying if alcohol or any other substance may be controlling and having a negative effect on a patient’s life.  During the assessment the nurse can identify alcohol dependence, abuse, or addictions.  The patient may not even realize they have an alcohol problem the nurse can not only assist the patient in identifying a problem they can provide education to assist the patient in finding and evaluating treatment options.  The nurse can also educate the patient during the assessment on how alcohol affects the body and mind short term and long term.

Advanced nursing assessment and forensic nursing may overlap on matters that may be related in some emergency situations caused from alcohol abuse.  A forensic nurse may be involved in the care of a patient in the ER from an alcohol related incident.  In this circumstance a forensic nurse would be required to utilize her advanced assessment skills to care for the patient as well as fulfill her role as a forensic nurse.

Original Post

September 28, 2009

Title: Alcohol addiction is a disease

Alcohol is the most commonly used and abused psychoactive drug in the United States. Of those seeking treatment 50% will relapse in the first few months of therapy. Everyone around these patients is effected by this disease. Nursing is on the forefront of the battle these individuals undertake. Alcohol use is broken down into two categories abuse and dependence. Alcohol abuse is characterized as a pattern of use leading to one or more manifestations in a period of a year such as a failure to fulfill major roles or obligations at work, school or home. Recurrent alcohol related legal problems or being in physically hazardous situations and continued use despite problems with relationships caused by or exacerbated by alcohol. Alcohol dependence is a pattern of three or more manifestations in a year such as having a tolerance to alcohol, showing signs of withdrawal, consuming larger amounts or over longer periods than had intended. Continued use of alcohol despite desire or failed attempts to cut down consumption. Drinking and recovering from use takes up more and more time. Continued use despite knowing it is doing damage physically or psychologically, as well as those listed above for abuse. Alcohol not only effects those who are abusing or dependent on the drug, but everyone around them. As a child I remember the late night phone call my mother received that her father, only 49 years old, had passed away after having too much to drink, vomited and aspirated his stomach contents. He was an abuser, a weekend social drinker whose life alcohol had very little impact on until that night, then it had the ultimate impact. A patient I took care of many years ago had a similar experience, he was a young man in his early 30’s, he too aspirated after vomiting, he survived this initially only to be left with damage to his brain from a lack of oxygen. He would live the rest of his life in a coma like state, with a grieving wife and child. Alcohol is a treatable disease, when a patient comes to a hospital or clinic, they have chosen to undertake the battle of their lives. They are not able to do this alone, the attitudes of family and nurses as well as others they may come into contact with are crucial. A compassionate nurse can change the life of a patient, as well as an unsympathetic nurse whose attitude may be “they did this to themselves.” Alcohol dependence or abuse should be seen for what it is a real disease that needs real treatment. These patients need all the support they can get from those around them, and education on the subject is paramount to recognizing the signs and symptoms that manifest. Education for healthcare workers so they understand these patients, as well as how to successfully treat them with medications, together with the patient’s desire to enter therapy will hopefully change that 50% to 25% or better 0% relapse in first few months.

Legal Services for Alcohol Abuse Addiction

Patient Education & Counseling online course

Public Health Nursing online certificate program

Forensic Nursing Online Certificate Program

Forensic Nursing Online Introduction Course

Online Advanced Nursing Health Assessment Course

POST TRAUMATIC STRESS DISORDER

March 11, 2010

Post traumatic stress disorder or PTSD is an anxiety disorder that can be triggered by witnessing or experiencing a traumatic event. PTSD is a medical diagnosis that applies when some one has difficulty coping with the after effects of trauma to the point where it disrupts their lives months or even years after the trauma occurred.

PTSD was once associated mainly with the survivors of war ,but today it is used to describe a wide range of trauma survivors –rape, crime, and torture victims; survivors of natural catastrophes, vehicular accidents, and technological disasters; and abused women and children. Also at high risk for PTSD are rescue squad workers, police officers, firefighters and nursing personnel who witnessed or experienced a traumatic or life threatening event that had the potential for bodily harm. Even people who had a miscarriage or experienced job loss may suffer from PTSD.

A clinical definition
Individuals must meet all the following criteria for a diagnosis of PTSD-
-Experienced or witnessed at least one trauma or life threatening event that had the potential for bodily harm to which they responded with fear, helplessness or horror.
-Continued reliving the trauma in the form of what is referred to as re-experiencing phenomena –nightmares, flashbacks and intrusive thoughts about the traumatic events.
-Numbing of emotions and persistent avoidance of situations reminiscent of the trauma
-Symptoms of physiological hyper arousal including startle response, difficulty falling asleep, irritability and hyper alertness.
-Persistence of symptoms for at least one month following the event.
-Evidence of clinically significant distress or dysfunction in social, occupational or other important areas of functioning.

Primary symptoms of those who suffer PTSD include insomnia substance abuse, night mares anxiety, depression, anger and fear that the horror will return. Because emotional distress can be overlooked in injured patients, researchers in a recent study of injured and uninjured soldiers caution caregivers to pay more attention to psychological aspects of patients conditions in general and to the early symptoms of PTSD in particular, both during hospitalization and after discharge.

REFERENCES
Helia your guide to healthy decisions http://www.helia.com
http://www.carolynchambersclark.com post traumatic stress disorder part 1

Online Introduction Forensic Nursing Course

Online Forensic Nursing Certificate Program

Online Nursing Assessment Course

Online Advanced Nursing Assessment Course

Post Traumatic Stress Disorder Attorney Lawyer

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Nursing and the Law

February 9, 2010

Now that the average criminal no longer uses rocks and fists to commit crimes, law enforcement must also advance. Hand in hand with the medical field they must teach us everything they know. How to handle evidence as well as victims and criminals. Evidence is how cases can get won or lost. The medical field and first responders are the first on the scene. Knowledge is their best weapon. Their assessment skills need to be honed to the finest.

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