Forensic Science in Healthcare: Caring for Patients, Preserving the Evidence

Forensic Science in Healthcare Caring for Patients, Preserving the Evidence

Forensic Science in Healthcare Caring for Patients, Preserving the Evidence Connie Darnell

Boca Raton London New York

CRC Press is an imprint of the Taylor & Francis Group, an informa business

CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2011 by Taylor and Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number: 978-1-4398-4490-8 (Paperback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright. com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging‑in‑Publication Data Darnell, Connie, author. Forensic science in healthcare : caring for patients, preserving the evidence / Connie Darnell. p. ; cm. Includes bibliographical references and index. ISBN 978143984490-8 (pbk. : alkaline paper) 1. Medical jurisprudence. 2. Victims of crimes--Medical examinations. I. Title. [DNLM: 1. Forensic Medicine--methods. 2. Forensic Nursing--methods. W 700] RA1051.D37 2011 614’.1--dc22 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com

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Contents

Preface Acknowledgments Author

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xvii xix xxi

Introduction to Forensics

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Red Flags The Evolution of Crime, Violence, and Crime Detection Living Forensics The Scope of Crime and Violence in Modern Society The Financial Cost of Violence The Emotional Cost of Violence The Role of Healthcare Standards of Care The Nursing Process Assessment: Data Collection Nursing Diagnosis Planning Implementation Evaluation Summary Appendix 1.1: Signs of Abuse, Neglect, and Exploitation References

2 3 3 4 5 6 6 9 9 10 10 11 11 11 11 13 14

Documentation

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Medical Documentation General Physical Examination Wound Documentation Blunt Force Injuries Abrasions Contusions Lacerations Sharp Force Injuries Cuts or Incisions Stab Wounds

17 19 20 22 23 25 35 37 38 38

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Contents

Mixed Blunt and Sharp Injuries Fast Force Injuries (Gunshot Wounds) Range of Fire Angle of Entry Types of Projectiles and Intervening Objects Photographing Gunshot Wounds Important Terms to Remember about Gunshot Wounds Bite Marks Fractures of Bone Thermal, Electrical, and Chemical Injuries Thermal Burns Classifications Scalding Burns Inhalation Injuries Electrical Burns Definitions Basics of Electricity Types of Electrical Burns Lightning Injuries and Death Weather-Related Hazards Overheating-Related Tissue Injury Cold-Related Tissue Injury Chemical Burns In Conclusion Photography Photographic Evidence Purposes of Photographs Basics of Photography Consent to Photograph Informed Consent Implied Consent Admissibility of Photographs Qualities of Photographs for Evidentiary Purposes Equipment for Forensic Photographs Scene Photography Sequence of Photographs Photographing Human Abuse and Assault Injuries Tips for Photographing Anatomical Features Digital Evidence What Is Digital Evidence and Cyberforensics? What Is the Unique Forensic Value of Digital Evidence? Implications for Healthcare and Forensic Personnel

43 43 45 51 52 57 57 57 58 58 58 58 59 60 61 61 61 65 68 70 70 71 72 72 73 73 73 74 75 75 76 76 76 77 77 78 78 81 82 82 82 84

Contents

Tampering and Spoliation of Records Safety and Security Concerns Reporting Appendix 2.1: Adult Male Body Diagram Appendix 2.2: Adult Male Body Diagram, Side View Appendix 2.3: Adult Female Body Diagram Appendix 2.4: Adult Female Body Diagram, Side View Appendix 2.5: Head and Neck Appendix 2.6: Hands Appendix 2.7: Feet—Toes and Bottom Appendix 2.8: Feet—Side View Appendix 2.9: Hands, Feet, Head, Eyes, Ears Appendix 2.10: Female Genitalia Appendix 2.11: Male Genitalia Appendix 2.12: Child Body Diagram Appendix 2.13: Infant Body Diagram Appendix 2.14: Consent to Photograph Forms Appendix 2.15: Some Commonly Used ICD-9 and CPT Codes References

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Evidence Healthcare Role in Evidence Collection Healthcare Providers Categories of Evidence Types of Evidence Physical Evidence Trace Evidence Verbal Evidence Questions to Ask Demonstrative Evidence Testimonial Evidence Digital or Electronic Evidence Behavioral Evidence Basic Principles of Evidence Collection General Procedures Personal Protective Equipment Collection Basics Drying Labeling Sealing Processing Storage and Security

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85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 103 104

105 106 106 107 108 108 108 109 109 110 110 110 111 111 112 112 112 113 114 114 115 115

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Chain of Custody Common Types of Physical Evidence in Medical Settings Clothing Bullets and Other Projectiles Foreign Objects Trace or Small Evidence Gunshot Residue Small or Loose Materials Large Loose Foreign Materials Fibers and Threads Hair Paint Metal or Sharp Items Glass Pollen Guidelines for Collecting Pollen Samples Biological Evidence Body Fluid Collection Control Swabs Dried Blood Moist Secretions (e.g., nondried blood or other moist substances; semen or unknown liquid) Dried Secretions Urine Samples Gastric Contents Bite Marks Blood Alcohol and Other Toxicological Specimens Testing for Drugs of Abuse Poisoning Things Not to Do Fetal Drug Exposure DNA—CODIS Sexual Assault After the Evidence Collection Summary Appendix 3.1: Evidence Tag and Chain of Custody Appendix 3.2: Classic Bindle Fold Diagram and Instructions Appendix 3.3a: Blood Collection Instructions Appendix 3.3b: Nail Collection Instructions Appendix 3.3c: Cord Tissue Collection Instructions References Additional Resources

116 118 118 119 120 120 121 121 122 122 123 123 123 124 124 125 125 125 125 126 126 126 126 127 127 128 130 131 132 133 133 134 134 135 136 137 139 140 141 142 142

Contents

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Domestic Violence and Abuse Physical Abuse Sexual Abuse Psychological Abuse Economic Abuse Joint Commission Intervention for Domestic Violence Screening Be Prepared and Comfortable Dealing with a “Yes” Answer! Assessment Safety First Patient History Psychological History Physical Examination Intervention Care Plan Mental Health Plan Safety Plan Resource List Community Resources Documentation Appendix 4.1: Danger Assessment—English Appendix 4.2: Danger Assessment—Spanish Appendix 4.3: Domestic Violence Assessment Tool Appendix 4.4: Domestic Violence CQI Tool References

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Sexual Assault Definitions Goals of Care Injuries Role of the First Responder and Healthcare Provider Sexual Assault Nurse Examiners (SANE) A National Protocol Appendix 5.1: Suggestions for Police Officers in Sexual Assault Cases Appendix 5.2: Suggestions for First Responders in Sexual Assault Cases References

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143 143 144 144 144 146 147 149 150 151 152 152 154 155 156 157 158 159 161 161 162 163 165 167 170 172

173 173 173 174 175 176 177 195 198 201

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Contents

Child Abuse and Neglect

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Definition of Child Abuse 203 Physical Abuse 203 Emotional Abuse 204 Sexual Abuse 204 Neglect 204 Munchausen by Proxy 204 Forensic Resources 204 Basic Assumptions 205 Why Parents or Caregivers Abuse 205 Child Abuse: Not an Isolated Event 205 The Vulnerable Child 206 Target Child 206 Healthcare’s Role 206 General Assessment 206 Recognizing Child Physical Abuse 207 Parent–Child Interaction 207 Evaluating Childhood Injuries 208 Accidental versus Abusive Injuries 209 Physical Exam 210 Head Injuries 210 Injuries to the Face and Mouth 212 Musculoskeletal Injuries 212 Burns 212 Review of Records 213 Interviewing the Abused Child 214 Healthcare Provider Actions in Cases of Suspected Poisoning 214 Reporting Responsibilities 215 What to Report 215 Child Neglect 215 Sexual Assault of Children 215 Pediatric Specimens 217 Bite Marks 217 Swab Technique for Bite Marks 217 Prenatal Alcohol and Drug Abuse 217 Poisoning 218 Laboratory, Radiological, and Ophthalmic Testing 218 Munchausen by Proxy Syndrome 219 Sudden Infant Death Syndrome (SIDS) 222 Failure to Thrive 222 Summary 222

Contents

Appendix 6.1: Guidelines for Initial Healthcare Provider– Child Interaction References Additional Resources

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Sexual Assault of Children Reporting Laws Definitions Child Sexuality Perpetrators and Victims Short- and Long-Term Psychological and Physical Harm Signs of Sexual Abuse in Children Prehospital Care Physical Injury Initial Disclosure Assessment Nursing Diagnoses Planning Intervention Evaluation Prevention Summary Appendix 7.1: Child Sexuality At Birth During First Year Two Years Three Years Four Years Five to Seven Years Eight to Twelve Years Thirteen Years and Older Appendix 7.2: Signs of Child Sexual Abuse References Additional Resources

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Youth Behaviors and Violence Risky Behavior Drug Use Dating Violence Bullying Guns and Gangs Dangers to Bystanders and Healthcare Workers

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227 228 228 229 229 230 230 231 231 232 232 234 234 234 235 235 236 237 237 237 237 237 238 238 238 238 240 240 241

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Female Gang Membership Effects of Gangs on Children Gangs in Rural Areas Homelessness Suicide Risk Factors for Suicide Deterrents Intervention Stranger Danger Child Pornography Summary References

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Elder Abuse Categories of Elder Abuse Joint Commission Standards Definitions Physical Abuse Sexual Abuse Emotional or Psychological Abuse Spiritual Abuse Neglect Self‑Neglect Fraud, Theft, and Financial or Material Exploitation Abandonment Risk Factors for Abuse Signs and Symptoms of Physical Abuse Signs and Symptoms of Sexual Abuse Signs and Symptoms of Emotional or Psychological Abuse Signs and Symptoms of Neglect Signs and Symptoms of Self-Neglect Signs and Symptoms of Abandonment Signs and Symptoms of Financial or Material Exploitation Reasons Elder Abuse Isn’t Reported Reasons for Abuse or Neglect in Institutionalized Settings Assessment Physical Assessment Mental Assessment History Intervention Reporting Safety Planning

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259 262 262 263 263 263 263 264 264 264 264 265 266 266 266 267 267 267 268 268 268 269 269 269 270 270 271 272 272

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Resources Appendix 9.1: Rights of Elders Fairness Freedom Self-Determination Privacy Appendix 9.2: Elder Abuse Assessment Tool Appendix 9.3: Support Agencies References

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Death Investigation Some Thoughts to Consider History Cause, Manner, and Mechanism of Death Manner of Death Mechanism of Death Example 1 Example 2 Autopsy Role of the Death Investigator Goals of Death Investigation Implications for Healthcare Providers Death Investigation Basics Goals of Evidence Collection at the Time of Death Handling the Deceased Assisting Survivors Traumatic Grief The Consultation Autopsy Organ and Tissue Donation Basic Information Regarding Donation Brain Death Criteria Summary of HCFA 42 CFR 482 In Conclusion Appendix 10.1: Deaths to Be Reported to the Office of the Medical Investigator (OMI) Appendix 10.2: Suspicious Circumstances of Death Appendix 10.3: Death Investigation Report References

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Occupational Issues for Forensic Personnel Safety in the Workplace The Clean Room

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281 281 283 283 284 285 285 285 285 287 287 287 287 288 288 290 290 291 291 292 292 292 293 294 295 296 297

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Workplace Violence Precipitating Factors Those at Greatest Risk Prevention Awareness and Responses Signs of Increasing Tension Responding to Increasing Tension Signs of Increasing Disruption Response to Increasing Disruption Types of Violent Behavior Responding to Violent Behavior Reporting Responsibilities Consequences for the Victim, Staff, Patients, and the Provider Organization OSHA Guidelines Hostage-Taking Scenarios Sexual Harassment Types of Sexual Harassment Sexual Harassment Policy Electrical Hazards Definitions Two Important Rules Toxins Carbon Monoxide and Oxygen Deprivation Cyanide Poisoning Hydrogen Sulfide Altitude-Related Illness Bomb Threats Forensic Response Regulations and Reporting Appendix 11.1: Equipment and Supplies Appendix 11.2: Minimum Required Equipment for Nontransport Medical Rescue Vehicles: New Mexico Administrative Code 2009 Appendix 11.3: Violent Incident Report Form Appendix 11.4: Bomb Threat Report References

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Legal Issues Testifying in Court Fear Not What Is the Law?

301 302 303 303 304 304 304 304 304 305 305 306 306 306 307 308 308 308 309 309 309 310 310 311 311 312 312 313 313 314 316 319 320 321

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Be Prepared Arrival Personal Characteristics Attire Presence on the Stand Do’s and Don’ts When Testifying Do’s Don’ts Testimony Depositions

Index

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324 325 325 325 326 326 326 327 327 328

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Preface

This book is written for personnel at all levels within the healthcare spectrum, and provides the basic knowledge and skills for ensuring that a forensic patient’s legal rights are protected within the healthcare setting. I have distilled the important concepts and principles applicable to clinical forensic practice, and present them in direct, easy-to-understand language. Following a brief introduction, the text describes how to identify patients with forensic issues, and guides the reader through the practical aspects of evidence preservation, documentation, and legal reporting procedures.

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Acknowledgments

My interest in forensics began when I was in college. While taking care of an 18-month-old who had been severely burned by her mother, I was appalled to learn that the child would be returned to her mother “in consideration of the mother’s mental health.” Finding there were few laws to protect children, I vowed to advocate for the rights of the vulnerable and abused. After more than 10 years, it would be impossible to acknowledge all those who have helped make this book a reality. There are several people, however, who stand out. First, that young child who motivated me to begin this journey—it is really for her, and all others like her, that this book was written. I would like to thank Janet Barber for her support, guidance, and friendship and for making this book become a reality, and her husband, Don Duval, for his quiet support from the background. I thank Dr. Patrick BesantMatthews for his willingness to share his expertise, enthusiasm, uncommon knowledge, photographs, and friendship over the years and for teaching me much of what I know. I also thank Dr. William Smock for permission to use some of his photographs, and for his never-ending support of those who follow in his footsteps. I also thank Robert Witter for his input and guidance on electrical burns and hazards. I especially thank Zech Robinson who has unselfishly given his time and expertise with computers and who kept me sane when I became overwhelmed by electronic demons, Jackie Kerwin and the Silverton Public Library, and George Romero, who completely redid our electrical system when ice avalanching off the roof wiped it out at a critical point in preparing this manuscript. I also acknowledge Bruce Elliot, who has always been my knight in shining armor, and last but certainly not least, my husband for his kindness and support all of my adult life. To them and to all those who listened, critiqued, consulted, and in general supported me in this endeavor, I will forever be indebted.

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Author

Connie Darnell is a charter member of the International Association of Forensic Nurses and has been involved in forensics since the early 1990s. She has worked as a deputy field death investigator for the New Mexico Office of the Medical Investigator and is a trained sexual assault nurse examiner. She has taught introductory undergraduate and continuing education forensic nursing classes at the University of New Mexico and has given numerous presentations to healthcare groups, local law enforcement, and volunteer fire departments. She lives with her husband at their homes in rural New Mexico and Alaska, where she is a member of the local volunteer fire and rescue departments. She is currently employed part time in Santa Fe, New Mexico.

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Introduction to Forensics

I thought forensics was for law enforcement and death investigators. What does it have to do with me?

Increased popularity of forensic * programs has led to increased interest in the forensic sciences. Many believe forensics to be limited to matters involving death.† This is simply not true. In fact, most forensic cases involve people who are alive, thus leading to the term living forensics. Clinical forensics is the application of forensic science to medical situations. A patient exhibiting symptoms of carbon monoxide poisoning is an example. Is there a product liability issue? Is this an accident, negligence, or an intentional attempt to harm or kill? Another example might be a pregnant woman who is exposed to radiation. Both of these examples require a detailed investigation into the circumstances surrounding the incident as well as determination of the health consequences to the individual. Motor vehicle accidents, sexual assault, and other interpersonal violence are commonplace. Substance abuse is widespread and crosses all socioeconomic boundaries. Terrorism and mass casualty incidents are a part of our daily topics of concern. All of these have forensic issues and implications for healthcare providers. Violence and traumatic incidents in America pose a mental health, public health, and public safety dilemma. Once limited to assessing and caring for a patient’s physical or psychological needs, healthcare’s responsibility now encompasses the identification and treatment of those impacted by crime, violence, and other intentional or unintentional trauma. The inclusion of criminal and civil liability into healthcare has made forensic knowledge and practice a legal imperative. In the past, healthcare’s failure to recognize victims of crime and violence was a significant factor in reduced reporting to authorities. Our justice system now requires healthcare providers to think and act with full regard for their ethical and legal responsibilities to the patient

* The word forensic comes from the Latin forensic, meaning “of a market or forum: public.” The term evolved into its current usage, of “belonging to courts of judicature or to public discussion and debate.” Thus, forensic medicine (also known as medical jurisprudence) is a science dealing with the relationship and application of medical facts to legal problems. † As contrasted with forensic pathology, living forensics is the application of forensic science to surviving victims.

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and to the justice system. It is the healthcare provider’s observations, coupled with an intuitive sense of the intangible, which may bring forensic issues to light. From initial assessment to discharge planning, forensic issues must be considered and, if applicable, included in the delivery of patient care. Collaborating with others along the continuum of care is a routine occurrence for providers of healthcare. Primary providers are uniquely positioned to function as a liaison between the medical community and law enforcement, the judicial system, insurance companies, social service organizations, community agencies, lawmakers, bureaucrats, and others. The creation of multidisciplinary teams has proven to be the most effective way to manage the effects of trauma and violence. Not only does a team approach provide for a better patient outcome, it helps ensure the safety of the healthcare provider. The very nature of the healthcare profession lends itself to follow through into the legal arena. Future victims benefit from the variety of viewpoints presented. Resources are maximized, expenses are minimized, and efficiency in the delivery of services is increased. To maintain credibility as professionals, it is essential that professional providers of care redefine their role as patient advocate. Providers at all levels must learn how to advocate for patients medically, psychologically, and forensically by being unbiased seekers of the truth. It is imperative that the healthcare provider not make value judgments or take sides. Rather, we must be impartial observers and recorders of the facts.

Red Flags In addition to the obvious (motor vehicle accident [MVA], gunshot wound, etc.) there are several “red flags” that may indicate that a patient has forensic issues or is the victim of interpersonal violence. Among these are: • Unexplained or unwitnessed traumatic injuries or illness—the patient and/or accompanying individuals have no explanation at all or say no one saw what happened • Unusual or avoidable delay in seeking medical care • Multiple injuries—different kinds of injury or multiple sites are involved • Multiple injuries indicating more than one incident—wounds of differing ages or stages of healing, or multiple presentations for healthcare for the same or similar injuries or illnesses • Patterned injuries—injuries suggesting a weapon or instrument was used

Introduction to Forensics

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• Injuries that are inconsistent with the account given or that are unlikely to have been caused as the scenario has been told—they simply do not “fit,” or the patient and accompanying individuals give differing accounts of what happened • Any time there is suspicion that the injury was not accidentally caused—a gut feeling that something just isn’t right

The Evolution of Crime, Violence, and Crime Detection In medieval England, the sheriff was charged with protecting the interests of the king. He was concerned with crimes committed against secular or religious authority and not necessarily crimes perpetrated against common people. Today the sheriff’s job is to encourage people to obey the law, apprehend those who do not, and investigate the circumstances. The office of the coroner was formalized in England in the twelfth century. As clinical forensic medicine matured, the concept of the police surgeon came into being. In 1842, the London city police department extended the role of law enforcement to include crime scene investigation. The creation of detective investigators was a significant improvement because it gave detectives the power to interview witnesses, collect and preserve evidence, and work collaboratively with other law enforcement professionals and the court system.

Living Forensics Dr. Henry McNamara, a New York medical examiner, believed that, in addition to medical needs, survivors of catastrophic events have legal issues. He also believed that healthcare had an important and undeveloped role to play. He introduced the concept of living forensics. Within a few short years, the first clinical forensic medicine training program was begun in Louisville, Kentucky. The International Association of Forensic Nursing (IAFN) was founded in 1992 and shortly thereafter formally recognized by the American Academy of Forensic Sciences (AAFS) and the American Nurses’ Association (ANA). Standards of forensic nursing practice were soon adopted and published (McNamara, 1986). In 1994, the Violence against Women Act (VAWA) was passed by Congress. Several hundred sexual assault nurse examiner (SANE) programs are now in place in the United States and numerous programs have been started in other countries. Employment for nurses as death investigators, clinical forensic nurse specialists, forensic correctional/psychiatric nurses, and legal nurse consultants is now a reality. Thousands of former nurses are

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now practicing law as nurse attorneys. Pediatric and geriatric nurses, emergency medical technicians (EMTs), and first responders now possess basic forensic skills.

The Scope of Crime and Violence in Modern Society* The Crime Index (FBI, 2002) estimated that there were 1.6 million violent crimes reported to law enforcement in 2001 (USDOJ, FBI, OJP, OVC, BJS, NCVS, cited in NVAA, 2002). According to the FBI, one violent crime occurred in the United States every 19 seconds, one forcible rape occurred every 5 minutes, and one murder occurred every 29 minutes. Tragically, less than half of violent crimes and only about one-third of all crimes are ever reported to the police. Healthcare’s failure to recognize victims and the impact on individual lives has been a factor in reduced incidence of reporting to authorities. Our failure to understand this has led to tragic and lifelong consequences for victims and their friends and families. A disaster is defined as an event or situation causing ruin or failure (Compact Oxford English Dictionary, 2005). Using this definition, the current level of violence in America is clearly a public health and safety disaster. This tragedy is a preventable circumstance that not only affects individual victims, friends, and families, but also touches communities and the country as a whole. The events of September 11, 2001, are a dramatic testament to the short- and long-term impact such events can make. In 1998, there were 8.1 million crimes of violence in the United States, only 46% of which were ever reported to law enforcement. In 1994, 1.4 million people were treated in emergency departments for suspected or confirmed interpersonal violence (BJS, August, 1997), 1.6 million violent crimes were reported to law enforcement (FBI, 1998) and an estimated 3.7 million adult women were victims of some type of sexual or aggravated assault during a one-year period (Tjaden and Thoennes, The National Women’s Study: Research in brief, 1992).† In our fast-paced lives, people succumb to increasing pressures of time and money. Substance abuse is widespread and has a multitude of significant consequences. These consequences are not limited to the health implications for the user or addict. Families and the stranger with whom the substance abuser comes in contact are also affected. Drugs and alcohol are implicated in motor vehicle accidents, interpersonal violence, sexual assault, homicide, * Begun in 1995, the National Victim Assistance Academy is a week-long, university-based training course on victimology, victims’ rights and victim services. (NVAA, 2002). † All of the above statistics are reported in the 2002 NVAA Manual.

Introduction to Forensics

5

suicide, and other injurious behaviors. Fetal alcohol syndrome and the crackaddicted newborns are just two of the many adverse consequences visited upon the innocent. Violence influences how people view the world. Trust is the glue that binds human relationships. Violence makes individuals wary of unfamiliar people. The result is an erosion of one’s sense of personal safety, leading to skepticism, cynicism, and self-imposed isolation. The overall quality of life is decreased because human interaction is stifled. Since the terrorist acts of 9/11, violence—or, more importantly, the fear of violence—has changed the way Americans think and live. People no longer feel safe at night, even in their own neighborhoods—indeed, in their own homes. Many have installed some type of home security system or purchased a weapon for self-protection. People no longer feel safe when traveling. Fear of violent encounters restricts individuals’ inclination to go where they wish, when they wish, how they wish. The once hated inconveniences of heightened security are now accepted. Our view of humanity has undergone a significant change.

The Financial Cost of Violence Key Point: Forensic cases have financial and emotional costs as well as medical ones. In 1996, the National Institute of Justice released a comprehensive report on the cost of violent crime (NVAA Manual, 1999; US Department of Justice [USDOJ], FBI, OJP, OVC). Data was gathered from criminal justice agencies, medical professionals, crime victim compensation programs, and crime victims themselves. The financial impact of violence amounts to well over $400 billion each year (National Institute of Justice [NIJ] 1997–1998 Academy Text Supplement Ch. 1 p. 3). As much as 20% of mental health expenditures in this country can be attributed to treatment of victims alone* (National Institute of Justice [NIJ] Cost of Victimization, February 1996). The U.S. government pays nearly $20 billion in health insurance payments and for services to victims. Crime costs private insurers approximately $45 billion annually (NIJ, 1996). * This estimate does not include figures for mental health treatment of offenders.

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The Emotional Cost of Violence Key Point: Psychological injuries impact more than just the victim: friends, family, coworkers, and others can also be significantly affected. Victims may have psychological wounds equal to or greater than the physical ones. The professional provider must be sensitive to those emotional needs. Understanding a victim’s reaction to crisis enables the healthcare provider to provide appropriate psychological care. It is important to remember that, to those impacted by trauma and violence, this is not just a case, it is a tragedy and their lives will never be the same. Even though every crime is not necessarily violent, a sense of violation remains. Survivors—whether they are direct victims or those affected by extension—may exhibit signs of posttraumatic stress disorder (PTSD), not only at the traumatic moment, but days, weeks, or months after the events have occurred.

The Role of Healthcare Survivors of catastrophic events encompass a wide variety of scenarios, including interpersonal violence, sexual assault, unnatural death, legal and custodial disputes, legislation, malpractice, workplace injury, drug and alcohol dependence, terrorist incidents, and others. Living forensics has implications for healthcare workers in many settings, including hospitals, clinics, insurance companies, government agencies, law enforcement offices, attorneys’ offices, judicial settings, industrial settings, legislative offices, and literally on the street. Violence, trauma, and other liability-related situations are pervasive in modern culture. It is imperative that healthcare providers develop a “forensic antenna” as part of their basic repertoire. Are the injuries consistent with the explanation given? All healthcare providers must learn the basic elements of forensic content, including how to document forensically, how to collect and preserve evidence, reporting requirements, and how to defend or explain medical situations in court. Key Point: Personal security concerns related to both the patient and the healthcare staff must be addressed throughout all phases of the forensic case management.

Introduction to Forensics

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Living forensic patients typically have experienced serious traumatic events, and need to be confident regarding their personal safety. Once a sense of personal security has been established, the patient, families, and friends need to be reassured that they are not being judged. Central to managing the short- and long-term effects of traumatic events is to ease feelings of guilt for the situation they find themselves in. When patients feel someone is listening to them in a nonjudgmental way, fear and anxiety are reduced. Patients begin to believe their needs will be satisfied. Explaining roles, procedures, and treatments provides reassurance and engenders trust. Rather than probative questioning, it is better to allow the patient to relate their experience in their own terms. The presence of family and friends is important to victims, and those needs must also be considered. Whether the patient is victim, perpetrator, or family, the healthcare provider must be courteous and respectful. These individuals need support, but boundaries must be set on behavior. Disruptive behavior can be minimized by a calm, professional, caring, and patientcentered approach. Out-of-control individuals may have to be restrained or removed from a particular clinical setting. This is not the responsibility of the healthcare provider, but rather the responsibility of security or law enforcement. Today’s professional healthcare provider understands basic anatomy and physiology and can help identify a mechanism of injury or cause of death. Nurses’ expertise in normal growth and development, the disease processes, medical terminology, and recognition of mental, emotional, and physical disabilities, helps interpret aspects of medical care to the legal community. Assessing a patient’s condition and documenting the care given become second nature to the experienced healthcare provider. Nurses and other healthcare professionals also possess communication skills that enable them to help individuals through a crisis, and to care for patients in uncontrolled and unpredictable environments. They use their knowledge of human psychology on a daily basis and are skillful at interacting with grieving individuals and noncompliant patients. Key Point: Nurses function in an ever-expanding variety of roles. Collaboration with other healthcare providers and agencies is important in the continuum of care. The frontline practitioner is in a unique position to collect and preserve evidence. Frontline practitioners may be the ones who initiate the all-important chain of custody. An example occurred during a forensic nursing class I taught. The class was condensed into two sessions, one month apart. In the

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interim between sessions, one of my students was working in the emergency department when a woman arrived with a “self-inflicted” gunshot wound. Based on the information this nurse had received in the first class, she was suspicious enough to package the woman’s clothing appropriately, initiate the chain of custody, and call the police. Their initial response was, “Where did you learn to do this?” Since the chain of custody had been properly initiated, police took the sealed, packaged evidence to the evidence locker, and, upon inspection, arrested the woman’s boyfriend. She died on the operating table before she was able to talk to law enforcement; he was charged and ultimately convicted of murder. Nurses are educators. Nurses routinely teach patients and their families how to manage their health, prevent disease, and ward off complications. Forensic patients provide the nurse with a unique opportunity to educate other medical professionals in the recognition and treatment of forensic issues as well as inform patients about things such as risky behavior. Legal nurse consultants review and analyze medical records for the legal community, insurance companies, and others. In certain instances, legal nurse consultants may also testify as expert witnesses. Nurses often serve as consultants for private and governmental agencies who draft rules and legislation. They are ideally positioned to help prevent trauma and injury through research, education, and outreach. In Minnesota, a nurse ran for the office of coroner and won. Once in office, she noticed the rate of teen suicide was higher than expected. She collaborated with local schools to set up suicide prevention programs. The result was a significant reduction in the number of teen suicides. Recently, in South Carolina, nurse coroners noticed an increasing number of deaths in the elderly. Utilizing creative, grassroots techniques, those nurses began an active campaign to educate the community and find ways to better support its elders. Terrorism has caused fear and apprehension on a scale previously unknown in America. Unsafe products, environmental, occupational, and epidemiological hazards create scenarios that change lives. It is the frontline healthcare provider who first recognizes a cluster of similar symptoms or illnesses that might be related. Recently, a number of individuals from a single apartment complex presented to emergency rooms with symptoms of carbon monoxide poisoning. Utilizing their “forensic antenna” (increased suspiciousness factor), healthcare providers collaborated with others, leading to the discovery of faulty heaters and use of ovens to keep warm in cold weather. The city forced the owner of the apartments to fix the problem or be shut down. The city also provided hotel vouchers to tenants so they had a warm, safe environment until the problem was rectified. The owner was ultimately charged with multiple crimes.

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Key Point: All healthcare workers have a responsibility to develop and maintain a forensic antenna in order to identify possible legal issues associated with their patients, including violations of human rights.

Standards of Care In order for a healthcare discipline to be credible, it must provide an objective and measurable foundation upon which quality of care, performance evaluation, and peer review can be achieved. In order to ensure quality patient care, healthcare providers are held to standards set by their peers. Standards are the foundation upon which patient care is provided. The standard of care relates to the direct and indirect care patients receive; the standard of professional performance relates to professional practice. Adherence to accepted standards generates respect, promotes further growth of the profession through research, and encourages collaboration with other professions. The document that outlines and describes the standards for forensic nursing practice was published by the International Association of Forensic Nurses in 2009 (IAFN, 2009). This organization has also released a similar document specifically related to intimate partner violence. These professional performance standards require that nurses are educated in a prescribed curriculum and attain basic competencies in legal as well as clinical nursing issues. They also describe the collaborative interfaces with other professional disciplines, and serve to define certain professional boundaries. The quality and effectiveness of forensic practice must be systematically and objectively evaluated in order to ensure quality patient care and the evolution of forensics as part of healthcare delivery.

The Nursing Process Nursing care is dependent upon a logical scientific process that structures care practices from the initial patient contact through a final evaluation when the nurse–patient relationship is severed. This basic framework is called the nursing process, and its components can be applied to victims of trauma, violence, and crime. Most related disciplines, such as physicians or emergency medical providers, use a similar approach.

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Key Point: Steps of the nursing process can be directly applied to forensic issues in patient care. Assessment: Data Collection The first step in the process is the collection of data. Data is used to assess the individual’s physical and psychological status and to formulate a nursing diagnosis. Forensic nursing diagnoses incorporate the legal aspects of a patient’s situation into the standard nursing diagnoses. Once nursing diagnoses have been made, the forensic nurse identifies expected outcomes and implements a plan of action. The plan is finally evaluated and modified, starting the process all over again. Using the process of elimination, where does the assessment process lead? Has the possibility of forensic issues been identified in the problem list or have they been ruled out? If so, does the plan of care include forensic concerns? Initial assessment includes the interview, physical exam, review of records, observations, and collaboration with staff and other healthcare providers. Once this data has been collected, it is assembled into a logical thought pattern so conclusions can be drawn from the signs, symptoms, and inferences (clues) gathered. The healthcare provider’s experience and intuition are critical in interpreting the factual data. Interpretation and evaluation are the next step in developing nursing diagnoses and forming of a plan of care. Forensic patients require balancing of competing interests. Examples of this conflict are the delivery of direct care versus the requirements of law, or patient confidentiality versus society’s interests. Because of the traumatic and often urgent nature of forensic patients’ conditions, medical assessment and intervention must often be done quickly. Legal consequences, however, require rapid and thorough forensic assessment and documentation. Nursing Diagnosis The North America Nursing Diagnosis Association (NANDA) has approved an official definition of nursing diagnosis as “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes” (Carpenito, 1993). Some approved nursing diagnoses include potential for violence, potential for injury, pain related to injuries, altered health maintenance, ineffective individual/family coping, and so forth.

Introduction to Forensics

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Planning Patient planning is the method by which nursing diagnoses can be addressed. Planning basics dictate that life threats be resolved first. Other issues are secondary and should be prioritized in a logical order based on patient safety and need. Short- and long-term goals need to be established and specific measurable objectives identified in order to achieve those goals. Objectives are simply descriptions of what is expected to happen to or for the patient after nursing intervention has been implemented. Strategies are problem-solving methods utilized to achieve the objectives. Again, these may be short-term methods, such as providing a stuffed animal to a child to reduce stress, or long-term methods, such as referring the family to counseling as a part of the discharge plan. Implementation Implementation includes the specific tasks needed to accomplish the objectives. The nursing process requires that the patient, family, and/or others be informed and/or consulted. Delivery of care must provide for patient safety, be outcome oriented, and be consistent with stated objectives. Once the care plan has been implemented, patient and family responses need to be documented. Evaluation Evaluation revolves around whether the patient and family are able to meet the specific goals and objectives. Will the patient be safe in the immediate future? Have mechanisms been put in place so the patient can cope with what has or is happening? Is there a mechanism in place to evaluate the care given, referrals made, and so on? Long term, has the patient or family changed in a positive way as a result of nursing intervention? How can that be evaluated? By whom? If family dynamics have not been changed, what safeguards have been put in place to help ensure the future safety and security of the patient, children, pets, or other members of this family?

Summary Healthcare’s responsibility was once limited to assessing and caring for a patient’s physical or psychological needs. The identification of injuries and deaths that may have medical-legal ramifications is now one of our responsibilities. Nurses all too often depended on the patients to tell them why they sought treatment or on the doctor to make a medical diagnosis. All healthcare providers must now use their scientific and intuitive skills to assess and

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Forensic Science in Healthcare

intervene on behalf of today’s forensic patients. Mastery of forensic content and skills provides a framework to build an intuitive forensic antenna—the art of critical “noticing” that enhances one’s insight and refines the suspiciousness factor (Winfrey and Smith, 1999). Appendix 1.1 lists general signs of abuse, neglect, or exploitation. The healthcare provider does not work in a vacuum. Communicating, collaborating, networking, and sharing of resources, information, research technology, and expertise are all methods we can use to achieve the common goal of improving the health and safety of individuals and society as a whole. The creation of multidisciplinary teams has proven to be the most effective way to manage the effects of trauma and violence. A team approach provides for better patient outcomes, and allows a variety of viewpoints to be presented and enhances the safety of providers. Additionally, resources are maximized by contributing to the reduction of expenses while increasing efficiency in the delivery of services. Healthcare personnel do not make judgments about forensic issues, nor do they take sides of either the victims or those who have offended. They care for those who are subject to ongoing abuse, neglect, or violence and bring to light those invisible victims who would have remained vulnerable without intervention. Well-educated and skilled individuals within healthcare serve as a vital link between meeting human needs and facilitating justice.

Introduction to Forensics

13

Appendix 1.1: Signs of Abuse, Neglect, and Exploitation* General: History inconsistent with physical findings Delay between injury and treatment Multiple healthcare providers Over-attentive partner, parent, or caregiver Suspicious death or suicide (including attempts) Physical and Sexual Abuse: Fractures and trauma injuries (including teeth and mouth) Bilateral, multiple, or patterned injuries Injuries in various stages of healing Inappropriate sexual behavior of a child Sleep disturbances Injuries to central or sexual parts of the body Inappropriate use of physical or chemical restraints Psychological Abuse: Extremely passive, apologetic Isolated or restricted contact with others Acting out, aggressive or regressive behavior Fear of parent, partner, child, or caregiver Demeaning language, tone of voice, disrespect from parent, partner, child, or caregiver Child witness to domestic violence Neglect/Self-Neglect: Poor hygiene Inappropriately or inadequately dressed Hungry, malnourished, and/or dehydrated Medications withheld or improperly administered Hypochondria Depressed, withdrawn, and/or apathetic Destructive behavior toward self or others Exploitation: Sexual abuse or assault Victim of financial abuse or fraud Mismanagement of resources by caregiver or other person

* Courtesy Deborah Williams, Clinical Forensic Nurse Specialist, Louisville, Kentucky.

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Forensic Science in Healthcare

References Carpenito, L. 1993. p. 5. In Murry, P. and Stein, M. Child Abuse, 4th ed., Clinical Nursing Series, p. 186. South Easton, MA: Western Schools Press. (1997). Child Maltreatment. 2007. (Washington, DC: U.S. Department of Health and Human Services, Administration on Children, Youth and Families, 2009), 23–25. http:// www.acf.hhs.gov/prorams/cb/pubs/cm07/cm07.pdf (accessed September 2, 2010). Ching-Tung Wang and John Holton. 2007. “Total Estimated Cost of Child Abuse and Neglect in the United States,” Washington, DC: Prevent Child Abuse America, 4, 5. Coleman, G., M. Gaboury, M. Murray, and A. Seymour. 1999. National Victim Assistance Academy Manual 1999. Grant No. 95-MU-GX-K002(S-4). USDOJ, OJP, OVC, NVAA 1999. 149.101.22.150/OVC/assist/nvaa99/welcome/html (accessed August 28, 2010) Compact Oxford English Dictionary of Current English, 3d Edition. 2005. Oxford, UK: Oxford University Press. Cost of Victimization. 1996. National Institute of Justice Journal, February 1996 http:// www. ncjrs.gov/odffukes/nijj 230.pdf (accessed September 2, 2010). Finkelhor, David. 2009. “Violence, Abuse, and Crime Exposure in a National Sample of Children and Youth,” Pediatrics 124, no. 5. http://ovc.ncjrs.gov/ncvrw2010/ pdf/6_StatisticalOverviews.pdf (accessed September 2, 2010). IAFN. 1997. Scope and Standards of Forensic Nursing Practice. International Association of Forensic Nurses (IAFN)/American Nurses Association (ANA). Washington, DC: American Nurses Publishing. Kilpatrick, D. G., C. N. Edmunds, and A. K. Seymour. 1992. Rape in America: A report to the nation. Arlington, VA: National Center for Victims of Crime. Charleston, SC: Medical University of South Carolina. McNamara, Henry. Living Forensics. (seminar pamphlet), Ulster County, NY. Office of the Medical Examiner, 1986. Cited in Lynch, Virginia A., Clinical Forensic Nursing: A new perspective in the management of crime victims from trauma to trial. Critical Care Nursing Clinics of North America, 7(3), 489-507, p. 491. (September 1995). National Association of Crime Victim Compensation Boards, “Crime Victim Compensation Helps Victims,” Alexandria, VA; NACVCB, 2009, http://www. nacvcb.org (accessed September 2, 2010). National Institute of Justice Journal. Cost of Victimization. February 1996. Accessed September 9, 2010 at http://www.ncjs.gov/pdffiles/hijj_230.pdf. National Victim Assistance Academy (NVAA) Manual. 2002. Seminars held simultaneously at 1) California State University, Fresno, CA; 2) Medical University of South Carolina, Charleston, SC; and 3) Washburn University, Topeka, KS. http:// www.ncjrs.gov/ovc_archives/nvaa2002/aboutbook.html (accessed September 9, 2010). Individual chapters can be accessed at http://www.NVAAchapter/ html/2002/chapter1_1.html. NMS Labs. 2010. http://www.nmslab.com (accessed September 9, 2010). Rand, Michael. “Criminal Victimization, 2008,” Washington, DC: Bureau of Justice Statistics, (2009), 1, http://www.ojp.usdoj.gov/bjs/pub/pdf/cv08.pdf (accessed September 2, 2010).

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Tjaden, P., and Thoennes, N. 1998. The National Women’s Study: Research in Brief. Office on Women’s Health, Department of Health and Human Services. Content last updated March 1, 2009. U.S. Department of Justice (USDOJ), Federal Bureau of Investigation (FBI), Office of Justice Programs (OJP), Office of Victims of Crime (OVC), National Victim Assistance Academy Manual (NVAA), 1999, Chapter 1, Scope of Crime, Historical Review of the Victims’ Rights Discipline. (June 1999). http://www. ojp.usdoj.gov/ovc/assist/nvaa1999/chapter1 (accessed January 18,2003.) U.S. Department of Justice (USDOJ), Federal Bureau of Investigation (FBI), Office of Justice Programs (OJP), Office of Victims of Crime (OVC), 1997-1998 Academy Text Supplement. http://www.ojp.usdoj.gov/ovc/assist/nvaa/supp/a-ch1.htm (accessed September 2, 2010). Citing Miller, T., Cohen, J., and Wiersema, B. February 1996. Victim Costs and Consequences: A new look. Washington, DC: National Institute of Justice, U.S. Department of Justice. U.S. Department of Justice (USDOJ), Federal Bureau of Investigation (FBI), Office of Justice Programs (OJP), Office of Victims of Crime (OVC). (2002). National Victim’s Assistance Academy (NVAA), 2002. http://www.ojp.usdoj.gov/assist/ nvaa2002/chaapter1 U.S. Department of Justice, (USDOJ). 2002. Bureau of Justice Statistics. National Crime Victimization Survey (NCVS), July 2002. Washington, DC. Walker, S. 1999. Scope of Crime: Historical review of the victim’s rights discipline. National Victim Assistance Academy Manual. Wikipedia. http://en.wikipedia.org/wiki/Disaster (accessed August 22, 2010). Winfrey, M. E. and A. R. Smith, A. 1999. The suspiciousness factor: Critical care nursing and forensics. Critical Care Nursing Quarterly, 22(1), 1–7. http:// www.preventchildabuse.org/about_us/media_releases/pcaa_pew_economic_ impact_study(final.pdf (accessed September 2, 2010).

2

Documentation

Medical Documentation Before the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO or “Joint Commission”) was established, nursing documentation was haphazard and not considered to be an important part of the medical record. Often, nurse’s notes were destroyed once the patient was discharged. The Joint Commission promoted formation of nursing standards and required that nurse’s notes be a permanent part of the patient’s record. This milestone improved overall patient care in several ways. • It provided a 24-hour snapshot of the patient’s day chronicling treatments given and changes in the patient’s condition. • It became an excellent source of information in investigating possible criminal and civil activity. • It provided a time sequence of events and documented the involvement of caregivers. • It tied other elements in the chart together, giving them context and meaning. Creation of nursing diagnoses in the mid-1970s allowed nurses to define patient problems and act on them. Unlike medical diagnoses, nursing diagnoses emphasize a patient’s biophysical, psychological, psychosocial, environmental, cultural, learning, and discharge planning needs. Nursing diagnoses identify strengths, weaknesses, and potential problems as the patient progresses toward wellness. Forensic issues lend themselves well to the use of nursing diagnoses in preparing a plan of patient care. It is important both medically and forensically for healthcare providers to use appropriate language and terminology, correct grammar, spelling, punctuation, and logical organization. Development of standard forms and checklists have made charting easier, faster, and more efficient for nurses, but in the rush to be efficient, charting can become routine, critical thinking is less common, and errors of omission are easier to make. Nursing documentation must accurately reflect a patient’s physical and emotional status, the care provided, and the patient’s response to that care. Nurses’ observations, assessments, and plan of care must be recorded. Nurses’ 17

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charting must reflect the care given, the quality of that care, and evidence of each healthcare provider’s participation in, and accountability for, providing that care. Nursing documentation must also include aspects of evidence collection and preservation. Forensically speaking, when medicolegal issues are identified, nurses must be acutely aware that everything they do is reflected in documentation, and may be scrutinized in a court of law. That scrutiny often occurs at a time far enough in the future that memories have faded and whatever is in the written record is all that is left of the moment. When charting the collection of evidence, the nurse must include a descriptive listing of • • • • • •

Item or items collected Date and time of collection Name and title of person or persons collecting the evidence Location of evidence collected Substantiating sketches, body diagrams, and/or photographs Item or case number so the evidence can be cross-referenced later on

If an interpreter was used, the name, qualifications, and language must be included. Information included must be legible, clearly and concisely stated, objective, and accurate. Handling of evidentiary items is discussed in further detail in Chapter 3. Recognition and documentation of injuries is an important step in the examination and treatment of victims of trauma and crime. The following discussion of the different types of injury will be helpful in understanding how to approach the narrative and body diagram portions of the nursing record. Important details include: • Clear identification of location, using correct anatomical terms • Specifying on which side of the body the injury is found • Using terms such as abrasion, laceration, contusion, burn, stab wound, and so forth, accurately and appropriately • Recording the size (length and width) of each injury • Describing an approximate shape of each wound (circular, ovoid, linear, triangular, patterned, irregularly shaped, etc.) • Using simple, commonly understood terms to describe the color of wounds • Back up the narrative with sketches, diagrams, and photographs Wounds are often difficult to describe, particularly for the novice or inexperienced nurse. Body diagrams can be very helpful adjuncts to the narrative if done properly (see Figure€2.1). Body diagrams and photographs are an adjunct to, not a substitution for, the nurse’s narrative. They are, however, an

Documentation 2 cm × 2 cm GSW, w/soot & stippling, 6 cm above nipple and 4.5 cm lateral to front midline

19 Old scar above left lateral eyebrow Tattoo of snake 8 cm wide × 11 cm tall

2.2 cm × 2.4 cm GSW, 8 cm below neckline & 6 cm lateral to back midline

IV start 18 ga.

2 cm × 2 cm GSW, w/soot & stippling 3 cm below and 2 cm lateral to nipple line

2.4 cm × 3 cm GSW, 11 cm below neckline & 8 cm lateral to back midline

16 fr. Foley catheter insterted by EMS

Name:

Case #:

Date:

Figure 2.1  Body drawing with annotations.

excellent way to visualize the distribution, pattern, and/or overall picture as seen through the nurse’s eyes. Diagrams and sketches need not be complex, but should convey the location and type of all injuries in as much detail as possible. Samples are included as Appendices 2.1 through 2.13. All medical treatments (e.g., attempted IV sites, EKG lead placement, etc.) should also be noted. Use of standard symbols is acceptable if a key is included on the body diagram sheet. Regardless of whether injuries are seen only on one body surface, both anterior and posterior views should be included. The absence of wounds may be as important later as their presence. In addition to body diagrams, additional sketches are acceptable if needed to accurately and completely illustrate the nature and extent of wounds to the body.

General Physical Examination The first step is to look at the victim or patient to evaluate his or her general overall state. Also note the patient’s behavior and reactions.

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Key Point: Psychosocial needs should be included in the secondary survey. Treatment of the patient’s immediate physical needs must be addressed before or simultaneously with gathering the history. However, whether the patient’s injuries are the result of accident or intentional harm, these patients have been traumatized. If possible, obtain the medical and forensic history in a quiet and private setting. Always be cognizant of the patient’s psychological needs prior to and during information gathering. Remember the patient’s body may be a crime scene. As with all patients, take and document initial vital signs and perform a quick initial assessment. Note and record the patient’s general appearance, affect, and attire, using objective terms. The healthcare provider’s job is to be an observer of the facts and to record those observations as accurately and completely as possible. Avoid use of judgmental terminology. Credibility of documentation is diminished when an individual’s characteristics, mental status, behavior, or any events are described in a critical or biased manner. Carefully document signs and symptoms, allergies, medications, and pertinent medical history. Do not forget to note the patient’s height, weight, hair, and eye and skin color. Ask straightforward questions regarding location, date and time of event, previous forensic history, nature of the incident/ assault, activities since the incident/assault, and any information known about the perpetrator. Carefully remove and package all clothing as described in the evidence collection chapter, noting their general condition and any evidence of trauma. Conduct a complete visual examination, starting at the head and working toward the feet, observing the body for signs of trauma. Use an ultraviolet (Wood’s Lamp) or alternate light source to help identify subtle injuries such as bite marks, rope marks or burns, or recent contusions. Observe for signs of redness, swelling, tenderness, or indurations. In cases of sexual assault, record hygiene and bathing activities immediately prior to, during, or after the assault. Collect all dried and moist secretions. Note the method used for collection and disposition of any specimens collected. If there are no relevant physical findings, physiological changes, or evidence of foreign material, their absence should be clearly stated in the record.

Wound Documentation Wounds provide a great deal of information about the mechanism of injury and information for treatment. They provide law enforcement with physical evidence for prosecution.

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Key Point: The essence of good surface documentation is:

1. Where it is 2. How big it is 3. What it looks like 4. The angle of entry (if appropriate)

Measure as accurately as possible, using standard anatomical landmarks (e.g., left corner of mouth, 3 inches below right nipple, etc.). An American Board of Forensic Odontology (ABFO) rule is the standard, especially for photography, and is shown in Figure 2.2. It is important that all body surfaces are examined, including the genital area. Have a second healthcare professional in attendance when conducting the physical examination. The purpose is threefold: (1) to verify the examiner’s findings, (2) to reduce embarrassment and to provide a sense of security for the victim, and (3) to protect the examiner from future false or misleading statements by the patient. In addition to looking for wounds—cuts, bruises, lacerations, and abrasions—you’re going to note the absence of signs that, based on the patient’s story, one would expect to see. Foremost in a forensic nurse’s mind is the question: Are the injuries consistent with the story? Does what you see correspond to the explanation being given? Clothing is an important source of information regarding the mechanism of injury. Clothing will be discussed in greater detail in the chapter on evidence.

Figure 2.2  Hand with ABFO rule.

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Figure 2.3  Using a quarter to approximate wound size.

Except in life-threatening situations, observation and documentation of physical injuries must be made prior to medical intervention. Much is lost in the process of cleaning, examining, medical or surgical intervention, and the effects of the passage of time (the healing process or infection). Initial observations include location, size, and appearance/character. Document each wound with respect to fixed landmarks such as ears, elbows, belly button, and so on. When documenting size, use of a ruler or scale is preferred; for example, “irregular abrasion measuring 2 cm × 3.5 cm.” However, comparison with a common object (nickel, quarter, pencil lead, etc.) can be used. See Figure 2.3. When documenting appearance, use words that denote texture, color, whether the wound was wet or dry, bloody, dirty, and so on (e.g., “grains of yellow sand imbedded in abrasion”). Physical injuries fall into one of four basic categories: blunt force trauma, sharp force trauma, gunshot or fast force wounds, and thermal injuries.

Blunt Force Injuries Blunt force injuries fall into one or more of four basic categories. They may be seen singly or in combination with other blunt force trauma. • • • •

Abrasions—scratches, grazes, and bites Contusions—bruises Lacerations—tears Fractures of bone—complete or incomplete disruption of bone integrity

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Figure 2.4╇ Post-mortem illustration of pattern injury. Victim was struck with

water pipe. Note the eight vertical thread markings on the right side of the image. (Four incised wounds below thread markings were incurred during pre-autopsy shaving procedure required to fully expose the pattern injury associated with the homicide.) Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Abrasions Abrasions are the removal of the outermost layer of skin. Two forces work simultaneously to create abrasions: compression or downward pressure on the skin, and sliding, the longitudinal force along the surface of the skin. Because direction can be determined, this information may be important. In addition to indicating contact with a rough surface, abrasions also signify the exact point of contact. In the living patient, abrasions will crust over (scab) and darken. See Figure€2.4. After death, they will dry and darken due to the lack of circulation. This darkening can lead to the false interpretation that the abrasion resulted from burning or bruising. Scratches are long narrow abrasions, like those made by a fingernail, thorn, or cat’s claw (see Figure€2.5). Grazes are wider (see Figure€2.6). An example of a graze is the large abrasion on the knee when someone falls on the ground. The form and appearance of abrasions should be noted: (1) to help determine the mechanism and circumstances of injury, and (2) because they may be of future significance in judicial or liability determinations. In a sliding abrasion known as shelving, tissues on the surface may be pushed toward one end, like dirt pushed by a bulldozer, indicating the direction of force (see Figure€2.7). Abrasions may also exhibit a characteristic pattern, indicating contact with a specific object, such as a rug. This type of injury is called a pattern injury. Pattern injuries are blunt force injuries where the instrument leaves an impression that reflects the characteristics of the instrument used (see Figures€2.8 through 2.20).

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Forensic Science in Healthcare

Figure 2.5  Scratch on woman’s neck. Courtesy Dr. William S. Smock. Used with permission.

Figure 2.6  Grazes. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

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Figure 2.7╇ Abrasion with accumulated tissue at one end showing direction of force. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

Abrasions may be seen in conjunction with bruises and lacerations. If the forces are sufficient to produce an abrasion, they may also distort the underlying tissue enough to tear small vessels and other tissue. Key Point: An abrasion indicates the exact site of contact or impact between skin and a rough surface or object, and may exhibit a characteristic pattern of the object contacted. Key Point: If sliding forces were involved, the direction of force may be determined by the accumulation of tissue at one edge of the abrasion.

Contusions Contusions (bruises)* result from leakage (large or small) of blood from vessels into the surrounding tissue (see Figure€2.21. The application of enough blunt force to distort the soft tissues will tear one or more vessels, resulting in leakage of blood into the tissues. Usually, these tears occur in capillaries, but if one or more of the vessels are big enough, the leak may be sufficient to cause swelling (see Figure€2.22). In cases such as strangulation, pinpoint * Ecchymosis is the leakage of blood into skin or mucous membranes and is seen in some disease states or in the elderly. It is the result of a physical condition and not the result of trauma. Contusions are exclusively the result of a traumatic event (however small). The term contusion is not synonymous with the term ecchymosis.

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Forensic Science in Healthcare

Figure 2.8╇ Pattern abrasion from blow with pipe. Courtesy Dr. Patrick BesantMatthews. Used with permission.

Figure 2.9╇ Threaded pipe used to strike victim. Courtesy Dr. Patrick BesantMatthews. Used with permission.

bruising, known as petechiae, can be seen in delicate areas such as the eyelids (see Figure€2.23). Key Point: Only an abrasion or patterned injury in or near the bruising itself will indicate the exact point of contact. Bruises may not become visible for hours, or even days, due to shock or delayed escape of fluids from a blood vessel. Because a contusion requires leakage of blood from a vessel, significant blunt force does not necessarily

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Figure 2.10  Pattern injury to right elbow; possibly defensive wound. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Figure 2.11  Injury from fork. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Figure 2.12  Fork used to inflict blunt-force wound seen in Figure 2.11. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Forensic Science in Healthcare

(a)

(b) Figure 2.13a,b  Pattern injury. Imprint of license plate on victim’s legs where struck by vehicle. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

Documentation

29

Figure 2.14  Pattern injury from grate. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

result in the formation of a bruise. Discoloration may not necessarily appear at the place where force was applied because blood may have to track around muscles, fascia layers, or other structures on its route to the surface where it can be seen. An abrasion near a contusion will indicate the point at which forces were applied (the exact point of contact), but a contusion itself is not an indicator of the point of contact. It is important for the healthcare provider to understand that the intensity and/or duration of force are difficult to estimate unless abrasions, lacerations, or other features are present. If a vessel laceration (tear) is significant, blood will tend to escape through the open wound rather than into the surrounding tissues. A fresh bruise usually appears as a reddish area (the color of oxygenated blood), but like vessels, it may appear blue. Coloring of bruises depends on depth, amount of fat, lighting, and of course, age. As bruises age, they turn

Figure 2.15  Grate associated with wounds seen in Figure 2.14. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Forensic Science in Healthcare

Figure 2.16  Human bite mark. File Photo. (From Catanese, C. (ed.) Color Atlas

of Forensic Medicine and Pathology, Taylor & Francis/CRC Press, Boca Raton, FL, 2009, p. 207. With permission.)

Figure 2.17  Human bite mark. File photo. (From Catanese, C. (ed.) Color Atlas of Forensic Medicine and Pathology, Taylor & Francis/CRC Press, Boca Raton, FL, 2009, p. 207. With permission.) (See color insert following p. 202.)

Documentation

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Figure 2.18  Human bite mark. File photo. (From Catanese, C. (ed.) Color Atlas of Forensic Medicine and Pathology, Taylor & Francis/CRC Press, Boca Raton, FL, 2009, p. 207. With permission.)

purplish. Finally, as the blood pigments break down, the sequence of colors passes through those of a ripening banana—green to yellow to brown—until the discoloration fades. The rate at which a bruise resolves depends on many factors, including the quantity of blood originally released, the effectiveness of the local circulation, the location on the body, and the individual’s

Figure 2.19  Pattern injury from cue stick at bottom of photo. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

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Forensic Science in Healthcare

Figure 2.20  Pattern injury. Burn from curling iron. Note: Arm was folded over

curling iron. Courtesy Dr. William Smock. Used with permission. (See color insert following p. 202.)

Figure 2.21  Beaten man with multiple bruises. Courtesy Janet Barber. Used with permission.

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33

Figure 2.22  Raccoon eyes. Courtesy of Dr. Patrick Besant-Matthews. Used with permission.

age, general physical activity, and condition. Therefore, estimating the age of bruises is very difficult and should be avoided. Documentation of bruising should be limited to size, shape, color, and location. Multiple bruises, especially those of varying colors, are an important fact and should be clearly documented. Bruises of different ages may be adjacent to, or overlap, one another. If the injury is the result of a single event, ask yourself why bruises of different colors are seen simultaneously. Bruising can also be masked by skin coloration and may be almost invisible in the heavily tanned or naturally dark-skinned individual. Bruises are easily overlooked in areas where blood has been forced, or has settled, or in

Figure 2.23  Petechiae. Courtesy Janet Barber. Used with permission. (See color insert following p. 202.)

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Forensic Science in Healthcare

Figure 2.24╇ Fingertip contusions from attempted strangulation. Courtesy Dr.€William Smock. Used with permission. (See color insert following p. 202.)

areas in which circulation is failing. It is generally easier for blood to escape into loose tissues and fat; therefore, bruising is more common in certain parts of the body, after weight loss, in obesity, at the extremes of age, and is more probable if there is any disease of the blood vessels themselves or the patient is on medication that affects clotting. Simply put, some individuals bruise more easily than others. Bruises, by their very nature, may not become visible immediately. Important internal injuries may exhibit little or no external sign of bruising. The appearance of bruising depends on blood accumulating near enough to the skin to be seen. In some cases, this requires that the blood move from the point where it leaked out of the vessel to its final destination. For this reason, reexamination of a victim a day or two after initial injury may be valuable. Distribution of bruises is significant. Small bruises around the neck or on a limb may be the only external physical signs of violence (see Figure€2.24). This is especially true in cases of domestic violence and sexual assault. Postmortem bruising is possible if a body is roughly handled or dropped very shortly after death. For this to occur, however, enough blood must still be present in the tissues and free to move, and gravity must be able to act.

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Bruising is accentuated in the presence of any bleeding disease (hemophilia, leukemia, scurvy) and in those taking medications, especially aspirin or other drugs with anticoagulant properties. Some antidepressants such as Zoloft inhibit blood platelets and bruising in unusual locations may be seen. The appearance of blotchy skin occurs with some skin diseases and in those individuals who use prednisone. Sometimes these skin conditions resemble bruising. Medical treatments, such as advanced cardiac life support, respirators, transfusions, antibiotics, and some drugs, can also alter the formation of bruises. A thorough assessment is necessary to determine if any of these factors are present. Lacerations The term laceration is one of the most commonly misused terms in modern medicine. Soft tissue injuries are either tears or cuts. Lacerations (tears) are the result of blunt forces; for example, a tear on a boxer’s forehead is the result of blunt forces (the other boxer’s glove) and is a laceration, not a cut. Cuts (incisions) are the result of sharp forces.* As with bruising/ecchymosis, the terms are not interchangeable. Tissue deformities resulting from blunt force trauma include tearing, ripping, crushing, overstretching, pulling apart, bending, and shearing. They are not the result of sharp forces. Key Point: Lacerations have ragged, irregular margins and may contain foreign material; cuts have clean margins and rarely contain foreign material. If the wound is linear, close inspection and good history taking will help determine whether the wound was caused by blunt or sharp forces. Skin lacerations are frequently found over bony prominences. This is because the skin is relatively fixed and less able to move when stressed (see Figure€2.25). Inside the body, organs and arteries such as the spleen, liver, and aorta are most frequently lacerated (in this case, torn) at points of relative immobility. It can be difficult to determine whether a wound is the result of blunt or sharp forces, or a combination. A skin laceration typically has an irregular margin. Look closely at Figure€ 2.26. Although the wound appears to have clean edges, there are skin tags all along the edges, making this a laceration. The margins around lacerations often display evidence of scraping and bruising. Because tissues are torn apart, the separation is frequently incomplete. * Description of a superficial wound to the face is dependent on the causative instrument: It is classified as a laceration if the forces are blunt (a hand, fork, or other object) and is classified as a cut if the forces are sharp (a knife or razor).

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Figure 2.25╇ Scalp laceration. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Stronger tissue elements, such as little blood vessels, nerves, and connective tissue strands, survive to bridge or span the gap from one part or side of the wound to the other (see Figures€2.27 and 2.28). When you see bridging, think “blunt force injury.” Bridging is most easily seen at the corners or deep within a wound. A blunt injury made with a linear object may initially appear to be a straight line, but upon closer inspection, the edges are irregular and stronger tissue components “bridge” the edges of the wound. Forensically, lacerations give clues as to the kind of surface that impacted the skin. Because they are the result of blunt impact, lacerations are clinically important in two ways. First, these wounds are more susceptible to infection

Figure 2.26╇ Laceration over soft tissue. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

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Figure 2.27  Bridging. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

because the crushing forces involved result in less blood flow to the area. Second, they are more vulnerable to infection because they are more likely to be contaminated with foreign material such as dirt, glass, fibers, and paint chips. These foreign materials may be of evidentiary value as trace evidence or foreign objects.

Sharp Force Injuries Sharp force injuries fall into two basic categories: cuts or incisions and stab wounds.

Figure 2.28  Bridging. Courtesy Dr. Patrick Besant-Matthews. Used with

permission.

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Figure 2.29╇ Cuts on abdomen. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

Cuts or Incisions A cut is sustained when a sharp object makes contact with the skin with sufficient pressure to divide it. The force necessary to produce a cut depends on (1) the sharpness of the cutting instrument and (2) the resistance of the skin and overlying objects (such as clothing). Incisions, cuts, and incised wounds are linear and generally longer than they are deep.* The force that creates a cut has enough inward pressure to create the cut, but the primary force is longitudinal along the surface of the skin. Cuts may be deeper at one end, suggesting left or right handedness. Cuts have clean edges and there is no bridging of tissue (see Figures€ 2.29, 2.30, and 2.31). Because they tend to bleed freely, blood escapes rather than collecting under the skin. Consequently, little or no bruising may be visible. If vessels are completely severed, they may be able to retract, and may not bleed much at all. If the object is sufficiently sharp, hair and other small structures will also be cut. Trace evidence is rarely found in a cut. Stab Wounds Stab wounds result whenever a sufficiently sharp and narrow object is forced inward. Stab wounds are deeper than they are long (see Figure€2.32). There may be some longitudinal motion, but the primary force is inward. The force * Although cuts are generally linear, they may be irregular if the skin was creased, wrinkled, or affected by clothing.

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Figure 2.30╇ Linear cuts with puncture wound to bottom of foot. Courtesy Dr.€Patrick Besant-Matthews. Used with permission.

may be a thrust or it may be due to falling on or being impaled by an object capable of penetration. Again, the two critical elements are force and sharpness of the object. The skin itself offers most of the resistance to a foreign object. Once it has been penetrated, the amount of force required to continue travel is diminished, unless tissues such as cartilage or bone are encountered. If an object is not sufficiently sharp or if it tapers and becomes thicker as it enters, the skin may stretch, resulting in an abrasion at the wound margin. Stab wounds are primarily sharp in character. It is possible, however, to force a relatively blunt object into the body. In such an instance, the wound is best classified as a laceration (see Figure€2.33).

Figure 2.31╇ Cuts to arm. Probably defensive wounds. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

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Figure 2.32╇ Multiple stab wounds to back. Courtesy Dr. Patrick BesantMatthews. Used with permission.

Stab wounds are more likely to reflect the causative instrument or weapon than are cuts. For example, a fairly thick knife blade with only one sharp edge will tend to leave a defect that has a cleanly cut acute angle at one end and a more squared-off or slightly torn, angular appearance at the other (see Figure€2.34). The exact depth of penetration cannot be determined unless the stabbing object is available. Areas of abrasion near the point of entry indicate that whatever weapon was used went in as far as was possible. Such stab wounds have a high potential for deep injury. In soft areas such as the abdomen, the skin is flexible enough to allow a stabbing object to reach much deeper than

Figure 2.33╇ Stab wound from Phillips screwdriver-type instrument. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Figure 2.34╇ Single-edge stab wound. (From DiMaio, V.J.M.,€ and Dana, S.E., Wounds Handbook of Forensic Pathology, Second Edition, p. 110. Boca Raton, FL: Taylor & Francis, 2006.)

the length of the object itself. Always look for evidence that a knife or tool was forced in as far as its handle. Stabbing instruments may occasionally break off inside a wound, especially if bone is encountered* (see Figure€ 2.35). Recovery and retention of such broken pieces should be done and the pieces handled as potential evidence. They may be vital to effective prosecution of a criminal case, or to prove the cause of an accidental injury. Important aspects of sharp wounds to remember are: • Cuts are generally wider than they are deep, and stab wounds are generally deeper than they are wide. • Injury to vital internal structures may not be immediately apparent. Internal bleeding may result in precipitous collapse of the patient. • Stab wounds may reflect the causative instrument or weapon. • There is relatively little abrasion of wound margins unless the weapon is tapered and it wedges/stretches the skin on its way in. • Generally, there is no bridging in cuts or stab wounds. * Modern knives are more flexible and stronger than those made in some other countries, so this phenomenon is relatively rare in the United States.

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(a)

(b) Figure 2.35  a) Knife with broken tip. b) Broken tip in x-ray. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Document the surface dimension, depth, and direction of these wounds if at all possible. Beveling or shelving of wound margins is a clue to the internal direction of a wound track. In the event that a chest tube or other device is placed through a suitably positioned injury,* it is important that this be clearly indicated in the record. Otherwise, it may be difficult to properly interpret the wounds inflicted by an assailant. This is precisely what happened in the shooting of President Kennedy: a tracheotomy tube was placed into his neck wound. Because no exit was identified, misinterpretation and speculation about the number of bullets that hit the president exists to this day.

Mixed Blunt and Sharp Injuries Victims of assault, motor vehicle accidents, and other multiple traumas may suffer both blunt and sharp injuries. For instance, a person involved in a motor vehicle accident may be cut by a piece of broken glass, impaled by a gear-shift lever (blunt injury that looks like a stab wound), and receive multiple blunt traumas to the chest from the steering wheel and/or dashboard.

Fast Force Injuries (Gunshot Wounds) Laceration from a fast force projectile is the crushing or tearing of tissue (blunt trauma) as the result of forces related to the transfer of energy from the penetration of a moving object (bullet or pellets; see Figure€2.36). Bullets of greater mass fired at high velocity have the greatest potential for causing

Figure 2.36╇ Bullets with lands and grooves. Courtesy Dr. Patrick BesantMatthews. Used with permission. * An exit wound in President John F. Kennedy’s neck was used to insert an endotracheal tube, thus causing confusion as to the number of shots fired.

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injury. Projectiles from handguns have relatively low velocity (800–1,500 feet/second). Bullets from rifles have up to three times the velocity of those from handguns. Shotguns produce low- to medium-velocity projectiles, but do more damage at close range because of the increased number of projectiles and larger total volume. When assessing the victim of a gunshot, it is important to remember that there is rarely damage to a single structure. For example, a young man was shot in the abdomen with a .22 caliber rifle. Although no vital structures were hit, the shockwave created significant cavitation of surrounding tissues. This cavitation caused a large amount of tissue damage and subsequent massive rupture of cellular membranes. The patient developed irreversible lactic acid acidosis and died several days later. A great deal of information can be gleaned from observing gunshot wounds, including the range of fire, angle of entry, and type of projectile(s), and any intervening object between the firearm and victim’s body. When examining a gunshot wound, any evidence should be photographed before the wound is cleaned or disturbed by medical treatment. Parallel narrative documentation as well as a body diagram, should be incorporated into the medical record. When projectiles are secured as evidence, it is critical that they not be marked in any way. Projectiles should be handled the same as any other evidence, not adding or subtracting from the original condition. If it is necessary to use forceps when removing projectiles, the tips must be covered with portions of a rubber catheter or other soft material that will not mark the projectile (see Figure€2.37).

Figure 2.37╇ Forceps and hemostats with soft tip covers. (See color insert following p. 202.)

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Regardless of the type of firearm used, there are three things that need to be evaluated and documented: range of fire, angle of entry, evidence or observations regarding the type of projectile and any intervening materials that may have been between the weapon and the victim. Range of Fire The range of fire relates to the distance between the end of the barrel or muzzle of the firearm and the target. We know how far burned and unburned grains of gunpowder travel, so range of fire can be determined (see Figure€2.38). Contact range gunshot wounds occur when the muzzle of a gun is touching the target at the instant it is fired. In these situations, the powder residue is deposited in the wound track itself (see Figure€2.39). If the muzzle is pressed tightly against the target, all the powder residue is deposited in the wound track; if the muzzle is not tightly sealed against the target, some of the powder and gas escapes into the surrounding surface (see Figure€2.40). In both cases, the entrance wound is modified by the gas and powder residue forced into it. The degree of modification is primarily a function of the amount of gas entering the tissues—the more gas, the more stretching, tearing, and so on. The degree of wound modification is also determined by the underlying anatomy. Blasting of gas into tissues that lie over a hard surface (such as the

Figure 2.38╇ Gun firing, illustrating soot and unburned grains of powder. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Figure 2.39╇ Contact gunshot wound to temple without stellation. Courtesy

Dr.€Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

Figure 2.40╇ Near-contact gunshot wound with soot in wound track and some escaping to side. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

skull; see Figure€2.41) create a much greater pressure and result in a much greater deformity than would occur in a soft, shock-absorbing cavity such as the abdomen (see Figure€2.42). In areas such as the head, part of the gas is deflected by the bone. The result is a rapid expansion and outward tearing of the skin as the gas escapes confinement. The skin is elevated and expanded by the gas, slamming back against the muzzle of the gun. This can produce an imprint of the muzzle’s end on the skin surrounding the perforation made by the projectile (see Figures€2.43, 2.44, and 2.45). This outward stretching and tearing of the skin

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Figure 2.41╇ Large stellate-shaped gunshot wound deformity of head. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

Figure 2.42╇ Contact gunshot wound to abdomen. Courtesy Dr. Patrick BesantMatthews. Used with permission. (See color insert following p. 202.)

creates a wound with a stellate or star-shaped appearance (see Figures€2.46, 2.47, 2.48. and 2.49). Because there are great variations in ammunition, and because target areas may or may not have underlying bone, contact range gunshot wounds vary greatly in appearance. These wounds range from a simple perforation to a large, complex skin defect; contrast Figure€2.41 with Figure€2.43. Close range gunshot wounds occur when the range of fire is only a few inches. The dustlike residue of burned gunpowder known as soot is deposited on the target (see Figure€ 2.50). This soot creates an appearance known as

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Figure 2.43╇ Contact gunshot wound to abdomen with light impression of muzzle. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Figure 2.44╇ Very close to contact gunshot wound. Note impression of muzzle on skin. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

fouling. The presence of soot usually indicates that the muzzle was less than 6 to 8 inches from the target* (see Figure€2.51). Intermediate range gunshot wounds occur when the large particles of unburned or partially burned gunpowder strike the skin and create individual small abrasions or hemorrhages called stippling. The presence of stippling and the absence of fouling usually indicate a range of fire greater than 6 to 8 inches but less than 18 to 36 inches. As the muzzle-to-target distance increases, the zone of stippling becomes larger and its density diminishes. * The term powder burn is a misnomer and should not be used. The heat and pressure of burning gases may create a skin reaction and gunpowder residues are deposited on or imbedded into the skin.

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Figure 2.45╇ Contact gunshot wound to soft tissue showing barrel of gun. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Depending on the density of particles and the amount of hemorrhage produced, stippling can be obvious or subtle. Always look for evidence of stippling and/or fouling around gunshot wounds (see Figures€2.52, 2.53, and 2.54). Gunshot wounds should not be cleaned before photographing as evidence of soot deposits may be lost. Distant range gunshot wounds occur when the muzzle of the weapon was greater than 18 to 36 inches from the point of entrance. Distant range gunshot wounds are usually round with an abraded margin. The defect in the skin is usually smaller than the bullet diameter due to the skin’s ability to stretch. Because the bullet itself will have some soot on its surface that

Figure 2.46╇ Stellate gunshot wound to temple and black eye. Note smaller skin deformation due to proximity to thinner bone of temple and blood traveling into eye socket causing “bruising.” Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Figure 2.47╇ Stellate gunshot wound to forehead. Courtesy Dr. Patrick BesantMatthews. Used with permission.

soot will be left on the skin as it enters. This is called wipe off and appears as a discoloration of the abraded ring at the point of entrance (see Figures€2.55 and 2.56). A good illustration of range of fire would be when an individual is brought to the emergency room with a self-inflicted shotgun wound to the abdomen without any evidence of soot or stippling. It is impossible for an individual to hold a shotgun far enough away from the abdomen so that no soot or unburned powder would impact the skin. This scenario is immediately suspicious, and unless some device was used to hold the gun allowing it to be fired from a distance, the story does not match the injury presented.

Figure 2.48╇ Perforating stellate gunshot wound to forehead with soot and ruler. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Figure 2.49╇ Stellate gunshot wound to mouth with soot deposit and stellate tearing. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Angle of Entry This is the relative angle at which the bullet entered the body. The term relative here is important. Relative angle relates to the angle between the firearm and the target at the time the projectile penetrated the skin. The relative angle differs with the victim’s position (standing, sitting, kneeling, etc.). A gunshot wound can provide information about the relative angle at which the bullet entered the body and associated conditions such as the type of firearm, ammunition, clothing, or interposing objects. When a bullet approaches the skin at an angle, the wider margin of abrasion on one side of the wound usually indicates the direction of travel (see Figures€2.57 and 2.58). Note the bullet itself just under the skin below the elbow. This angle helps detectives

Figure 2.50╇ Contact gunshot wound to temple with soot deposit. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Figure 2.51╇ Contact gunshot wound to forehead with soot and stippling. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

confirm the location of the shooter and may also help confirm or disprove different versions of the story (see Figure€2.59). Types of Projectiles and Intervening Objects Information about the type of weapon and ammunition used, or about any objects that may have been interposed between the firearm and the victim at the time of shooting, may be detected by careful observation of an entrance wound.

Figure 2.52╇ Small entrance gunshot wound to forehead with stippling, raccoon

eyes, abraded ring. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

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Figure 2.53  Stippling. Courtesy Dr. Patrick Besant-Matthews. Used with

permission.

A wound from shotgun pellets has a different appearance than a wound made by a single shell bullet. The size, number, and velocity of projectiles will make a big difference in the severity of injury. Correct documentation of gunshot wound details (including corroborating photographs) is important. Unusual or atypical entrance wounds can be produced for a number of reasons. A defective firearm or bullet may be the cause. Ricocheting causes a bullet to tumble, changing the appearance of the entrance wound. If a bullet passed through an intermediate object, it may carry traces of that object with it, embedding them in the subsequent object it hits. In the case of interposing objects, you may see bits of clothing, plaster or wood from a wall, or other

Figure 2.54  Gunshot wound anterior to left ear with fouling and stippling. Note sparing around sidepiece of glasses. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

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Figure 2.55  Abraded ring without significant soot deposit or wipe off. Courtesy

Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

Figure 2.56  Abraded ring with wipe off. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

signs that something else was hit before the projectile penetrated the victim’s skin. Bullets that strike the ears, nose, or hands also produce unusual patterns due to contours in the skin. Wounds on the skin can be difficult to interpret, especially when intervening items such as clothing, are struck first. For this reason, evidence, particularly trace evidence may be more easily found in clothing.* Depending on the tightness of the fabric weave and the numbers of layers that are perforated, * Screen doors, regular doors, windows, and walls are examples of items that may be struck by a bullet before it hits a person. In the healthcare setting, clothing is the most common and can have significant evidentiary value.

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Figure 2.57╇ Bullet angle of entry sketch.

clothes may act as a filter and can retain most or all of the powder residue (see Figures€2.60 and 2.61). Entrance and exit wounds vary widely in size and appearance and can easily be confused. Exit wounds are usually nonabraded lacerations. They may be larger than entrance wounds, but this is not always the case. Exit wounds may be circular, oval, and/or smaller than the entrance wound. This can cause confusion and misinterpretation. It is best not to label a gunshot wound as entrance or exit. Describe its size and characteristics instead. The use of terms such as abraded ring or stellate-shaped is better technique. Skin offers greater resistance to perforation by bullets than any other tissue except bone and teeth. Most bullets that do not exit are lodged either in bone or are found just beneath the skin. Subcutaneous bullets usually present as small bumps under the skin. They are easily palpable and are often surrounded by a bruise.

Figure 2.58╇ Angled entry with bullet under skin near elbow. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Figure 2.59  Angle of entry. Courtesy Dr. Patrick Besant-Matthews. Used with

permission.

Figure 2.60  Spent bullet with fibers embedded in nose. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Figure 2.61  Near-miss gunshot wound. Note angle of entry and abrasion from bullet. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Photographing Gunshot Wounds All wounds should be photographed both before and after treatment. Two photographs should be taken of each gunshot wound: one with a ruler and one without a ruler. Descriptive notes and an accurate diagram should always accompany photographs. (See the “Photography” section in this chapter.) Important Terms to Remember about Gunshot Wounds Soot is the product of burned powder and usually only travels 6 to 8 inches before dissipating. Soot that has been deposited on a target may be wiped off; do not clean a gunshot wound before photographing and documenting the presence of soot! If the muzzle is less than 3 inches from the target, the soot is compact and dense and it may not be possible to completely remove it. Stippling is caused when grains of unburned powder are imbedded into the skin. This leaves a tattoo-like appearance near the entrance. Searing is the result of hot gases escaping the barrel of the gun. Stretching or cavitation is the formation of a cavity due to the transfer of kinetic energy from the bullet to the surrounding tissue. Contact between the weapon and the skin causes unique tissue damage due to the gases released in addition to the damage caused by the bullet itself. Bite Marks Bite marks are a significant injury pattern because of their evidentiary value. Their characteristics can be unique enough to match a bite mark to the dentition of the individual who made the bite. (See discussion of bite marks in Chapter 3.)

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Human bite marks are oval (elliptical), superficial abrasions and may be single or double. They show indentation, puncture and/or petechiae (pinpoint bruising; see Figure€2.23), contusion (larger bruising), and abrasions. Bites from children are generally smaller than those of adults. Animal bites are oblong, V-shaped deep lacerations, and are almost always multiple. Fractures of Bone Bone may fracture in different ways depending on the amount of force and the manner in which that force was applied. Bone fractures display two basic patterns depending on the type of force applied. • A transverse or V-shaped fracture indicates a direct force • A spiral fracture demonstrates a twisting force Again, documentation of fractures should be limited to their existence, appearance, and placement, leaving interpretation to the orthopedic or forensic specialist.

Thermal, Electrical, and Chemical Injuries Healthcare providers encounter burns in association with fires, heated objects, chemical agents, electrical accidents, and lightning strikes. Electrical burns are typically incurred by construction workers and electricians. There are, however, cases among do-it-yourselfers who fail to observe prudent practices associated with electrical wiring, appliances, and tools. Electrical burns are usually the result of accidents or intentional acts of homicide. However, there are rare reports of suicide involving electricity. Burns from these causes differ significantly from those induced by lightning. They are the combined result of direct tissue heating, contact burns, arc burns, and thermal burns from the ignition of clothing (Stewart, 1990). Forensic investigators are responsible for gathering evidence and reconstructing the scenario to help determine whether or not there is civil or criminal liability, or whether it is merely the result of an accident. Healthcare personnel can make observations, document, identify, and collect evidence that provides invaluable information to law enforcement, death investigators, arson investigators, and other healthcare providers. Thermal Burns Classifications Burn wounds are classified in terms of the extent of tissue damage. Historically, burns were placed into four groups based on the degree of injury.

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• First-degree burns: Involve the epidermis; victim experiences redness and pain • Second-degree burns: Affect both the epidermis and dermis; blister formation is common • Third-degree burns: Extend into subcutaneous tissue • Fourth-degree burns: There is deep tissue loss including muscle and bone As a practical matter, most wounds have areas with more than one classification. A wound may have deep tissue involvement in the center, but firstand second-degree injury at the periphery. Recent burn literature suggests that burns fall into two categories: • Partial thickness: superficial or first- and second-degree burns • Full thickness: characterized by whitish skin changes, charring, or deep tissue loss (fourth-degree burns) It is essential to examine the burn wound for patterns that suggest direct contact with a heated object such as a lighted cigarette or curling iron. These objects can readily produce full-thickness burns, especially when intentionally held in contact with the skin. Defenseless young children and the elderly are the most at risk for these types of burns because their skin is more sensitive to temperature extremes and they are less able to protect or defend themselves. Accidental burns have a more erratic appearance because the victim is able to rapidly pull away from the hot object (Olshaker, Jackson, and Smock, 2007). Scalding Burns Scalding burns associated with hot liquids or steam can be divided into three groups: • Immersion burns • Splash or spill burns • Steam burns Although any of these burns may be accidental, it is essential to evaluate each situation to detect intentional acts of abuse or torture. When bodies or extremities are immersed forcefully, the burns are often well demarcated. When the burn is accidental, the uneven margins suggest that splashing has occurred. The irregular appearance suggests that the victim had the freedom to move willfully away from the hot liquids. In extremely hot water (130– 140°F), contacts as brief as one second can cause full-thickness burns.

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Figure 2.62╇ Cross-section of trachea with charred areas. Note the classical pink color of high carbon monoxide exposure. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

Inhalation Injuries Patients with thermal burns are at high risk for additional inhalation injury (see Figure€2.62). Signs and symptoms of inhalation injury include: • • • • • •

Shortness of breath and severe coughing Difficulty swallowing Hoarseness Soot on face or mouth Singed hair on the head or face, especially around the nose or mouth Facial burns

Respiratory involvement associated with a burn suggests the victim was unable to leave a confined space or that an explosive substance or accelerant may have been associated with the fire. All observations and other information should be documented carefully and conveyed to an arson investigator or other forensic specialists. Important evidence to preserve includes: • Photographs of the scene, the victim, and any obvious burn injuries • All clothing associated with the victim or others, including discarded jackets, gloves, shoes, or other pertinent items found at or near the scene • Any secretions from the mouth or respiratory tree including blood, sputum, fluids from bronchial washings, and nasal or oral swabs

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Electrical Burns Definitions • Electrocution is death by electrical shock. • Electrical shock is the passage of electrical current through the body with or without subsequent death. When an injured or dead victim is found near electrical wires, electrical shock or electrocution should be suspected. Basics of Electricity An ampere is the amount of electrical current (volume or flow of electricity) passing a given point in an electrical circuit. Contrary to common assumption, circuit breakers are not designed to prevent shock to humans or other living organisms; they are designed to stop a current overload, thus preventing a fire. Circuit breakers are usually rated at 15 amperes or more. The amount of electricity needed to affect a human is in milliamperes (a milliampere is one one-thousandth of an ampere). One milliampere can create a slight tingling sensation in humans. In 90% of people, the amperage required to create tetanic contracture (the no-let-go phenomenon) is between 0.009 (9 milliamperes) and 0.015 amperes (15 milliamperes) (see Figure€2.63). In victims with previous burns, or nonintact skin, less amperage is required to create organ and tissue damage. Even at very low amperages of electrical shock current, there is a lower probability of complete recovery due to multiorgan damage because the electrical current often follows the vascular, lymph, and nervous system and can cause permanent damage to them.

Figure 2.63╇ “Blow out” appearance of electrical burn to hand. Courtesy Dr.€Patrick Besant-Matthews. Used with permission.

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Figure 2.64╇ Electrical burn through glove to thumb. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Even if a suspected victim of electrical shock may seem fine at the moment, it is imperative that they seek medical treatment immediately. Why? Because the tissues have been exposed to a damaging force sufficient to silently injure or destroy cells. Swelling, airway obstruction, and/or cardiac complications can follow. Monitor your patient continuously for signs of cardiac involvement, especially V-fib or asystole. These patients can deteriorate precipitously. Awareness of the patient’s condition is extremely important because the patient’s condition may require prescience (anticipation of potential patient deterioration) and rapid intervention. Physiologically, flexor muscles are stronger than extensor muscles. This is why the no-let-go phenomena occurs. The electrical stimulus causes the flexor muscles to override the extensors, making it physically impossible for someone to let go of the active electrical circuit. The effects on tissue are dependent on two things: time and current (amperage). The determining factor in shock cases is the amount of current to which the victim is exposed. The amount of electrical resistance (clothing, shoes, environmental conditions) presented by the shock victim will influence the amount of current reaching the body; that is, the greater the resistance (protection), the less current that is allowed to flow into the body. Some clothing can act as a poor insulator against electrical current and can allow electrical current to pass through relatively easily, depending on the resistance of the material encountered (see Figure€2.64). It does, however, provide some protection. Metal is a good conductor of electricity and heat. In clothing, it can provide the point of entry into the body (see Figure€2.65). Note the overall effect (see Figure€2.66). Note the general resistance provided by the thick leather sole, but the easy entry point where metal was attached (see

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Figure 2.65╇ Belt buckle point of electrical entry, left upper corner. Courtesy Dr.€Patrick Besant-Matthews. Used with permission.

Figure 2.66╇ Effect of electrical contact through belt buckle. (Note belt below

and to left of cuff of sleeve.) Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Figure€2.67). It is for this reason that steel-toed shoes are not recommended for those working with electricity or on fires. It is important both for the first responder and follow-up EMS and hospital personnel to understand that the amount of current required for serious electrical shock injury is about one thousand times less than it takes to trip a breaker in a building. It only takes 20 to 40 milliamps (0.020–0.040 milliamps) to paralyze the intercostal muscles and diaphragm, leading to respiratory arrest. This level of current may not yet be high enough to cause cardiac symptoms, so the patient’s heart is still beating normally. Beginning cardiopulmonary resuscitation (CPR) as soon as possible is vital because one or two rescue breaths may be all that is needed to stimulate spontaneous respiration.

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Figure 2.67  Point of electrical entry through metal attachment to shoe. Courtesy Dr. Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.)

If spontaneous respiration does not stimulate the patient to breathe on his or her own, continue ventilating the patient and watch for signs of cardiac involvement. Key Point: In the case of electrical shock injury, it is not safe for responders to begin CPR until the patient is away from potentially energized electrical wires or circuits. Tissue damage is largely due to heat, which induces vascular spasms, thrombosis, neurological injury, and muscle necrosis. Certain body organs and tissues are more subject to electrical energy than others due to their physiological properties, which contribute to low resistance. For example, central nervous system tissue, which is specifically designed to carry electrical signals, has exceptionally low resistance. Cardiovascular and respiratory systems also have low resistances due to their high composition of electrolytes. Skin, tendon, fat, and bone have higher resistances, but if the voltage is high, the heating becomes greatest in the more electrically resistive tissues. During prolonged contact with electrical energy, fat and tendons actually melt and bone incurs significant periosteal damage. (Stewart, 1990). Other damage includes muscle necrosis and rhabdomyolysis. Rhabdomyolysis can be detected by massive amounts of hemoglobin in the urine, but without red cells or red cell fragments. Assays for myoglobin should also be done along with creatinine phosphokinase (CPK) levels. Levels range up to 20,000 units for victims of severe electrical injuries.

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Key Point: Remember the ABCs! One or two rescue breaths may be all that is needed for the shocked patient who is not breathing but who has a maintained a pulse. Ventricular fibrillation is a common symptom of electrical shock. Asystole (no heartbeat) can occur following prolonged shock or shock with higher current levels. Between 50 and 150 milliamperes may cause ventricular fibrillation. Seventy-five milliamperes may be sufficient to cause cardiac arrest. Even at these very low amperages, there is a low probability of complete recovery due to multiorgan damage because the electrical current often follows the vascular, lymph, and nervous system. Electrolyte imbalance, release of myoglobin into the bloodstream, scarring, and/or eventual cellular death can be long-term consequences of having been shocked. For instance, rhabdomyolysis releases myoglobin into the bloodstream. The myoglobin molecule is larger than the kidney can normally handle, plugging the arterioles and causing damage to the kidneys, even to the point of kidney failure. The history of this event would be the clue that high volumes of IV fluids are needed to help flush the kidneys. Electrical burns can create extensive local burn wounds as well as a range of systemic effects, depending upon the intensity of current flow and duration of contact. Skin and tissue resistance and current pathway through the body are also determining factors in the electrical injury and the resultant burn wounds. Factors that increase current density include perspiration, tissue resistance, the electrical current pathway through the body, electrical grounding, and a small contact area and high voltage (more than 1,000 V). Types of Electrical Burns There are three types of electrical burns: contact burns, arc-flash burns, and arcing burns. Contact Burns╅ Contact burns occur when the body comes into direct contact with energized electrical appliances or current. Electrical contact wounds (formerly referred to as entry and/or exit wounds) may or may not be present depending on length of contact time, condition of the skin surface affected (wet vs. dry, thin vs. calloused), and the amount of current passing through the body. Assess these issues during the primary assessment (see Figures€2.68 and 2.69). Healthcare providers should be alert to lip or mouth burns in toddlers who bite or suck on electrical cords or sockets. The electrolyte content of saliva rapidly conducts the electricity and an oral burn occurs. Serious sequelae from these burns are uncommon, but they deserve a thorough

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Figure 2.68╇ Electrical burn on foot. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Figure 2.69╇ Electrical burn at juncture of thumb and palm. Courtesy Dr.€Patrick Besant-Matthews. Used with permission.

initial assessment and follow-up. Management by a surgical specialist may be needed to prevent lip contractures and to ensure optimum cosmetic results as healing occurs. Electrical Damage to Vital Organs*â•… AC electrical energy below 1,000 V produces ventricular fibrillation at a rate of 3,600 times per minute. The human heart can only tolerate rates up to 300 beats per minute, above which * A standard laboratory blood test (CKMB) should be performed on all suspected victims of electrical exposure. It measures the level of red blood cell destruction. Normal ranges differ, but usually range from undetectable to 7U/L or so (http://www.clinlabnavigator. com).

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the patient promptly expires. High-voltage electrical energy, however, essentially overrides the heart’s natural electrical conduction system. Once the electrical flow has been stopped, the heart can resume a normal rhythm (James and Nordby, 2009). The environment and historical accounts of witnesses are important in determining whether a death has been caused by electrocution. Deaths from high-voltage electricity produce obvious burn injuries. Deaths from low-voltage electricity may produce no evident physical injury at all. The death scene should be carefully photographed and all clothing should be saved using standard evidence collection techniques. Burns to the skin can result from clothing that has caught on fire. Where were the contact points? Assessing potential vascular, lymph, muscle, and nerve pathways that may have been involved will assist in evaluating possible internal and organ damage. Cardiopulmonary involvement should be suspected when the contact is between one hand and the other. Hand- or foot-to-head is highly suspicious for brain involvement, and may result in brainstem damage. The patient’s age, basic general health,* and mental state are big factors in how well a patient recovers from an electrical shock. Key Point: After an electrical shock incident, in addition to providing immediate care for the victim, a thorough account of the accident should be obtained in order to estimate the extent of nonvisible tissue injury. Assess the patient for superficial burns and treat according to local protocol. Assess the superficial burn area using the rule of nines or other standard method of estimating the amount of body surface area involved. The rule of nines is a method of assessing the percentage of body surface burned using multiples of 9%. (Emedicinehealth, 2010). Head = 9% Chest – front = 9% Abdomen = 9% Upper and mid-back = 9%

Each arm = 9% (4.5% each side) Each leg = 9% Palms and groin = 1% each Lower back and buttocks = 9%

* Younger patients with healthy hearts have a greater potential for recovery with EMS intervention. Older patients with coronary artery disease, lymph system diseases, nervous system diseases, and possibly autoimmune diseases involving any of the above systems or musculoskeletal diseases may not fare as well as younger patients.

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Arc-Flash Burns  Electrical arcing is the “luminous discharge of electrical current through the atmosphere” (Witter, January 29, 2010).* An arc-flash burn is an electrical burn caused by radiant heat, not because of direct contact with an electrical current (as when trying to pull a meter). The severity of burn is dependent upon the temperature of the arc, duration of exposure, and distance from the arc. Burns can range from mild skin reddening to full-thickness third-degree burns. Temperatures involved can be several thousand degrees and may last as little as 0.1 second. An exposure of 0.1 second at a distance of 2 feet can cause third-degree burns. Up to 80 % of electrical burn injuries are the result of arc flash and ignition of clothing. Arcing Burns  Arcing burns are a combination of current flow through the body and a flash of electrical arc. The victim may experience all injuries associated with a contact burn plus those of an arcing burn. Loss of limb(s) is very possible. Treat the patient under standard burn care protocol and continue to assess for inhalation burns. Be prepared for tracheal edema and respiratory arrest. Arc Blast Injuries  An arc blast is a pressure wave caused by the rapid expansion of gases and conducting material with flying molten materials. It is a violent explosion of electrical components and rapidly moving shrapnel. A 25,000 ampere arc blast can exert 480 pounds of force on the average person’s body at a distance of 2 feet. The blast can destroy structures, and knock workers from ladders or across a room. First responders and subsequent healthcare personnel should maintain a high index of suspicion for concussion, skeletal and/or spinal injuries, flash burns, and penetrating injuries. Ultimate survival from these injuries is low. Scene safety is paramount in arc-blast situations. Lightning Injuries and Death Lightning is a high-current electrical injury that can kill by direct or indirect contact. Of greatest concern with an indirect lightning strike is the presence of differing voltages in the ground. Think of a stone thrown in a lake. The ripples move away from where the stone hits the water and the ripples eventually die out. The same thing happens with lightning. When lightning hits ground or something on the ground, the voltage gradients move away from the point of the strike, and the voltages in the ground * Interestingly, arcing can result from an indirect lightning strike with the current conducted over a metallic path and is a source of fires in many homes that use a newer form of gas piping known as corrugated stainless steel tubing. If the metallic components, water pipes, and gas pipes are not all electrically bonded together, there can be an arc caused by an indirect lightning strike that can burn a hole in the gas line and ignite a fire.

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vary from one point on the ground to another. This phenomenon occurs instantaneously. If someone is near an indirect strike, their feet can be subjected to differing voltages in an extremely short period of time, which can be lethal. Direct lightning strikes often result in immediate unresponsiveness and death from cardiac arrest or motor paralysis involving the respiratory centers. In these cases, thousands of amperes flow through the body. The cardiovascular system is immediately compromised by massive vasomotor spasm causing loss of peripheral blood flow, loss of sensation, and loss of color in the extremities. Peripheral arterial thrombosis and tissue death may follow. However, other victims are merely stunned or have retrograde amnesia. Paralysis or slow reflexes may be noted, and it is not uncommon for victims to be unable to speak or to hear. Hysteria, personality changes, and visual impairment have also been reported. Typically, if the individual survives, he or she may suffer less brain damage than other individuals experiencing respiratory or cardiac arrest because cell metabolism is halted as electrical forces pass through the body. Myoglobinuria is common with lightningrelated injuries. A simple urine test helps to confirm that an injured individual has been struck by lightning or suffered a similar electrical energy event* (Lanros and Barber, 1997). Lightning should be considered as a cause of death when an individual is found outside and there is, or has been, a thunderstorm in the area. Featherlike imprints are characteristic of being hit by lightning strikes (see Figure€2.70). As electrical current spreads over the skin, it produces linear, spidery arborescent and erythematous skin imprints and discolorations. This is a hallmark of electrocution. These wounds should be promptly photographed because

Figure 2.70╇ Featherlike appearance of lightning injury. Courtesy Dr.€ Patrick Besant-Matthews. Used with permission. (See color insert following p. 202.) * Myoglobin is not normally found in urine.

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this characteristic pattern may disappear within hours of the death (Wagner, 2009). If lightning exposure is suspected, there should be a thorough search for exit wounds, paying particular attention to obscure areas such as the bottom of the feet or the anus. The presence of lens injuries and perforated tympanic membranes also suggest lightning injury. Lightning strikes often result in rapidly developing cerebral edema, which can be found on autopsy. Weather-Related Hazards Overheating-Related Tissue Injury Emergency responders and forensic personnel are often subject to extremes of heat and cold at the scene of an incident. Working fast and furiously with heavy protective clothing can contribute to both increased heat production and the inability to dissipate the heat generated. Individuals tend to sweat, losing valuable fluid from the body. For well-acclimatized individuals accustomed to working in hot environments, tolerance will be significantly better than for those workers who typically perform in comfortable, air-conditioned spaces. Those in the latter group fall prey more readily to atmospheric temperature extremes. Other predisposing factors are certain medications, high humidity, obesity, and cardiovascular disease. Heat-related problems, in order of their severity, include: • Heat cramps: painful contractions of skeletal muscles due to sodium loss from sweating. Fluid replacement is the mainstay of both preventing and managing this problem. Sports drinks are recommended since they contain important electrolyte replacements. • Heat syncope: fainting episode due to vasodilation, peripheral pooling of blood, volume deficits, and sluggish vasomotor tone. Fluid and electrolyte replacement and rest in a recumbent position are required for recovery. • Heat exhaustion: a more serious heat-stress condition that encompasses heat cramps, heat syncope, and an altered mental status. Headache, dizziness, irritability, a rapid heart rate, and hyperventilation also commonly occur. The treatment is the same as for heat syncope. • Heat stroke: the most serious heat-related condition resulting in death if not vigorously treated. The hypothalamus loses its ability to regulate body temperature. Normal modes of temperature regulation such as sweating are simply overwhelmed. Seizures may occur and the body’s basic metabolic and cardiopulmonary systems fail. Life support measures and prompt definitive emergency medical care at a hospital are required.

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Cold-Related Tissue Injury Any prolonged exposure to cold resulting in significant vasoconstriction and sluggish circulation can create injury to exposed areas of flesh. Eventually, a person’s core temperature is affected, leading to death. Cold-related problems, in order of their severity, include the following. Frostnip  Frostnip is a condition in which exposed skin areas farthest from the trunk are nipped (nose, ears, cheeks, chin, hands, or feet) from cold exposure. The victim experiences burning and tingling sensations. Frostbite  Frostbite is a condition that occurs when frostnip persists and progresses to the extent that the superficial layers of the skin are frozen. Deeper tissues usually remain resilient, however. The skin appears waxy and is numb. Upon rewarming, the affected areas become mottled or purplish and remain numb. Edema, burning, stinging, and blister formation eventually occur. Deep frostbite damages not only the skin, but the subcutaneous tissue and blood vessels as well, producing pain and throbbing that persists for several weeks. When the blisters eventually dry and the skin sloughs, the new skin will remain sensitive to cold. Pain, itching, and excessive moisture are felt throughout the affected area. In the most severe cases when management is delayed or poorly executed, gangrene may complicate the condition, requiring amputation. Hypothermia  Hypothermia is a life-threatening condition that occurs when the core body temperature is less than 95°F or 35°C. The most serious problems occur when the body temperature reaches 90°F or 32.2°C. At this temperature, shivering stops and muscles become rigid. When the core temperature falls below 78°F or 25.5°C, death is typically imminent. An important fact to remember is that the brain and vital processes that ordinarily fail when anoxia and circulatory arrest occur are somewhat protected because of the slowing metabolic demands that occur during hypothermia. If an individual is found in a cold environment and appears rigid, resuscitation should be attempted. Successful recoveries have been reported up to two or three hours after what was apparent death. Therefore, the American Medical Association states that “the recommended treatment of hypothermia in the field is core re-warming to prevent post-rescue collapse” (JAMA, 1992; Alaska protocol, 2010; U.S. Coast Guard protocol, 2010).* Some authorities believe that you cannot * In dire circumstances where warming equipment and supplies are not rapidly available, wrapping the victim together with two undressed normothermic individuals has proven effective.

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declare death unless rewarming has taken place and resuscitation has been attempted. Chemical Burns An important aspect of chemical exposures is that caustic materials continue to burn until they are removed or neutralized. The pathophysiological changes are different than those from thermal burns. The chemical reaction may be an oxidization or reduction reaction, or a protoplasmic poison, desiccant, vesicant, or corrosive (Stewart, 1990). The skin destruction is a product of the extent and nature of the exposed skin surface and the length of time exposed. Delicate areas such as the face, eyes, and genitalia are often the target in cultural crimes aimed at disfiguring the victim or rendering the victim to a state of permanent discomfort or dependency. The eschar provides some clues to the chemical used. Sulfuric acid causes green-black to dark brown discoloration; nitric acid produces yellow eschar and tissue staining; hydrochloric acid creates yellow-brown eschar and tissue staining, and hydrofluoric acid produces a grayish to brown eschar (Stewart, 1990). It is rare that chemical burns result in death. However, there are incidents where individuals are targeted and intentionally assaulted with chemicals in an attempt to maim or kill. Healthcare providers should be attuned to historical details related to the incident and the scene in order to determine if foul play is a factor to be considered. It is rare that chemicals alone are used to commit homicide. Some cultures use chemicals as a form of punishment. Most of these cases involve the face, hands, or genitalia. In Conclusion The healthcare provider must have an appreciation of the basic issues in tissue injury due to heat and cold, burns or electrical injuries, including lightning strikes. Cold-related injuries, especially of the limbs and extremities, often mimic burns. These thermal injuries, as well as hypothermia, pose special challenges for healthcare providers and forensic personnel. First responders, clinical personnel, and death investigators must carefully assess patients to distinguish accidental injuries from intentional abuse or violent acts by offenders. Initial assessment of accidental versus nonaccidental causes and other forensic issues is a vital process, ensuring that victims of abuse are properly identified and protected, those responsible apprehended, and the innocent are not incorrectly branded as perpetrators. Precise collection of evidence and prompt reporting of forensic cases will greatly facilitate the decision-making process and apprehension of offenders.

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Photography There are many reasons to photograph a scene, a person, and/or evidence. Photographs document the location of a crime and confirm the presence or absence of evidence found at the scene. Photographs are critical for those not actually at the scene. They show the visual relationships among the scene, items at the scene, and the victim. Photographs provide a visual record for witnesses and the police. At trial, photographs become a visual aid to the court and jury, adding weight and credibility to testimony. It is important to remember that in sexual assault cases the person is the crime scene. If the patient is reluctant to be photographed, remind him or her that photographs cannot be taken later. Photographs can be taken at the present time and saved in case the victim wishes to prosecute at some time in the future. For this reason, it is frequently in the victim’s best interest to be photographed. Institutions and businesses should have a formal policy including forms for patient consent or refusal to be photographed. Photographic Evidence Photographs can aid in documenting evidence that is found at a scene or on the body of a victim or offender. It is especially valuable in recording scene details that might be easily overlooked while attending the injured, or to preserve the initial appearance of wounds that may heal or change over time such as bruises, abrasions, or lacerations. Photographs will ensure that other witnesses, caregivers, and members of the jury can appreciate the forensic scenario and its related evidence. Photographs visually preserve the scene and associated evidence, and illustrate relationships among the overall scene, various items of evidence, and the victim(s) or offender(s). Photographic images add credibility to testimony and permanently preserve recollections of events and circumstances that tend to be lost over time. Photographs should be obtained promptly before any aspect of the scene is modified by law enforcement or medical intervention. Having stated that objective, healthcare personnel must never delay or defer lifesaving care merely to obtain evidentiary photographs. Purposes of Photographs The purposes of photographs are as follows: • Documents evidence at the scene or on the body • Records scene details that might be overlooked while providing care to the injured

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• Preserves the initial appearance of wounds before treatment or healing processes begin • Provides witness of jury members’ access to scene details and onsite evidence • Demonstrates relationships among the scene, evidence, and victims • Supplements written medical records • Can be used as a teaching aid for law enforcement, emergency care personnel, and forensic investigators When a human being has been wounded, assaulted, or killed, the body is considered to be the crime scene. It is vital to explain the benefits of recording injuries as soon as possible, even though the victim may not have yet decided whether to press charges against the offender. It is preferred to have the photographs taken and to not need them, than to wish later that you had recorded these valuable evidentiary images. Bruises fade, scratches and abrasions fade, and other wounds heal. It is typically in the victim’s best interests to consent to forensic photography. Each hospital or healthcare agency will have specific policies and procedures regarding forensic photographs, including forms for informed and implied consent. Basics of Photography Keep these points in mind: • Photograph as soon as possible. • Photograph as you find it. Do not disturb the scene or the victim before taking photos. • Have a plan and stick to it. • Get a complete series of photographs. • Treat each exposure as if it contains a hidden clue. • Record each photo in a log as it is taken. The log becomes a reference. This is especially useful in conjunction with use of a contact sheet. • If you use 35-mm color slide film, not black and white, the slides themselves become evidence. • Use point and shoot until you’re comfortable with more sophisticated cameras. • Digital photography is generally accepted both by law enforcement and by the judiciary. Understand any restrictions on taking, securing, and presenting digital photographs in your area. • Look at lighting; consider the direction and intensity. When lighting is questionable, use a flash.

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A photographic log should be maintained for each case with the following information: • • • • • • • •

Identification data for the subject Date of the photography Name of law enforcement agency and the case number Medical record number Type of examination completed Identification of the photographer Chain of custody form Location of non-rewritable CD copy of images

Consent to Photograph Consent is not required for forensic photographs if the subject or focus is • Unconscious or deceased • A public place such as a street, sidewalk, restaurant, or public event • A forensic scenario or subject when there is a court order to obtain such photographs of the scenario and its victims or offenders Consent is required for forensic photographs if the subject or focus is • Able to provide informed consent (e.g., adult who is alert, oriented) • Preserved for teaching purposes or publication Written, informed consents are typically requested, although implied consents are also acceptable. Informed Consent The photographer must explain to the subject: • The reason for requesting the photograph • Risks and benefits of photographs • How the photographs might be used Note: Photographers must appreciate that subjects may refuse to provide consent. However, if the reasons for obtaining the photographs are fully explained, most subjects are willing to have images recorded. Many hospitals now obtain the consent for photography as a clause within the routine consent forms for care and treatment. A sample consent form is provided in Appendix 2.14.

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Implied Consent This type of consent is reserved for those individuals who are too injured, ill, or who are unconscious, and therefore unable to execute an informed consent, but who would be expected to consent if they were able to understand the circumstances. For example, it would ordinarily be in the subject’s best interests to have photographic documentation that would help in the evaluation and treatment of their injuries or to aid in the prosecution of a perpetrator, offender, or other individual who might have liability for their condition. Admissibility of Photographs The photographs and the photographer must be able to withstand judicial tests for authenticity, integrity, and credibility. Courts must determine if the photograph: • • • • •

Shows original appearance and findings Fairly and accurately depicts what was visualized by eyewitnesses Assists in identification or characterization of wounds or other injuries Aids the court or jury in evaluating elements of the crime scene Is not unduly gruesome or intended to sensationalize facts or events

Courts usually challenge the photographer by requesting information such as: • • • •

Exactly when and where the photograph was taken Why the photograph was taken What the photograph precisely depicts Type of camera used and whether or not a filter was employed on the lens • If implied or informed consent was obtained from the subject • The processing details of the image • Whether the chain of custody can be verified Qualities of Photographs for Evidentiary Purposes The photographer must: • Use a new memory card or a new roll of film for each particular case or subject. • Record an initial image that provides case-specific identification data for the photographs to follow. • Exclude bystanders when possible unless their presence might aid to authenticating the crime scene.

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• Compose images to frame the original appearance of crime scene elements, including wounds or injuries, to highlight important evidence, and to demonstrate its relationship to other elements of the scene. • Use a small ruler in the plane of body parts or wounds to demonstrate the exact wound size in inches or centimeters. An ABFO ruler is typically used for this purpose (see Figure€2.2, ABFO rule). • Remove extraneous items from the photo such as bloody clothing, soiled dressings, or unused medical equipment. • Ensure that recorded descriptions in the medical record correspond with what is illustrated in the picture. If there are discrepancies, these should be annotated and explained. (For example, if a hemostat is in place to arrest arterial bleeding in the initial photo, but was removed after the victim died and therefore is not present on a subsequent photo, this should be explained.) Equipment for Forensic Photographs There are several types of cameras that may be used, but in today’s forensic community, digital images are preferred to film. First responders and healthcare personnel should concentrate on good-quality images that convey the evidence, and most digital cameras support that objective by offering autofocus, lighting correction, automated auxiliary flash, and other fail-safe devices. Even an amateur is capable of recording a useful image. All first responder units should have a digital camera with a new memory card in place upon arriving at any forensic scene. The paraphernalia associated with sophisticated 35-mm or other older camera types, which require film, flash attachments, filters, and other adjuncts, are too cumbersome to manage when your primary role is the provision of emergency care to injured victims or a suspect. The wide range of available options and prices make the digital camera an excellent choice for first responders and in-hospital applications. Individuals recording digital images must be aware of nuances about the operation of their camera including formatting the memory card, changing batteries, file compression precautions, and preserving photographs to ensure that they will be admissible in court. Scene Photography Ordinarily, the crime scene photos are taken by law enforcement, but may be taken by first responders from a fire department, emergency medical services, or others at the forensic incident. There are many specific elements to crime scene photography that are beyond the scope of this book. However, there are some fundamental rules that any forensic photographer should follow.

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In the early years, there was considerable concern about the ease of altering digital images. It was thought that their authenticity might be questioned or that the potential for tampering would cause the images to be nonadmissible in a forensic case. However, there are several safeguards used today to prevent image manipulation and to detect any alteration that might have occurred. Infrared, ultraviolent, and alternate-light-source photography is occasionally used to capture images of physical evidence that might otherwise be impossible to visualize or to successfully record with ordinary light sources or a flash. Sequence of Photographs Photographs are taken sequentially in a proscribed order starting at the perimeter of a scene or person and working toward detail. The first photograph taken is known as the distance photograph. It is taken as far away from the scene/victim as is necessary to establish the location and general conditions. Subsequent photographs are taken increasingly closer to the scene/subject with the following guidelines in mind. • An intermediate distance photograph records the overall scene and ties distance and close-up images together. At a scene, it places the victim within the scene and locates specific objects within that scene. • The close-up photo establishes the victim’s identity (face and other identifying information), records detail, the victim’s position, and documents wounds. It is imperative that photographed subjects understand the importance of having photodocumentation to verify their identity. • The ultra close-up of any detail (1:1 of specific wounds and items) should include a white balancing or gray scale to verify subtle aspects of coloration and lighting. During the initial scene encounter, certain items of evidence may be collected. Each specific item should be photographed in place before collection and once again after collection to ensure that this process is fully documented. Photographing Human Abuse and Assault Injuries Victims of violence must provide written or informed consent prior to physical assessment and before obtaining photographic images of the condition of their bodies and the related injuries. Parents or legal guardians may consent for a minor child.

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Physical abuse and injuries of interpersonal violence as well as other traumatic injuries create contusions, abrasions, lacerations, cuts, burns, punctures, and the characteristic wounds associated with various firearms. The characteristics and locations of such wounds or soft tissue defects provide helpful clues in determining injury forces or weapons used in an assault. When feasible, such photographs should be obtained before permitting the patient to wash hands or to shower and change clothes. The body and clothing often provide additional trace evidence and physical clues about the biomechanics of injury. It is helpful to annotate body diagrams to accompany the series of documentation photographs (see Figure€2.1). Photographs and body diagrams are to be managed as an element of the medical record and are subject to the same guidelines for safeguarding and release. Chain-of-custody forms are vital tools for verifying the authenticity and preventing tampering with images. See Chapter 3. A photographic log should be maintained with the name of patients (or case number), an identification photo, the date and time that images were recorded, and the name of the photographer along with credentials and affiliation. The human subject should be photographed with an orientation photo that reveals identification information and the anatomical locations of primary injuries. Intermediate range photos and close-ups should be taken with the close-up having a ruler and gray scale held parallel to the central point of interest. It is common that victims will have injuries on several body parts. The presence or absence of trauma to a body part will assist investigators in corroborating the history provided by the victim or any witnesses. For example, the victim’s hands and arms may reveal bruises, abrasions, or musculoskeletal trauma incurred during the struggle with the assailant. These wounds are termed defensive injuries since they are the result of fending off blows or self-protective maneuvers during the attack (see Figures€2.31 and 2.71). The nature and extent of injuries often determine the sequence of recording of photographic images. However, many experts suggest that you start with orientation photos; then proceed to the extremities, chest, and abdomen prior to obtaining images of genital regions. Drape parts of the body that are not essential to the photography of any specific area or detail. Avoid extraneous exposure of breasts, buttocks, the perineum, or genitalia. When the situation dictates the recording of details in these sensitive areas, careful draping of adjacent parts should be accomplished. A longer focal length macro lens that permits the photographer to remain well out of the patient’s personal space should be used if available.

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Figure 2.71  Defensive injuries. Courtesy Dr. Patrick Besant-Matthews. Used with permission.

Although most injuries can be successfully documented using any standard 35-mm or digital camera, there are some indications for special equipment. A common adjunct is an electronic flash unit to augment natural light. The use of flash should be reserved for those items that are visible to the naked eye. Care should be taken against overexposure that can actually make injuries less obvious due to reflection from the patient’s skin. Holding the flash unit at an angle to the skin may help in guarding against this common problem. A ruler and color and gray scale should always be included as a reference. The photographer must position size and color reference tools at a nonreflective angle to the camera and flash unit. Specific techniques using alternate light sources may be employed by those who perform evidentiary examinations for sexual assault and child or elder abuse cases. An important alternate light source for forensic work is reflective ultraviolet photography that will reveal bite marks or bruises that are not apparent with white-light illumination. Long-wave ultraviolet penetrates the skin, highlighting soft tissue trauma. Special filters must be used on the camera lens in order to block light other than the UV source. Light-emitting-diode (LED) technology is another useful, inexpensive, and portable tool for use in forensic cases. Operators must understand various wave lengths and the applications in certain settings and within color ranges. For instance, blue color ranges highlight body fluids such as semen, saliva, or urine; purple enhances bruises and abrasions. When using any alternate light sources, the photographer should have special training and experience in using the equipment properly.

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Figure 2.72╇ Camera mounted on colposcope. Courtesy Janet Barber. Used with permission.

In the hospital setting, a colposcope-mounted camera may be used to elicit highly magnified images of soft tissue trauma associated with sexual assault injuries (see Figure€2.72). Tips for Photographing Anatomical Features When photographing rounded anatomical areas such as the face, breast, or buttocks, several angles and perspectives should be obtained. If the photographer knows the approximate position of the subject at the time the injury was inflicted, this position should be duplicated and the injury photographed to appreciate the relative mechanics associated with the wound. For example, if a female subject was standing upright when her breast was bitten by an assailant who was standing in front of her on the left side, the bite mark should be photographed with the subject standing upright and the photographer oriented to duplicate the relative position of the attacker. Clothing with blood stains, cuts, tears, or holes should be photographed too, giving special attention to preserving any possible trace evidence such as sand, rocks, glass shards, hairs, or fibers. When all wounds have been photographed, the patient’s ID should be photographed once again before the memory card is removed from the camera. Images should be duplicated and stored per local policies and procedures. The original should be properly labeled and sealed as evidence. No images, even those that are fuzzy or out of focus, should be deleted or altered in any way. All original images that have been recorded must be submitted as evidence.

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Digital Evidence Forensic science has discovered new challenges as well as vast opportunities associated with the digital age. Computers, voice and video recorders, surveillance cameras, and many wireless devices used in homes, public spaces, and within healthcare venues provide new sources of event documentation as well as forensic evidence for law enforcement and the legal systems. Forensic personnel must be aware of these important sources of information and take safeguards to ensure that digital information is not disregarded, lost, or destroyed during routine encounters with potential crime scenes, victims, or suspected offenders. What Is Digital Evidence and Cyberforensics? Digital evidence is any information that is stored or transmitted by digital devices, which can be recovered and analyzed to determine facts and circumstances related to a forensic event. The detection, analysis, and reporting related to evidence found in the physical and virtual memory of any computer is termed computer forensics or cyberforensics. Digital evidence can be obtained from: • • • • • • • • • •

Computers Scanners Compact flash cards Compact discs Digital audio and video recorders including telephone answering machines Digital cameras Cell phones Digital fax machines Personal digital assistants (PDAs) Other handheld digital devices

What Is the Unique Forensic Value of Digital Evidence? Information contained in digital devices can be used to: • • • •

Establish identities of individuals Reconstruct the sequence of events Determine movement and location of forensic subjects Provide precise documentation of details by digital photographs or recordings

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• Confirm the relationships between people and physical locations at exact points in time • Appreciate the typical behaviors of victims or offenders Forensic investigations often use digital evidence to supplement physical evidence to draw conclusions about a forensic event. Three specific phases are essential: (1) data acquisition, (2) analysis. and (3) presentation. Every organization (i.e., business, industry, healthcare organization, military, or other governmental agency) has a unique set of standards and organization policies in regard to computer usage and recovery of any stored data. • Data acquisition involves saving, copying, or producing an exact image of allocated and unallocated space on the hard disk • Analysis of the data examines files and directories as well as recovering deleted content • Presentation of findings, with a distinct focus on policy and law Governmental and other public agencies as well as various types of business enterprises have their unique policies and procedures regarding acquisition and use of digital evidence. Hospitals and healthcare agencies have detailed protocols as well, but employees are typically not aware of the specific provisions. However, when legal actions occur, healthcare workers may be surprised that their personal devices may be confiscated in order to recover or corroborate important evidentiary details. The United States has distinct requirements for lawfully intercepting communications or obtaining information from voicemail, e-mail, and text messages. Search or eavesdropping warrants or consents of a customer may be required in certain instances. The legal basis for capturing digital data related to criminal forensic investigations associated with drug trafficking, manslaughter and murder, armed robbery, or other serious offenses is probable cause as defined by the Fifth Amendment of the U.S. Constitution. Healthcare workers must be aware that some situations mandate an immediate release of digital data. For example, the content and caller ID associated with emergency 911 calls, ambulance dispatch records, emergency department switchboards, and public agencies such as police and fire departments must be made available in real time. Crisis lines for suicide prevention or other personal issues may not have the same provisions, however (Hoffman and Terplan, 2006, 345). Forensic investigations are often able to use data from such resources to reconstruct events associated with either victims or suspects. However, they must have a clear understanding of the policies and procedures that pertain to the acquisition and use of such data.

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Digital data sources that may prove to be valuable in forensic investigations include: • Archived CD-ROMs or other recordings of 911 calls • Personal cell phones or other handheld devices used by victims or suspects • Recordings of communications between emergency personnel and hospital emergency department staff • Surveillance camera recordings • Computerized medical records • Digital recordings captured by monitors or other medical devices • PDAs (personal digital assistants) of staff members • Tracking records of personnel, equipment, supplies, or pharmaceuticals Although the Health Insurance Portability and Accountability Act (HIPAA) protects patient privacy, the intent of the act is to prevent unauthorized and accidental disclosures of medical information during transmission within and among medical facilities, healthcare workers or providers, and third-party payers (Frank-Stromborg, 2006). Implications for Healthcare and Forensic Personnel The use of both wired and wireless digital devices poses certain security risks for both patients and their caregivers. Some of the devices are strategically placed and designed to record sequence of events, personnel actions, physiological information, and communication transactions. Much of the record keeping within and among such devices occurs seamlessly in the care environment, often even without the knowledge of the caregiver or the patient. Events are timed, tracked, and recorded, and personnel interactions with such devices are also documented on embedded software that in turn is linked to the hospital information system. Automated drug dispensing units precisely record who accessed the locks and removed various items at a specific time. Some are capable of sending automatic messages to the pharmacy to control inventory or to a patient’s chart to generate charges or to record administration. Hospital beds may be equipped with smart technology that periodically downloads its status. For example, beds contain software that records whether or not the fall-prevention system is armed, the height of the bed and any articulations such as the degree of head elevation, which side rails are up or down, and if the brakes are properly set. This type of information assists nurses in routine safety monitoring and becomes quite valuable in determining a root cause if a patient suffers from a bed-related fall.

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Hospital personnel may be surprised about the number of ways that their actions are watched and recorded. It is imperative to understand that events are also time stamped regularly and if written documentation is used, care must be taken to ensure that serious time discrepancies are not introduced. If a cardiac monitor detects ventricular fibrillation at 3:09 p.m. and the nurse uses her personal wristwatch to determine when the code was called, even a few minutes of discrepancy between the two times could create doubt about the staff responsiveness to the emergency event. Assume that the in-house physician’s cell phone records indicate that he received the call at 3:14 p.m. but the unit clerk logs that the call was placed at 3:11 p.m. according to a wall clock at the nurses’ station. If the patient does not survive the resuscitation attempt, and a wrongful death suit is brought against the hospital several months later, considerable debate will be required to decipher the sequence of events and the precise timing. Hospital personnel should always use digital time references from a computer or cell phone rather than rely on personal timepieces such as a wristwatch. Elapsed time clocks are desirable to precisely record the overall length of an event such as a cardiac resuscitation. When lawsuits allege negligence, malpractice, or medical device malfunction or failure, digital documentation can prove extremely valuable to confirm the actions of caregivers, especially when there is suspected tampering of the written record. A late entry into a record is viewed as a red flag by those who audit or review medical records. When it is recognized that an important data point was not added to the record in a timely manner, it may be documented later, along with the annotation “late entry.” The date and time should also be recorded. It is unacceptable to insert a supplemental page expressly for such late entries. Even brief notes should not be added to the margins of chart pages or inserted between existing lines of an earlier note. All late entries are certain to be scrutinized if there are legal issues about the patient’s care. This is especially true if the late entry pertains to a time period immediately before or after an adverse event. Occasionally, entries are made into another patient’s record by mistake. These errors should never be corrected by obliterating the mistaken entry by using white-out fluid or a black marker. A single line should be drawn through the entry, annotating, “mistaken entry” on the line. The date, time, and a signature should accompany the correction.

Tampering and Spoliation of Records Tampering is an intentional act to secretly corrupt or alter the record in an attempt to influence its value as an item of evidence.

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Spoliation is an intentional act to avoid discovery of wrongdoing by altering records. It can take many forms, ranging from subtly changing entries to completely destroying an entire medical record file. Acts of spoliation usually are committed by those implicated with some sort of involvement or those who are guilt ridden about an untoward medical event such as a medication error, patient fall, or other devastating event that is likely to precipitate a legal action. Spoliation actions include: • • • • •

Altering record entries Destroying records The design of fabricated entries that support one’s guilt or innocence Threatening witnesses not to testify Willful destruction of property that could be used to support one’s cause, defense, or a specific claim • Recording procedures or treatments that were not completed in order to collect nonearned monies from third-party payers or to gain other financial advantages For example, the trashing of EKG tracings after a botched code, the destruction of a drug ampule after a medication error, or the willful failure to preserve material evidence such as a faulty infusion pump could all be termed spoliation acts in terms of legal proceedings. If an attorney can show that there is evidence that has been lost, destroyed, or altered, a significant advantage is gained in the legal proceedings. Safety and Security Concerns Medical records should be maintained as secure documents and kept in a location where they cannot be altered. With the advent of electronic records, new challenges exist in regard to prevention of unauthorized tampering or spoliation. Even though passwords are issued, it is easy to become complacent about them when working among cohorts who are known and trusted. However, passwords should never be revealed or shared with coworkers. When password access has been used to open a record, the file should not be left open if unattended. If the computer must be abandoned, even for a minute or two, the healthcare worker should log off promptly to prevent others from making entries. Since electronic records have automated time and date stamps, it is fairly easy to discern when others change or delete data. Detectable electronic footprints remain that permit expert investigators to reconstruct all documentation transactions. Additional protection can be realized by the use of an infrared radio frequency (IR/RF) system to link caregivers to a recording device. An employee badge serves as an electronic key to access the computers or certain medical devices. It is imperative that

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such badges be carefully controlled to ensure that they do not become lost, misplaced, or stolen, which might lead to misuse of the key. Careless misplacement of the badge could permit other employees to steal your identity in order to gain access to controlled narcotics, medical records, or off-limit locations within the hospital. Most hospitals have automated record back-up systems and have safeguards such as encryption to prevent computer hacking and unlawful access of individuals who might be intent on medical-record tampering. The use of a laptop at the bedside poses vulnerabilities for the safe maintenance of sensitive patient information. For example, a bedside laptop can be accessed and information downloaded using a simple flash drive. Such actions could compromise the security of both medical and financial information of many patients. The use of personal cell phones or other handheld devices that can record images as well as voice communications can compromise patient privacy and serve as media for surreptitiously recording information from monitor screens, labels from infusion bags, the appearance of dressings or wounds, contents of drainage bags, and even the actions or photos of caregivers. Reporting Any individual who believes that they have witnessed electronic medicalrecord tampering must report it at once to computer security personnel. Other nondigital tampering acts should be promptly brought to the attention of supervisory personnel.

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Appendix 2.1: Adult Male Body Diagram Name:

Case #:

Date:

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.2: Adult Male Body Diagram, Side View Name:

Case #:

L. Arm

Date:

R. Arm

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.3: Adult Female Body Diagram Name:

Case #:

Date:

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.4: Adult Female Body Diagram, Side View Name:

Case #:

L. Arm

Date:

R. Arm

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.5: Head and Neck Name:

Case #:

Date:

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.6: Hands Name:

Case #:

Date:

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.7: Feet—Toes and Bottom Name:

Case #:

Date:

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.8: Feet—Side View Name:

Right

Case #:

Date:

Left

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.9: Hands, Feet, Head, Eyes, Ears         Name:      

Case #:      

Right

Date:      

Left

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.10: Female Genitalia        Name:      

Case #:      

Date:      

External Female Genitalia

A

B C

D E

F

G

H

A. Clitoris B. Labia majora C. Orifice of urethra D. Labia minora E. Hymen F. Vaginal opening G. Posterior fourchette H. Anus

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.11: Male Genitalia        Name:      

Case #:      

Date:      

External Male Genitalia

A. Shaft of penis B. Corona C. Scrotum D. Glans E. Prepuce (foreskin) F. Urethral meatus

A

F

B D

C E

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Appendix 2.12: Child Body Diagram        Name:      

Case #:      

Date:      

Child Body Drawing

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.13: Infant Body Diagram Name:

Case #:

Date:

Courtesy Dr. Patrick Besant-Matthews. Used with permission.

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Appendix 2.14: Consent to Photograph Forms Consent to Photograph I,                   consent to being photographed by                 and its staff, employees or other authorized persons while under the care of this facility or agency. I have been informed and understand that any photographs taken may become a part of my permanent medical record and may be subject to subpoena. I understand photographs in my record may be released if they are requested by a person authorized to obtain my medical record. If I do not want photographs released with my medical record, I must specifically exclude them in any authorizations I sign. I (do    ) (do not    ) consent to use of these photographs for educational purposes. I (do    ) (do not    ) consent to publication of these photographs for educational purposes.                        Signature                       Street Address                                City State Zip Code Dated:                                  Witness Deposition of Photographs: To be completed by Staff    

(Number of photographs taken)

    Photographs were placed in a sealed envelope marked with patient’s name and medical record number and were sent to medical records.    

Photographs were stored digitally according to policy.

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Consent for Educational, Research, Public Relations, or Publishing of Photography                    Name



            Date

__________________ _ ____ _________ Date of Birth Age

_____        __ Sex

                   Name of Agency, Individual or Institution

_______       __ Case or File Number

                   Address of Agency or Institution I understand these materials may be included in my permanent medical record or the permanent records of the above agency and may be subject to subpoena. I also authorize the above agency, individual or institution to interview, photograph or make other visual or audio recordings of me. I also authorize the above agency, individual or institution to use or permit others to use, the interview, photographs, or recordings for staff education, publication, public relations, and/or any other purpose or manner as they may determine to be appropriate. This permission is given of my own free will and without coercion subject to the following restrictions and/or limitations:                                                                 I acknowledge that I have voluntarily given this authorization without expectation of payment or other compensation, whether now or in the future. I hold the above-named institution harmless from and against any claim for compensation or harm resulting from the activities authorized by this agreement and extend this agreement to my family, heirs and assigns.                    Patient or legal representative (signature)

            Date and time

                               Printed name of patient or legal representative Witness or translator

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Appendix 2.15: Some Commonly Used ICD-9 and CPT Codes Diagnostic ICD-9 codes (Hart, Stegman, and Ford, 2009) for Adult Maltreatment and Abuse: (995.8) • • • • •

Physically abused person, battered person, spouse or woman Adult emotional/psychological abuse Adult sexual abuse Adult neglect (nutritional) Other adult abuse and neglect (multiple forms)

CPT codes are used in conjunction with ICD-9 diagnostic codes. Codes are not specific for domestic violence or sexual assault. However, the following codes are examples of ones that might be used in the evaluation and treatment of a victim of interpersonal violence (Beebe, 2009). • 99303 Complex evaluation and management: comprehensive history, comprehensive examination, medical decisionmaking of moderate to high complexity, counseling and/ or coordination of care with other providers or agencies • 99361-2 Team conference • 99374-5 Care plan oversight • 99381 Preventive medicine services • 99401 Preventive medicine counseling

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References Alaska protocol. Hypothermia prevention, recognition and treatment. Articles, protocols and research on life-saving skills. http://www.hypothermia.org/protocol. htm/rev1/2005 accessed August 28, 2010. Beebe, M., et al. Nov. 2008. Current Procedural Terminology. 2009 CPT Standard Edition: AMA. Emedicine Health: http://www.emedicinehealth.com/burn_percentage_in_adults_ rule_of_nines/article_em.htm, 8/24/2010 Frank-Stromborg, M., K. Burns, and D. B. Sisneros. 2006. Health insurance portability and accountability act (HIPAA) in P. Iyer, B. J. Levin and M. A. Shea (eds.) Medical Legal Aspects of Medical Records (Chapter 11). Tucson, AZ: Lawyers and Judges Publishing Co. Hart, A. C., M.S. Stegman, and B. Ford. 2008. 2009 ICD-9-CM, Expert for Physicians, Vol. 1 and 2. (6th Ed.) Salt Lake City, UT: INGENIX. Hoffman, P. and K. Terplan. 2006. Intelligence support systems: Technology for lawful intercepts. Boca Raton, FL: Auerbach Publications. 345. JAMA protocol. Journal of the American Medical Association (JAMA). American Heart Association, Emergency cardiac care committee and subcommittees. October 28, 1992. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. http://www.hypothermia.org/jama.htm. Accessed 8/28/2010. James, J. H. and Nordby, J. J. 2009. Forensic science (3rd ed.) Boca Raton, FL: CRC Press, Taylor & Francis 55-56. Joint Commission on Accreditation of Healthcare Organizations (JCAHO or “The Joint Commission”). 1995. AMH Accreditation Manual for Hospitals. Oakbrook Terrace, IL. Lanros, N. E. and J. M. Barber. 1997. Emergency nursing (4th Ed.). Stamford, CT: Appleton and Lange. 510-511, 519-524. Olshaker, J. S., M. C. Jackson, and W. S. Smock. 2007. Forensic emergency medicine (2nd Ed.). Philadelphia: Lippincott, Williams & Wilkins: 161. Stewart, C. E. 1990. Environmental emergencies. Baltimore: Williams & Wilkins. 58-59, 290-291. U.S. Coast Guard Protocol. Steinman, A. M. Hypothermia, drowning and coldwater survival. PVSS Conference. http://www.uuscg.mil/pvs/docs/coldwater1.pdf. (Accessed September 9, 2010).The protocol can also be accessed from http:// www.uuscg.mil/hq//cgl/cgll2/docs/pdf/SAR_CPR_protocols.pdf. Wagner, S. A. 2009. Death scene investigation: A field guide. Boca Raton, FL: CRC Press, Taylor & Francis, 101-104. Witter, Robert. January 29, 2010. Unpublished presentation given to La Cueva Volunteer Fire Department, Jemez Springs, NM.

3

Evidence

Evidence is defined as the means by which an alleged matter or fact is established or disproved. Legal evidence is that which is admissible in a court of law under the rules of evidence to prove or disprove a claim. Widely accepted among the scientific community, Locard’s principle of interchange states that a person visiting a particular environment will leave traces of his or her presence in that environment, and will carry traces of the environment away when he or she leaves, thus making an exchange. For legal purposes, evidence may be information or a physical item admitted to the court for the purpose of determining the truth of a statement or fact under consideration. In cases of interpersonal violence, the injured individual may be the only witness, and his or her body may be the actual crime scene. As such, it is the source of many types of evidence that needs to be collected and preserved. If the victim fought back, the perpetrator may retain evidence of having been scratched or bitten by the victim. Trace evidence such as hair, makeup, and fibers from carpets or clothing may help link the victim to the perpetrator. The Centers for Disease Control and Prevention (CDC) estimates that there were over 4 million visits to emergency services providers for injuryrelated problems in 2000 (Assid, 2005). Nurses, emergency department physicians, primary healthcare providers, and first responders are in an ideal position to observe and document these injuries. The critical first step nurses must take is to develop a forensic antenna. By recognizing those who are victims within our patient population, we help to ensure that objective usable information is available to those making critical medical and legal decisions. The first step in this process begins by recognizing existing evidence in the presenting scenario. Once the injured party has been identified as having possible forensic issues, the healthcare provider must be knowledgeable regarding their role in collecting the evidence, documenting the collection process, and preserving the integrity of that evidence so it can be used in criminal or civil proceedings.

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Healthcare Role in Evidence Collection The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), or the Joint Commission (JC), requires accredited healthcare institutions to establish and implement a program to address victims of violence. Written policies and procedures are required, and all personnel must be trained to detect victims of violence, abuse, and neglect (JCAHO, 2009).* The Joint Commission further emphasizes that personnel must know how to preserve vital evidence and to take an active role in reporting their suspicions or findings. Healthcare personnel can no longer assume a passive role in these cases without risking repercussions. Practicing healthcare professionals can be prosecuted for failure to cooperate with law enforcement. State boards of nursing also confirm the position that its members have a legal, moral, and ethical obligation to act in the best interests of the public. This includes gathering and preserving evidence. In the clinical setting, it is important to recognize that the patient may be the crime scene. Each scene is unique, thus requiring those taking care of the victim to make complex decisions, often in a very short period of time. Evidence should be collected in a comprehensive, systematic manner without compromising delivery of medical care. To facilitate this process, evidence collection protocols should be developed in each and every healthcare setting. Although care of the traumatized patient is a multifaceted process, maintaining an organized environment allows those involved to think, avoid rushing, and proceed in a rational manner so that possible evidence is not overlooked. Evidence that is ignored, unnoticed, or not documented at this point is simply lost forever. It cannot be re-created later. In addition to the fact that all evidence may be important in proving the facts,† absent evidence leaves the prosecution with little to support their case. It also opens the door for the defense to raise doubts as to whether the “loss” may have been intentional.

Healthcare Providers In order to effectively carry out these responsibilities, nurses must have education and training in evidentiary procedures including collection of physical and trace evidence, maintaining a chain of custody, and being * Standards are general and must be implemented by each agency in policy and demonstration of practice. † Many cases are based on the cumulative effect of overwhelming circumstantial evidence rather than items of direct evidence (crime.about.com, 2010).

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able to demonstrate competency in written and photo documentation. Initial training as well as refresher courses should be available on a regular basis. Regardless of the clinical setting, evidence should be collected based on recognized norms. Healthcare providers must understand the concepts, principles, and techniques for evidence collection, and realize that various jurisdictions may have differing standards or procedural requirements. Evidence needs to be handled according to local jurisdictional policies in order to hold up in court later on. Local, state, and federal laws differ in many areas. The healthcare provider needs to know how to access those laws and be able to recognize the nuances of each in order to properly manage evidence collection in their jurisdiction. Understanding what resources are available in your particular community is invaluable, not only in the planning of referrals, but also to ensure that vital evidence is preserved to support any subsequent legal proceedings. The following is a partial list of situations where the nurse might be required to collect forensic evidence: • Trauma resulting from motor vehicle accidents (including automobiles, motorcycles, planes, boats, trains, or any other motorized apparatus) • Any motor vehicle versus pedestrian trauma • Attempted suicide or homicide • Injuries involving firearms or other weapons • Child or adult victims of abuse, neglect, or sexual assault • Work-related accidents • Accidents resulting from fires, falls, electrocution • Poisoning, overdoses, or illegal drug use • Trauma in unidentified victims or suspects • Trauma of suspicious origin • Injuries resulting from improperly used or malfunctioning equipment • Injuries or illness from work-related incidents, environmental hazards, or pollution • Anyone in police custody • Sudden, unexpected, or unattended death • Injuries resulting from suspected medical malpractice

Categories of Evidence Evidence generally falls into two major categories: Direct evidence and indirect evidence. Direct physical evidence is that which proves a fact without inference or presumption. It is also known as positive evidence because it establishes a solid connection directly tying one thing to another. It is the

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uniqueness of a particular item that guarantees only one person can be tied to that particular piece of evidence. Examples of positive evidence are latent fingerprints and DNA. Indirect physical evidence is that which establishes circumstances from which one can infer facts at issue. Indirect evidence, more commonly thought of as circumstantial evidence, is considered to be indirect because it implies that something occurred but does not directly prove it. Circumstantial evidence can be one or more facts from which another fact can be deduced, or it can be a chain of events indicating that something did or did not occur (crime.about.com, 2010). The connection between the fact and the inference must be strong enough to be probable. In other words, there is a reasonable surety that the inference can be made.

Types of Evidence Physical Evidence Physical evidence consists of tangible objects that may help prove or disprove a statement at issue—any matter, material, or condition that may be used to determine the facts in a given situation. Physical evidence includes: clothing, biological evidence, trace evidence, missiles, projectiles, and foreign objects. Examples of physical evidence are blood, saliva, seminal fluid, urine, drugs, bite marks, clothing, footwear, glass, pollen, explosives, firearms, insects, and tire track impressions. Trace Evidence Trace evidence is physical evidence that is found at a scene or on a patient’s body in small but measurable amounts. With the exception of DNA, most trace evidence is circumstantial. Examples of trace evidence include hairs, fibers, glass, wood, metal, paint chips, soil, botanical materials, biological specimens (saliva, semen, etc.), and residue from firearms, explosives, or volatile hydrocarbons (e.g., accelerants used to start a fire). Traces of gunpowder may be found on either the victim or perpetrator’s hands. When sexual assault is alleged, the perpetrator’s pubic hair provides a link between the victim and the perpetrator. Taken alone, it does not prove the allegation. In concert with other evidence, however, it may prove that the sexual assault was, indeed, perpetrated by a certain individual. Likewise, dirt, paint chips, or blunt force injuries may link the victim to a scene or weapon. Such evidence may also lead investigators to discover the scene location or the object used as a weapon. For instance, a patterned injury of a belt buckle, may lead to the actual belt used and possibly to its owner.

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Verbal Evidence Verbal evidence consists of statements given at a deposition or a trial that tend to support or refute, negate, or contradict a fact at issue. The following examples illustrate the differences in types of verbal evidence. • Direct evidence consists of eyewitnesses and witness statements that directly tie one thing to another: “I looked out the window at midnight and it was snowing.” • Circumstantial evidence establishes a fact from which an inference can be drawn: “There was no snow on the ground when I went to bed. When I woke in the morning, there was snow on the ground.” • Hearsay is a statement referring to something said by someone other than yourself. As a general rule, medical records are considered hearsay (Quinn, 2005):*,† “Jim said that it was snowing last night.” It is important that the victim’s and perpetrator’s statements be recorded exactly as stated. Tape recording is acceptable, but often impractical, and a written transcript eventually needs to be made. Regardless of the initial method used, the patient or victim’s words must be recorded precisely using quotation marks. Statements must not be paraphrased. If the speaker is talking too rapidly, have him or her slow down or repeat so you can record the wording correctly. Questions to Ask • Who? Was the assailant known to the victim? Describe the physical characteristics of the perpetrator (height, weight, ethnicity, clothing, smells, distinctive voice, etc.). • How many perpetrators were there? • Were there any witnesses? • What happened? Describe the scenario in precise detail. • When? Document the exact time, if known. Describe what activities were going on immediately prior to the incident. • Where? Was the victim transported from the place of initial attack? How was the victim transported and by whom? How far? * Medical records generally fall into the hearsay category. Notations in the medical record are recordings of second-hand information and are “out of court” declarations. † Hearsay evidence is not admissible in court unless it meets certain criteria, which allows exception to the hearsay rule. The hearsay rule generally prohibits a person from providing testimony because the information is second-hand. The rules of evidence (formal court rules) favor testimony based on a person’s own observation or knowledge. The subject of hearsay is complicated.

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• How was initial contact made? What methods did the perpetrator(s) use to gain control of the victim? • Were weapons used? If so, describe the characteristics of the weapon. • What did the perpetrator or perpetrators say? • Were there any unusual circumstances? (e.g., “It was thundering and raining hard. It was difficult to see or hear clearly.”) • In addition to what the victim saw, did the victim notice any distinctive sounds, smells, etc.? • Listen to how questions are answered as well as to the substance of the answers. • Are the injuries consistent with the explanation? • Does the story change with time and by how much? Demonstrative Evidence Demonstrative evidence is the visual materials presented during legal proceedings. Examples are photographs, drawings, sketches, plaster casts or molds, scale models, maps, charts, body diagrams, police composite drawings, mug shots, computer reconstructions or animations, and scientific tests or experiments. Demonstrative evidence is intended to amplify or explain other testimony. Testimonial Evidence Testimonial evidence is evidence given in writing (such as in answers to interrogatories), or verbally (court testimony), or any other way that expresses a person’s thoughts or observations. It may be obtained through inquiries, interviews, interrogatories, or questionnaires. A deposition is testimonial evidence. Digital or Electronic Evidence Digital or electronic evidence is any information stored or transmitted in digital form that may be used in a court of law. Digital evidence might include computer documents or data entry, social networking pages, intimidating or threatening e-mails, and photographs or video images captured on cell phones, surveillance cameras, or handheld personal devices. Other types of digital materials may be used as evidence in copyright proceedings, identity theft or other cyber crimes, unlawful disclosure of information, or proceedings regarding the ownership of intellectual property. Global positioning systems also may be used to track or locate persons or vehicles of interest in a crime.

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Behavioral Evidence Behavioral evidence can be defined as any acts or omission of acts that demonstrate a general or specific pattern of behavior or indicate a general or specific plan, objective, or purpose. The inclusion of behavioral evidence implies that cumulative behavior should be identified and documented so it can be compared to normal behavior, and become meaningful in light of the overall assessment of a patient or forensic situation as a whole.

Basic Principles of Evidence Collection The patient’s medical needs and safety are always the first priority. The process of collecting evidence need not interfere with lifesaving measures. Members of the healthcare community can become competent to identify, preserve, and collect evidence without compromising care of the patient. Proper collection of evidence is a systematic, comprehensive, and scientifically based process, beginning with recognition of potential evidence (both physical and verbal). It is an objective, logically driven endeavor. Use knowledge and experience to extend your forensic antenna. In the nurse’s mind, the possibility of forensic issues needs to be addressed immediately and ruled out or pursued from the moment the patient is first encountered. This means approaching the victim, offender, or witness, and evaluating their appearance and/or statements made with an index of suspicion. Because treatment or surgical intervention destroys evidence, initial photography and direct quotations from the patient should be done from the outset. Forensic techniques can be incorporated into your existing interview and treatment routine. If you are unable to photograph, use body diagrams or make a sketch. Initial notes should include direct quotes, incorporating them appropriately when preparing your final documentation. Appropriate handling of evidence facilitates the prosecution of offenders; inadequate, sloppy evidence collection and preservation leads to its downfall. Likewise, memories easily deteriorate and the opportunity to capture statements made at the time the patient is first encountered will be lost. Standard evidence collection procedures includes recording the person(s) from whom it was obtained and to who whom it was given, including the date and time of transfer. In the clinical setting, this is done in the medical record as well as on the evidence tag and chain of custody form given to police. A copy of the completed evidence tag should be placed in the medical record. See specific details in the “Chain of Custody” section of this chapter. Comprehensive documentation is needed for continuity of care and medical review. When a case has forensic implications, either the prosecution or the defense may subpoena notes and photographs, making content

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critical. A sketch of the scene* along with thorough and accurate notes will be helpful when preparing final documentation (see Chapter 2).

General Procedures Personal Protective Equipment To protect both the integrity of the evidence and the health and safety of personnel, all persons coming into contact with victims of crime and trauma should always wear clean, powderless gloves and change them often. Wash your hands before putting on gloves and rewash when gloves are removed. Always wear clean, powderless gloves when collecting items of evidence. Do not touch the victim/patient with your bare hands. Biological material may contain hazardous pathogens, including the HIV and hepatitis C viruses. Although manageable to some extent, they are not yet curable and their associated disease processes can be debilitating and deadly. Change gloves between handling of biological evidence to avoid crosscontamination, especially if the gloves become contaminated, stained, soiled, or torn. Change gloves between packaging large items such as clothing and collecting small or trace evidence items. To protect yourself from contamination, avoid touching any area where body fluids might exist. Be especially careful when handling wet items. Keep any contaminated surfaces, including gloved hands, away from your face to prevent contact with mucosal surfaces of the nose, mouth, and eyes. Collection Basics Trace evidence is fragile by its very nature. According to Locard’s principle, it may be transferred from the patient to the caregiver and then to another person or item. Items of trace evidence such as sand, plant material, hair, and so on, are often loosely attached. This is why they transfer easily from their original source. Likewise, they can fall or brush off of the intermediate carrier—the victim or perpetrator. This is the underlying reason that linen as well as the victim’s clothing must be packaged—it has the potential to carry trace evidence. Package each item separately. Never put two items in the same container. Cross-contamination between items of evidence can be avoided by placing only one item in a package. Place each item in a new, unused paper bag or box. Do not allow one evidentiary specimen, particularly those containing * A simple diagram will do. Mark the sketch as “not to scale.”

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biological specimens, to come into contact with another. Collect each stain or other biological evidence droplet separately. Do not use plastic bags or containers to package evidentiary items. When moisture is trapped inside, it allows the formation of mold, mildew, and other biological processes that can deteriorate the specimen and render it unusable. Handle items of evidence as little as possible and in a manner that minimizes deterioration (e.g., keep away from heat and chemicals). Collect as much sample as possible from each source. Always take control samples if possible. The size of the container should correspond to the size of the object collected. Make sure that the paper container is large enough to allow air circulation around the evidence item, but not so large that the specimen can be tossed around. Do not place evidence samples on a contaminated surface. Thoroughly clean any surface before using it to package evidence. Avoid cross-contamination between each item collected. Do not talk, cough, sneeze, or blow onto biological evidence. Do not lick the glue on envelopes to moisten them for sealing. Use a moistened cloth, sponge, or paper towel. Keep medical specimens separate from forensic specimens. Store metal or glass items at room temperature and submit them to law enforcement or the crime lab as soon as possible. Keep in mind that evidentiary materials include examination documentation and photographs. Proper recording of exam findings and preservation of evidentiary materials is critical for admissibility in a court of law. Remember to follow jurisdictional procedures for documentation of examination findings, medical forensic history, drying, packaging, sealing, and labeling of evidence. Drying Air-drying is the preferred method of preserving damp or wet evidence samples. Dry each item separately, out of drafts and high-traffic areas. If drying is impracticable or impossible, the items may be refrigerated or frozen, but should be turned over to law enforcement as soon as possible. Contact local law enforcement for advice on local protocols. • Liquid blood samples should be refrigerated, but not frozen. • To prevent any possibility of contamination, do not dry samples from one patient in the same area as those from another patient. • Never expose damp or wet items to heat. • Do not leave samples or evidence unattended while drying. • Never place items of evidence that may contain DNA in a plastic bag or container.

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Labeling All items of evidence must be clearly identified and labeled and secured for later use in court. Label each evidence bag or container with the following: • Patient’s full name • Patient’s age and date of birth • Patient’s ID or medical record number, or law enforcement case number • Brief description of the source including the location from which it was collected • Date and time of collection • Initials or signature of person collecting and packaging the evidence. Write this across the edge of the tape onto the evidence container itself To avoid damaging or altering small or delicate evidence, write on the envelope before placing items of evidence inside. Envelopes or small containers may need to be placed into a second appropriately sized bag or container. To avoid damaging or altering evidence, it is a good practice to prelabel all bags and containers before placing the evidence inside. Note the contents of each bag on the outside of the bag. Prepare a chain of custody form for each item collected and attach it to the bag or container. Record in your notes the total number of bags released as well as the name and badge number of the person receiving items of evidence (detective, law enforcement officer, medical examiner’s office representative, etc.) and the date and time you released the evidence. This will serve as a cross-reference to the chain of custody form in case it is misplaced or lost. Sealing Each bag must be sealed so its contents cannot be tampered with or removed and nothing can be added. Place tamperproof evidence tape across the edges to be sealed. Proper sealing is accomplished by securely taping the container, and initialing and dating the seal by writing over the tape onto the evidence container. Do this in at least two places. This practice makes it more difficult to remove and replace the tape exactly as it was placed initially. Completely seal all edges of the outer container so that attempted tampering could be detected. Staples may enhance closure, but are not considered a secure seal. Tamperproof tape is the only secure method of ensuring a seal is intact. To ensure an envelope or container is tamperproof, all outer edges must be covered securely with tape (see Figure€3.1).

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Evidence tape

KLP Write across tape onto envelope

Cover edge of flap with tape Fold tape around sides

Figure 3.1╇ Sealed envelope.

Never seal gummed envelopes by licking; use a moistened paper towel, sponge, or clean cloth moistened with plain water. Sponge-tipped, reusable water-filled envelope moisteners are inexpensive and are available at office supply stores (see Figure€3.2). Processing Not all evidence that is collected is processed. There are times when processing of evidence may be unnecessary (the perpetrator pleads guilty) or it is simply not cost-effective. Nurses still have a responsibility to collect it. Storage and Security Documentation of the patient examination, including sketches and photographs, are considered evidentiary items. Follow jurisdictional policies regarding chain of custody and release of documentary evidence. If the patient dies, the medical examiner or coroner may want to see the body before it is taken to the morgue. Contact their office before moving a deceased person.

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Figure 3.2  Bottle moistener.

Chain of Custody To retain its legal value, there must be a clear trail showing that the item presented in court is exactly the same as the one found at the scene. This is accomplished by a written recording of every person who had possession of the item of evidence from the time it is collected until the time it is presented in a court of law or other legal proceeding. This procedure is called the chain of custody. The chain of custody is the knowledge or record of each person who has come into possession of a physical object from the time it was discovered until it is presented in court. To retain their evidentiary value, items of evidence must be unaltered and uncontaminated in any way. Any break, however small, can be lethal to the admissibility of that piece of evidence at trial. Key Point: The chain of custody is a procedure ensuring continuous accountability and validating that items of evidence are authentic, have been under constant surveillance, have been secured in a locked area, and have remained unaltered during handling and transfer.

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The chain of custody begins with the person who first collected the evidence. It must be maintained throughout legal proceedings regardless of who originally obtained it. At trial, the custodian must be able to demonstrate that the item presented in court is the same as the one originally collected. He must be able to show that it has not been altered or tampered with except for examination by the criminologist. All persons handling items of evidence must protect it from damage, deterioration, or loss. Any evidence damaged, misplaced, or lost can be deemed inadmissible. Careless handling of evidence also reflects poorly on the professionalism of the responsible agency. The security and integrity of evidence is the responsibility of all persons who may identify, collect, package, store, transport, or examine evidentiary items. In the medical setting, initiating and maintaining the chain of custody is the responsibility of the licensed professional. The chain of custody form includes a description of the item, the date and time it was collected, and the name and signature of the person who collected it. Each successive custodian must note their name, title, date, time, signature, and the agency they represent. Appendix 3.1 is provided as an example. When all evidence has been collected, each bag or container should have a chain of custody form firmly affixed on the outside. Items should be numbered sequentially and a list should be made. A copy of this list should be attached to the nurse’s notes or a corresponding note made directly into the progress notes in the medical record. The following is an example: Bag 1 of 7 Bag 2 of 7 Bag 3 of 7 Bag 4 of 7 Bag 5 of 7 Bag 6 of 7 Bag 7 of 7

left shoe left sock right shoe right sock underwear pants shirt

The chain of custody form indicates all persons releasing and receiving custody of the item, and the date and time it was transferred. In the clinical setting, this is done in the medical record as well as on the evidence tag and chain of custody form that accompanies the item of evidence. A copy of the completed tag and/or a complete list of items of evidence should be placed in the medical record. Transfers should be kept to a minimum. The number of individuals handling and transporting evidence should be kept to as few custodians as possible. This reduces the chances of compromising the chain, thus minimizing the opportunity to challenge the validity of the evidence at trial. The patient should never be left alone with items of evidence—either potential or collected specimens. Patients, family members, or other

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bystanders should never be given responsibility for safeguarding or transporting physical items of evidence. When items of evidence are transferred to law enforcement, a signed receipt should be obtained from the law enforcement representative and placed in the patient’s medical record. In cases where evidence cannot be turned over to law enforcement in a timely manner, all items must be locked in a secure cabinet with only one key readily available. That key should be kept by the designated custodian, preferably the licensed professional, house supervisor, or security officer. If the key is turned over to another individual, a chain of custody documentation must occur. Forensic evidence should not be stored in a narcotic cabinet, unit refrigerator, or staff locker. It is not necessary to maintain a chain of custody on medical specimens. Specimens collected for medical purposes should remain at the hospital for routine processing. Biological specimens (for example, blood for toxicology) taken for medical reasons are not treated as evidence. Generally speaking, specimens for law enforcement are taken separately. If law enforcement requires medical specimens, the patient’s consent or a subpoena must be obtained before the specimens are released to law enforcement and the occurrence noted in the progress notes along with a copy of the subpoena or signed consent form. Check with your local district attorney regarding current law in your state.

Common Types of Physical Evidence in Medical Settings Clothing Staff should be prepared to treat all clothing as potential evidence. When the patient is the victim of a crime, trauma, or other medicolegal situation, collect all garments and personal items, including scarves, hats, shoes, undergarments, hair ornaments, jewelry, and so on. Inspect clothing for damage, foreign material, or stains. Note any rips, tears, stretching, missing buttons, or other signs of damage. Also note any apparent biological substances such as blood, saliva, hair, seminal fluid, and/ or other materials such as dirt, grass, or other debris, and collect as biological or trace evidence. To avoid cross-contamination, wet or damp clothing should be air-dried before packaging. Place each item in a clean, separate paper bag—one item per bag. Plastic containers are not suitable because damp materials will degrade biological materials (blood, body fluids, tissue, etc.), possibly rendering the item unusable for evidence recovery. If you do not have secure facilities to dry clothing, place clean sheets of white paper between folds to protect from cross-contamination and package

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as above. If you think an article is wet enough to leak through a paper container, it can be placed on, not in, a plastic sheet. Notify law enforcement that you have wet items that need to be picked up and dried as soon as possible. Law enforcement should know the importance of drying, the proper procedures, and have evidence-drying cabinets to handle wet materials. The only exception to packaging wet clothing in paper is the presence of volatile or explosive chemicals (such as might be found in a suspected arson fire). These garments should be placed in airtight containers and law enforcement must be notified immediately. Gently fold clothing inward, placing a clean piece of white paper against any stain that might come into contact with another part of the garment or the inner surface of the bag itself. Never shake clothing or handle it roughly. Ask the patient if the clothing he or she is wearing now is the same clothing worn at the time of the injury. If the original clothing is not present, try to determine its location and notify law enforcement immediately. If possible, have your patient remove his or her own clothing. If the patient can stand, place two clean sheets on the floor. The top sheet will be collected and bagged as evidence. The purpose of the top sheet is to catch any loose evidence that might fall from the clothing or body while disrobing. The purpose of the bottom sheet is to protect the top sheet from dirt and debris on the floor. Fold the sheet into a bindle to ensure that all foreign materials are contained inside (see Appendix 3.2). Hospital and prehospital linens should also be collected—one item per bag. This includes patient gowns, stretcher or gurney sheets, operating room table linen, and drapes. Handle clothing gently to prevent loss of trace evidence and preserve signs of force (e.g., torn buttons, stretched fabric, etc.). Never shake clothing. Regardless of who removes the clothing, do not cut through any disruption in the fabric. Do not cut through holes made by trauma. Instead, cut along seam lines or well outside the margins of rips, tears, holes, or other areas that might be of evidentiary value. If clothing was damaged or cut by healthcare personnel, document this in the nursing record. Bullets and Other Projectiles Handle bullets and other penetrating objects very gently. It is important that no additional markings are made on bullets or other penetrating objects. Use gloved hands if possible. Sterile or new disposable instruments should be used. If tweezers or forceps are required to extract foreign objects, make sure the jaws are smooth (no teeth) and padded to avoid marring the surface. Plastic or rubber instrument tips are available from the operating room (OR) (see Figure 2.37). If rubber tips are not available, use 2 × 2 gauze as alternative padding. Document the fact that padded forceps were used in the medical record.

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To clean tools between specimens, wipe them under running water and thoroughly dry with a paper towel. Repeat this process twice before using the tool to manipulate or obtain another sample. Air-dry the projectile and gently wrap it in a 2 × 2 gauze to protect it. Place it carefully into a sterile, sealable receptacle (e.g., urine specimen container). Do not drop a bullet or other missile into a metal basin. Make sure the item is dry before sealing and attaching evidence labels. Labeling the container is sufficient to maintain the item’s identity and chain of custody. If more than one missile is collected, use a separate container for each. Foreign Objects Foreign materials collected from the patient’s clothing or body may be of significant forensic value. They can be compared to similar evidence collected from the scene or to an assailant. They may also provide information regarding the circumstances of an assault. Examples are hair, fibers, glass shards, paint chips, soil, sand, grass or other vegetation, or unknown materials. Always air-dry vegetation or damp soil samples prior to packaging. Otherwise, mildew or mold growth may occur, potentially making the sample less valuable for evidentiary recovery. If soil or other foreign materials are firmly attached to some object or garment, do not remove, but air-dry and place in a clean paper bag. Again, label with patient’s name and date of birth (if known), collector’s signature, date, time, and case number. If soil is present on the item (e.g., shoes), make a notation on the outside of the evidence container (such as, “Sand particles present on shoes”). Trace or Small Evidence Trace evidence is physical evidence so small it can easily be overlooked by a healthcare provider or detective. Common examples are gunshot residue, pollen, paint residue, fingerprints, and chemical residues. A cotton-tipped swab is probably the standard collection device for trace or small evidence items. Include the swab in the package with any fragment or small item of evidence before sealing. A new method of collection allows trace evidence to be gathered using dry, durable Teflon surface wipes. The advantage of these wipes is that they are shred resistant making them a more effective method of gathering samples of trace evidence from rough or jagged surfaces. Dry sampling is also preferable in cases where the pieces of debris are too large to use solvent extraction methods effectively or to conduct microscopic investigations. Teflon surface wipes can be used for sampling explosives residue from other surfaces such as clothing, hands, and luggage.

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Figure 3.3╇ Bagged hand.

Gunshot Residue Gunshot residue is extremely fragile evidence and should be collected as soon as possible—preferably within three hours of the shooting. In addition to hands, gunshot residue can be found on the clothing and skin of the victim, the person discharging the weapon, and on objects that were in the immediate vicinity of the weapon when it was fired. Each potential surface should be swabbed or collected, labeled with the exact site, placed in a separate container, and sealed, noting all of the above in the patient’s chart. If the patient was involved in a shooting, cover each hand with a brown paper bag and secure to the patient’s skin with tape, mitten fashion (see Figure€ 3.3). Covering hands in this fashion preserves any gunshot residue that may be present. Liquor bottle bags are a good size for this purpose unless the patient has very large hands. Do not use white paper or plastic bags to cover hands. Remove all clothing carefully as noted above. (Fold inward onto itself with clean paper between layers and place in a brown paper bag, labeling and sealing appropriately.) Small or Loose Materials Small or loose foreign materials such as fibers, soil, paint, splinters, and glass may be removed with clean forceps, using the sticky side of transparent tape, gently scraping the materials with a clean slide or the back of a scalpel knife, or cutting with a pair of clean scissors. Place in a labeled bindle (see Appendix 3.2, “Bindle Diagram and Instructions”). Place the bindle in a clean paper envelope and seal. Do not lick the gummed surface

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on the envelope. Use a dampened paper towel or gauze. Label the bindle with patient’s name and date of birth (if known), collector’s signature, date, time, and case number. Large Loose Foreign Materials Large loose foreign materials such as grass and hairs may be removed with clean forceps. Place in a clean paper bindle. Place in a clean paper envelope and package appropriately. Fibers and Threads Fibers and thread evidence are often found in torn or abraded areas of clothing or other materials. Examination of fibers and threads can be matched to the victim, perpetrator, clothing, bedding, carpet, vehicle, proving an exchange was made from one to the other. Examination may help determine the type, color, and composition of various fabrics indicating the nature of garment or fabric from which they originated. Fibers are best handled with tweezers or smooth-jawed forceps. Place each fiber into a separate glass tube, vial, or bindle noting the location where it was found in addition to the patient name, date of birth, date, time, and initials of the person retrieving the fiber. For large threads or fibers, pick up with gloved fingers or forceps and place in a paper bindle. Place the vial or bindle in a clean outer envelope. Regular letter envelopes work well for this purpose as long as the edges are sealed. Seal and label the outer envelope appropriately. Affix a completed chain of custody tag. Never place loose fibers directly into an envelope, since they can be lost. Bindle or otherwise contain the fibers first. Make a small bindle out of clean white paper if a glass vial is not available. A clean coin envelope may also serve as the inside container. Label the envelope before putting fiber inside, fold ends over, and tape closed. Always package and send clothing of the patient from which fibers or threads might have originated to the forensic laboratory for comparison purposes. Individually package each item of clothing on which fibers and threads were found. Make a note on the outside of the envelope as to where fibers were seen. If a suspect has been apprehended, advise law enforcement that you have collected representative fibers from the victim and suggest that they may want to do the same from the suspect’s clothes, bedding, residence, or vehicle, and submit to the crime laboratory for comparison.

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Hair Hair should be collected by picking up with tweezers, placing in a labeled bindle or capped glass vial, and then into a labeled, sealed envelope with a chain of custody label attached to the outside. When collecting hair samples from a victim, guidelines similar to those of the United States Drug Testing Laboratories, Inc., are suggested. Those instructions are found in Appendix 3.3. Paint Paint fragments or smudges may be found on skin, under fingernails, in hair, and on clothing. Paint fragments may be visible to the naked eye or they may be so small that they can only be detected by microscopic examination. Examine all areas, paying particular attention to those showing pressure, glaze, tears, or other signs of contact. Be alert to the possibility of paint transfer to clothing in pedestrian–motor vehicle accidents because its presence is usually minute. Glass vials or cardboard pill boxes should be used to collect paint chips, since they protect paint from breakage and damage. If cardboard pill boxes are used, seal the box to prevent spillage of small paint samples. Never place paint samples into envelopes without bindling first. • Small paint samples: Handle sample as little as possible. Carefully place samples in clean paper folded in a bindle. Place in a small clean envelope. Seal and package appropriately. • Large paint chips: Handle sample as little as possible. Carefully place in a pill box or other clean protective container to protect from breakage. Seal and package appropriately. • Paint on clothing: If paint is found on clothing, do not remove the paint. Carefully wrap each item separately by rolling it in paper, and placing each garment in clean separate paper bag. Seal and package appropriately. Make a note on the outside of the bag regarding visible or suspicious areas where paint might be found. Metal or Sharp Items To protect those handling evidence, knives, broken glass, or other sharp objects should be secured so they are unable to pierce the sides of the container. Small, sharp glass fragments, wire, and other such objects may be saved in a test tube or glass specimen jar. Avoid securing objects with tape. Paper or plastic-coated twist ties may be used to secure the item to a piece of

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Figure 3.4╇ Glass packaging.

cardboard as follows. Puncture small holes in a piece of cardboard, place the twist tie through one hole around the object to be secured, back through a second hole in the cardboard, and twist together to secure (see Figure€3.4). Glass Fragments of glass may be found on personal belongings of suspects or victims involved in various types of crimes. Collect all glass present on clothing because more than one type may be present. Place small glass fragments in paper bindles, then in clean coin envelopes, pill boxes, or film cans. Seal and label appropriately. Place large glass fragments in clean, solid protective container boxes. Separate individual pieces with cotton or tissue to prevent breakage and damaged edges. Seal and label appropriately. If glass is present on shoes or clothing of the suspect or victim/patients, remove shoes and clothing carefully, handle gently, fold, wrap in paper, and place in clean paper bag. Seal and label appropriately. Submit to the crime laboratory for examination. Do not freeze metal or glass evidence items with blood or other body fluid stains. Rather, submit these items to law enforcement or the laboratory as soon as possible. As with all items of evidence, do not leave them unattended or unsecured at any time. Pollen Soil, dirt, dust, and hair contain abundant pollen and spores.

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The goal in pollen evidence collection is to find a match between the pollen in a known geographical region with the pollen in a forensic sample, linking the victim or suspect with the location where the crime occurred. These samples must be collected carefully, gently, and without contamination. Always use sterile gloves and sterile collection tools when collecting pollen evidence to ensure that ambient pollen does not contaminate the sample. When collecting soil pollen samples, advise law enforcement to collect control samples from the scene. Control samples are specimens of surface dirt from the region where a crime is believed to have been committed. The pollen recovered from the forensic specimen can then be compared to the crime scene pollen to see if they match. Guidelines for Collecting Pollen Samples • Make sure that all collecting tools and all collection containers are sterile. • Avoid using contaminated tools. • Place samples in sterile, paper containers, tightly sealed. • Always collect more sample than is needed. • If pollen is attached to clothing, do not remove from clothing. Place clothing in sterile paper bag. Label and seal appropriately. • If pollen samples are soil, dust, or dirt, advise law enforcement to collect several control samples from the scene where the crime was committed.

Biological Evidence Do not place items containing biological evidence in any type of plastic container! Bags containing wet items that may leak through the bag may be placed on a metal, glass, or plastic surface, but never inside one.

Body Fluid Collection Control Swabs The control swab provides the crime laboratory with a baseline of the patient’s own secretions or possible contaminants adjacent to the stained area. Collect a control swab by moistening a clean cotton applicator or swab with sterile or distilled water and swab an unstained area adjacent to the stain. For example, if the stain is on the right arm, collect the stain from an unaffected area near the stain on the same arm. Collect one control swab for

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each stain collected, unless several stains are collected within a small area. In that case one control swab is sufficient. Package each control swab separately. All evidence and control swabs must be air-dried prior to packaging. Dried Blood When dried, blood retains its usefulness as evidence indefinitely. Drying is, in fact, the preferred method of preserving body fluids. Blood type and DNA can be determined from dry samples. Dried blood should be collected with a clean cotton cloth or swab that has been moistened with sterile water. Leave a portion of the cloth or swab unstained as a control. Air-dry the cloth or swab and pack it into a clean paper bindle or an envelope with sealed corners. Do not use plastic containers. Moist Secretions (e.g., nondried blood or other moist substances; semen or unknown liquid) Absorb the material onto a clean, dry cotton cloth or cotton-tipped applicator swab to avoid dilution of the specimen. Gently roll the applicator or swab over the affected area(s); begin at the exterior of the area and move inward. For larger stains, collect the entire stain, using several swabs held together as a unit. Air-dry the specimen and pack it into a clean paper bindle or place it into an envelope or box with sealed corners. Do not use plastic containers. Label the specimen and seal with tamperproof tape. Dried Secretions For all dried specimens or secretions, slightly moisten a clean cotton applicator (for small areas) or gauze (for larger areas) with sterile distilled water. Gently move the swab inward over the injured or affected area(s) beginning at the outside edge. Label and air-dry prior to packaging. Place in an envelope, date, seal with writeable tape, and sign. It is important that all specimens be allowed to dry completely before packaging. Urine Samples Collect the first available urine sample. The forensic examiner always observes the collection process. If the patient must urinate prior to or during the evidence collection, collect the urine specimen at that time. Containers must be clean and tightly sealed in plastic or glass containers. Have the patient void directly into the urine specimen bottle provided and fill the specimen container, if possible. After the specimen is collected,

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replace the cap and tighten to prevent leakage. Label with the patient’s name, ID number, date of birth, date, time, and initials of person collecting the sample. Place the sample in a clean, leak-proof plastic bag, and attach chain of custody form. Note specimen collection in the nurse’s notes of the patient’s chart. Gastric Contents For collecting urine or gastric contents, use sterile containers for collection when feasible. If you are collecting these fluids in an uncontrolled scenario (e.g., the patient vomits onto the floor or is incontinent), use a clean towel to absorb the fluid. Ensure that one portion of the towel is maintained clean and dry as a control segment. After air-drying, package the towel(s) in a clean paper bag or large envelope. In some instances (e.g., items that are impractical to dry or if they are suspected of containing toxic substances), place them into a glass jar or paper bag placed on top of (not in) a plastic bag. Because plastic traps moisture and heat, damp materials are susceptible to mold, mildew, decay, or biological degradation.

Bite Marks Human bite marks generally imply abuse, but not always. Bites from children are generally smaller than those from adults (see Figures 2.16 through 2.18). Animal bites are V-shaped lacerations and are almost always multiple. Forensic odontologists (forensic dentists) can make an imprint of a bite mark as well as one of the teeth. Bite marks are uniquely identifiable (positive evidence), much the same as a fingerprint. Because the inflammatory process continues for some time after initial infliction of the bite, identification of a bite mark may be made several days after it is inflicted. An assailant can be identified by either a bite imprint on the victim, or by the victim’s bite on an assailant. The most common location of bite marks are the back, breast, thigh, and buttocks. An attempt should be made to recover secretory substances such as seminal fluid and saliva. Use moist swab techniques described in this chapter. These fluids are also observable under alternative light sources such as the Woods lamp. Due to heavy bacterial loads in saliva, bite marks may lead to local and systemic infections. All bite marks must be thoroughly cleaned and aggressively managed by a medical team after evidence has been collected.

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Blood Alcohol and Other Toxicological Specimens Specimens collected in the course of medical treatment are not necessarily admissible for forensic purposes. Distinct forensic specimens may be required. There is currently debate on this subject, so it is advisable to know your local laws and practice. Your local prosecuting attorney can be contacted for current information. Standard policies and procedures should be in place and reviewed annually. In many states, a written request for obtaining the sample must be received from law enforcement, and a duly authorized forensic laboratory must analyze the specimen. Common blood samples taken are: • • • •

Alcohol and drugs—gray top vacuum tube (contains sodium fluoride) Serology DNA—yellow top vacuum tube Pregnancy, HIV

If an authorized forensic laboratory is not available, national labs can be found on the Internet.* Many specimens can be sent by certified mail. For instance, a forensic blood alcohol profile from United States Drug Testing Laboratory (USDTL) (BloodStat) identifies usage over a one- to two-day period and has the ability to provide under-the-influence interpretation. Their PEthStat will produce a positive result for an individual who has consumed one drink per day for 6 to 7 days a week. Their drug panels include amphetamines, cannabinoids, cocaine, opiates, phencyclidine (PCP), benzodiazepines, and barbiturates, plus methadone and propxyphene. It also includes the approximate number of drinks consumed as well as the blood alcohol concentration (BAC). A gray top tube containing at least 2 ml of blood should be submitted with a chain of custody form. USDTL suggests collecting the sample using an alcohol-free skin preparation. In addition to drug testing services, USDTL provides addiction program support, research partnerships, child and family services, and transplant patient monitoring and a list of CPT codes for their procedures. NMS Labs has over 2,500 standard blood, urine, and other fluid tests, including blood alcohol screening and testing,† testing for alcoholic content in beverages, and testing for flunitrazepam (Rohypnol—a date-rape drug). They even do blood spatter-pattern interpretation. Their Web site address is: http://www.nmslab.com. * The following comments are for informational purposes only, and although they are all reputable laboratories, they are not necessarily a recommendation from the author. † A forensic blood ethyl alcohol profile includes the approximate number of drinks consumed as well as the blood alcohol concentration (BAC).

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Drug Detection Laboratories (DDL) can retest urine, blood, and drug samples for criminal prosecution, or may be used to check quantitative accuracy of samples previously tested by other laboratories. They can be found on the Internet at http://www.drugdetection.net. They offer forensic toxicologists who will qualify as experts in all aspects of the testing and interpretation of results. Although most facilities have a distinct procedure for drawing specimens for blood alcohol levels, there are some basic principles and concepts that nurses need to understand. It is always a good idea to draw an extra purple top and red top tube in case they are needed at a later time. The first specimens obtained upon admission are the most likely to contain usable evidentiary data. Note: Procedures as outlined in this section are relevant to any toxicology specimens drawn for forensic purposes in the healthcare setting. Samples taken for medical reasons are not the same as those taken for forensic reasons and are handled differently, including having a chain of custody. Collect toxicology samples as soon as possible. Drugs may have been used during the commission of the crime and the presence of drugs or alcohol in the body will have legal significance. Many drugs are quickly eliminated from the body. Vials containing liquid blood samples should be refrigerated rather than frozen. Cleanse the blood collection site with a nonalcohol solution. Always fill the blood vial, if possible. Immediately after the blood collection, ensure proper mixing of the anticoagulant powder by slowly inverting the blood tube several times. Do not shake vigorously. Label appropriately. An alcohol blood test must relate to an offender who committed a crime while under the influence of alcohol or while intoxicated. If the patient is on anticoagulants or has a known blood abnormality such as hemophilia, he or she may be exempt from an ordered blood draw. When there is any question, obtain clarification prior to taking the specimen. When obtaining the specimen, the usual procedures for a blood draw are followed with one exception. Use an alternate skin antiseptic such as providone iodine or benzalkonium to prep the skin prior to puncture. Note in the medical record that an alternate skin antiseptic was used. Although the use of an alcohol skin preparation does not adversely affect the value of the forensic sample, defense attorneys frequently dispute the findings on the basis that higher alcohol levels might be due to presence of medical alcohol on the skin and its inadvertent entry into the sample. Ethyl alcohol, however, can be distinguished from other forms during laboratory analyses. It is always prudent to eliminate any unnecessary courtroom disputes in the admissibility or credibility of any evidence. Therefore, it is advisable to specifically note that no alcohol was used in skin preparation. If a patient refuses to have a venipuncture for blood alcohol level determination, the procedure should not continue until a subpoena or court order

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has been issued. Restraint and force are never appropriate to obtain a forensic specimen in a healthcare setting, even in police presence. Law enforcement officers are both witnesses to the procedure and custodians of blood alcohol specimens. When the sample is obtained, (usually 10 ml) it should be sealed with tape and labeled with the name, date, time drawn, and the initials of who performed the phlebotomy. It should be given directly to the witnessing officer for transport to the state-approved laboratory. This information should also be precisely recorded in the patient’s medical record. In serious cases such as negligent homicide, two samples may be requested. Taken one hour apart, they help determine the alcohol level at the time of the incident or crime. Either the blood alcohol level will have peaked and started down, or it will be higher, indicating that the subject consumed alcohol immediately prior to the incident. It is estimated that the blood alcohol level falls 15–20 mg/100 ml per hour. For instance, if a blood alcohol sample is drawn four hours after an arrest and tests at 0.18% (180 mg/100 ml), it can be assumed that the subject’s blood alcohol level at the time of arrest was approximately 0.26% or 260 mg/100 ml. Testing for Drugs of Abuse Medicines, controlled substances, marijuana, and drugs of abuse found in the possession of patients involved in various crimes can be analyzed by the crime laboratory. In cases where prescriptions are involved, the label itself provides valuable information regarding what should be found in the container, who prescribed the medication, when, and for whom the prescription was written. Therefore, leave medicines and other drugs in the original containers. Do not remove any marking or labeling. If loose drugs (e.g., crack cocaine) are found, bindle and place in a prelabeled paper envelope. Place in a clean paper bag or container. Label the bag or container and seal using standard procedures. Seal loose materials securely, as they may spill or seep out of the container. National laboratories can do forensic analysis/exclusion screens for many substances and drugs of abuse with one specimen. These Rapid Tox screens can test for amphetamines, sedatives, hallucinogens, hypnotics, narcotic analgesics, stimulants, and other substances including barbiturates, benzodiazepines, cannabinoids, cocaine and its metabolites, methadone, methanol, and opiates, as well as distinguishing between ethyl alcohol, methyl alcohol, and isopropyl alcohol. Toxicology screens generally require 8–10 ml of blood in a gray top (Fluoride Oxalate) tube. These specimens are stable for 10 days at ambient temperature and up to 20 days if refrigerated. Similarly, urine can be used for Rapid Tox screens with as little as 4–6 ml of urine. Urine specimens are stable for up to 7 days if refrigerated (NMS Laboratories, http://www.nmslab.com/).

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Poisoning Myriad substances, including lead, carbon monoxide, and some plants, can cause illness and death. They may be ingested, inhaled, or injected into the human body. Medicines, cleaning solutions, and other toxic materials are commonly found in the home. Keep all such substances out of the reach of children. Read labels carefully. Make sure all containers are clearly labeled and do not mix medicines or chemicals. Safely dispose of unused, unneeded, or expired prescription drugs. Do not treat medications as “candy”! Poisoning can be self-inflicted or meted out by someone else. It can be accidental or intentional.* If the victim has collapsed, call 911 immediately, assess ABCs, start cardiopulmonary resuscitation (CPR), and transfer the patient to a life-support facility immediately. If the patient is awake and alert, call the National Poison Control Center’s phone number: 800-222-1222. They are open 24 hours a day, 7 days a week. Have the following information available: • • • •

Victim’s age and weight Container or bottle of poison, if available The estimated time of poison exposure Address where poisoning occurred

Careful inquiry by the forensic nurse may shed light on the cause of the poisoning. When the following symptoms are not clearly tied to a cause, poisoning should be considered. • • • • • • • • • • •

Abdominal pain Blue lips Burns around the mouth Chest pain Confusion Cough Diarrhea Difficulty breathing Dizziness Double vision Drowsiness

* According to the CDC (Poisoning in the United States, Fact Sheet), in 2005, 32,691 poisonings were intentional—5,744 were suicides, 89 were homicides. In 2005, poison control centers received about 2 million poisoning calls and in 2006 over 700,000 individuals visited emergency departments for unintentional poisoning.

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• • • • • • • • • • • • • • • •

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Fever Headache Heart palpitations Irritability Loss of appetite Loss of bladder control Muscle twitching Nausea and vomiting Numbness or tingling Seizures or convulsions Shortness of breath Skin rash or burns Stupor Unconsciousness Unusual or chemical breath odor Weakness

If the person vomits, clear the airway. Always wear gloves, and if possible, wrap a clean cloth or paper towel around your fingers before cleaning out the mouth and throat. Roll the patient onto his or her left side and keep the person there to help prevent aspiration. Save any emesis or plant parts so they can be inspected visually or tested by a laboratory. Keep the patient comfortable and warm. If the poison has spilled on the person’s clothes, remove clothing, brush off any visible powdered chemical that might become corrosive when combined with water, and then flush the skin with water. Things Not to Do • Do not give an unconscious victim anything by mouth. • Do not induce vomiting unless directed to do so by a poison control center. • Do not try to neutralize the poison with lemon juice, vinegar, or any other substance unless directed by the poison control center. • Do not use a universal antidote. • Do not wait for symptoms to develop if you suspect poisoning. Most poisons can be tested for by national labs. Numerous Web sites can be found on the Internet that can test for obvious and clandestine poisons. These Web sites also provide a wealth of information regarding taking, packaging, storage, and shipping of samples. An example from U.S. Drug Testing Laboratories can be found in Appendix 3.3.

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Information on how to prevent poisoning should be available in all healthcare settings. The CDC has free materials such as buttons and badges. Fact sheets on poisoning prevention and can be found on the Internet at http://www.cdc.gov/HomeandRecreationalSafety/Poisoning/index.html.

Fetal Drug Exposure Fetal exposure to drugs has been linked to long-term health problems in newborns. There is now a fast and reliable meconium drug testing method for the detection of fetal drug exposure providing the opportunity for appropriate treatment and intervention. Meconium sample testing is noninvasive and eliminates the need to collect a blood or urine specimen from a newborn. The analysis provides up to a 20-week gestational detection window and results can be obtained in 48 hours or less, allowing for rapid healthcare treatment and planning for both mother and child. Meconium drug testing not only provides evidence of fetal drug exposure, but can also provide documentation of fetal alcohol exposure. Meconium testing has rapidly become the gold standard for diagnosing fetal alcohol and drug exposure. It is available as a 5-, 7-, 9-, and 12-drug panel. Alcohol and oxycodone levels are also available as add-ons (United States Drug Testing Laboratories [USDTL], 2010; Wikipedia, 2010).

DNA—CODIS The Combined DNA Index System (CODIS) is an electronic database of DNA profiles administered through the Federal Bureau of Investigation (FBI). The system lets federal, state, and local crime labs share and compare DNA profiles (Zedlewski and Murphy, 2006). CODIS uses two indexes: the Convicted Offender Index, which contains profiles of convicted offenders, and the Forensic Index, which contains DNA profiles from crime scene evidence. In the past several years, CODIS has added several other indexes, including an Arrestee Index, a Missing or Unidentified Persons Index, and a Missing Persons Reference Index. A record in the CODIS database, known as a CODIS profile, consists of a specimen identifier, an identifier for the laboratory responsible for the profile, and the results of the DNA analysis (known as the DNA profile). Other than the DNA profile, CODIS does not contain any personal identity information— the system does not store names, dates of birth, or social security numbers. CODIS has a matching algorithm that searches the various indexes against one another according to strict rules that protect personal privacy.

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For solving rapes and homicides, CODIS searches the Forensic Index against itself and against the Offender Index. A Forensic-to-Forensic match provides an investigative lead that connects two or more previously unlinked cases. A Forensic-to-Offender match actually provides a suspect for an otherwise unsolved case. The real strength of CODIS lies in solving no-suspect cases. If DNA evidence entered into CODIS matches someone in the Offender Index, a warrant can be obtained authorizing the collection of a sample from that offender to test for a match. If the profile match is in the Forensic Index, the system allows investigators—even in different jurisdictions—to exchange information about their respective cases. For this reason, collecting blood samples for DNA analysis can be critical.

Sexual Assault In cases of sexual violence, anal evidence is collected before conducting the vaginal examination and evidence collection. Contamination of the anal site and destruction of other evidence is then avoided. If anal penetration is reported, always observe for rectal trauma. Take photographs of the area. A standard protocol has been developed by the Office of Violence against Women and is available free of charge from them. It is also downloadable from the Internet from http://www.SAFEta.org or through the International Association of Forensic Nurses at http://www.iafn.org. Specimens to consider collecting include oral, anal, and rectal swabs, vaginal and cervical samples, and condoms for trace evidence.* After the Evidence Collection After the evidence collection, make sure all items of evidence have been labeled, dried, packaged in the appropriate containers, and sealed. Never, for an instant, leave the evidence unattended before placing it in a locked area. Advise law enforcement that the packaged evidence is ready for transfer. Verify each piece of evidence with the law enforcement person receiving custody and note that the evidence has been verified and the individual’s name and badge number in the nursing record. * Condom trace evidence is valuable for many reasons. In cases of sexual violence, recovered trace evidence from condoms may provide evidence of penetration or may correspond to those used by a certain manufacturer helping to link a serial rapist to a certain brand of condom.

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Provide the patient a change of clothing. Arrange for follow-up care for treatment of medical and psychological issues as indicated. Give patients information on support groups so they can get help after leaving the hospital. Arrange transportation for patients if needed.

Summary Nurses’ observations of patients can yield an abundance of information in addition to appearance and anatomy. The watchful eye, discerning mind, and active forensic antenna will help to prevent many a forensic patient from falling through the cracks. It is worth repeating that the chain of custody is equally important to the admissibility of evidence in a court of law. Without a solid, unbroken chain of custody, evidence and its analysis are worthless. Understanding the chain of custody and meticulous adherence to evidence collection procedures are powerful tools nurses can use to aid in the administration of equity and justice.

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Appendix 3.1: Evidence Tag and Chain of Custody Patient’s Name:               Date of Birth:               Patient sticker here Date:                   Case or File Number:             Name (printed) of individual sealing this container:            Signature of individual sealing this container:              Evidence contained:                                                                                         Released by:       Released by:       Released by:       Released by:       Released by:       Released by:      

Received by:      Received by:      Received by:      Received by:      Received by:      Received by:     

This container is item     

of     

Date:     Date:     Date:     Date:     Date:     Date:    

Time:     Time:     Time:     Time:     Time:     Time:    

.

Deliver to Forensic Lab as soon as possible! Completing this data is critical to the prosecutorial value of the enclosed evidence.

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Appendix 3.2: Classic Bindle Fold Diagram and Instructions

Instructions Classic ‘Bindle’ Fold

Diagonally fold the paper in half as illustrated

Now fold the left 1/3 of the paper to the right as shown...

Now fold the lower 1/2 of the square upward as shown...

Fold the right 1/3 of the paper to the left as shown.

...and then tuck the left point between the sheets of the right point as shown.

...and then fold down and tuck the upper point between the double sheets to close as shown.

© Dr. Kenneth Mills; all rights reserved.

Used with permission.

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How to Make a Bindle

Step #1

Fold the paper in half.

Step #2

Fold the half sized paper into thirds.

Step #3

Fold over the right flap.

Step #4

Step #5

Fold over the left flap.

Step #6

Step #7

  

Fold in half. Seal the open end of the bindle, not the folded end. Initial the tape prior to sealing.

Evidence

Appendix 3.3a: Blood Collection Instructions

Used with permission.

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Appendix 3.3b: Nail Collection Instructions

Used with permission.

Evidence

Appendix 3.3c: Cord Tissue Collection Instructions

Used with permission.

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References Assid, P. A. 2005. Evidence collection and documentation: Are you prepared to be a medical detective. Topics in Emergency Medicine. 27(1), 1–25. New York: Lippincott Williams and Wilkins, Inc. Joint Commission on Accreditation of Healthcare Organizations (JCAHO or “The Joint Commission”). 2009. Family Violence, PC 01.02.09. http://www. JointCommission.org. Individual JCAHO recommendations cannot be accessed online. JCAHO can be reached at 630-792-5900. NMS Labs. http://www.nmslabs.com Quinn, C. 2005. The medical record as a forensic resource. Sudbury, MA: Jones & Bartlett Publishers, 156, 215. USDOJ. 2010. Downloaded 8/23/2010 from http://www.dna.gov/dna-databases/ codis USDOJ. 2010. Downloaded 8/23/2010 from http://www.fbi.gov/hq/lab/html/codis1. html USDOJ, OJP, NIJ (2006).USDOJ, Washington, DC. http://www.ojp.usdoj.gov/nij/ journals/253 (accessed August 23, 2010). United States Drug Testing Laboratories, d.b.a. MedStat Laboratories. Meconium testing. http://www.usdtl.com/mecstatsm.html (accessed August 23, 2010). United States Drug Testing Laboratories, d.b.a. MedStat Laboratories. http://www. usdtl.com/medstat.html (accessed August 23, 2010). United States Drug Testing Laboratories, d.b.a. MedStat Laboratories. Blood collection instructions. http://www.usdtl.com/uploads/users/files/collectioninstructions_Peh_%20FD_091809.pdf (accessed August 23, 2010). United States Drug Testing Laboratories. Blood Collection. http://www.usdtl.com/ collection_instructions_and_training.html (accessed August 23, 2010). United States Drug Testing Laboratories. Cord Tissue Collection. http://www.usdtl. com/collection_instructions_CodStat_%20FD_071009.pdf (accessed August 23, 2010). United States Drug Testing Laboratories. Nail Collection. http://www.usdtl.com/ collection_instructions_Nail_Stat_%20FD_091809.pdf (accessed August 23, 2010). Wikipedia. en.wikipedia.org/wiki/Combined_DNA_Index_System (accessed August 23, 2010). Zedlewski, E. and M. B. Murphy. 2006. DNA analysis for “minor” crimes: A major benefit for law enforcement. USDOJ, OJP, NIJ Journal, (253), 4. Washington, DC.

Additional Resources http://www.cdc.gov/ncipc/factsheets/poisoning.htm (accessed August 23, 2010). http://www.ojp.usdoj.gov/nij/journals/253 http://crime.about.com/od/current/a/scott04718.htm http://www.dna.gov/dna-databases/codis (accessed August 31, 2010). http://www.fbi.gov/q/lab/html/codis1/htm (accessed August 31, 2010). http://www.usdtl.com/uploads/users/files/collectioninstructions_PEth_%20 FD_091809.pdf (accessed August 31, 2010).

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Domestic violence is a pattern of assaultive and coercive behaviors including physical, sexual, and psychological attacks that adults or adolescents use against their intimate partners (Warshaw and Ganley, 1998)* (see Figure€4.1). The range of behaviors used by an abusive partner is extensive, and runs the gamut from intimidation to death. All are designed to increase the perpetrator’s sense of power by exerting control over the victim, be it physical, sexual, emotional, financial, or a combination. Patients generally fall into one of four categories: • The patient has no history, disclosure, or pattern of behavior that suggests abuse. • There is a history of abuse, but there is no abuse in the current relationship. • There is current or recent abuse without physical injury. • Abuse is currently or recently occurring and includes physical injury and/or threats of suicide or homicide.

Physical Abuse Examples of physical abuse include: • • • • • • • • • •

Hitting Kicking Slapping Punching Pushing Restraining or pinning to the wall, floor, or an object Hitting or breaking objects Threatening or actually hurting other people and/or animals Prohibiting access to medications (including birth control) Prohibiting access to healthcare

* As suggested by Warshaw and Ganley (1998), this is a behavioral definition rather than a legal one. You should check local statutes for the legal definition in your jurisdiction.

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Figure 4.1  Domestic violence victim. Courtesy Dr. William Smock. Used with permission.

Sexual Abuse Sexual abuse includes marital rape, including coercion into sexual activity under threat of violence or retaliation, forcing painful or uncomfortable sexual practices or positions, demanding the victim participate in unprotected sex, forced pregnancy or abortion, and forcing sexual conduct in front of children or other people.

Psychological Abuse Psychological abuse includes the use of threats, intimidation, and ridicule as well as withdrawing attention and affection as punishment. Victims are often isolated from friends, family, church, work, and other social interaction. The perpetrator may also threaten to hurt or take away children, pets, parents, or other family members, and objects of personal value such as family heirlooms or special mementos.

Economic Abuse Economic abuse includes limiting access to money by restricting employment, education, or other resources, incurring major debt, placing assets in only the perpetrator’s name, and/or placing debt only in victim’s name. Most often, males are the perpetrators and females are the victims. Males are also victims of domestic violence, but the vast majority of victims are female (Tellez, Robinson, and Russell, 1999). The U.S. Department of Justice

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estimates that 95% of reported assaults on spouses or ex-spouses are committed by men against women (Douglas, 1991). Gay and lesbian partners are equally susceptible to being in an abusive relationship. The incidence is about the same as for heterosexual couples. For the sake of simplicity and ease of reading, victims will be referred to as female and perpetrators will be referred to as males. An important aspect of domestic violence and abuse is the escalating nature and pattern of complete domination over time. A variety of acts and tactics are used to manipulate, intimidate, coerce, and terrorize the victim, exerting an ever-tightening net of control. When these tactics form a pattern, the relationship is no longer a “bad” or “dysfunctional” relationship, it is abusive. That is not to say that a single incident of violence is not abusive. It is, but violent behavior is rarely limited to a single event. Single events are merely a harbinger of the future. Any disclosure of interpersonal violence needs to be taken seriously. Victims of domestic abuse are silent for many reasons. Often they are simply terrified. A significant aspect of abuse is that many tactics do not result in significant physical injury. Injuries resulting from physical assault are more easily recognized and can be debilitating or even life threatening. However, it is the psychological consequences of threats and coercion backed by the actual physical battering that result in profound and debilitating sequelae. It is critical for the healthcare provider to understand that many victims of domestic abuse are unable or unwilling to leave the perpetrator immediately. We are obligated legally, ethically, and morally to make a good faith effort to identify victims of family violence and provide the victims with appropriate resources, giving them an opportunity to exit the cycle of violence when they are ready. We cannot, however, force the patient to make a particular decision or take a particular action. Much as we would like to rescue them, except for our legal obligations, the most effective thing healthcare providers can do is to show them kindness and understanding. Ultimately, an honest and trusting relationship between the healthcare provider and patient will serve the patient best. Standards and laws to protect victims of domestic violence are now in place in most states. These vary from one jurisdiction to another, so it is advisable to review your local statutes, regulations, and ordinances. Failing to ask about violence in the home or living circumstances may expose the health practitioner to legal and regulatory liabilities. It is incumbent upon all healthcare provider institutions to develop policies and procedures to facilitate screening and intervention. Policies must specify the tools used for assessment, outline personnel responsible for tasks, list how the referral process is initiated and followed through, identify the elements of a safety plan, and describe how patient goals are to be met.

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Joint Commission The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or more recently referred to as the Joint Commission (JC), has created standards for screening and treating suspected victims of abuse. The healthcare provider must be able to demonstrate compliance with the intent of the standard (Scott and Matriccian, 1994). Applicable Joint Commission standards are: • Possible victims of abuse are identified using criteria developed by the hospital. • Patients who are possible victims of alleged or suspected abuse or neglect have special needs relative to the assessment process. • Administrators, business owners, government leaders, or healthcare providers ensure that the competence of staff is assessed, maintained, demonstrated, and improved continually. The Joint Commission has noted that the intent of these recommendations is as important as the standards themselves. As noted by Scott and Matriccian (1994) it is incumbent upon the healthcare provider to demonstrate compliance with the intent of the standard. Criteria for meeting the standards should be developed by each institution. Criteria need to be objective and measurable. Individual patient differences, including general presentation, cognitive skills, needs (including language barriers),* disabilities, and emotional status need to be considered. This means that staff must not only make an effort to identify victims of abuse, they must understand the extent and circumstances surrounding the current and past events and document it. Staff must not act in a manner that would encourage a patient to allege or fabricate abuse. Allegation alone is insufficient. Information and evidence collected in the medical setting may have legal consequences. Special procedures to safeguard information and evidence must be in place, including how to initiate and maintain the chain of custody. Additional measures may be necessary for photography, special procedures, and release of information. Hospital policies must specify how information and evidence is to be handled and who is responsible. Documentation in the patient’s record must include special consents * Procedures should consider language barriers and the need for an interpreter. Interpreters should be available if the patient does not speak English. Family members do not make good interpreters, not only for domestic violence screening purposes, but for medical purposes because they may misunderstand or misinterpret legal terms used in the healthcare setting.

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obtained, handling of evidentiary materials and chain of custody procedures, special legally required notifications, referrals made, lists and other resource materials given to the patient, and information and/or evidence given to law enforcement. The Joint Commission recommends that staff be able to demonstrate competency in assessing, treating, and reporting victims of abuse. Simply remembering to ask is not enough. Records of staff education must be up to date and demonstrate that education is ongoing and competence is routinely evaluated.

Intervention for Domestic Violence • Inquire about abuse in a routine and standardized manner. • Assess safety issues. See Appendix 4.1, “Danger Assessment— English” or Appendix 4.2 “Danger Assessment—Spanish.” • Treat medical and mental health issues. • Discuss options and resources that are available. • Provide advocacy and referral information. • Document the abuse, referrals made, and treatments given. • Provide for follow-up care (Warshaw and Ganley, 1998). Patient privacy concerns must be addressed. Victims are reluctant to reveal abuse because they are afraid that disclosure will result in repercussions later. Perpetrators often accompany their victims to the healthcare setting and are reluctant to leave the victim.* Before inquiring about abuse, it is essential to create an environment where the victim feels she can talk freely. Hospital policy may set up protocols so that the patient is initially seen alone and accompanying individuals may join her later. Anyone accompanying the patient (including another woman) should be considered a potential perpetrator until ruled out. They may be charming and overly concerned or defensive, controlling, abusive, or threatening. The healthcare provider must create an environment of privacy that fosters disclosure and outlines procedures to be followed if the immediate safety of the victim or staff is a concern. Healthcare settings should have posters and pamphlets visible and available free of charge. Post notices and support agency phone numbers regarding domestic violence on the inside of restroom doors or on the back doors of ambulances and rescue units. Perpetrators can be dangerous to healthcare staff as well as the victim. Don’t be intimidated by an overly protective partner. Think proactively. Have * A red flag that domestic violence may be occurring is the demeanor and behavior of the person accompanying the victim.

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a plan in place to separate the patient from the perpetrator or other overly watchful companion. For your own protection as well as that of the patient, have a plan in place to alert security that a potentially volatile situation may be in the making. Staff should be able to lock doors quickly and easily, panic buttons should be available, alternate routes of escape should be established and clearly marked. Protocols for notifying security and or law enforcement should be in place and reviewed annually. The Joint Commission recommends that staff be able to demonstrate competency in assessing, reporting, and treating victims of abuse (Mitchell, 2004; Scott and Matriccian, 1994).* Staff needs to become familiar with red flag conditions and suspicious circumstances. Simply remembering to ask is not enough. Policies and procedures must form the backbone of every patient’s care. A complete, up-to-date list of private and public resources should be developed and revised annually. Acute medical injuries must be assessed in conjunction with overall health and safety needs. Immediate safety needs are paramount, both for the victim and for staff. Even in emergency situations, safety must be assessed simultaneously with medical needs. Psychosomatic illnesses may occur. Depression, posttraumatic stress disorder, and suicide are common psychiatric implications. Drug and alcohol use has been shown to increase among victims once domestic violence begins. This increase is most likely a coping mechanism and a consequence of the abuse rather than the cause of the violence and abuse (Warshaw and Ganley, 1998). Keep in mind that information and evidence collected during the screening, assessment, and treatment phases may be used later in legal proceedings. Policies and procedures must define the healthcare provider’s responsibility for collecting, retaining, and safeguarding that information and evidence, including who is responsible for implementation and followthrough. In addition to assessment, treatment, and so on, documentation should include consents, chain of custody forms, legally mandated notifications, release of information to authorities, resource lists provided, referrals made, and plans for follow-up and other discharge planning activities. Check with the local and regional prosecuting attorneys for revisions to laws and practices. * The three applicable standards are: 1. Possible victims of abuse are identified using criteria developed by the hospital 2. P  atients who are possible victims of alleged abuse or neglect have special needs relative to the assessment process 3. L eaders ensure that the competence of all staff is assessed, maintained, demonstrated and improved continually (Scott and Matriccian, 1994).

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Screening Basic screening is often done as part of initial intake and assessment procedures. The process is generally one of ruling out domestic violence. Those patients who provide negative answers to the initial screening can be exempted from further inquiry unless the interviewer has doubts about the truthfulness of the patient’s responses. Screening should be standardized and consistent so compliance and outcomes can be measured and evaluated. Chart prompts, check boxes, and standardized care plans are helpful and can save time. Standardized screening questions should be straightforward and simple. Start with an introductory statement, such as the fact that about one-third of all women report having been a victim of domestic violence at some point in their lives. Tell the patient that routine screening is now a requirement for all healthcare providers and that all patients are now asked these questions as a matter of routine. Inform the patient that their responses will be kept confidential. Three basic questions suggested in the University of California, Davis guidelines are:* • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? • Do you feel safe in your current relationship? • Is there a partner from a previous relationship who is making you feel unsafe now? End with questions regarding violence in the home and patient concerns about violence or coerced/forced behavior (Mitchell, 1994). The key is to look for a pattern of behavior both on the part of the perpetrator and on the part of the victim. The following are considered to be clinical and patterned behavioral events that may be red flags for abuse: • • • •

The history is inconsistent with clinical findings. The patient is young, isolated, or vulnerable. There is a history of stress-related illnesses or diseases. A history of mental health problems not otherwise explained and documented, including depression, a high level of anxiety, or suicide attempts.

* Basic screening does not ask about forced sex, emotional and psychological abuse, or about attempted strangulation. These issues can be explored if more in-depth questioning is warranted.

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• There is a history of domestic violence and/or sexual assault in past as well as current living situations. • There is suspicion of excessive or chronic alcohol or drug use, including prescription pain relievers or sedatives (especially when the diagnosis is absent or unclear or there are multiple healthcare providers). • Physical injuries are central, bilateral, patterned, defensive, or inadequately explained. • An injury occurs during pregnancy. • The patient has avoided or been prevented from entering the healthcare system (including no treatment or inadequate treatment). • The patient has a history of multiple minor or vague complaints, especially if the patient has been seen repeatedly. • The patient defers healthcare decisions to the dominant partner. • The patient reveals excessive or unexplained absences from work or other social activities. If the patient denies abuse but her clinical presentation or behavior is highly suspicious for domestic violence, you may want to ask a second time. Use straightforward questions such as, “How did this happen?” or “Were your injuries caused by someone close to you?” Be Prepared and Comfortable Dealing with a “Yes” Answer! Key Point: When assessing incidents of domestic violence, it is important to determine how long the abuse or threats have been occurring, and if there have been incidents of sexual or emotional abuse leading to mental health or physical consequences. The presence of children in the home is particularly important. Any domestic violence safety plan must include any involvement of children—either as witnesses or as direct victims of abuse and/or neglect. Once children are identified, the next step is to evaluate the risk to children and seriousness of the violence on the children. Attempt to determine how they are being impacted and whether reporting is appropriate. Reporting of direct abuse of children is now required in all fifty states. Also note whether the patient has access to resources outside the home—work, social activities, access to family and friends, children’s activities, and so on.

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As healthcare providers, each of us needs to be aware of our own prejudices and biases that create barriers to an effective response.* Education and training that explore these issues should be a part of the standard protocol. Victims of abuse may not report abusive situations due to one or more of the following factors: • Concern that the batterer will retaliate with further abusive acts • Social, cultural, and religious indoctrination that has instilled beliefs that marriage or other partnerships must be honored at all costs • Age, disability, and language that reinforce that the individual is dependent upon the abusing partner If your patient exhibits fear and begins to distance herself, reassure her that you are not a law enforcement officer and in most states are not required to report domestic violence. Offer the victim a card with local and national hotline numbers on it as well as basic information on developing a safety plan. If screening is negative, accept it and move on to the standard intake and assessment. A Domestic Violence Assessment Tool in both English and Spanish is included in Appendices 4.1 and 4.2. Also included are a Domestic Violence Assessment Tool (Appendix 4.3) and an Interpersonal Violence Continuous Quality Improvement (CQI) tool (Appendix 4.4) for your facility. Created by Ms. Lisa Leiding for use in New Mexico, they can be adapted to fit other jurisdictions based on current law in your state. If the answer is “no” and there is strong suspicions that domestic violence may be occurring, this information should be noted in the chart and the chart should be flagged for a situation reassessment at the next and every subsequent visit.† Explain to the patient that informational materials and resources are available at any time in the future, and explain what support is available locally, with precise information such as local shelters and toll-free hotline numbers.‡

Assessment Once a domestic violence victim has been identified, a more in-depth evaluation needs to occur. Assessment requires an understanding of the dynamics * Known barriers to effective response include the provider’s own attitudes and misconceptions about domestic violence, apprehension regarding the length of time involved, familiarity with the patient, perpetrator, or their families, cultural assumptions and biases, belief that interpersonal relations are a private affair, and others. † Chart prompts include notation that domestic violence (DV) screening was done: DV yes; DV no. Outcome of initial screening can be done using check boxes with DV+ (positive), DV− (negative), and DV? (suspected or questionable). ‡ The national domestic violence hotline number is: 800-799-SAFE.

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of the relationship and the patient’s level of understanding of the problem. In addition to physical and sexual findings, the clinician needs to assess contributing factors including personal history, family dynamics, support, and influence, as well as community values and support and other sociocultural values and influences. Safety First • • • • • •

Is the patient in immediate danger?* Is the staff in immediate danger? Where is the perpetrator? Where will the abuser be when the patient leaves? Does the victim want security or law enforcement to be notified? Are children and/or vulnerable adults safe?

Patient History A complete history of recent events, particularly the one that precipitated contact with the healthcare system needs to be obtained. When, where, and how was the victim attacked? Have her describe the physical surroundings (bathroom, nearby woods, car, etc.). Assess the pattern and history of abuse: How long has the abusive situation been going on? What techniques does he use to gain physical control? Has the intensity of abuse escalated either in frequency or severity? Discuss the tactics used, including use of physical force, restraints, economic coercion, and psychological tactics such as threats of further injury and intimidation. • Are drugs or alcohol involved? • Can the victim predict violent episodes and has she developed any mitigating or preventive measures? • Is there any sexual involvement? • Are others also being abused or are they witnesses (children, vulnerable adults such as elderly or disabled parents, or others)? • Does the abuser control the victim’s activities, money, or access to the outside world? • Does the victim believe she is being stalked? Has the abuser threatened to abduct her or actually taken her hostage for a period of time? * A danger or lethality assessment should be done as part of the initial assessment.

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• Was a weapon involved? What kind? Was the weapon threatened or actually used? How many times? • Have there been threats of homicide or suicide?* Identify the abuser by full name and his (or her) relationship to the victim. If known, document the abuser’s current whereabouts. If there is current risk to the victim or healthcare provider, notify law enforcement. Inform the patient if law enforcement has been notified and why notification is necessary (i.e., legal requirement, patient and/or staff safety, etc.). Assess the health impacts (physical, psychological, emotional, spiritual, etc.). Have previous incidents resulted in physical injuries? How is the abuse affecting the victim’s overall mental and psychological health? Assess the patient’s understanding of the situation and willingness to leave. It is not uncommon for victims of domestic violence to be reluctant to leave their abuser. Despite orders of protection, the risk of serious physical harm or homicide increases once the victim leaves. Determine appropriate resources and access to advocacy and support services. What personal resources does the victim have? Has the victim tried to use available resources in the past? What was the outcome? Is the victim willing or able to contact them again? What barriers does the victim have that might prevent using available resources (e.g., family, religious belief, cultural beliefs and/or practices, community or societal values)? Prepare a lethality or danger assessment.† Include information and descriptions from the patient, if possible.‡ Determine whether children or other persons witnessed the event. The patient’s medical history is also important. It may reveal medical complaints without a specific diagnosis (headaches, heart palpitations, vague GI complaints, pelvic pain, chronic pain, insomnia, unexplained weight gain or loss, and other stress-related conditions). Because of coercion and forced sex, the patient’s reproductive history may include accounts of chronic pelvic pain, frequent vaginal and urinary tract infections, sexually transmitted diseases, pelvic inflammatory diseases, and HIV. Women victims of domestic violence are also prone to having an unplanned pregnancy, or a pregnancy with little or no prenatal care. Pregnancy is also a time when women are particularly vulnerable to domestic violence. Domestic violence is a leading cause of maternal death (Fildes, Reed, Jones, Martin, and Barret, 1998). * When a perpetrator says suicide, think homicide! † See Appendix 4.1. ‡ Include information from other people sparingly, if at all. When used, clearly identify the person giving the information by name, relationship, and how they had possession of the information given. If the information is not firsthand, do not include it.

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If the victim is pregnant, an obstetric consultation including a more thorough interview and exam is warranted. If blunt trauma to the abdomen is suspected, the workup should also include assessment of possible fetal, placental, or uterine injury. Was the pregnancy planned and welcomed by both partners? Was prenatal care postponed or totally absent? Have there been previous complications such as miscarriage, premature onset of labor, placenta abruptio, reports of decreased fetal movement, questionable rupture of membranes, or antenatal hospitalization?

Psychological History Although acute physical injuries are the most obvious signs of domestic violence, it is the psychological sequelae that may be the most debilitating in the long term. There is a higher incidence of domestic violence among patients presenting with psychiatric issues. Interpersonal violence may exacerbate existing psychiatric illness or may actually be the cause of psychiatric difficulties. Long-term exposure to stress, depression, anxiety, and a feeling of hopelessness and helplessness may lead to tragic consequences. A major goal of psychological assessment is to determine the patient’s understanding and view of the problem. Does she (or he) understand that there really is a problem? Is she in denial? Try to determine the victim’s general frame of mind. What, if any, communication and coping skills does the victim have when conflict arises? Is the victim rational or out of control? Where is she in the continuum between denial and readiness to leave? Is the violence and attempt to control increasing? What effect has this had on the victim’s mental and emotional status? What effect have other manipulative, threatening, or coercive acts such as attempted strangulation or presence of a gun in the house had on the victim? What is the nature and extent of threats made by the perpetrator? Is the perpetrator violent at work or in social situations? How does this impact the victim? What is the level of intimidation or violence toward any children who are present? What impact does the violence have on the children? Does the patient have psychosomatic complaints that cannot be explained? Examples are persistent headaches, chronic pain, GI problems, and musculoskeletal problems. Does she have stress-related symptoms, including increased anxiety, depression, posttraumatic stress disorder, changes in sleep or appetite patterns, fatigue or lack of energy, difficulty concentrating, sexual dysfunction, dizziness, palpitations, difficulty breathing, or unexplained paresthesias? Has she contemplated, threatened, or attempted suicide? Can she elaborate on her reasons?

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Physical Examination Ask the patient to remove all of her clothing as described in Chapter 3. To avoid further trauma to the patient, explain in detail the process of physical assessment and evidence collection, informing the patient about each step as you go. Perform a complete, head-to-toe review of systems. Evaluate and describe each injury found, describing the type, number, size, and location. Mark each on a separate body map. Be particularly aware of injuries that support the narrative of the assault. For instance, injuries to the neck and throat might support an allegation of attempted strangulation (see Figure€4.2). Also note defensive wounds on hands, arms, and legs, and such details as hair, makeup, and torn clothing. Acute injuries should be documented and treated. Included in a standard domestic violence assessment should be body diagrams and photographs. In addition to a standard head-to-toe physical examination, the forensic examination of a domestic violence victim includes assessment of the victim’s demeanor, suicidal or homicidal ideation, and notation of the condition

Figure 4.2╇ Fingertip contusions on neck. Courtesy Dr. William Smock. Used with permission.

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and type of clothing worn and whether appropriate for weather and social environment. Any injury to the face, eyes, mouth, or ears is suspicious for domestic violence. As with any repeated abuse, multiple injuries or bruises in various stages of healing are highly suspicious for domestic violence. Physical findings that warrant further inquiry about the possibility of partner abuse include injuries to the neck, face, breasts, abdomen, and any injuries to the genital or rectal area. Also note defensive injuries on the lateral surfaces of the victim’s forearms or legs. As previously noted, injuries that are inadequately explained or are inconsistent with the injury patterns seen are highly suspicious for abuse. See Chapter 2, the section on patterned injuries* for things to look for and appropriate terms to use when documenting (Figures 2.8–2.20). Victims may also be prohibited from seeking medical care for acute or chronic conditions. Chronic conditions such as diabetes, hypertension, heart disease, or other conditions such as epilepsy may be exacerbated in the presence of abuse. Victims of domestic violence may not take their medications as prescribed or be prohibited from doing so. Chronic pain is a common complaint among domestic violence victims. If the patient is taking medication, what is the diagnosis and who prescribed the medication? Are there multiple prescribing physicians? Assess for conditions that could have been caused by prior acts of violence. These include hearing loss, headaches, back and neck pain, depression, or symptoms of posttraumatic stress disorder. What is the patient’s level of alcohol and drug use?

Intervention Appropriate intervention for domestic violence includes the following: • • • • • • •

Inquire about abuse in a routine and standardized manner Assess safety issues Treat medical and mental health issues Discuss options and resources Provide advocacy and referral information Provide for follow-up care (Warshaw and Ganley, 1998) Document the abuse, referrals made, and treatments given

* Marks left by objects or burns from hot appliances or liquids.

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Listen to the patient! Respond sincerely, thoughtfully, and nonjudgmentally. Let the victim know you understand. Validate her experiences and feelings. Acknowledge that the issues are complex and that it takes time to sort out emotions and make decisions. Support the victim’s choices. Advise the victim that she is not alone. Tell her you are there to help and resources are available when she is ready. Inform the patient that domestic violence is a serious medical and psychological health issue. Advise her that acts of domestic violence are rarely static; more often than not they escalate in both frequency and severity over time. Tell the victim she is not to blame. Domestic violence is not her fault, and responsibility for stopping it rests with the abuser. Offer the victim referrals to local resources, and specifically address safe shelter, counseling, legal advocacy, and involvement of law enforcement. Provide the victim with a list of hotline numbers and local resources. Work with the victim to prepare an individualized safety plan. Schedule follow-up per protocol. Document your findings and interventions.

Care Plan Reassure the victim that she is not responsible and that help is available when she is ready. Provide appropriate information on resources that are available. Recognize that the victim may have feelings of shock, bewilderment, depression, fear, shame, denial, or isolation, and acknowledge that these are normal. Immediate safety needs are a priority. Is the perpetrator there now or likely to be there in the near future? What response would she like from the healthcare staff? Does she want security or law enforcement to be notified? Does she have an order of protection? If so, does she want the abuser arrested? Where are children and other vulnerable family members? Does someone (family, friend, neighbor, etc.) need to be notified to pick them up? Will she go with the abuser if he wants her to leave? Is she prepared to go to a shelter or other safe place? Does she have the resources to do so? Victims are often reluctant, unwilling, unable, or afraid to leave their abuser. Their safety and the safety of children and others in the household is a very real concern. Recognize, however, that it is unrealistic to expect the victim to immediately leave her situation. Family, friends, culture, finances, religious faith, and so on are barriers to a victim leaving a domestic violence situation. The average number of times a victim of interpersonal violence is seen before leaving the abuser is seven. The care plan should address forensic (legal and social investigation) as well as medical, psychological, and safety needs. Included in the care plan should be narrative and photographic documentation and treatment for physical trauma or other unaddressed medical needs, assessment and care

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of mental health and safety needs, preparation of a safety plan and lethality checklist, and preparation of a follow-up plan that includes legal scenarios. Inform the victim that battering is a crime and help from the legal system is available. Notify the victim early on whether reporting is mandatory in your area. Legal implications for the healthcare provider may involve a duty to report a battering assault to law enforcement and a duty to warn a third party if the provider is aware of a patient’s, perpetrator’s, or other individual’s intent to harm them (Warshaw and Ganley, 1998, pp. 78–79). Battered women’s shelters are usually aware of reporting requirements, police procedures, and consequences of reporting. Staff needs to be educated and knowledgeable in this regard so they can educate the victim at the time a safety plan is being developed. This is an area where a clinical forensic specialist is especially valuable. Although reporting of domestic violence may or may not be mandatory, reporting of child abuse is. It is important to discuss the realities, benefits, hazards, and potential consequences of child protective enforcement services’ involvement. It is not acceptable to return to an abusive situation if the children are also being abused or are in danger. Appropriate intervention is dependent upon the care plan’s specificity and thoroughness. Individuals responsible for each aspect of the care plan should be identified and listed. It is important to appreciate that the care plan is part of a comprehensive, collaborative, coordinated effort among healthcare, law enforcement, community services, victim advocacy organizations, and the legal community. Care plans must include preparation for follow-up, including follow-up photographs, showing the progression of injuries over time.

Mental Health Plan The patient’s ability to cope and availability of a support system are critical to the success of the patient’s psychological recovery. It is important that the practitioner understand the victim’s ability to make decisions. A psychiatric referral may be necessary to adequately assess the patient’s psychiatric future. Severe depression, panic disorder, psychosis, and suicidal or homicidal ideation may require further psychiatric evaluation and treatment. Secondary psychiatric issues such as emotional, behavioral, and cognitive responses to abuse may be more a response to the abuse than true psychological illness. Once the victim is out of the abusive situation and safe from further violence, these issues may resolve.

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Safety Plan A detailed safety plan should be developed before the patient leaves. The patient’s current circumstances, priorities, options, and readiness to leave will determine the specifics of the plan. Items to be addressed include the personal safety of the victim, other family members at risk, how to avoid and manage an explosive episode, how to identify and utilize resources, and how to prepare to leave if and when she is ready to do so. Safety planning goals are based on whether any aspects of a safety plan are already in place. Find out what the patient has done to protect herself and her children. Determine whether she has made a realistic assessment of the extent and severity of the abuse. Assess what her current risk is for dangerous events and what she has done to protect herself and other family members. Temporary housing is an immediate concern. List realistic options available include shelters, family, and/or friends. Or does she want to leave the community altogether? Does she consider this move temporary or permanent? If the victim intends to return to the abuser, discuss what has worked in the past to reduce the level of violence. Does she believe previous strategies have been successful and has she thought of other strategies? Encourage her to inform her children to leave if possible and not to try to protect her. The best strategy is to arrange a safe place to meet the children later. Does she have an escape (exit) plan for herself and her children? Has she discussed the exit strategy with them? What options are available to get her and the children out of the house and to safety? Does she have a support network and how does she plan to use it in an emergency? Is there a friend or neighbor she can rely on if violence erupts or threatens to erupt? Would a family member or friend’s presence in the home deter or mitigate a battering episode? Discuss other options she might have from her support network. Is the patient able to anticipate a violent episode? If so, would she have time to leave before violence starts or escalates? If not, can she prepare a locked “delay” or “safe” room where she and children can buy some time while getting help or attempting to escape? What precautions might she take to prevent escalation of violence? If the situation becomes violent, would she call the police? Could she call the police? Could children or others in the household call the police? Does she have an emergency signal established with a neighbor who could call for help? If not, could she develop one, and with whom? Are there weapons in the home? How accessible are they? Can she remove them or remove ammunition? Does she have a cell phone? (Landline phone lines can be cut.) Is it preprogrammed? To whom?

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Encourage her to discuss the violence with her children, reassuring them that it is not their fault. Teach them how to use the telephone in an emergency and how to make collect calls should the abuser take them from the home. Notify schools and those who provide child care with the names of those who may and may not pick up the children. Discuss safety going to and from work and suggest she confide her situation with a sympathetic coworker, boss, or company security officer. Does she usually take the same route to work? Are there alternate routes or methods of transportation? Is she alone going to or from work? Can she arrange for someone to accompany her? Would security or someone else be willing to walk her to and from her car? Encourage her to discuss the violence with a trusted friend or family member and discern who might be willing to help her in an emergency and to what extent are they willing to become involved. Encourage her to read as much as she can about domestic violence. Remind her, however, that if such materials are discovered by the abuser, their presence might provoke an attack. Does she have or could she get a post office box and is there someone to whom she could give access to the mailbox? Does she have a protective order in place? Would she be willing to get one? What would she do if the abuser violated a protective order? Discuss safety measures such as changing locks on doors and windows, installing smoke detectors, having fire extinguishers readily available in several places throughout the house, and having outdoor lighting motion sensors installed. What items would she need to have if she needed to flee suddenly? The following are items she might want to have sequestered away from the home. • Medications and prescriptions • Identification (driver’s license or identification card, Social Security card, passport or green card, birth certificates for herself and her children) • Important papers (marriage license, car title, lease/rental agreements, house deed or mortgage papers, insurance information and claim forms, school and health records, immigration papers, etc.) • An extra set of keys • Extra glasses • Money, including change for a pay phone • Checks or checkbook, banking books or account numbers, credit cards • Protective orders, divorce and/or custody papers, and any other court documents • Phone numbers of family and friends she can trust

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• Phone numbers and addresses of shelters and other community or religious agencies • Clothing and comfort items for herself and any children or dependent adults If the victim is leaving the abuser, is there anyone with whom she can stay? Does she want to go to a battered woman’s or homeless shelter? Are other temporary housing options available such as hotel vouchers?* The most dangerous time for a victim of domestic violence is when she leaves. Does the victim want or need a protective order? What measures can she take to ensure it is enforced? Does the victim want law enforcement to be notified? If the abuser is leaving, suggest she take additional safety measures such as having locks changed, developing a secondary escape route (including second story egress such as a portable window ladder), installing motion sensors, security system, smoke detectors, and fire extinguishers. Have friends, family, neighbors, coworkers, clergy, and others call 911 if they see the abuser near the house, work, school, church, or other place she habitually visits.

Resource List All healthcare providers should maintain an up-to-date list of resources available in their community. That list should include the organization, its address, and the name and phone number of the contact person.

Community Resources The following are resources within the community to which the victim can be referred: • • • • • • •

Emergency shelters Counseling and treatment programs Crisis providers Local and national hotlines Legal advocacy centers Education services Employment assistance

* Vouchers may be available from social services, advocacy programs, or your institution.

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Public awareness centers Child protective services Faith-based organizations and churches Alcohol and substance abuse counseling Support networks for the disabled and elderly Cultural organizations

Documentation When documenting, remember to use direct patient quotes. Use the patient’s own words to describe a discrete event, critical element, or history of abuse; do not paraphrase victim statements. Use the patient’s own words to describe the health impacts of domestic violence. Write down the patient’s utterances verbatim; do not change or alter words or word order. Remember that the patient’s own words can be used in court as an exception to the hearsay rule and are therefore critical in the legal setting. Use quotation marks to enclose key elements or phrases to indicate that they are the patient’s words. Avoid use of the phrase “patient alleges”; use the phrase “patient states” instead. Avoid the use of judgmental evaluations or third-person or passive statements. Examples are “Patient overly excited” and “Patient struck in face.” Instead, describe patient’s emotional or mental status in observable terms. Use the patient’s own words to describe who, what, when, where, and how. Documentation specific to domestic violence needs to address all physical signs and symptoms, a danger assessment, and an assessment of risk for children as well as other adults in the household. Cultural, social, and familial considerations must be included. Note any special needs of disabled victims and actions taken on their behalf. All intervention or attempted intervention, referrals made or offered, and educational material provided should be clearly documented. Documentation must include a safety assessment and plan, options discussed, whether police or other official agencies were notified, referrals made (including the name of the individual[s] taking the report), follow-up arrangements, and discharge instructions. List all of the information or literature regarding domestic violence that is given to the patient.

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Appendix 4.1: Danger Assessment—English DANGER ASSESSMENT Jacquelyn C. Campbell, Ph.D., R.N. Copyright 1985, 1988 Several risk factors have been associated with homicides (murders) of both batterers and battered women in research conducted after the murders have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of severe battering and for you to see how many of the risk factors apply to your situation. Using the calendar, please mark the approximate dates during the past year when you were beaten by your husband or partner. Write on that date how bad the incident was according to the following scale:

1. Slapping, pushing; no injuries and/or lasting pain 2. Punching, kicking; bruises, cuts, and/or continuing pain 3. “Beating up”; severe contusions, burns, broken bones 4. Threat to use weapon; head injury, internal injury, permanent injury 5. Use of weapon; wounds from weapon (If any of the descriptions for the higher number apply, use the higher number.) Mark Yes or No for each of the following. (“He” refers to your husband, partner, ex-husband, ex-partner, or whoever is currently physically hurting you.)    1. Has the physical violence increased in frequency over the past year?    2. Has the physical violence increased in severity over the past year and/or has a weapon or threat from a weapon ever been used?    3. Does he ever try to choke you?    4. Is there a gun in the house?    5. Has he ever forced you to have sex when you did not wish to do so?    6. Does he use drugs? By drugs, I mean “uppers” or amphetamines, speed, angel dust, cocaine, “crack,” street drugs, or mixtures.    7. Does he threaten to kill you and/or do you believe he is capable of killing you?    8. Is he drunk every day or almost every day? (In terms of quantity of alcohol.)

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     9. Does he control most or all of the your daily activities? For instance: does he tell you who you can be friends with, how much money you can take with you shopping, or when you can take the car? (If he tries, but you do not let him, check here: ____)    10. Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him, check here: ___)    11. Is he violently and constantly jealous of you? (For instance, does he say “If I can’t have you, no one can.”)    12. Have you ever threatened or tried to commit suicide?    13. Has he ever threatened or tried to commit suicide?    14. Is he violent toward your children?    15. Is he violent outside of the home?    Total “Yes” Answers Thank you. Please talk to your nurse, advocate, or counselor about what the Danger Assessment means in terms of your situation. From Jacquelyn Campbell, PhD, RN. 1985, 1988. Danger Assessment. Used with permission.

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Appendix 4.2: Danger Assessment—Spanish ESCALA DEVALORACION DE PELIGRO En estudios realizados en mujeres que han muerto a consecuencia de violencia doméstica se han observado varios factores de riesgo tanto en el abusador como en la mujer golpeada. No podemos predecir que sucederá en su caso, pero me gustaría advertirle acerca del peligro de homicidio que se presenta en situaciones de agresión física severa con el fin de que usted se de cuenta de cuantos factores de riesgo se aplican a su situación. (En las preguntas a continuación cuando hablamos de “el” nos estamos refiriendo a su esposo, compañero, ex-esposo o quienquiera que le esté haciendo daño físico en estos momentos) Porfavor marque SI o NO a cada una de las siguientes preguntas. SI  NO □  □ 1. ¿ Durante el último año su pareja ha aumentado la frecuencia con que la golpea? □  □ 2. ¿ Durante el último año su pareja ha aumentado la severidad de la violencia física, ha utilizado un arma o ha amenazado con usarla? □  □ 3. ¿ Alguna vez ha tratado de estrangularla? □  □ 4. ¿ Hay alguna pistola en la casa? □  □ 5. ¿ Alguna vez su pareja la ha forzado a tener relaciones sexuales en contra de su volunted? □  □ 6. ¿ El utiliza algun tipo de drogas? por drogas me refiero a estimulantes, anfetaminas, “speed,” polvo de angel, cocaína, crack, drogas que se venden en la calle, heroína, pastillas, inhalantes (thiner, cemento) cocktailes de drogas? □  □ 7. ¿ El la amenaza con matarla y/o usted cree que él es capaz de hacerlo? □  □ 8. ¿ El se emborracha diario o casi diario? (refiérase a la cantidad de alcohol) □  □ 9. ¿ El controla la mayoría de sus actividades diarias. Por ejemplo le dice quienes pueden ser sus amistades, cuánto dinero puede llevar cuando va de compras, cuando puede usar el coche, que no puede trabajar fuera de casa? □  □ 10. ¿ Alguna vez ha sido usted golpeada estando embarazada? (Si no era el padre de su hijo marque aqui      ) □  □ 11. ¿ El es extremadamente celoso al grado de portarse violento? (por ejemplo el le dice cosas como “Si no eres mía no vas a serlo de nadie”) □  □ 12. ¿ Alguna vez usted ha amenazado o ha intentado suicidarse?

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□  □ 13. ¿ Alguna vez el ha amenazado o ha intentado suicidarse? □  □ 14. ¿ El es violento fuera de su casa? Total de respuestas SI      GRACIAS POR SU COLABORACION. PORFAVOR HABLE CON SU MEDICO, ENFERMERA, ASESOR LEGAL O CONSEJERO ACERCA DE LOS RESULTADOS OBTENIDOS EN LA ESCALA DE VALORACION DE PELIGRO Y LO QUE ESTOS RESULTADOS SIGNIFICAN PARA SU SITUACION PERSONAL. From Jacquelyn Campbell, PhD, RN. 1985, 1988. Danger Assessment. Used with permission.

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Appendix 4.3: Domestic Violence Assessment Tool INTIMATE OR DOMESTIC VIOLENCE IMMEDIATE SAFETY Where is your abuser now?        Do you feel that you are in danger now?   □ No □ Yes

Where will the abuser be when we are done with the medical exam? □ Jail □ House □ Unknown   □ Other:                Hospital security notified? □ No □ Yes

VICTIM INFORMATION BASIC INFORMATION

MEDICAL ASPECTS OF ABUSE

Height:               Weight:               Pregnant: □ No □ Yes □ Unknown Ethnicity:             

Are you allowed to have a primary care doctor?   □No □ Yes   Who:             Are you forced to seek care from a variety of providers or E.R.’s? □ No □ Yes What prescription medications do you take?       Does your abuser hide or take your medications?   □ No □ Yes Do you drink? □ No □ Yes Were you using during the violence? □ No □ Yes Do you use illegal drugs? □ No □ Yes Were you using during the violence? □ No □ Yes Are you suicidal? □ No □ Yes Have you thought about killing your abuser?   □ No □Yes

HISTORY OF ABUSE HISTORY Who hurt you today?         Relationship:             How long have you known your   abuser?              How long has the violence been going   on?                Has the violence increased in frequency over the last year? □ No □ Yes   How frequent?           Has the violence increased in severity over the last year? □ No □ Yes Have others been harmed by your abuser?   □ No □ Yes □ Unknown If yes – what was their relationship to your abuser?          

SEXUAL ASSAULT Has your abuser forced or harmed you sexually?   □ No □ Yes How long ago was the last   incident?                   (If within 7 days stop the interview and call the SANE to examine). STALKING Have you ever felt trapped? □ No □ Yes Has you abuser followed you? □ No □ Yes Are you keeping written records? □ No □ Yes Have you ever had an order of protection for your abuser? □ No □ Yes Has anyone else ever filed an order against your abuser? □ No □ Yes □ Unknown Has your abuser ever violated an order? □ No □ Yes

From Leiding, Lisa, RN, SANE. Interpersonal Violence C.Q.I. Tool for Medical Facilities. Used with permission.

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PSYCHOLOGICAL ABUSE □ Jokes □ Insults □ Namecalling □ Crazy-making □ Jealousy □ Isolation □ Abandonment □ Monitoring □ Threats □ Lying □ Coercion □ Humiliation □ Sabotage-parenting □       

ECONOMIC ABUSE

PHYSICAL ABUSE

□ Controlling money □ Stealing money □ Accusing victim of stealing money □M  isuse family income □R  uining victim credit □ Forcing to work □ Getting victim fired □ Not allowing to work □ Making all decisions □ Destroying documents □ Forcing criminal activity □       

□ Harming pets □ Harming children □ Denying basic needs □ Destroying property □ Use of weapons □ Using car as a weapon □ Driving recklessly □ Throwing objects □ Being thrown □ Restraining □ Strangulation □ Suffocation □ Drowning □ Spont. Abortion □ Threat. Abortion

PHYSICAL ABUSE □ Biting □ Burning □ Drugging □ Poisoning □ Pinching □ Poking □ Grabbing □ Slapping □ Spanking □ Punching □ Beating □ Whipping □ Pushing □ Tripping □ Kicking □       

SEXUAL ABUSE □ Sexual jokes □ Use of pornography □ Control contraception □ Withholding sex □ Groping/ grabbing □ Prostitution □ Forced sex with others □ Sex in front of kids □ Sadism □ Humiliation during sex □ Beating after sex □ Beating during sex □ Sex after beating □ Rape □ Raped while drugged □ STDs

SPIRITUAL ABUSE □ Insulting beliefs □ Making victim convert □ Using religion to justify abuse □ Not permitting religious practice

STAFF SIGNATURES MD:                      NURSE:                    

PATIENT’S STICKER

CURRENT HISTORY OF EVENTS IN PATIENT’S OWN WORDS                                                                                                                                                                                                                                                       SUBJECTIVE OBSERVATIONS DURING INTERVIEW PROCESS                                                                                                                                                                                                             

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ABUSER INFORMATION AND FUTURE RISK BASIC INFORMATION MEDICAL HISTORY Age:         Sex: □ M □ F Pregnant: □ No □ Yes Ethnicity:             

Height:      Weight:      Medical history: □ None □ Unk      Mental history: □ None □ Unk       Does your abuser drink? □ No □ Yes Does your abuser use drugs? □ No □ Yes Does your abuser take prescription medications? □ No □ Yes   What?             

LETHALITY

WORKPLACE VIOLENCE

THREATS AND BEHAVIOR

Has your abuser threatened suicide?   □ No □ Yes Has your abuser threatened to kill anyone? □ No □ Yes   Who?         When?      Have you asked for separation or divorce from your abuser? □ No □ Yes   □ Not Applicable

Has your abuser come to your work place unexpectedly? □ No □ Yes Does your abuser call your work place frequently? □ No □ Yes Has your abuser ever hurt you in any way in a public place? □ No □ Yes

Has your abuser lost a job or experienced problems at work? □ No □ Yes Has your abuser displayed acts of extreme jealousy? □ No □ Yes Has abuser threatened to take the kids away? □ No □ Yes Has your abuser made threats to call immigration? □ No □ Yes Has your abuser isolated you from family or friends? □ No □ Yes

WEAPONS Does your abuser have access to a weapon? □ No □ Yes □ Unknown Did your abuser use a weapon? □ No □ Yes

CHILDREN Are there children involved? □ No □ Yes Have children been hurt? □ No □ Yes Have children witnessed the violence? □ No □ Yes

PATIENT’S STICKER

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Appendix 4.4: Domestic Violence CQI Tool INTERPERSONAL VIOLENCE C.Q.I. TOOL FOR MEDICAL FACILITIES Created By: Lisa Leiding, RN, SANE Hospital or Clinic: GENERAL INFORMATION Incident(s) CHECK ALL THAT APPLY □ Domestic Violence □ Intimate Partner □ Teen dating violence □ Sibling Abuse □ Parent Abuse □ Child Abuse □ Elder Abuse

Presentation □ January    □ February □ March     □ April □ May       □ June □ July       □ August □ September □ October □ November □ December

□ 0801 – 1600 □ 1601 – midnight □ 0001 – 0800 □ Private Vehicle □ Walk □ Ambulance □ Law Enforcement

□ Saturday □ Sunday □ Monday □ Tuesday □ Wednesday □ Thursday □ Friday

REPORTING MANDATORY REPORTING □ Child Abuse □ Elder Abuse Interpersonal violence with: □ Shooting □ Stabbing □ Blunt Force Object □ Unconscious Patient □ Death

AGENCY □ City Police □ County Sheriff □ State Police □ Tribal Police □ BIA □ Children, Youth and Families (CYFD) □ SANE

WEAPONS □ Gun □ Knife □ Bat □ Car □ Phone calls □ Hands □ Feet □        □        □       

DISCLOSURE □ Screened □ Self-disclosure □ Suspected D. V. PATIENT TYPE □ Trauma (using    trauma    documentation) □ Abuser □ Victim

VICTIM INFORMATION □ Physical Abuse ○ Bruises ○ Scratches ○ Abrasions ○ Lacerations ○ Broken Bones ○ GSW ○ Burns ○ Bites ○ Internal Organ Injury ○ Head Trauma ○ Unconscious ○ Abortion: Spontaneous or Threatened

Ethnicity:       Immigration Status: □ Documented □ Undocumented Age:        

Injury Assessment: □ Psychological Abuse □ Economic Abuse □ Spiritual Abuse □ Sexual Assault/Abuse

Sex: □ Male □ Female Pregnant: □ Yes □ No □ Not Known

Victim Prescription Drug Use: □ None □                              

ABUSER INFORMATION Ethnicity:        Immigration Status: □ Documented □ Undocumented Age:          □ Unknown age Sex: □ Male □ Female Pregnant: □ Yes □ No □ Not Known

□ Same sex relationship □ Relationship to victim             □ Recent Separation/ divorce □ Never Married □ Children Present □ 1st Violent Incident □ 2 + Violent Incidents □ Violence in other relationships

Substance Use What was in system at time of incident?           Victim Abuser None          □   □ Illegal Drugs      □   □ Alcohol        □   □ Abuser Prescription Drug Use: □ None □             _ □              

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DISPOSITION AND REFERENCES □ Restraining Order □ Discharged □ Transferred to: □ Legal Aide □ Home             □ Law Enforcement □ To friend’s house □ Shelter □ Admitted unit:     □ Follow-up Pictures Counseling/Advocacy □ Critical Care □ Other: □ Rape Crisis Center □ Med – Surg             □ D.V. Counseling □ Mental Health □ Patient refused to discuss domestic violence. (Given hotline number and shelter information) □ Safety plan only □ Exam without photographs □ Full exam (examination, photographs, safety planning) Identified problems in transportation, examination or FOR OFFICE USE ONLY referral process: HealthCare Systems Implications:                        Private Insurance: □ Yes □ No                        Carrier                            Medicaid: □   Both □                        Medicare: □                        Self Pay: □ Yes □ No Indigent Funds: □ Yes □ No FOR OFFICE USE ONLY RECOMMENDED SOLUTIONS: How many prior visits? (1 year)                        Medical: _____                        Trauma related: ____                        How many subsequent visits?                          (1 year review)                        Medical: _____ Trauma related: ___ Domestic Violence Team Comments or Suggestions: (EMS, MD, Nursing, Advocate, Shelter, Law Enforcement, Charge Nurse, etc.)

                                                                                                                                                                                                             PATIENT’S PRIMARY MD:    

This patient has no Primary Doctor – made referral to:    

STAFF MD:                    PRIMARY NURSE:               CRISIS COUNSELOR:             

PATIENT’S STICKER OR Patient Initials:    Date of Birth:    Date of Exam:    Account #:      Medical Record Number OR Employee Number:      

This C.Q.I. tool must be removed from the Domestic Violence Flow Sheet after completed. This tool will be routed to the Trauma Program Office ASAP. Statistics will be made available at the completion of every quarter. THIS FORM IS NOT PART OF THE PATIENT’S MEDICAL RECORD. Confidential; Pursuant to Section 41-9-5, NMSA. From Leiding, Lisa, RN, SANE. Interpersonal Violence C.Q.I. Tool for Medical Facilities. Used with permission.

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References Douglas, H. 1991. Assessing violent couples. Families in Society. 72(9), 525–535. Fildes, J., L. Reed, N. Jones, M. Martin, and J. Barret. (1998). Trauma: The leading cause of maternal death. Journal of Trauma 32(5): 643–645, referenced in Warshaw and Ganley. (1998). 56. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2009). Family Violence, PC 01.02.09. http://www.jointcommission.org (accessed August 23, 2010). Mitchell, C. 2004. University of California, Davis Medical Center, California Medical Training Center, Connie Mitchell, M.D., Director, Domestic Violence Education. Guidelines for the Health Care of Intimate Partner Violence for California Health Professionals. Grant Award No. EM99041141 from the California Office of Emergency Services. Sacramento, CA. Scott, C. J. and R. M. Matriccian. 1994. Joint Commission on Accreditation of Healthcare Organizations standards to improve care for victims of abuse. Maryland Medical Journal. 43(10): 891–898. Tellez, T., K. Robinson, and M. Russell. 1999. Domestic Violence. Topics in Emergency Medicine. 21(2): 70–79. Tjaden, P. and Thoennes, N. 1998. Prevalence, incidence and consequences of violence against women: Findings from the national violence against women survey. Research in Brief. Washington, DC: U. S. Department of Justice, National Institute of Justice. Also in 2002 National Victim Assistance Academy Text, Chapter 10. http://www.ojp.usdoj/ovc/assist/nvaa2002/chapter10.html (accessed August 31, 2010). Warshaw, C. and A. Ganley, (eds.) 1995. Improving the healthcare response to domestic violence: A resource manual for health care providers. San Francisco: The Family Violence Prevention Fund. Warshaw, C. and A. L. Ganley. 1998. Improving the healthcare response to domestic violence: A resource manual for health care providers. San Francisco: The Family Violence Prevention Fund, p.16.

5

Sexual Assault

Sexual assault (Kilpatrick, Edmunds, and Seymour, April 23, 1992) and abuse is any type of sexual activity to which the receiving individual does not agree. It can be verbal, visual, or anything that forces a person to participate in unwanted sexual contact. In addition to actual rape (vaginal, anal, or oral penetration), unwanted sexual contact includes inappropriate touching, child molestation, voyeurism, exhibitionism, incest, and sexual harassment (Women’s Health, September 2010). Sexual assault is a crime.

Definitions A clear, definitive definition of sexual assault is difficult to establish for a number of reasons. Social norms and expectations have changed over the generations. There are vast differences between localities and cultures. The United States federal statutes (U.S. Code, Title 18, 2010) are gender neutral, allowing for inclusion of male victims. They also do not limit criminal behavior to acts of penetration of the vagina by a penis, allowing for inclusion of other acts such as oral, anal, and digital penetration. Abusive sexual contact* includes behaviors such as intentional touching, including biting, of genitalia, anus, groin, breasts, inner thigh, or buttocks of any person (age and gender neutral) with an intent to abuse, humiliate, harass, degrade, or arouse, or to gratify the sexual desire of another. As stated in the National Victim Assistance Academy (NVAA) manual (2002), these federal definitions imply that the victim’s state of mind at the time of the crime and the victim’s physical and psychological injuries are important in helping to classify the crime and determine the appropriate punishment.

Goals of Care The primary goals of patient care are to provide for immediate and long-term physical, psychological, emotional, and safety needs of the patient in a timely, sensitive, and supportive manner. Adjunct goals are more forensic in nature. They are to * Note that the federal law does not use the term rape, nor does it require use of the term rape in order to meet the requirements of a crime.

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• Encourage disclosure. • Assist law enforcement in investigation by collecting high-quality, admissible evidence. • Participate in a collaborative effort to determine the facts. • Facilitate appropriate prosecution by cooperation with attorneys. • Provide substantive, unbiased testimony at trial. Although healthcare personnel see themselves as advocates for the patient in the medical setting, it is extremely important that they function as neutral, impartial collectors, protectors, and disseminators of the facts, and nothing else. Healthcare systems also have a legal and moral obligation to provide equivalent and unbiased healthcare services to the perpetrator.

Injuries Serious physical injuries do occur and must be a priority in patient care. Most physical injuries, however, are minor—abrasions and contusions, minor cuts, and so on. The most consequential issue for the sexual assault victim is the devastating psychological impact. An intimate personal violation such as sexual assault can have a long-term emotional impact on the victim. For the victims of sexual assault, life will never be the same. Rape, or even attempted rape, leaves the victim feeling overwhelmed and vulnerable. Shock, anger, grief, and depression are common reactions. Victims are often confused and find it difficult to concentrate or make decisions (including the decision to cooperate with law enforcement or prosecution). Posttraumatic stress disorder (PTSD) is a serious and debilitating psychological disorder and can occur months or years after a traumatic event. Almost one-third of sexual assault victims develop PTSD at some point in their lives. In short, sexual assault is a psychological crisis rarely trumped by any physical trauma that may have occurred. Essential elements of recovery include rapid psychological intervention and stabilization. It is vital for healthcare personnel to understand the important role of psychological issues in the long-term recovery of the sexual assault victim and to respond promptly by providing supportive care. In addition, safety issues are a paramount concern. Sex offenders frequently repeat their offense. For a variety of reasons, many victims never report their rape to the authorities. Not only does the victim fail to receive justice (or achieve closure), the rapist remains unpunished and is able to victimize others (Kilpatrick, Edmunds, and Seymour, 1992). Most perpetrators of sexual assault are known to the victim and victims fear retaliation. Therefore, safety and confidentiality issues are extremely important to the victim. Additionally, according to the National Women’s Study (Tjaden and Thoennes, November 1998), over two-thirds of sexual assault victims were

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under the age of 17—an age where emotional and psychological abilities are not yet fully matured and integrated.

Role of the First Responder and Healthcare Provider First and foremost, determine that the scene, the patient, and you are safe. If the whereabouts of the assailant are unknown or likely to return, remove the patient to the rescue vehicle and leave the scene as soon as possible. Collect any bedding, clothing, and so on, according to chain of custody standards if possible, but do not delay getting yourself and the patient to a safe place. In addition to standard emergency response measures, there are some things the first responder can and should do when first encountering the victim of sexual assault.* In addition to getting consent for treatment and advising the patient of his or her rights under Health Insurance Portability and Accountability Act (HIPAA), have the patient sign a consent to photograph form. Explain that the victim has the right to revoke permission at a later date, but immediate and follow-up photography are critical pieces of prosecution, even if prosecution is delayed. If the scene is determined to be safe, take photographs as soon as possible using the basic techniques described in Chapter 2. Photograph the scene and victim exactly as found. Try to determine where the assault occurred. If it occurred in another room, photograph that scene as well. If the sexual assault occurred at another location, get as much information as possible as to the location and notify police so they can investigate. Collect and secure any evidence as explained in Chapter 3 or have law enforcement do it if they are available. Wear appropriate personal protective equipment (PPE), especially gloves. Change them often to avoid cross-contamination. If you come into direct contact with biological fluids that may contain evidential material, you may airdry the gloves and package as other evidence, labeling appropriately with the name of the responder and location biological material was encountered. Encourage the patients to proceed with evidence collection, even if they are unsure whether they will cooperate with police or pursue prosecution. Evidence not collected is evidence that cannot be used if patients change their minds later. Because some evidence is time-sensitive and fragile, it is also important to document the time the assault allegedly occurred and the time the evidence was collected. * Suggestions for police officers and first responders on how to interact with victims of sexual assault are found in Appendices 5.1 and 5.2.

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Ask if there was any oral involvement during the assault. If so, do not give the patient anything to eat or drink until oral swabs have been collected. Ask if the patient has showered. If so, using the evidence collection procedures listed above, collect all clothing the patient was wearing at the time, including shoes. If the patient has not showered, inform her that because there may be valuable evidence on her body, it is advisable she does not shower or change clothes. Collect any blanket or sheets that might have been under or around the patient. Have someone pack a bag with a complete set of clean clothes for the patient to wear home after the physical exam. Ordinarily, the patient will be offered the opportunity to shower as soon as the exam has been completed and evidence has been collected. Give the patient a brief overview of what to expect: an initial interview (with or without police and rape crisis advocate present), a physical exam (including pelvic exam), screening for pregnancy and sexually transmitted diseases, and prophylactic treatment offered, photographs taken, and collection of evidence for prosecution (including clothes, hair, and body fluids). Inform patients that they can refuse any services offered at any time, and that they will not be responsible for the cost of the forensic exam.* Some states, but not all, will also pay for portions of the exam that are medical in nature (i.e., treatment for preexisting conditions or diseases).

Sexual Assault Nurse Examiners (SANE) To meet the unique needs of victims of sexual assault, the sexual assault nurse examiner (SANE) or sexual assault forensic examiner (SAFE) programs were developed. Examination by a SANE nurse is highly recommended. National protocols for adults and adolescents have been written and are available free of charge as a download from the Internet or in CD form from the Department of Justice, Office of Violence Against Women (USDOJ, OVW, 2004),† Educational programs for SANE nurses have been created and certifications have been established. Because of the victim’s special needs, the SANE nurse’s higher level of education and expertise, and the collaborative relationship between law enforcement, advocacy, and the judicial system, it is highly recommended that all victims of sexual assault be referred to a SANE program as soon as possible. Legal and prosecutorial issues are complicated. SANE nurses are trained in how to avoid common pitfalls in the process such as the issue of consent, jurisdictional issues, handling biological evidence, the difference between * Make sure you know where billing should be sent in your jurisdiction. † Note that these do not apply to prepubescent children as those exams are significantly different.

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medical specimens and forensic specimens, and payment for treatment. It is strongly suggested that all healthcare providers read and understand the President’s DNA Initiative National Protocol for Sexual Assault Medical Forensic Examinations.

A National Protocol A National Protocol for Sexual Assault Medical Forensic Examinations of Adults and Adolescents (SAFEta) is available free of charge from the U. S. Department of Justice, Office of Violence Against Women (September 2004; NCJ 206554). The following material is a replication of the Goals of the National Protocol and the Recommendations at a Glance (a summary) (USDOJ, OVW, SAFEta, 2004). The entire protocol is downloadable from the Internet or available free of charge in CD form. The author strongly urges the reader to acquire and review the information contained therein. (Note: footnotes have been styled for clarity and ease of reading. Page references have been left intact; they refer to specific pages in the National Protocol.) Goals of the National Protocol for Sexual Assault Medical Forensic Examinations Consider what it might be like to be a victim of sexual assault who has come to a healthcare facility for a medical forensic examination. Sexual assault is a crime of violence against a person’s body and will. Sex offenders use physical and/or psychological aggression to victimize, in the process often threatening a victim’s sense of privacy, safety, and well-being. Sexual assault can result in physical trauma and significant mental anguish and suffering for victims. Victims may be reluctant, however, to report the assault to law enforcement and to seek medical attention for a variety of reasons. For example, victims may blame themselves for the sexual assault and feel embarrassed. They may fear their assailants or worry about whether they will be believed. A victim may also lack easy access to services. Those who have access to services may perceive the medical forensic examination as yet another violation because of its extensive and intrusive nature in the immediate aftermath of the assault. Rather than seek assistance, a sexual assault victim may simply want to go somewhere safe, clean up, and try to forget the assault ever happened.* It is our hope that this protocol will help jurisdictions to respond to sexual assault victims in the most competent, compassionate, and understanding manner possible. This protocol was developed with the input of national, local, and tribal experts throughout the country, including law enforcement representatives, * Paragraph adapted in part from the Ohio Protocol for Sexual Assault Forensic and Medical Examination, 2002, p. 2.

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prosecutors, advocates, medical personnel, forensic scientists, and others. We hope that this protocol will be useful in helping jurisdictions develop a response that is sensitive to victims of sexual assault and that promotes offender accountability. Specifically, the protocol has the following goals: • Supplement but not supercede the many excellent protocols that have been developed by States, tribes, and local jurisdictions, as well as those created at the national level. We hope that this protocol will be a useful tool for jurisdictions wishing to develop new protocols or revise their existing ones. It is intended as a guideline for suggested practices rather than a list of requirements. In many places, the protocol refers to “jurisdictional policies” because there may be multiple valid ways to handle a particular issue and which one is best should be determined by the jurisdiction after consideration of local laws, policies, practices, and needs. • Provide guidance to jurisdictions on responding to adult and adolescent victims. Adolescents are distinguished in the protocol from prepubertal children who require a pediatric exam. Pediatric exams are not addressed in this document. This protocol generally focuses on the examination of females who have experienced the onset of menarche and males who have reached puberty. Legally, jurisdictions vary in the age at which they consider individuals to be minors, laws on child sexual abuse, mandatory reporting policies for sexual abuse and assault of minors, instances when minors can consent to treatment and evidence collection without parental/guardian involvement, and the scope of confidentiality that minors are afforded. If the adolescent victim is a minor under the jurisdictional laws, the laws of the jurisdiction governing issues such as consent to the exam, mandatory reporting, and confidentiality should be followed. • Support the use of coordinated community responses to sexual violence. Although this document is directed primarily toward medical personnel and facilities, it also provides guidance to other key responders such as advocates and law enforcement representatives. This type of coordinated community response is supported by the Violence Against Women Act and subsequent legislation. Such a response can help afford victims access to comprehensive immediate care, minimize trauma victims may experience, and encourage them to utilize community resources. It can also facilitate the criminal investigation and prosecution, increasing the likelihood of holding offenders accountable and preventing further sexual assaults. • Address the needs of victims while promoting the criminal justice system response. Stabilizing, treating, and engaging victims as essential partners in the criminal investigation are central aspects of the protocol. Thus, this protocol includes information about concepts such as “blind reporting,” which may give victims needed time to decide if and when they are ready to engage in the criminal justice process. A blind report may also provide law enforcement agencies with potentially

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useful information about sex crime patterns in their jurisdictions. The objective is to promote better and more victim-centered evidence collection, in order to provide better assistance in court proceedings and hold more offenders accountable. • Promote high-quality, sensitive, and supportive exams for all victims, regardless of jurisdiction and geographical location of service provision. The protocol offers recommendations to help standardize the quality of care for sexual assault victims throughout the country. It also promotes timely evidence collection which is accurately and methodically gathered, so that high-quality evidence is available in court. This protocol discusses the roles of the following responders: healthcare providers, advocates, law enforcement representatives, forensic scientists, and prosecutors. Clearly, each of these professions has a role in responding to victims, investigating the crime, and/or holding offenders accountable. But rather than dictate who is responsible for every procedure within the exam process, the protocol is designed to help communities consider what each procedure involves and any related issues. With this information, each community can make decisions for its jurisdiction about the specific tasks of each responder during the exam process and the coordination needed among responders. The following is a general description of what each responder may assist with: • Advocates may be involved in initial victim contact (via 24-hour hotline or face-to-face meetings); offer victims advocacy, support, crisis intervention, information, and referrals before, during, and after the exam process; and help ensure that victims have transportation to and from the exam site. They often provide followup services designed to aid victims in addressing related legal and nonlegal needs. • Law enforcement representatives (e.g., 911 dispatchers, patrol officers, officers who process crime scene evidence, and investigators) respond to initial complaints, work to enhance victims’ safety, arrange for victims’ transportation to and from the exam site as needed, interview victims, coordinate collection and delivery of evidence to designated labs or law enforcement facilities, and investigate cases. • Healthcare providers assess patients for acute medical needs and provide stabilization, treatment, and/or consultation. Ideally, sexual assault forensic examiners perform the medical forensic exam, gather information for the medical forensic history, and collect and document forensic evidence from patients. They offer information, treatment, and referrals for sexually transmitted infections (STIs) and other nonacute medical concerns; assess pregnancy risk and discuss treatment options with the patient, including reproductive health services; and testify in court if needed. They typically coordinate with advocates to ensure patients are offered crisis intervention, support, and advocacy during and after the exam process and encourage use of other victim services. They may follow up with patients for medical and forensic purposes. Other health

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This document is intended only to improve the criminal justice system’s response to victims of sexual assault and the sexual assault forensic examination process and does not create a right or benefit, substantive or procedural, of any party. Recommendations at a Glance: A National Protocol for Sexual Assault Medical Forensic Examinations The National Protocol for Sexual Assault Medical Forensic Examinations offers guidance to jurisdictions in creating and implementing their own protocols, as well as recommending specific procedures related to the exam process. Recommendations at a Glance highlights key points discussed in the protocol, but it is not designed to be a stand-alone checklist on exam procedures or responsibilities of each involved responder. The protocol should be read to understand and respond to the complex issues presented during the exam process. See the protocol introduction for an explanation of select terms used in this chapter and the protocol. Goal of the Protocol A timely, well-done medical forensic examination can potentially validate and address sexual assault patients* concerns, minimize the trauma they may experience, and promote their healing. At the same time, it can increase the likelihood that evidence collected will aid in criminal case investigation, resulting in perpetrators being held accountable and further sexual violence prevented. The examination and the related responsibilities of health care personnel are the focus of this protocol. Recognizing that multidisciplinary coordination is vital to the success of the exam, the protocol also discusses the responses of other professionals, as they relate to the exam process. * Sexual assault patients are also referred to as victims, depending on which responders are primarily being discussed. The term “patients” is generally used by health care professionals.

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1. Coordinated approach: A coordinated, multidisciplinary approach to conducting the exam provides victims* with access to comprehensive immediate care, helps minimize trauma they may experience, and encourages their use of community resources. Such a response can also enhance public safety by facilitating investigation and prosecution, which increases the likelihood that offenders will be held accountable for their actions. Raising public awareness about the existence and benefits of a coordinated response to sexual assault may lead more victims to disclose the assault and seek help. Recommendations for jurisdictions to facilitate a coordinated approach to the exam process: • Understand the dual purposes of the exam process to address patients’ needs and justice system needs. Addressing patients’ needs may include evaluating and treating injuries; conducting prompt exams; providing support, crisis intervention, and advocacy; providing prophylaxis against sexually transmitted infections (STIs) and referrals; assessing reproductive health issues; and providing followup contact/care. Addressing justice system needs may include obtaining a history of the assault; documenting exam findings; properly collecting, handling, and preserving evidence; and (postexam) interpreting/analyzing findings, presenting findings, and providing factual and expert opinions. • Identify key responders and their roles. • Develop quality assurance measures to ensure effective immediate response. 2. Victim-centered care: Victim-centered care is paramount to the success of the exam process. Response to victims should be timely, appropriate, sensitive, and respectful. Recommendations for health care providers and other responders to facilitate victim-centered care: • Give sexual assault patients priority as emergency cases and respond in a timely manner. Provide them with as much privacy as possible, while ensuring that they are supported. • Recognize that the medical forensic exam is an interactive process that must be adapted to the needs and circumstances of each patient. • Be aware of issues commonly faced by victims from specific populations. For example, certain characteristics (e.g., culture, religion, language skills/mode of communication, disabilities, gender, and

* The term “victim” is not used in a strictly criminal justice context. The use of “victim” simply acknowledges that persons who disclose that they have been sexually assaulted should have access to certain services.

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•

• •

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• • •

• •

age) may influence a victim’s behavior in the aftermath of an assault, including the exam process. Understand the importance of victim services within the exam process. Victim service providers/advocates typically offer victims support, crisis intervention, information and referrals, and advocacy to ensure that victims’ interests are represented, their wishes respected, and their rights upheld. Providers/advocates also may offer support for family members and friends who are present. In addition, they can promote sensitive, appropriate, and coordinated interventions. Involve victim service providers/advocates in the exam process as soon after a victim discloses an assault as possible. Victims have the right to accept or decline victim services. Accommodate patients’ requests to have relatives, friends, or other support persons (e.g., a religious/spiritual counselor) present during the exam, unless the presence of that person could be considered harmful. (See C.4. The Medical Forensic History for confidentiality considerations regarding the presence of these individuals during history taking.) Accommodate victims’ request for responders of a specific gender as much as possible. Prior to starting the exam and before each procedure, describe what is entailed and its purpose to patients. Be sure that communication/ language needs are met and information is conveyed in a manner that patients will understand. After providing this information, seek patients’ permission to proceed and respect their right to decline any part of the exam. However, follow exam facility and jurisdictional policy regarding minors and adults who are incompetent to give consent. (For a more detailed discussion on seeking informed consent of patients, including consent by victims from specific populations, see A.3. Informed Consent.) Assess and respect patients’ priorities. Integrate exam procedures where possible (e.g., blood samples needed for medical and evidentiary purposes should be drawn at the same time). Address patients’ safety concerns during the exam. Sexual assault patients have legitimate reasons to fear further assaults from their attackers. Local law enforcement may be able to assist facilities in addressing patients’ safety needs. Provide information that is easy for patients to understand and that can be reviewed at their convenience. (Also see C.10. Discharge and Followup.) After the exam is finished, provide patients with the opportunity to wash, change clothes (providing clean replacement clothing if necessary), get food or drinks, and make needed phone calls.

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3. Informed consent: Patients should understand the full nature of their consent to each exam procedure. By presenting them with relevant information, they are in a position to make an informed decision about whether to accept or decline a procedure. However, they should be aware of the impact of declining a particular procedure, as it may negatively affect the quality of care, the usefulness of evidence collection, and, ultimately, any criminal investigation and/or prosecution. They should understand that declining a particular procedure might also be used to discredit them in court. If a procedure is declined, reasons why should be documented if the patient provides such information. Recommendations for healthcare providers and other responders to request patients’ consent during the exam process: • Seek informed consent as appropriate throughout the exam process for medical evaluation and treatment and the forensic exam and evidence collection. Coordinate efforts to obtain consent among responders. • Be aware of statutes and policies governing consent in cases of minor patients, vulnerable adult patients, and patients who are unconscious, intoxicated, or under the influence of drugs. In all cases, however, the exam should never be done against the will of the patient. 4. Confidentiality: Involved responders must be aware of the scope and limitations of confidentiality related to information gathered during the exam process. Confidentiality is intricately linked to the scope of patients’ consent. Members of a Sexual Assault Response Team (SART) or other collaborating responders should inform victims of the scope of confidentiality with each responder and be cautious not to exceed the limits of victim consent to share information in each case. Recommendations that jurisdictions may take to maintain confidentiality of patients: • Make sure that jurisdictional policies address confidentiality related to the medical forensic exam (e.g., of forensic documentation, photographs, and colposcopic video images). • Increase responders’ and patients’ understanding of confidentiality issues (e.g., scope of confidentiality advocates can provide; scope of confidentiality of information shared with examiners, law enforcement, prosecutors, and other responders with whom patient has contact; and what happens to information once it enters the criminal justice system). • Consider the impact of Federal privacy laws regarding health information on victims of sexual assault. • Strive to resolve intrajurisdictional conflicts. 5. Reporting to law enforcement: Reporting provides the criminal justice system with the opportunity to offer immediate protection to victims, collect evidence from all crime scenes, investigate cases, prosecute if there is sufficient evidence, and hold offenders accountable for crimes

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Forensic Science in Healthcare committed. Given the danger that sex offenders pose to the community, reporting can serve as a first step in efforts to stop them from reoffending. Equally important, reporting gives the justice system the chance to help victims address their needs, identify patterns of sexual violence in the jurisdiction, and educate the public about such patterns. It is recommended that service providers encourage victims to report due in part to the recognition that delayed reporting is detrimental to the prosecution and to holding offenders accountable. Victims need to know that even if they are not ready to report at the time of the exam, the best way to preserve their option to report later is to have the exam performed. Reporting requirements in sexual assault cases vary from one jurisdiction to another. Every effort should be made to facilitate treatment and evidence collection (if the patient agrees), regardless of whether the decision to report has been made at the time of the exam. Victims who are undecided about reporting who receive respectful and appropriate care and advocacy at the time of their exam are more likely to assist law enforcement and prosecution. Recommendations for jurisdictions and responders to facilitate victim-centered reporting practices: • Where permitted by law, patients, not healthcare workers, should make the decision to report a sexual assault to law enforcement. Patients should be provided with information about possible benefits and consequences of reporting so that they can make an informed decision. • It is not recommended to require reporting as a condition of performing or paying for the exam. Even if patients are undecided about reporting, they should be encouraged to provide a medical forensic history, undergo the forensic exam, and have evidence collected and stored. • Jurisdictions may want to consider alternatives to standard reporting procedures. For example, an anonymous or blind reporting system may be useful in cases in which victims do not want to report immediately or are undecided about reporting. • Jurisdictions should consider a variety of approaches that promote a victim-centered reporting process. Payment for the examination under VAWA: Under the Violence Against Women Act (VAWA),* a State, Territory, or the District of Columbia is entitled to funds under the STOP Violence Against Women Formula Grant Program only if it, or another governmental entity, incurs the full out-of-pocket cost of medical forensic exams for victims of sexual assault. The VAWA provisions indicate the exam should minimally include “an examination of physical trauma; determination of penetration/force; a victim interview; and collection and evaluation

* 42 U.S.C. § 3796gg-4.

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of evidence.”* “Full out-of-pocket costs” means any expense that may be charged to a victim in connection with the exam for the purpose of gathering evidence of a sexual assault.† Recommendations for jurisdictions to facilitate payment for the sexual assault medical forensic exam: • Understand the scope of the VAWA provisions related to exam payment. • Ensure that victims are notified of exam facility and jurisdictional policies regarding payment for medical care and the medical forensic exam, as well as if and how reporting decisions will impact payment. Relevant government entities are strongly encouraged to pay for medical forensic exams regardless of whether victims pursue prosecution. B. Operational Issues



1. Sexual assault forensic examiners: These are the health care professionals who conduct the examination. It is critical that all examiners, regardless of their discipline, are committed to providing compassionate and quality care for patients disclosing sexual assault, collecting evidence competently, and testifying in court as needed. Recommendations for jurisdictions to build the capacity of examiners performing these exams: • Encourage the development of specific examiner knowledge, skills, and attitudes. • Encourage advanced education and supervised clinical practice of examiners, as well as certification for nurses who are examiners. 2. Facilities: Health care facilities have an obligation to provide services to sexual assault patients. Designated exam facilities or sites served by specially educated and clinically prepared examiners increase the likelihood of a state-of-the-art exam, enhance coordination, encourage quality control, and increase quality of care for patients. Recommendations for jurisdictions to build capacity of health care facilities to respond to sexual assault cases: • Recognize the obligation of health care facilities to serve sexual assault patients. • Ensure that exams are conducted at sites served by specially educated and clinically prepared examiners. A designated facility may employ or have ready access to examiners to conduct the exam. Some

* 28 C.F.R. § 90.2(b) (1). The analysis of evidence gathered during the examination, along with examiner documentation of findings, may help in determining whether penetration occurred or force was used. However, examiners are not responsible for drawing conclusions about how injuries were caused or whether the assault occurred or not (although they can note consistency between patients’ statements and injuries they identify). † 28 C.F.R. § 90.14(a).

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Forensic Science in Healthcare jurisdictions have examiner programs that serve one or multiple exam sites within a specific area. • Explore what is best for the community regarding locations for exam sites. It is critical to consider how accessible facilities are to patients disclosing sexual assault, as well as the facility’s capacity to properly conduct these exams and treat related injuries. • Recognize that exam facilities and examiners may benefit from networking with examiners in other facilities or areas for support with peer review of medical forensic reports, quality assurance, and information sharing (e.g., on training opportunities, practices, and referrals for patients). • Consider developing basic jurisdictional requirements for exam sites. • Promote public awareness about where exams are conducted. Use specially educated and clinically prepared forensic examiners to conduct the exam, ensuring dissemination of relevant information to appropriate agencies and community members. Encourage first responders to work together to assist victims in using these sites. • If a transfer from one health care facility to a designated site is necessary, use an established protocol that minimizes time delays and loss of evidence while addressing a patient’s needs. However, avoid transferring these patients whenever possible. 3. Equipment and supplies: Certain equipment and supplies are essential to the exam process (although they may not be used in every case). These include a copy of the most current exam protocol used by the jurisdiction, standard exam room equipment and supplies, comfort supplies for patients, sexual assault evidence collection kits, an evidence drying device/method, a camera, testing and treatment supplies, an alternate light source, an anoscope, and written materials for patients. A microscope and/or toluidine blue dye may be required, depending on jurisdictional policy. A colposcope or other magnifying instrument is strongly suggested. Some jurisdictions are also beginning to use advanced technology (telemedicine), which allows examiners offsite consultation with medical experts by using computers, software programs, and the Internet. Recommendations for jurisdictions and responders to ensure that proper equipment and supplies are available for examinations: • Consider what equipment and supplies are essential. • Address cost barriers to obtaining equipment and supplies. 4. Sexual assault evidence collection kit (for evidence from victims): Most jurisdictions have developed their own sexual assault evidence collection kits or purchased premade kits through commercial vendors. Kits often vary from one jurisdiction to another. Despite variations, however, it is critical that every kit meets or exceeds minimum guidelines for contents: broadly including a kit container, instruction sheet and/or checklist, forms, and materials for collecting and preserving all evidence required by the

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applicable crime laboratory. Evidence that may be collected includes, but is not limited to, clothing, foreign materials on the body, hair (including head and pubic hair samples and combings), oral and anogenital swabs and smears, body swabs, and a blood or saliva sample for DNA analysis and comparison. The instruction sheet and/or checklist should guide examiners on maintaining the chain of custody for evidence collected. Recommendations for jurisdictions and responders when developing/customizing kits: • Use standardized kits (across a local jurisdiction, region, State, Territory, or tribal land) that meet or exceed minimum guidelines for contents, as described above. • Make kits readily available at any facility that conducts sexual assault medical forensic exams. • Periodically review the kit’s efficiency and usefulness and make changes as needed. 5. Timing considerations for collecting evidence: Although many jurisdictions currently use 72 hours after the assault as the standard cutoff time for collecting evidence, evidence collection beyond that point is conceivable. Because of this, some jurisdictions have extended the standard cutoff time (e.g., to 5 days or 1 week). Advancing DNA technologies continue to extend time limits because of the stability of DNA and sensitivity of testing. These technologies are even enabling forensic scientists to analyze evidence that was previously unusable when it was collected years ago. Thus, it is critical that in every case where patients are willing, examiners obtain the medical forensic history, examine patients, and document findings. Not only can the information gained from the history and exam help health care providers address patients’ medical needs, but it can guide examiners in determining whether there is evidence to collect and, if so, what to collect. Recommendations for health care providers and other responders to maximize evidence collection: • Whether or not evidence is collected, examiners should obtain the medical forensic history as appropriate, examine patients, and document findings (with patients’ consent). Patients’ demeanor and statements related to the assault should also be documented. • Promptly examine patients to minimize loss of evidence and to identify medical needs and concerns. • Decide whether to collect evidence and what to collect on a caseby-case basis, remembering that outside time limits for obtaining evidence vary. • In any case, where the need for evidence collection is in question, encourage dialogue about the potential benefits or limitations of collection. Avoid basing decisions about whether to collect evidence on a patient’s characteristics or circumstances (e.g., the patient has used illegal drugs).

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Forensic Science in Healthcare • Responders should seek education and resources that aid them in making well-informed decisions about evidence collection. 6. Evidence integrity: Properly collecting, preserving, and maintaining the chain of custody of evidence is critical to its subsequent use in criminal justice proceedings. Recommendations for health care providers and other responders to maintain evidence integrity: • Follow jurisdictional policies for drying, packaging, labeling, and sealing the evidence. • Follow jurisdictional policies for documenting exam findings, the medical forensic history, and the patient’s demeanor/statements, and packaging, labeling, and sealing such documentation. • Follow jurisdictional policies for consistent evidence management and distribution. A duly authorized agent should transfer evidence from the exam site to the appropriate crime lab or other designated storage site (e.g., a law enforcement property facility). • Make sure storage procedures maximize evidence preservation. Ensure that storage areas are kept secure and at the proper temperature for the evidence. Also, make sure jurisdictional policies are in place to address the secure storage of evidence in cases in which patients are undecided about reporting. • Maintain the chain of custody of evidence. All those involved in handling, documenting, transferring, and storing evidence should be educated regarding the specifics of their roles in properly preserving evidence and maintaining the chain of custody. C. The Examination Process



1. Initial contact: Some sexual assault patients may initially present at a designated exam facility, but most who receive immediate medical care initially contact a law enforcement or advocacy agency for help. If 911 is called, law enforcement or emergency medical services (EMS) may be the first to provide assistance to victims. Communities need to have procedures in place to promptly respond to disclosures/reports of sexual assault in a standardized and victim-centered manner. Recommendations for jurisdictions and responders to facilitate initial contact with victims: • Build consensus among involved agencies regarding procedures for a coordinated initial response when a recent sexual assault is disclosed or reported, and educate responders on procedures. Encourage victims to interact with advocates as soon after disclosure as possible. • Recognize essential elements of initial response. In particular, encourage victims to seek medical care and have evidence collected. In the case of life-threatening or serious injuries, obtain emergency medical assistance according to jurisdictional policy. Any life-threatening

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wounds should be treated and victims’ immediate safety needs should be addressed before evidence is collected. • If victims decide to seek medical care and/or have evidence collected, follow jurisdictional policies for preserving evidence, collecting a urine sample if needed, and transporting victims to the exam site. 2. Triage and intake: Once patients arrive at the exam site, health care personnel must evaluate, stabilize, and treat for life-threatening and serious injuries according to facility policy. Standardized procedures for response in these cases should be followed, while respecting patients and maximizing evidence preservation. Recommendations for health care providers to facilitate triage and intake that addresses patients’ needs: • Consider sexual assault patients a priority. Use private locations in the exam facility for the primary patient consultation and initial law enforcement interviews, offer a waiting area for family members and friends, and provide childcare if possible. • Respond to acute injury, trauma care, and safety needs of patients before collecting evidence. Patients should not wash, change clothes, urinate, defecate, smoke, drink, or eat until initially evaluated by examiners, unless necessary for treating acute medical needs. • Alert examiners to the need for their services at the exam site. • Contact victim advocates so they can offer services to the patient, if not already done. • Assess and respond to safety concerns, such as threats to the patient or staff, upon arrival of patients at the exam site. • Assess patients’ needs for immediate medical or mental health intervention. Seek informed consent from patients before providing treatment, according to facility policy. 3. Documentation by health care personnel: Examiners document exam findings, the medical forensic history, and evidence collected in the medical forensic report. Examiners and/or other involved clinicians separately document medical care in the patient’s medical record. Recommendations for health care providers to complete needed documentation: • Ensure completion of all appropriate documentation. The forensic details of the exam are documented in the medical forensic report, according to jurisdictional policy. The only medical issues documented in this report are acute findings that potentially relate to the assault or preexisting medical factors that could influence interpretation of findings. Separate medical documentation by examiners and other involved clinicians follows a standard approach—address acute complaints, gather pertinent historical data, describe findings, and document treatment and followup care. • Ensure the accuracy and objectivity of medical forensic reports by seeking education on proper report writing.

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Forensic Science in Healthcare 4. The medical forensic history: Examiners ask the patient questions to obtain this history. This information guides them in examining the patient and collecting evidence. Recommendations for health care providers to facilitate gathering information from patients: • Examiners should coordinate with other responders, primarily law enforcement representatives, to facilitate information gathering that is respectful to patients and minimizes repetition of questions. • Keep in mind that advocates may support and advocate for patients when the medical forensic history is taken (if desired by patients), but they may not actively participate in the process. Patients should be informed that the presence of family members, friends, and others offering personal support during this time may influence or be perceived as influencing their statements. If patients choose to have others present despite this knowledge, these individuals should not actively participate in the process. • Consider and address patients’ needs prior to information gathering, including identifying the level of their communication skill and modalities and then tailoring information gathering accordingly. • Obtain the medical forensic history in a private, quiet setting. • Gather information for the history according to jurisdictional policy. Include the date and time of the assault, pertinent patient medical history (e.g., menstruation history), recent consensual sexual activity of the patient, the patient’s activities since the assault (e.g., took a shower), the patient’s assault-related history (e.g., loss of consciousness), suspect information, if known (e.g., number and gender of assailants), nature of the physical assault, and description of the sexual assault. 5. Photography: Photographic evidence of injury on the patient’s body can supplement the medical forensic history and document physical findings. Recommendations for health care providers and other responders to photograph evidence: • Come to a consensus about the extent of forensic photography necessary. Some jurisdictions routinely take photographs of both detected injuries on patients and normal (apparently uninjured) anatomy, while others limit photography to detected injuries. • Consider who will take photographs and what equipment will be used. Photographers should be familiar with equipment operation as well as educated in forensic photography and in ways to maintain the patient’s privacy and dignity while taking photographs. Consult with jurisdictional criminal justice agencies and examiners regarding the type of equipment that should be used. • Obtain informed consent from patients before taking photographs. Patients should understand the purpose of the photographs, what will be photographed and any related procedures, the potential uses

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of photographs during investigation and prosecution, and the possible need for followup photographs. • Consider the patient’s comfort and need for modesty. • Identify who will be present when photographs are taken. • Take initial and followup photographs as appropriate, according to jurisdictional policy. 6. Exam and evidence collection procedures: Examiners examine patients and collect evidence according to jurisdictional policy. Findings from the exam and collected evidence often help reconstruct the events in question in a scientific and objective manner. Recommendations for health care providers to conduct the exam and facilitate evidence collection: • Strive to collect as much evidence from patients as possible, considering the scope of informed consent, the medical forensic history, the examination, and evidence collection kit instructions. • Be aware of evidence that may be pertinent to the issue of whether the patient consented to sexual contact with the suspect. Understand how biological evidence is tested. • Prevent exposure (of both patients and staff) to infectious materials and contamination of evidence. • Understand the implication of the presence or lack of semen (in cases involving male suspects). • Seek informed consent from patients for each portion of the exam and evidence collection. • Modify the exam and evidence collection to address the specific needs and concerns of patients. • Conduct the general physical and anogenital examination, guided by the scope of informed consent and the medical forensic history. Document findings on body diagram forms. With the patient’s consent, use an alternate light source, colposcope, and anoscope, as appropriate and if available, to increase the likelihood of detecting evidence. • Collect evidence to submit to the crime lab for analysis, according to jurisdictional policy. • Collect blood and/or urine for toxicology screening, if applicable. • Keep medical specimens separate from forensic specimens collected during the exam. 7. Drug-facilitated sexual assault: Responders must consider the possibility that drugs may have been used to facilitate an assault. They must know how to screen for suspected drug-facilitated sexual assault, obtain informed consent of patients for testing, and collect toxicology samples when needed. Recommendations for jurisdictions and responders to facilitate response in suspected drug-facilitated sexual assault: • Educate examiners, 911 dispatchers, law enforcement representatives, prosecutors, judges, and advocates on related issues. Develop

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Forensic Science in Healthcare jurisdictional policies to clarify first responders’ roles in cases involving suspected drug-facilitated assault. • Be clear about the circumstances in which toxicology testing may be indicated (for optimal care or when there is a suspicion of drugfacilitated sexual assault). Routine toxicology testing in all sexual assault cases is not recommended. • Informed consent of patients should be sought to collect toxicology samples. Patients should be aware of the purposes and scope of testing that will be done, potential benefits and consequences of testing, any followup treatment necessary, how they can obtain results, who will pay for the testing, and if they have any opportunity to revoke consent to testing. • With patients’ permission, immediately collect a urine specimen if it is suspected that ingestion of drugs used to facilitate sexual assault occurred within 96 hours prior to the exam. The first available urine should be collected—law enforcement and emergency medical services should be trained and prepared to collect a urine sample if patients must urinate prior to arrival at the health care facility for the exam. Advocates and other professionals who may have contact with patients prior to their arrival at the exam site should also be educated to provide those who suspect drug-facilitated assault with information on how to collect a sample if the patient cannot wait to urinate until getting to the site. • Also, collect a blood sample if it is suspected that the ingestion of drugs used to facilitate sexual assault occurred within 24 hours of the exam. If a blood alcohol determination is needed, collect blood within 24 hours of ingestion of alcohol, according to jurisdictional policy. • Jurisdictional policies should be in place and followed for packaging, storing, and transferring samples. 8. Sexually transmitted infection (STI) evaluation and care: Because contracting an STI from an assailant is of significant concern to patients, it should be addressed during the exam. Recommendations for health care providers to facilitate STI evaluation and care: • Offer patients information about the risks of STIs (including HIV), the symptoms and what to do if symptoms occur, testing and treatment options, followup care, and referrals. Referrals should include free and low-cost testing, counseling, and treatment available in various sections of the community. For HIV testing, confidential and anonymous testing is recommended. • Consider testing patients for STIs during the initial exam on a caseby-case basis. If testing is done, follow the guidelines of the Centers for Disease Control and Prevention (CDC). • Encourage patients to accept prophylaxis against STIs during the initial exam. (Note, however, that treatment may not be appropriate

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for some individuals—for example, if they have a condition that may be adversely affected by taking prophylaxis.) The CDC suggests a regimen to protect against chlamydia, gonorrhea, trichomonas, and bacterial vaginosis (BV), as well as the hepatitis B virus. If accepted, provide care that meets or exceeds CDC guidelines. If declined, it is medically prudent to obtain cultures and arrange for a followup exam and testing. Seek informed consent from patients for treatment, according to facility policy. • Encourage and facilitate followup STI examinations, testing, immunizations, and treatment as directed. • Offer postexposure prophylaxis for HIV to patients at high risk for exposure, particularly when it is known that suspects have HIV/ AIDS. Meet or exceed CDC recommendations. Discuss risks and benefits of the prophylaxis with patients prior to their decisions to accept or decline treatment. Careful monitoring and followup by a health care provider or agency experienced in HIV issues is required. 9. Pregnancy risk evaluation and care: Female patients may fear becoming pregnant as a result of an assault. Health care providers must address this issue according to facility and jurisdictional policy. Recommendations for health care providers to facilitate pregnancy evaluation and care: • Discuss the probability of pregnancy with patients. • Administer a baseline pregnancy test for all patients with reproductive capability. • Discuss treatment options with patients, including reproductive health services. 10. Discharge and followup: Health care personnel have specific tasks to accomplish before discharging patients, as do advocates and law enforcement representatives (if involved). Responders should coordinate discharge and followup activities as much as possible to reduce repetition and avoid overwhelming patients. Recommendations to facilitate discharge and followup: • It is important to ensure that patients are fully informed about postexam care. Information may include referrals to other professionals to make sure that patients’ medical and/or mental health needs related to the assault have been addressed, discharge instructions, followup appointments with the examiner or other health care providers, and contact procedures for medical followup. In addition to medical followup, followup may be indicated to document developing or healing injuries and complete resolution of healing. • Advocates and law enforcement representatives, if involved, should coordinate with examiners to discuss other issues with patients, including planning for their safety and well-being, physical comfort needs, information needs, the investigative process, advocacy and

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Forensic Science in Healthcare counseling options, and law enforcement and advocacy followup contact procedures. 11. Examiner court appearances: Health care providers conducting the exam should expect to be called on to testify in court as fact and/or expert witnesses. Recommendations for jurisdictions to maximize the usefulness of examiner testimony in court: • Encourage broad education for examiners on testifying in court. • Promote prompt notification of examiners if there is a need for them to testify in court. • Encourage pretrial preparation of examiners. • Encourage examiners to seek feedback on testimony to improve effectiveness of future court appearances (USDOJ, A National Protocol [SAFEta] 2004).

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Appendix 5.1: Suggestions for Police Officers in Sexual Assault Cases Law enforcement exemplifies the concept of public service. The motto is to serve and protect. Those goals are achieved in a variety of ways, including physically protecting a person or their property, interviewing victims and witnesses, collecting and securing evidence, analyzing evidence and maintaining it for presentation in court, testifying, and helping prevent crime and violence in our communities. In cases of sexual assault, the long-term psychological consequences usually outweigh the physical ones. Therefore, focusing on the victim before and during your handling of the case is crucial to the long-term outcome. Although the following comments may seem like common sense to the experienced officer, other officers may be relatively unfamiliar and/or uncomfortable in dealing with victims of sexual violence. These guidelines are intended to provide all officers with a reminder of how to best handle the victims of sexual crime. Many victims are quite unfamiliar with the victim experience and our criminal justice system. Initially it all appears to be quite impersonal, frightening, and overwhelming. While a successful prosecution will go a long way to help a survivor move toward a positive resolution and may help to reduce the overall incidence of sex crimes in our communities, if the victim is inadvertently intimidated by the system, she is less likely to cooperate and follow through with prosecution. 1. Be mindful of the severe psychological trauma the victim has just suffered. Approach the victim in an unhurried, professional manner; don’t “charge in” like a rescuing cowboy. A gentle, supportive demeanor works best in these cases. 2. Speak softly and avoid any aggressive or intimidating behavior that might further frighten the victim. 3. If you are first on-scene make sure EMS is in route and let the victim know they should be arriving shortly. If EMS is not coming, accompany the victim to medical care. Explain basic procedures to help alleviate the victim’s fears. 4. Let the victim know you are concerned for her safety and well-being. Try to determine whether the perpetrator is still nearby or might return soon. In addition to time and place of assault, try to obtain information on the perpetrator to assist in apprehension: physical description, clothing worn, vehicle used (if any), direction of flight and any weapon used. Transmit this basic information by radio, if possible, but do not release the victim’s name or address. Local media DO listen to radio transmissions.

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5. If the assault was recent, advise the victim not to wash, douche, or urinate. Explain that valuable evidence may otherwise be lost. 6. Advise the victim that sexual assault nurse examiners (SANE nurses) are available and that they specialize in sexual assault cases, including confidential interviews, evidence collection, pregnancy and sexually transmitted disease prophylaxis, and follow-up review. 7. Photographs and evidence collection may be done at the scene, but examination of the victim’s body and wound photographs will be taken by the SANE nurse. A national protocol is available free online from SAFEta (http://www.safeta.org/index.cfm). Explain procedures in your jurisdiction and include a mention of this in your notes. 8. Avoid in-depth questioning until meeting up with the sexual assault nurse examiner. If you will not be assigned to this case, leave such questioning to that officer. This reduces the number of times the victim has to initially tell her story. 9. Throughout contact with the victim and/or family, avoid the appearance of being judgmental and making statements that might be construed as prejudicial. Regardless of any poor choices made by the victim, including the choice to be in a vulnerable situation, now is not the time to berate or “educate” the victim. 10. Remember, the family has also been affected by this event. Treat the family with the same respect and caution as the victim. 11. Try to conduct interviews in a room or space different from the actual “scene” of the attack. This will help to reduce inadvertent contamination of the scene. 12. Interview family and others present separately. Be sure to let them know that the victim is blameless and acted correctly in submitting. Otherwise, she might have been killed. 13. Protect the victim’s anonymity by minimizing exposure to unwanted attention from bystanders, media, or others. 14. If the victim presents to the police station, determine if a family member may have perpetrated this crime and contact the local victim’s advocacy center or other community support agency to find the victim a safe place to stay. 16. If the victim specifically and continuously requests a female officer, make every effort to provide one. There are, however, advantages to having a sensitive male deal with sex crimes. In addition to showing the victim that not all men are aggressive and violent, a supportive male can connect with a female victim in a way that another female cannot. Additionally, a supportive officer can ease the transition between fear of males and trust. The gender of the investigating officer is not nearly as important as their attitude, approach, sensitivity, and skills in crisis intervention and investigative competence.

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17. Especially for victims who choose not to have a medical evaluation and consult, initiating contact with victim support services such as the local rape crisis center is important in the victim’s recovery. Inform the victim of locally available counseling and support services and recommend they take advantage of these services. Many of them are free. 18. Do not try to explain investigative or judicial procedures at this time. When in crisis, victims remember little of what happened and almost none of what was said. In addition, the victim will need support and guidance throughout the entire process. Counseling services, victim support providers, and legal advocacy services are designed for these purposes. 19. Remember, the immediate safety, support, and treatment are of paramount concern. Key Point: The actions of the first officer on scene may have a vital impact on the future psychological well-being of the victim and may play a significant role in deciding whether or not to follow through with filing charges and prosecution. Victims of sexual assault will never be the same. Memory of the assault will fade with time and support, but it will never be erased. Life will go on. Hopefully, the rape will become something that happened but not define the victim’s entire identity. By recognizing the need for appropriate sensitivity, all providers assist victims by helping them make the transition from victim to survivor. Source: Adapted. Original information contained in North Coast Forensics, Richfield, Ohio, FBI training manual, 1992. Additions and suggestions from Sgt. George Kral, TPD, Personal Assault Unit, John W. Calogar, retired Chief Olmsted Falls, Ohio Fire Dept., Sally Royston, RN, SANE Coordinator, Toledo Area SANE/SART Program. Secondary source unknown.

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Appendix 5.2: Suggestions for First Responders in Sexual Assault Cases Fire, rescue, and emergency medical service providers are the people we turn to in a time of crisis. Like law enforcement, these public servants provide the unseen, and hopefully unneeded, security net supporting our health and daily activities. The goals of emergency services are achieved in a variety of ways, from rescuing a cat or stranded skier to getting the heart attack victim to definitive care at a hospital, to caring for the victims of trauma, interpersonal violence, or sexual assault, and from preventing fires to putting them out. Be it in the home, at work, on the street or out in the wilderness, fire, rescue, and EMS personnel are the knights in shining armor in times of crisis. In cases of sexual assault, the long-term psychological consequences usually outweigh the physical ones. Therefore, focusing on the victim’s psychological needs is as important as your handling of the case to long-term health and welfare of the patient. Although the following comments may seem like common sense to the experienced provider, other healthcare providers may be relatively unfamiliar and/or uncomfortable in dealing with victims of sexual violence. These guidelines are intended to provide all providers with a reminder of how to best handle the victims of sexual crime. 1. Many victims are quite unfamiliar with the victim experience and our criminal justice system. It initially appears to be quite impersonal, frightening, and overwhelming. While a successful prosecution will go a long way to help a survivor move toward a positive resolution and may help to reduce the overall incidence of sex crimes in our communities, if the victim is inadvertently intimidated by the system she is less likely to follow through to see prosecution finalized. 2. Be mindful of the severe psychological trauma the victim has just suffered. Approach the victim in an unhurried, professional manner; don’t charge in like a rescuing cowboy. A gentle, supportive demeanor works best in these cases. 3. Speak softly and avoid any aggressive or intimidating behavior that might further frighten the victim. 4. Let the victim know you are concerned for her safety and well-being and try to determine whether the perpetrator is still nearby or might return soon. If there is any chance the perpetrator might return or the scene is unsafe in any other way (e.g., there is a gas leak or other danger), call law enforcement immediately and remove yourself, your crew, and the victim to a safe location. 5. Do your primary assessment.

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6. If life-threatening conditions exist, load and go. a. Please try to avoid cutting through stains, cuts, or other places where evidence might be found. b. Have dispatch advise the receiving facility that you have a sexual assault victim. c. If the assault was recent, advise the victim not to wash, douche, or urinate. Explain that valuable evidence may otherwise be lost. d. Have dispatch advise the local SANE unit or healthcare facility that a sexual assault victim is on the way. 7. If life-threatening conditions do not exist, finish your assessment and determine if the patient needs transport to the hospital or SANE unit and if she wishes to be transported by rescue or wishes to go on her own. a. Recognize that the patient’s body may be a crime scene containing evidence. b. If the assault was recent, advise the victim not to wash, douche, urinate, or change clothes. Explain that valuable evidence may otherwise be lost. Notify the SANE unit or hospital if the patient has urgent need to void. c. Do not use alcohol or germicidal agents, especially in areas where there are signs of biomaterial or where the patient indicates the perpetrator may have left body fluids by licking, spitting, ejaculating, etc. Pick a different spot to start the IV. d. If the patient has not changed clothes, leave them on. Please do not cut clothing where evidence might be found—underwear, through tears, rips or cuts, and any area where stains might be found. e. Unless there is a reason* not to wait for law enforcement, let them collect evidence. If the patient has already changed clothes, wearing appropriate PPE, collect each item separately and place it in a paper bag. If paper containers are not readily available, notify law enforcement of the whereabouts of all clothing (including shoes, underwear, etc.). Evidence rapidly decomposes in plastic bags and the chain of custody is all-important, so law enforcement should be involved and evidence properly collected. 8. Advise the victim that sexual assault nurse examiners (SANE nurses) are available and that they specialize in sexual assault cases, including confidential interviews, evidence collection, pregnancy and sexually transmitted disease prophylaxis, and follow-up review. * Including length of time for them to arrive and/or demonstrated lack of competence in evidence collection.

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9. Protect the victim’s anonymity by minimizing exposure to unwanted attention from bystanders, media, or others. 10. Appropriate photographs and evidence collection may be done at the scene, but examination of the victim’s body and wound photographs will be taken by the SANE nurse. A body diagram and good narrative should suffice if the patient is going to a medical facility. 11. Explain procedures in your jurisdiction and include a mention of procedures followed in your notes. (A National Protocol, USDOJ, SAFEta, 2004.) 12. Obtain a basic recitation of the assault, but avoid in-depth questioning as that will be done by law enforcement and the sexual assault nurse examiner. This reduces the number of times the victim has to re-live the experience. 13. Throughout contact with the victim and/or family, avoid the appearance of being judgmental and making statements that might be construed as prejudicial. Regardless of any poor choices made by the victim, including the choice to be in a vulnerable situation, now is not the time to berate or “educate” the victim. 14. Remember, the family has also been affected by this event and may be in a state of crisis themselves, especially if the victim is young. Treat the family with the same respect and caution as the victim. If appropriate, let the family know that the victim acted correctly as she is still alive. 15. Try to conduct the patient interview in a room or space different from the actual “scene” of the attack. This will help to reduce inadvertent contamination of the scene. 16. Interview family and others present separately. Be sure to let them know that the victim is blameless and acted correctly in submitting. Otherwise, she might have been killed. 17. If the victim specifically and continuously requests a female provider, make every effort to provide one. There are, however, advantages to having a sensitive male deal with sex crimes. In addition to showing the victim that not all men are aggressive and violent, a supportive male can connect with a female victim in a way that another female cannot. Additionally, a supportive male provider can ease the transition between fear of males and trust. The gender of the healthcare provider is not nearly as important as their attitude, approach, sensitivity, and skills in crisis intervention and investigative competence. 18. Especially for victims who choose not to have a medical evaluation and consult, initiating contact with victim support services such as the local rape crisis center is important. Have a list of local counseling and support services and recommend the victim contact them,

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especially if they are not going to a SANE unit or other medical care facility. 19. Do not try to explain investigative or judicial procedures at this time. When in crisis, victims remember little of what happened and almost none of what was said. In addition, the victim will need support and guidance throughout the entire process. Counseling services, victim support providers, and legal advocacy services are designed for these purposes. 20. Remember, the immediate safety, support, and treatment are of paramount concern. Key Point: The actions of the first responder on scene may have a vital impact on the future psychological well-being of the victim and may play a significant role in deciding whether or not to follow through with pressing charges and following up with prosecution. Victims of sexual assault will never be the same. Memory of the assault will fade with time and support but it will never be erased. Life will go on. Hopefully, the rape will become something that happened but not define the victim’s entire identity. By recognizing the need for appropriate sensitivity, all providers assist victims by helping them make the transition from victim to survivor. Adapted from: Original information contained in North Coast Forensics, Richfield, Ohio, FBI training manual, 1992. Additions and suggestions from Sgt. George Kral, TPD, Personal Assault Unit, John W. Calogar, retired Chief Olmsted Falls, Ohio Fire Dept., Sally Royston, RN, SANE Coordinator, Toledo Area SANE/SART Program. Secondary source unknown.

References Kilpatrick, D. G., C. N. Edmunds, and A. K. Seymour. 1992. Rape in America: A report to the nation. National Victim Center and Crime Victims Research and Treatment Center. April 23, 1992. National Victim Assistance Academy Manual (NVAA). 2002. http://www.ovc.gov/ assist/nvaa2002/ (accessed August 28, 2010). Sexual Assault: Frequently asked questions. http://www.womenshealth.gov/faq/sexualassault.pdf (accessed October 18, 2008). Tjaden, P. and Thoennes, N. 1998. The National Women’s Study: Research in Brief. Office on Women’s Health, Department of Health and Human Services. Content last updated March 1, 2009.

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U. S. Code, Title 18, Chapter 109A, Sexual Abuse, §2241-2243 http://www.law.cornell.edu/uscode/uscode18 (accessed September 2, 2010). U.S. Department of Justice (USDOJ), Office of Violence against Women. A National Protocol for Sexual Assault Medical Forensic Examinations for Adults and Adolescents. President’s DNA Initiative, NCJ 206554. 42 U.S.C. §3796gg-4(d) September 2004. http://www.safeta.org/index.cfm and from http://www.safeta. org/associations/8563/files/National%20Protocol.pdf (accessed August 31, 2010), and http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf (accessed September 2, 2010). Also available free of charge from SAFEta as a CD. Women’s Health. 2010. The National Women’s Health Information Center, U.S. Department of Health and Human Services, Office on Women’s Health. http:// www.womenshealth.gov/faq/support-assault.pdf (accessed August 28, 2010).

6

Child Abuse and Neglect

Each of us, whether we have anything to do with children or not, is directly affected by how they are treated. —Bookmark produced by Uniquity booksellers, P. O. Box 10, Galt, CA. (209) 745-2111

Every day children in America are beaten, sexually abused, and murdered, often at the hands of members of their own family or family friends. Child abuse is not an accident.

Definition of Child Abuse Harm done to a child by a parent or caregiver* is known as child abuse.† It includes physical, emotional, and sexual abuse as well as neglecting to provide for the basic needs of a child. Child abuse and neglect, as defined by Congress in 1993 (PL 93-247), means “the physical or mental injury, sexual abuse, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate that the child’s health or welfare is harmed or threatened thereby.” Physical Abuse Physical abuse is the direct and intentional infliction of physical injuries to a child by a parent or caregiver. Child abuse may be a single physical attack or a pattern of behavior repeated over time. Injuries include hitting, kicking, biting, use of an implement or weapon on a child, burning (as with a cigarette or other hot object), bruising, shaking, strangulating, use of excessive force, immersion in hot water, broken bones, internal trauma, or torture.

* The caregiver may be long term as in a grandparent or short term as when someone babysits. † Maltreatment by someone other than a caregiver or parent falls under different statutes.

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Emotional Abuse Emotional abuse is the failure of a parent or caregiver to provide appropriate support, attention, and affection necessary for a child to develop intellectually and emotionally. Abusive features may include intentional use of words that hurt, threaten, or unduly criticize. The parent may withhold love and affection from a child even to the point of outright rejection. It is also emotional abuse when a parent looks to the child to meet their own physical and/ or emotional needs. Sexual Abuse Sexual abuse is inappropriate sexual touching or contact with a child. It involves the use of a child or adolescent for the sexual gratification of another person and includes such behaviors as intercourse, sodomy, oral-genital stimulation, verbal stimulation, exhibitionism, voyeurism, fondling, and involving a child in prostitution or the production of pornography. Incest is sexual abuse that occurs within a family. Neglect Neglect is the failure to provide a nurturing environment that supports a child’s growth and development. They are acts of omission that fail to meet the basic needs of a child such as food, shelter, medical care, educational opportunity, protection, and supervision. Munchausen by Proxy Munchausen by proxy is a specific abuse/neglect situation where the caregiver (usually the mother) exaggerates, fabricates, or actually causes illness in a child in an attempt to satisfy her own needs.

Forensic Resources Healthcare providers must know their forensic resources—both in-house and communitywide. Proactive healthcare providers should know who the child abuse experts are in their community and develop a working relationship with them. Each geographical or geopolitical region should designate someone in healthcare to be a community liaison and resource. That representative needs to be forensically educated and encouraged to remain up to date on current standards, research, and specialists, and to network with specialists in their geographic region. For example, the Child Abuse and

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Neglect Conference (CAAN Conference), sponsored by the University of California Davis, includes a clinical forensic medicine institute and is held annually in Sacramento, California. An excellent written resource for evaluating cases of child abuse and neglect is Child Abuse and Neglect: Guidelines for Identification, Assessment, and Case Management by Marilyn Strachan Peterson and Michael Durfee (published by Volcano Press, Inc., P.€ O. Box€ 270m, Volcano, CA 95689; it can also be found online at http://www. volcanopress.com or by writing [email protected]).

Basic Assumptions Why Parents or Caregivers Abuse Although it seems hard to imagine, even parents who love their children and value them can be abusive. All adults have varying temperaments and some have little or no impulse control. When faced with day-to-day stressors at the workplace and at home, they often unleash frustration on their children. They may hit or slap them, shove them, or throw something at them in an outburst of anger. This type of offender may have been abused when they were children. Violence is the accepted norm and it may seem safer to express anger toward a fairly defenseless child than to a spouse or significant other who may strike back. Venting hostility and frustration are factors in minor cases, but certainly do not provide an explanation when there are horrific acts such as locking the child in a basement, tying the child to a bed, or intentionally burning the child with cigarettes or curling irons. Child Abuse: Not an Isolated Event Although a single, significant event can be considered abusive, maltreatment or neglect of a child is usually a linear sequence of events occurring over weeks, months, or even years. The current incident is merely one that invoked enough concern to seek medical attention. It may be a broken bone that disables the child from walking or engaging in normal activities; it may be a burn on the face or extremities that is highly visible to others; it may be a chest or abdominal injury that impairs the child’s breathing or creates significant blood loss, or a head injury that results in unconsciousness. In these dramatic cases, parents or adult caregivers are more likely to seek medical care. Most abuse occurs in the home, and once the pattern of abuse begins, it often continues, escalating in successive incidents of serious injury. As humans, we adjust to changes. When presented with new situations, our responses modify. Over time, these changes become the norm. Behaviors

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that were once unacceptable become “OK.” It is not a stretch to see how parents can minimize the episodes by saying their child is “unlucky,” “accident prone,” or a “clumsy kid.” The Vulnerable Child Certain groups of children are considered to be more vulnerable than others and are therefore more likely to be abused. These include children from 6 months to 3 years of age (those with limited language abilities), stepchildren, handicapped children, and those who require special care. Target Child Occasionally parents select one of several children to be the target for their aggression and abusive acts. In former times, this child was termed “the whipping boy.” This child is blamed for everything that happens. When an event occurs and blame is assigned, this child is the target. Siblings may find value in having a whipping boy in the family because they may escape punishment. In some cases, other children blame themselves since punishment is unjustly misdirected to the target child (Pelzer, 1993).

Healthcare’s Role Life-threatening conditions such as breathing difficulties, cardiac arrest, seizures, loss of consciousness, or multiple trauma require immediate intervention. However, when suspicions of child abuse surface, reasonable efforts should be made to preserve evidence for future evaluation. If no life-threatening issues exist, obtaining a history is the first step in assessing a child for abuse. In addition to the signs of abuse listed above, the initial interview will help determine how the patient and family respond to health and illness in general. The healthcare provider may be able to learn what the family’s assumptions or cultural values are related to healthcare, hospitals, and so on. It is also very helpful to evaluate their coping strategies as related to the current situation. General Assessment Assessment of child abuse involves a physical exam, evaluation of the child’s and caregiver’s mental and emotional status, coping methods, and abilities, review of medical records, and review of the precipitating incident or current condition.

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When talking with the parent or caregiver regarding the child’s history, does one or the other give the impression they feel vulnerable? Using general introductory questions, try to evaluate the caregiver’s coping mechanisms, strengths, and weaknesses. Recognizing Child Physical Abuse Parent–Child Interaction The first step in helping abused or neglected children is to recognize the signs. A single sign does not necessarily indicate the child is being abused. However, it should raise a red flag so you are on the lookout for others. A pattern of repeated abusive behavior with a child or in a family certainly warrants suspicion and reporting. Adults who abuse children often do not seek medical attention immediately after an injury or event. They may minimize the traumatic incident or provide unconvincing or conflicting stories about its occurrence. Others seem baffled about the child’s condition and indicate that they do not know how the child was injured. Stories may change over time and differ from what the child victim or other witnesses may have related. Some parents may tend to minimize the injury despite its severity, while others appear overly attentive and concerned. Some children seem afraid of the abusing adult and others cling to the abuser, seeking their approval and comforting gestures. No single factor is a certain indication that child abuse has occurred, but all must be taken into consideration when performing a comprehensive assessment of the child’s injuries. Typical injuries of physical abuse are bruises, welts, patterned burns, and fractures. The history should be structured to verify details about the trauma if possible. • Could the injuries have occurred from the events as described? • Are the mechanisms of injury consistent with the scenario that has been related? • Do the injuries seem plausible when considering the child’s developmental capabilities? (Is it possible for a month-old infant to roll off a bed? How likely can a 9-month-old climb into a tub of hot water and have clearly demarcated burn levels on both lower legs with no evidence of splashing?) • Is the caregiver unable to provide an adequate explanation of the injuries? The healthcare provider needs to think critically: • Is the history possible?

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Is it a reasonable explanation or are you unsure? Are there unexplained gaps in the history? Is there a delay in seeking treatment? Are there conflicting histories among caregivers? Is there a change in the historical “story” upon subsequent questioning? Does a caregiver refuse to be interviewed? What if a caregiver did not accompany the child to the hospital? Why? Was the injury reportedly unwitnessed or unknown? Why? Is a third party blamed for the injury? Do siblings have a history of suspicious injuries? In daycare situations, do other children have a history of suspected abuse or injury?

Evaluating Childhood Injuries Key Point: An absent, inconsistent or changing history is a red flag for child abuse. Such histories suggest an attempt to hide something. Inconsistencies should be explored in further detail, thinking through cause and effect as the interviewer probes inconsistencies and gaps in the event’s history. When evaluating childhood injuries, it is important to consider the mechanism of injury in relation to the developmental status of the child. In order for a child to receive a certain injury, he or she must have reached a stage of development where such an injury is possible. A normal child can roll over from front to back at about 4 months of age, followed shortly thereafter by an ability to roll over from back to front. At about 6 months of age, they develop the ability to extend their arms when falling forward. An injury to a 4-month-old’s hand or wrist is unlikely to occur from a fall off the bed. Because an infant’s head is by far the heaviest part of the baby’s body, it is most likely to strike the floor or furniture, but serious injury is unlikely because the distance is short and forces applied are often relatively minor. Nor would one see multiple bruises on the shins of a child who is not yet able to “cruise.” Collision and fall injuries such as superficial cuts, fractures of forward-moving surfaces such as the clavicle, distal radius/ulna and skull, and bruises over bony prominences are common in toddlers. Abdominal bruising is not. Whereas a splash burn (multiple irregular burns) may be seen on the anterior surface of a toddler, an immersion burn (where a limb or body part is forced into hot water) exhibits a definite line of demarcation and is indicative of abuse.

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Any abnormal findings—physical, emotional, psychological, and mental—should be identified and placed into logical groups. Are symptoms localized into a particular area or are they general in nature? All of this should be centered on the short-term health and safety of the child. How will the immediate needs of the child be addressed? Is reporting to authorities required? If so, how are they going to be implemented and what consequences should be anticipated? What provisions need to be made for both the child and family to help prevent future abuse? Do referrals need to be made, and if so, to whom and when? Who is responsible for contacting referral agencies? Are there other children in the home? What provisions have been made to protect the safety and well-being of those children? Is there a feedback mechanism in place between your healthcare provider and child protective services so children with repeated visits to healthcare facilities are identified? Are charts flagged for follow-up? How? If not, how could such a system be implemented? Follow-up in child abuse cases is an excellent example of interagency cooperation and collaboration. Accidental versus Abusive Injuries Physical injuries may, indeed, be accidental. There are medical conditions that may mimic child abuse. They must be evaluated and ruled out before a final diagnosis of child abuse can be made. In some cases, the parent or caregiver is embarrassed to admit to carelessness or stupidity and is reluctant to divulge the true reason for the injury. Skin conditions and variations in pigmentation may lead the casual observer to think they are indicative of abuse. Hyperpigmentation, slate gray pigmentation, Mongolian spots, or port wine spots are some conditions that may be mistaken for bruising or scarring from abuse. Impetigo may mimic cigarette burns. Inflammation of a child’s buttocks from corrosive diarrhea may mimic an immersion burn. Contact or allergic inflammation may cause unusual, worrisome skin lesions. Broken bones in children are not all that unusual, particularly as their mobility increases. A series of broken bones, however, should be initially viewed with suspicion. The mechanism of injury, placement of the injury, and normal activities of the child are important factors to be explored. Genuine medical conditions must be considered. For instance, osteogenesis imperfecta is a genetic disorder resulting in fragile bones. A number of other factors, including medications or prolonged inactivity, can also be the underlying cause. Injuries to the leading or exploring (hand or foot) edge of a body surface such as the shin, knee, or elbow of a toddler are more likely to be accidental; injuries to nonexploring surfaces such as the inner aspect of the upper arm or thigh, abdomen, genitalia, and buttocks are less likely to be accidental.

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Leading-edge injuries, such as those found on the forehead and chin, are most likely accidental while injuries to cheeks, eyes, ears, and neck are less likely to be accidental. When there is more than one type of injury (burn + bruise + fracture) it is more likely to be abusive in nature. Coagulation disorders such as hemophilia, idiopathic thrombycytopenic purpura, and Von Willebrandt’s disease are all conditions that may cause symptoms suggestive of child abuse. Again, the history and past medical record are crucial components in ferreting out the true cause of symptoms. Physical Exam The physical exam (physical observations of the child) as well as lab, x-ray, and other objective findings will help establish the initial clinical picture. For each symptom found, identify and evaluate its location, quality, severity, and timing. (When does the symptom occur? How long does it last? What brings it on?) Also important are the setting in which it occurs and factors that make it better or worse. As with any physical exam, do a general, overall assessment of the patient’s body, including vital signs and demeanor or affect. Do a head-to-toe exam noting normal as well as abnormal findings. Make sure you have considered all body parts and surfaces and all systems. Identify and record both positive and negative findings (i.e., the absence of a sign or symptom; see Figure€6.1). Head Injuries Most victims of head injury caused by abuse are under 1 year of age, and almost all occur before the age of 3. Children in this age group should be watched closely during their waking hours. Try to get a clear history of the event. Severe injury does not result from a minor incident. Incidents resulting in minor trauma may not produce a strong memory, but events resulting in major head trauma involve severe, dramatic forces and should be memorable. A mismatch between severity of force needed to produce the injury and history given is highly suggestive of child abuse, not accidental injury. Accidental head injuries do occur and children do die from accidental head trauma. Simple skull fractures and fractures of the clavicle in infants are not that uncommon. However, the high incidence of morbidity and mortality associated with head trauma make determining the cause of injury critical. All layers of the head, from the hair, through the scalp, skull, and intracranial components (subdural, subgaleal, or subarachnoid hematomas) can be involved. Areas of the scalp where hair has been pulled out forcefully (traumatic alopecia) or where the scalp is bruised from superficial trauma are indicative of abuse. Bruises on the forehead or even the scalp on a cruising toddler are not uncommon, but a child does not normally have bruises on the

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Figure 6.1  Fingertip bruising on torso from holding while shaking.

face, eyes, or ears. Fortunately, although such injuries are suspicious for child abuse, they are rarely fatal. Intracranial injury or bleeding indicates a higher level of force and should be investigated by further testing such as x-ray or CT scan. Injuries suggestive of abuse include subdural hematoma and retinal hemorrhage. Any decreased level of consciousness in a child is serious and should be explored in depth. A missed head injury diagnosis can be lethal. There will likely be another abusive event. It is important to distinguish between abusive and accidental head trauma. Mild trauma, especially that occurring without ocular involvement, may be indicative of accidental head trauma. Conditions such as meningitis, arteriovenous malformation, tumors, blood disorders, recent head surgery, and other syndromes can cause symptoms that may confuse the healthcare practitioner. All possibilities must be considered and a differential diagnosis made based on symptoms, history, clinical picture, familial history, and diagnostic testing. Time is critical when head injury is suspected. The clinical picture can deteriorate rapidly, resulting in death or permanent injury to the child. Subtle symptoms such as vomiting, irritability, facial bruising, or decreased mental status may be clues to lesser head trauma in minor cases of child abuse. The

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confirmation of minor head injury associated with abuse may preclude a devastating or fatal incident in the future. Injuries to the Face and Mouth Injury to a child’s face is always suspicious as being the result of abuse. Carefully compare the observed injuries with the history given by the caregiver and child. In addition to general facial evidence of blunt trauma, abrasions, redness, bruising, or scarring at the corners of the mouth may indicate that a gag has been used. Forced ingestion of hot or caustic liquids may cause burn injuries both inside and at the edges of the mouth. Musculoskeletal Injuries Obvious deformity or painful or limited movement indicates injury to the musculoskeletal system. Suspicious skeletal injuries include rib fractures in young children, metaphyseal injuries, and high-energy or multiple fractures without history of serious accident (motor vehicle accident [MVA], fall from high places, etc.). Burns Children’s skin is more delicate and sensitive than adults and is therefore more vulnerable to extremes in heat and cold. Because children have a larger body surface in relation to body mass, a burn of the same percentage is more significant in a child than it is in an adult. Burns are classified in three ways: (1) percent of body surface affected, (2) depth of the burn (first, second, or third degree), and (3) the agent or causation of the burn (chemical, thermal, electrical, etc.). Accidental scald burn patterns most commonly affect the face, chest, or arm and are irregular in shape and size. Scald burns of this type are more common in toddlers whereas flame burns (lighters, fireworks) are more commonly seen in older children. Burns inflicted intentionally are frequently characterized by a clear line of demarcation created when a hand or foot (often both) is submerged in hot water. This type of burn pattern is known as the stocking or glove burn (see Figure€6.2). Again, and this cannot be emphasized enough, consistency and plausibility between the history given and the physical findings are critical in raising the suspiciousness factor. Questions to ask are: (1) is the burn pattern consistent with the history? and (2) is the history of the burn possible given the child’s stage of development? Most common body parts involved in abuse are the buttocks, perineum, and upper and lower extremities. Use a body diagram to document burn patterns, using different markings for first-, second-, and third-degree burns (see Figure€2.1, “Body drawing with annotations.”)

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Figure 6.2  Child scalding sketch. Courtesy Janet Barber. Used with

permission.

Mothers, fathers, and boyfriends are the most frequent perpetrators of burns to children. Babysitters, daycare workers, and other relatives account for approximately one-fourth of intentionally inflicted burns to children. Review of Records Previous records may give you important clues in cases where child abuse is suspected. If available, records from other facilities or healthcare providers such as clinics and physician’s offices may be helpful. At the very least, a phone call should be made to determine if other facilities have suspicions of child abuse. In light of Health Insurance Portability and Accountability Act (HIPAA) regulations, this may be a challenge. Suspicions of child abuse must be reported by law. If a previous chart is available, has a forensic issue been previously identified? When inquiring about family history, include questions that might help identify patterns of abuse or neglect. Is there evidence of poor decision making?

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Interviewing the Abused Child The critical part of a child sexual assault exam is the initial interview. This interview should be done by someone specially trained in interviewing children and should be done first, before clothing is removed for the physical exam. See Appendix 6.1, “Guidelines for Initial Healthcare Provider–Child Interaction.” The child’s emotional status will greatly influence the effectiveness of the interview. He or she may be embarrassed, scared, or ashamed. The child may feel guilty or responsible for causing the abuse. He or she may feel helpless and that the situation is out of control. A child victim may be anxious about the consequences of telling. The child may be fearful of teasing at school or by siblings, or of separation from the family. When confronted with a child who has been the victim of abuse, the healthcare provider may experience initial disbelief followed by a sense of disgust and outrage. Both the interviewer and the victim may be sad or angry. This is not unusual. These feelings are normal and should be acknowledged, but they cannot interfere with the task at hand: to establish the facts, record them logically, concisely, and truthfully. Most importantly, provide for the immediate health and safety needs of the child. Healthcare Provider Actions in Cases of Suspected Poisoning Always wear personal protective equipment (mask, gloves, cover gown) when dealing with a potential victim of poisoning. Attempt to determine if the patient has, indeed, been poisoned and, if so, by what. Determine the child’s age and weight, time of exposure, and suspected poison. Has the accompanying adult brought the container? Did the child vomit and was it saved? If the person vomits, make sure the airway is clear and be prepared to initiate CPR. Have suction available. Save the emesis for analysis. Do not induce vomiting unless advised by the poison control center. In cases of suspected inhalation poisoning, advise telephone callers not to try to rescue the victim until the room is safe to enter. Advise the caller to call 911 or contact their local fire department, which can enter the room safely using self-contained breathing apparatus (SCBA). Have them ventilate the room if possible and extinguish any open flames (such as pilot lights). Do not give anything by mouth, including water. Do not try to neutralize the poison unless advised to do so by the poison control center. Keep the person comfortable and normothermic. Remove clothing that may contain poison residue. Wash skin underneath with copious amounts of tepid water. Keep the patient on their left side to reduce the risk of aspiration.

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Reporting Responsibilities Healthcare providers are mandatory reporters of child abuse. Laws in all 50 states require that healthcare providers who suspect child abuse report it to authorities. The person who initially suspects or identifies child abuse is the individual responsible for making the call. This unpleasant but important task may not be transferred to anyone else. It is each healthcare provider’s individual responsibility. Investigation, however, is solely the responsibility of law enforcement and child protective services; investigation is not the responsibility of healthcare. It is up to law enforcement and state child protective service departments to follow through with an investigation. Contact your local police, child protective services, or the national child abuse hotline (1-800-4ACHILD). What to Report • The type of allegation and any specific details known or reported • All known demographic information on the child and family • Location of the child and family, including any immediate safety situation of the child • Potential risks for the child and other family members • Potential risks for the investigator

Child Neglect Neglect is a common form of child abuse. The effects of neglect are as devastating to the victim and have a more lasting impact than most physical abuse. When assessing children, signs of emotional and physical neglect should be noted as well as any physical injuries of abuse. See the definition of child neglect at the beginning of this chapter. Dental neglect has been defined by the American Academy of Pediatric Dentistry (2010) as “the willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.” Evidence of dental neglect should be noted in the physical findings and listed as a nursing diagnosis in the plan of care.

Sexual Assault of Children Sexual assault is a forensic subject on its own and will be dealt with in Chapter 7. Pediatric (prepubescent) sexual assault is a distinct subset of sexual assault with complex issues related to physical and emotional development of a child

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(see Appendix 7.1, “Child Sexuality”). Ideally, all victims of sexual assault should be referred to a pediatric sexual assault nurse examiner (SANE) nurse. These SANE nurses are specially trained in the assessment and evaluation of prepubescent child sexual abuse. Physical damage to young children is usually rare as most child sexual abuse falls into the fondling, touching arena. Physical cues are often absent or so subtle they can be missed. Abnormal findings in the genital areas should be examined carefully, photographed if possible, and documented. The oral area is also a common site of injury. Blunt trauma (bruising, abrasions, tears, or scarring) to the frenulum or throat is indicative of penile insertion into the mouth. At least one child death has been attributed to choking from penile insertion into an infant’s mouth. Genital bruising, edema, swelling, pain, abrasions, or bite marks are highly suspicious. Also note any perianal redness, scarring, hemorrhoids, fissures, ulcers, or warts. These findings may be indicative of digital as well as penile insertion or attempted insertion. Testing for sexually transmitted diseases (STDs) need not be done on a routine basis unless there is an indication of sexually transmitted disease. The presence of sexually transmitted diseases in young children and adolescents who are not sexually active is an important finding and is highly suspicious for sexual assault. Specific treatment protocols are constantly being updated and are not covered here. As noted above, young children who are suspected of being victims of child sexual abuse should be referred as soon as possible to a specialist in this area. Unless physical findings indicate immediate intervention, however, these exams, although urgent, are not an emergency and can be scheduled within the next few days. The primary focus of initial care is psychological support and issues of safety. Sexual abuse of the adolescent is more common and assessment techniques ride the line between child and adult. Generally speaking, prepubescent girls are treated more as children, whereas pubescent girls can withstand a vaginal exam. Again, this is a general rule of thumb and expert SANE nurses should be consulted if at all possible. Screen for STDs if symptoms are present or the suspected perpetrator is known to have a sexually transmitted disease. If the girl has begun her menses, a urine pregnancy test can be done and prophylactic drugs administered within the first 72 hours after the assault. Urine and toxicology screens should be done if there is suspicion that the victim was drugged prior to or during the assault. Rohypnol and gammahydroxybutyric acid (GHB)—current drugs of preference—can be found in urine, but clear rapidly, so the first time the patient voids is the best time to obtain a specimen.

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Pediatric Specimens Bite Marks Children do bite and are bitten by other children. In the case of child abuse, the bite mark is made by a caregiver or parent. As noted in Chapters 2 and 3, bite marks of children are smaller than those of adults and look different from those made by animals. Swab Technique for Bite Marks Moisten a sterile cotton-tipped applicator with sterile water. Collect a central swab from an unbitten, atraumatic area of skin nearby, but not involved in the bite. Roll the swab back and forth over the area rather than scrubbing. This is the control swab. Collect a second swab in the same manner from the central area of the bite and, if desired, a third from the margins. Label each swab with date, time, patient’s name and date of birth, hospital or clinic ID number, and site from which the specimen was taken. Dry in a drying box. As previously noted, drying specimens is critical to preventing biological degradation of the specimen. If a drying box is not available, turn a paper cup upside down, poke a small hole in the bottom and place the swabs in the hole standing up. Use one paper cup per swab. To prevent confusion as to which swab is which, use a magic marker to label each cup as control, center of bite, or margin of bite. Dry completely in a secure, clean, nondrafty area. Once dry, place each applicator in a separate container, label, and initiate chain of custody documentation before sending to the lab or handing over to law enforcement. Do not rely on photographs alone; document visible injuries descriptively in nurse’s or field notes and on a diagram, leaving interpretation to the expert. Prenatal Alcohol and Drug Abuse Drugs and alcohol cross the placenta and can be toxic to the developing fetus. Fetal alcohol syndrome is the most preventable cause of mental retardation in children. Pregnant women presenting with suspected alcohol abuse should be screened with a blood alcohol or basic toxicology screen. In some cases, a court order may need to be obtained not only for toxicology screening but to prevent further alcohol consumption during pregnancy. Mothers who consume excess amounts of alcohol can be prosecuted for child abuse. Institutional policies ought to be developed in tandem with local law enforcement agencies and prosecuting attorneys. The newborn infant suffering from postnatal drug withdrawal may present with hyperirritability, jitteriness, increased muscle tone, GI dysfunction, rapid breathing, increased temperature, or seizures. Feeding difficulties and altered

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sleeping patterns may also be present at birth and last up to 10 to 15 days. These symptoms are vague and may be a normal variant, but the astute healthcare provider’s intuition can be a key factor in raising one’s forensic antenna. Laboratory testing of meconium for drugs of abuse is available. See Appendix 3.3 for tests available from the United States Drug Testing Laboratory. The infant who has been exposed to cocaine while in utero can present with a cerebral infarction. This is a rare condition, but deadly. In addition, prenatal substance abuse by the mother may be indicative of postnatal child abuse or neglect. Even when such suspicions are unsubstantiated, it is well worth careful assessment and documentation. Poisoning Millions of people are poisoned each year and hundreds die. Most are accidental. Any suspected ingestion or exposure to toxic fumes or substances should be treated as a possible poisoning until ruled out. Sudden or worsening onset of vague, undiagnosed symptoms may signal that the victim has been poisoned. Remedial action should be taken as soon as possible. The local poison control center should be consulted immediately. The National Poison Control Center is available any time of the day or night: 1-800-222-1222. Poisoning agents are as varied as the mind is creative. A common source of child abuse poisoning is high concentrations of salt combined with limited amounts of water causing dehydration. Pepper causes upper airway obstruction due to edema. Alcohol ingestion may be accidental or intentional. Antifreeze (ethylene glycol) tastes sweet and is toxic to infants, even in small doses. Ethylene glycol is often used to poison animals. Other common causes of child poisoning include medicines (over-the-counter [OTC] medications such as aspirin and Tylenol), household plants, household cleaners, insecticides, paints, sprays, carbon monoxide (from furnaces, space heaters, small engines, etc.), chemicals and glues used for crafts, woodworking, and so on. Laboratory, Radiological, and Ophthalmic Testing • CBC to screen for anemia (found in cases of neglect) • Prothrombin time (PT), partial thromboplastin time (PTT), and platelet count help in diagnosing causes of bruising • Urinalysis (UA) to screen for kidney damage • Chemistry panel to screen for damage to internal organs • Meconium drug testing for newborns • CT and x-rays for skeletal and head trauma • Dilated indirect opthalmoscopy for retinal hemorrhage

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Munchausen by Proxy Syndrome Munchausen by proxy is a syndrome wherein a parent, almost always the mother, intentionally exaggerates, fabricates, or actually induces physical or psychological illness in a child. The cause is unknown, but it is thought to be a means whereby a mother meets her own internal needs—often for attention and valuation by others—because her child is ill. It has been hypothesized that the perpetrator may have been a victim of Munchausen by proxy herself. She may have feelings of inadequacy regarding her parenting skills and uses medical professionals to confirm her validity as a parent. The perpetrator’s ability to deceive others she views as intelligent and powerful may also provide her with a sense of satisfaction and validation. The mother’s personal needs overpower her ability to see the victim as a person with needs, feelings, and rights; she sees the victim merely as a vehicle to meet her own needs. There is no standard method of operation, test, evaluation, or profile for perpetrators. Perpetrators are practiced at avoiding detection and there is seldom prior child protection services involvement. Interestingly, perpetrators may not have a mental health history. They may or may not have a history of falsification of illness in themselves. Perpetrator–victim interaction is usually good, making it difficult for the healthcare provider to search out the true cause of the child’s illness. Perpetrators often have some sort of medical background and appear to be normal, helpful, friendly, concerned, and believable. They have plausible, convincing reasons for the child’s illness and their own behavior. They are extremely concerned and tenacious, demanding further tests, second opinions, treatments, and even surgery. Multiple hospitalizations and switching healthcare providers are not uncommon. It has been noted that there is often a distant relationship between the parents. This may provide an early clue to Munchausen by proxy. The noninjuring parent may appear uninterested and remote, failing to visit the child or consult with doctors and nurses regarding the child’s care or condition. This parent may be a good source of family history. Victims are typically preschool-age children. Boys and girls are equally vulnerable to becoming victims, but 98% of the time the perpetrator is the mother. If a child lives to the age to go to school, the abuse often stops and the perpetrator’s “attention” is turned to younger siblings. Occasionally, as a child ages, the victim may be afraid of abandonment and may actually participate in the abuse because they feel the only time they get attention is when they’re “sick.” Generally, however, there are three end-game scenarios: (1) the perpetrator is identified and apprehended, (2) the perpetrator moves on to a younger child when the first victim gets old enough to tell, or (3) the child dies. This tragedy is preventable. It is a tragedy because not only is an

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innocent life lost, but emotional consequences for the child’s family, acquaintances, and medical staff can be significant. Munchausen by proxy is a pattern of attention-seeking behavior and should be considered an immediate threat to the child’s life as the abusive behavior escalates. There are issues of long-term consequences, both physical and psychological, to the victim as well as his or her siblings. Child victims present with multiple, persistent medical problems. Symptoms are often vague and are limited only by the creativeness and medical knowledge of the perpetrator. Often, they do not typically respond to treatment. The “disease” course often follows a puzzling, unconventional, and atypical clinical path. The clinical findings are unusual and don’t correspond to the patient’s history. Symptoms may be physically or clinically unlikely or even impossible. Yet the perpetrator is so convincing and seems so genuinely concerned about the child’s condition that medical professionals are fooled into believing the child’s condition is genuine. The perpetrator is good at conning and disarming healthcare providers. It is difficult for medical personnel to perceive such loving, caring mothers to be capable of harming their own children. She is seen as a devoted, self-sacrificing parent. Disbelief and denial between healthcare professionals is not uncommon, causing delay in making a diagnosis of Munchausen by proxy. Once healthcare providers become suspicious, the perpetrator often changes to a new healthcare provider. Abusive behavior knows no bounds and may change from time to time. Perpetrators use ingenious methods to induce illness in the child. They may add blood or urine or other substances to specimens, and inject unbelievable substances into IV lines or tissue. They have been known to suffocate their children and then call for rescue at the last moment. They manipulate wounds so they won’t heal, irritate skin and mucous membranes, and falsify rashes and skin conditions with abrasives or chemicals. Abusive behavior may be physical, psychological, or sexual, and often includes aspects of neglect. Symptoms may include vomiting, diarrhea, seizures, allergic reaction, asthma, failure to thrive, and infection. In addition to the risk from the abusive behavior of the perpetrator, there are associated and long-lasting risks from medical and surgical intervention. Diagnosis is extremely difficult to prove, especially in light of the mother’s ability to deceive, and is often made based on a pattern of circumstantial evidence rather than direct evidence such as videotaping or eyewitness testimony. The key is knowledge regarding Munchausen by proxy leading to early suspicion and accurate diagnosis. As noted earlier, Munchausen by proxy can be lethal to the victim, but misdiagnosis can be devastatingly traumatic to the falsely accused.

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The healthcare provider’s gut feeling can be critical in raising one’s forensic antenna—his or her index of suspicion. Again, the difference between the reported history, the validity and plausibility of reported symptoms, and whether the symptoms make sense developmentally, physically, and psychologically is critical in becoming aware of the possibility of Munchausen by proxy. Perpetrators of Munchausen by proxy are unusually comfortable in the healthcare setting. They appear to actually enjoy the hospital environment and being the center of attention, are overly cooperative, and are highly supportive of healthcare providers. Key Point: A red flag of this type of abuse is that the mother isn’t reassured by good news—negative test results, surgical or other findings—and insists on further intervention. Another is an unusually calm demeanor when the child is critical. Key Point: Once suspected, a tool that can be used to make a differential diagnosis is to separate the suspected perpetrator from the victim. Symptoms usually disappear when the perpetrator no longer has access to the victim. Symptoms suddenly reappear when the perpetrator returns. The healthcare provider can also gather information from medical, dental, psychological, and school records of the affected child, siblings, and parents. This information can be helpful in preparing a detailed summary of the child’s history and course of illness. Try to determine if reports of symptoms can be verified by staff or witnesses other than the mother. Covert surveillance of the mother and child may be the method of last resort and may require a court order. A multidisciplinary team of experts in suspected diagnoses, toxicology, and forensics may need to be assembled. A psychiatrist familiar with factitious disorder by proxy (FDP) should also be consulted. The child must be removed to a safe environment where appropriate treatment of injuries and symptoms can continue and where psychological management for depression, anxiety, posttraumatic stress disorder, and other psychiatric complications can begin. Inquiries regarding siblings or other potential victims in the household need to be made. As with all other forms of child abuse, reporting to authorities is mandatory.

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Sudden Infant Death Syndrome (SIDS) SIDS is the sudden death of an infant under the age of one year. Sudden, unexplained death in children over the age of one year is extremely rare, if at all. The death may be due to asphyxia (intentional or accidental, including aspiration, nasal obstruction, or laryngospasm), cardiac arrhythmia or undiagnosed cardiac abnormality, or a metabolic syndrome such as undiagnosed diabetes. Recent postmortem studies implicate a serotonin deficiency, but this is as yet unproven and no preventive measures have been proposed (Anderson, 2010). There is no proven cause, so SIDS remains a diagnosis of exclusion. Again, a thorough history and review of the child’s medical records can be very helpful in diagnosing a SIDS death. Autopsy may or may not be helpful as some injuries may occur when the desperate parent tries to resuscitate the child. The Back to Sleep program has been an invaluable tool in reducing the number of SIDS deaths in recent years (National Institutes of Health, 1994, 2009).

Failure to Thrive The fundamental cause of failure to thrive (FTT) is a nutritional deficiency. It is commonly found in infants and young children who fail to gain or retain weight according to established age-related norms (The Magic Foundation, 2010). It is not a diagnosis, but rather a condition resulting from an underlying organic or nonorganic nutritional deficiency. Organic causes can be an acute or chronic medical condition in which the intake, absorption, metabolism, or excretion of calories and nutrition is low enough that the child shows inadequate growth patterns or actual weight loss over time. Children who fail to thrive fall within less than the third percentile of accepted norms. Inorganic causes are usually environmental factors or stimulus deprivation, either intentional or unintentional. Poverty is believed to be the biggest single risk factor for FTT both worldwide and in the United States. Because “a significant number of children develop the syndrome as a consequence of child neglect,” the American Academy of Pediatrics strongly recommends that FTT cases be reported to child protective services if the condition persists after appropriate interventions have failed (Block and Krebs, 2005; American Academy of Pediatrics, 2008).

Summary Child abuse includes problems resulting from the lack of reasonable care and protection that ought to be provided by parents, guardians, or other caregivers. It may involve physical injury, emotional or mental abuse, neglect,

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or sexual assault or abuse. Recent definitions include injuries to the unborn resulting from drugs and alcohol abuse. Special attention must be paid to infants and children who are at high risk for abuse—those between 6 months and 3 years of age, premature or low-birth weight infants, stepchildren, handicapped children, or those who have special care needs. Since abuse tends to recur within the home, it is imperative that the problem of child abuse be recognized and managed promptly; returning a child to an abusive environment will lead to further abuse or even the child’s death.

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Appendix 6.1: Guidelines for Initial Healthcare Provider–Child Interaction The medical interview is conducted to document physical findings (or lack thereof), determine whether the child needs further medical or psychiatric treatment, establish the possibility of abuse, and determine if the child will be safe in the home environment. It also helps by providing initial information for law enforcement and child protective services. The forensic interview is more in-depth and is designed to reinforce existing information or uncover new fact descriptions or insight. These interviews are beyond the purview of the basic healthcare provider and should be conducted by a trained law enforcement officer or social worker who is familiar with appropriate methods of interviewing children. The following are guidelines for a basic medical interview of a child who is suspected to be a victim of any kind of child abuse: 1. Interview the child alone. 2. Interview the parent or caregiver in a separate setting, out of sight and hearing of the child. 3. If a suspected perpetrator is present, separate the child and the perpetrator. 4. Create a safe, comfortable, child-friendly atmosphere. Provide a quiet, private setting. Keep interruptions to a minimum. 5. Take the time to establish rapport before discussing abuse issues. 6. Listen carefully to what the child is saying and respond appropriately. • Does the story given fit with the clinical findings? • Is the story plausible? • Look for clues, unanswered questions, and gaps in the story. 7. Try to determine the child’s level of understanding and ability to communicate. • Consider the child’s vocabulary and verbal understanding. • Talk to the child in terms he or she can understand. • Do not “talk down” to the child. • Use simple words in simple sentences; do not use complex or compound questions. • Do not use double negatives. 8. Believe the child. 9. Reassure the child. • Reassure the child the abuse was not his or her fault. • Reassure the child regarding his or her future safety. • Tell the child you are required to try to stop the abuse so you will be making a report.

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10. Do not intimidate or judge the child. 11. Be sensitive to the needs of the child. Do not assume he or she is feeling a certain way. 12. Never make promises you cannot keep (e.g., “I won’t tell anyone”). 13. Be supportive in your demeanor. Children, especially in these types of situations, are very sensitive to adults who are anxious, uncomfortable, or hurried. Switch places with another co-worker if necessary. 14. Keep the interview focused and short but unhurried. • Listen to what the child wants to tell you. • Do not ask for details but try to get enough information so you can see the whole picture. • Do not ask direct or suggestive (leading) questions. • Ask open-ended questions such as “Tell me what happened.” Follow with, “And then what happened?” or “What happened next?” • End with, “Is there anything else you want to tell me?” or “Is that all you remember right now?” • In-depth questions should be delayed until an interviewer who is qualified to talk to children can be located. • Avoid “when” questions unless the child can relate the abuse to another specific event such as a holiday, birthday, or event at school. 15. Record exact quotes. Do not paraphrase. 16. Record the interview for future reference if allowed by policy or by law. 17. Do not discuss what the child told you with anyone who is not directly involved in helping the child. Adapted from New Mexico Children Youth and Families, New Mexico Department of Health handout.

References American Academy of Pediatric Dentistry http://www.aap.org/media/Policies_ Guidelines/D_DentalNeglect.pdf (accessed August 24, 2010). American Academy of Pediatrics. http://www.aap.org.advocacy/releases/nov05thrive. htm (accessed October 16, 2008). Anderson, Pauline. Sudden infant death syndrome due to brainstem serotonin abnormality. Journal of the American Medical Association (JAMA) 303:430-437. http://www.medscape/viewarticle/716500 (accessed March 31, 2010).

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Block, R. W. and N. F. Krebs, and Committee on Child Abuse and Neglect and the Committee on Nutrition. November 2005. Clinical report: Failure to thrive as a manifestation of child neglect. Pediatrics, 116(5), 1234–1237. http://www. aapolicy.aappublications.org/cgi/content/full/pediatrics; 116/5/1234. (accessed August 24, 2010). Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1995). AMH Accreditation Manual for Hospitals. Oakbrook Terrace, IL. The Magic Foundation. http://www.magicfoundation.org/docs/176.157/failure_to_ thrive_children.html (accessed August 24, 2010). National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health & Human Development, Back to Sleep campaign (1994, updated 2009). http://www.nichd.nih.gov/publications/pubs/safe_sleep_gen.cfm (accessed September 23, 2010). Pelzer, Dave. 1993. A child called “It”: One child’s courage to survive. Omaha, NE: Omaha Press. Peterson, Marilyn Strachan and Michael Durfee. 2003. Child abuse and neglect: Guidelines for identification, assessment and case management. Volcano, CA: Volcano Press.

Additional Resources http://www.cdc.gov/HomeRecreationalSafety/Poisoning/poisoning-factshet.htm. http://www.ncjrs.gov/App/publications/Abstract.aspx?id=207348 http://en.wikipedia.org/wiki/Child_sexual_abuse http://www.womenshealth.gov/faq/sexual-assault.pdf

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Unlike sexual assault of adults, most cases of child sexual assault involve inappropriate touching or fondling rather than actual genital or anal penetration. Sexual assault of children is defined from both legal and clinical perspectives. The federal definition of child maltreatment is found in the Child Abuse Prevention and Treatment Act (CAPTA) 1974 (2003).* States define and regulate child sexual abuse in slightly different ways. Child protection statutes are civil laws designed to protect the child; criminal statutes classify crimes and outline penalties in terms of the severity of the crime. Civil laws, such as Megan’s Law, outline reporting and investigation of child abuse, removal of children by child protective services, and other laws designed to protect children.†,‡ The Sexual Offender (Jacob Wetterling) Act of 1994, was enacted as part of the Federal Violent Crime Control and Law Enforcement Act of 1994, Public Law No. 103-322. Civil penalties may include liability for damages, injunctions, commitment, and loss of custody or parental rights. Criminal penalties may include imprisonment, fines, registration as a sex offender, and restrictions on probation and parole. Penalties depend on the age of the child, the level of force used, the relationship between the child and the perpetrator, and the type of sexual act involved. Therefore, it is imperative that all information substantiating the nature and extent of abuse be described and documented in detail. For example, in most states, penetration of the mouth, vagina, and anus constitute separate sexual acts and therefore the offender would be charged with three counts of rape rather than one. This significantly adds to the severity of the crime and the duration of criminal confinement. Photographs will also help to establish the presence of injuries and help to validate the type of force used for the act.

* Federal law regulates Native American children, crimes committed on federal property, interstate transport of minors for sexual purposes, and the shipment and possession of child pornography. † The Jacob Wetterling Act of 1994 requires convicted sex offenders to register their current place of residence and makes that list available to the public. ‡ The National Sex Offender Public Registry can be found at http://www.nsopr.gov. This Web site allows the user to search by name, state(s), zip code, country, city, or town, and nationwide. Other Web sites include http://www.sexualoffenders.com and http://www. familywatchdog.us.

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In cases of child sexual abuse, issues regarding consent are essentially irrelevant. In most jurisdictions, a child is incapable of giving consent.*

Reporting Laws In addition to federal law (Child Abuse Prevention and Treatment Act of 1974), all states have laws making it mandatory to report child abuse, including child sexual abuse. Although details of state laws differ, two basic principles prevail and relate also to sexual abuse: • There is a mandate to report any injury suspected of being caused by neglect or being willfully inflicted, including sexual contact. • There is exemption from liability for any professional person reporting suspected child abuse, including sexual contact. All healthcare providers should know the nuances of reporting requirements in their jurisdiction.†

Definitions The American Academy of Pediatrics defines child sexual abuse as “when a child is engaged in sexual activities that he or she cannot comprehend, for which he or she is developmentally unprepared and cannot give consent, and/or that violate the law or social taboos of society” (Aldrich, 1977). Another definition is “any sexual act with a child performed by an adult or older child” (Kellogg, 2005; Aldrich, 1977). Laws also prohibit noncontact sexual acts such as pornography, voyeurism,‡ intentionally causing a child to view and/or listen to sexually explicit conduct for the purpose of arousing or gratifying the perpetrator or to humiliate or degrade the victim, and communicating with a child in a sexual manner whether in person, by telephonic device, or over the Internet. Child sexual abuse of all types is a crime punishable by law. Nations participating in the United Nations Convention on the Rights of the Child (1989) (http://www.unicef.org/crc) agreed to “take all appropriate * Thus, in a case involving the charge of statutory rape of an adolescent who may have given verbal consent, the adolescent is actually unable to give consent because their minority makes it impossible. † Information about each state’s requirements is available at http://www.childwelfare.gov. ChildHelp USA has a national child abuse hotline: 1-800-422-4453. ‡ Gaining pleasure from watching, especially secretly, other people’s bodies or the sexual acts in which they participate.

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legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse.” This includes “measures to prevent: (a) The inducement or coercion of a child to engage in any unlawful sexual activity; (b) The exploitative use of children in prostitution or unlawful sexual practices; (c) The exploitative use of children in pornographic performances and materials” (Wikipedia, 2010).

Child Sexuality Children are sexual beings from birth. Children develop sexually throughout their lives just as they develop physically, emotionally, and mentally (see Appendix 7.1, “Child Sexuality”). For many reasons, responding to the disclosure of sexual assault of a minor, particularly a prepubescent child, is a very different affair than responding to alleged sexual assault of an adult. Observable injuries are rarely found when a child has been sexually abused. Physical contact between child and perpetrator is often limited to fondling, masturbation, and oral/genital contact. Nonphysical contact involves exposure, voyeurism, and child pornography. The age, cognitive and language limitations, and fear of abandonment are some of the other reasons disclosure and diagnosis of child sexual abuse is difficult to make. Success of prosecution is highly dependent upon the initial and subsequent interviews with the child. For these and other reasons, it is extremely important that interviewing a suspected victim of child abuse be done by a trained professional. The initial patient–healthcare provider encounter is critical to the path of healing. A significant component of managing the victim of child sexual abuse is supportive treatment of the child from the beginning. Short- and long-term consequences of child sexual abuse are most often the biggest problem faced by victims. Beginning within two years of the time the abuse ends and often lasting many years—even a lifetime—the negative effects of child sexual abuse range from minor problems to total breakdown of one’s psychological framework leading to psychopathology later on in life.

Perpetrators and Victims Although girls are more often abused than boys, and males are more often the perpetrator, male children are also victimized and females can be perpetrators. The majority of sexual offenders are people the child knows. They are often family members, friends, neighbors, clergy, or other familiar

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individuals. Abuse by a total stranger is not a common occurrence. Contrary to common belief, homosexuals are no more likely to be perpetrators of sexual violence against children than are heterosexual men (Patterson, 1995).

Short- and Long-Term Psychological and Physical Harm Factors contributory to the depth of psychological harm include the age of the child, the relationship between the child and perpetrator, the duration and frequency of the abuse, and the degree of force used. Also of importance is the child’s perception of how deeply his or her physical and psychological boundaries were invaded. Psychological sequelae include general psychological distress and neuroses, depression, anxiety, poor self-esteem, eating disorders, posttraumatic stress disorder, dissociative and anxiety disorders, antisocial and/or criminal behavior, learning difficulties, and suicidal ideation. Substance abuse, eating disorders, obesity, alcoholism, and chronic pain are more common in adults who were sexually abused as children. Victims of child sexual abuse also tend to be more frequent users of emergent and nonemergent medical care (Wikipedia, 2008).

Signs of Sexual Abuse in Children* Signs of child sexual abuse include: • • • • • • • • • • • • • •

Unusual interest in or avoidance of all things of a sexual nature Sleep disturbances (including abrupt onset of bed-wetting) Depression Withdrawal from family Seductiveness Sexualized drawings Sexual knowledge and/or behavior inappropriate for the child’s age Refusal to go home, to school, or other normally visited places Problems with conduct in school or delinquency Secretiveness Fear of a particular person A significant increase or unusual fear of physical examination Heightened awareness of or fears about their genital area Statements from the child implying that they are “dirty” or “damaged.”

* See Appendix 7.2 Signs of Child Sexual Abuse.

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The presence of any of these signs warrant further exploration. Children are naturally curious about all sorts of things, including genitalia and sexuality. Victims of chronic sexual abuse may have more sophisticated sexual knowledge than their peers and may attempt to get other children to participate in sexual acts beyond mere curiosity. The key here is to talk to the child in a nonjudgmental manner, listen for subtle clues, and be aware of unusual or unexpected responses from the child. These are red flags that call for further exploration. In all cases, take their disclosure seriously and let the child know you believe her or him. Other behavioral changes include aggression, depression, withdrawal, unexplained anxiety, low self-esteem, regression (especially for young children), nightmares, bed-wetting, school problems, and sexualized behavior that is advanced or inappropriate for the child’s age. Self-destructive behaviors such as substance abuse, self-mutilation, and prostitution can be seen in older children. Other maladaptive behavior in older children is exemplified in running away, submitting to intimate partner violence, or loss of memory.

Prehospital Care If a child is reported to be the victim of a suspected or actual sexual assault, your first responsibility is to determine the safety of the child. If the child spontaneously discloses sexual abuse, delegate members of the team to take care of the child and seek immediate advice from your medical director and child protective services. In all cases, take their disclosure seriously and let the child know you believe her or him. If acute abuse is suspected or divulged, advise the child and the child’s caregiver not to bathe the child or give anything to eat or drink. Reassure the child and/or reporting caregiver, but avoid direct questioning until appropriate interviewing can be arranged. Document the disclosure including what the child said, who was present, when the disclosure occurred, and what prompted the disclosure. Remember to document the child’s exact words using quotation marks.

Physical Injury Physical trauma is usually minimal or not found at all. Obvious physical injury should, of course, be treated immediately and thoroughly documented, using photographic images if possible. Physical indicators include bruises or pinch marks on the arms, legs, anal region, and genitalia. Oral bruising, petechiae,

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or abrasions from tying hands or feet may also be seen. Other physical signs of sexual abuse include the presence of sexually transmitted diseases and changes in the genital or anal regions, especially those that might be consistent with previous physical contact (i.e., abnormal physical scarring).

Initial Disclosure If a child discloses sexual abuse during the course of a medical examination, it is important that the healthcare provider document what prompted the disclosure, who was present, and the exact words used by the child (put in quotation marks). Other ways children disclose are to friends, parents, or other trusted individuals. In some cases, there is no actual disclosure, but a parent, school nurse, teacher, or religious mentor may observe behavioral changes warranting further inquiry. Children often do not disclose abuse until they feel safe. For this reason, most disclosures do not involve immediate physical injury and may be outside the window of time to warrant immediate physical examination. Any child presenting with acute bleeding or injury should be examined immediately. This is known as an emergent examination and is done as soon as possible. Urgent (not emergent) evaluation is done when the child presents with medical issues needing timely, but not immediate, intervention such as suspected sexually transmitted disease (STD) exposure or possible pregnancy. Evaluation of these patients should be done as soon as possible. To reduce parental and patient anxiety, however, early assessment may be advisable. Encourage the child to talk freely, without asking leading questions. Take what the child says seriously. Write down verbatim what the child discloses. In general, allegations of sexual abuse by a child are true. Exceptions are usually in conjunction with child custody disputes or other legal matters. Assure the child that they did the right thing in telling you, and tell the child that he or she is not to blame for the abuse. Do not make promises you cannot keep, but do reassure the child that you will provide immediate protection and take steps to stop the abuse. In any event, investigation by authorities is warranted. Resist the temptation to “investigate” yourself. It is the responsibility of law enforcement and child protective services to get specific answers to who, what, when, where, and how the abuse occurred. Involve these professionals as soon as possible.

Assessment The biggest part of your job is to recognize that the patient has urgent safety and legal issues that must be resolved.

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The most common way child sexual abuse is discovered is either by spontaneous disclosure from the child or a secondary individual witnessing an event. Since actual physical trauma is rare, there is no need to perform an internal physical examination in the prepubescent child unless there is obvious oral, genital, abdominal, or pelvic trauma, or the child is actively bleeding. The history of child abuse events is the most important part of assessing a child for sexual abuse. A complete childhood history includes general medical (including vaccinations), behavioral, familial, social, and (if appropriate) gynecologic information. A medical evaluation is not the same as a forensic interview and investigation. Neither can be substituted for the other. The medical history is necessary for good patient care; the forensic interview is essential for prosecution and must be able to withstand the rigors of legal scrutiny during criminal or civil processes. Child advocacy centers were begun in the 1990s. They are multidisciplinary teams with the requisite experience and expertise to interview children. They have two goals: (1) make the interview process less stressful for the child, and (2) prevent inappropriate interviewing of sexually abused children. They are experts at evaluating whether the child’s history or behavior are appropriate for his or her developmental age. Professional child interviewers are also best able to glean clues regarding if and where physical injuries might be found. They also help to focus further investigation efforts. If, for whatever reason, a professional child abuse specialist is not consulted, it is critical that questions not be asked in a leading manner! In other words, don’t blow it by doing more than you’re trained to do. Professionals experienced in interviewing children should be contacted as soon as possible. Having said that, however, a history that includes family history, social history, developmental history, and behavioral history, as well as the medical history can be very helpful in understanding the environment in which the child lives and the abuse occurred. The way questions are framed is critical in obtaining information that will withstand the scrutiny of the legal process. For example: A question such as “Did Mr. X touch you in your private parts?” would be considered a leading question. A better way of eliciting the information would be: “Tell me what happened last night.” Use the child’s exact words when documenting his or her response. Never, never paraphrase. The physical exam is done in the same manner as any other head-to-toe examination with the external genital examination performed as part of the whole. Nonperpetrating parents and the victim should be informed regarding each aspect of the exam beforehand, giving him or her (or the reporting caregiver) an opportunity to absorb the information and ask questions. All areas of the body should be assessed for injury, including abrasions, lacerations, and bruising. Positioning for a female genital exam is usually the frog-leg position or knee-chest position. Examination of males can be done

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in the supine position or with the patient standing. Physical findings specific to the vaginal and anal areas include foreign bodies, painful urination or defecation, or other genitourinary (GU) complaints, bleeding, itching, discharge, constipation, diarrhea, STDs, and pregnancy. Unexplained oral complaints may be discovered in children who have been sexually abused. Of course, rope burns on wrists and ankles are indicative of abuse with or without a sexual component and warrant further inquiry. A gynecological history is warranted in pubescent children and should include the date of last menstrual period, use of contraception, date of last consensual intercourse, possible or previous pregnancy, any gynecological or urological surgery, disease or trauma to the genitals and internal sex organs, and previous STDs. A complete listing of laboratory tests, imaging studies, and other procedures has been published by Dr. Ann S. Botash and can be found online at http://www.emedicine.medscape.com/article/800770-overview (Botash, 2010). Rape kits are available through your local SANE provider, law enforcement agency, or your state sexual assault coalition. Their use, however, is only appropriate if disclosure and examination occurs within 96 hours of the event.

Nursing Diagnoses With the exception of treatment for actual physical injuries, nursing diagnoses are generally related to present and future mental health needs. The possibility of other children in the home also being abused needs to be investigated by authorities.

Planning What are the immediate safety needs of the child and others? What are the present and future mental health needs? Are there local children’s resources such as child advocacy centers available? If not, are there local specialists in interviewing and examining child victims of sexual abuse? If not, where are the nearest resources and how do you arrange for the child to receive care from them?

Intervention If at all possible, refer the child to a child sexual abuse specialist. Make specific referrals to law enforcement, child protective services, and resource agencies, and document these referrals in the chart.

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Evaluation • Is there a mechanism in place to evaluate the outcomes of treatment and/or referral? • If a child advocacy center is available, is there a feedback mechanism in place? • Are there regular meetings to discuss client outcomes, successes, and areas where improvements can be made? • Is there a mechanism in place to notify the child’s pediatrician? • Are other children in the home being protected?

Prevention Darkness to Light is a national nonprofit 501(c)(3) organization and initiative located in Charleston, South Carolina. Its mission is to diminish the incidence and impact of child sexual abuse and raise awareness of the prevalence and consequences of child sexual abuse by educating adults about the steps they can take to prevent, recognize, and react responsibly to the reality of child sexual abuse. The organization’s information and referral service hotline is 1-866-367-5444. Darkness to Light promotes the concept that a child’s safety is an adult’s job. Online training is currently available at http://www.darkness2light.org. They have also developed a seven-step booklet that is available for download. The seven basic steps are (1) learn the facts, (2) minimize opportunity, (3) talk about it, (4) stay alert, (5) make a plan, (6) act on suspicions, and (7) get involved. Stop It Now (also known as the Child Sex Abuse Prevention and Protection Center) provides an online help center, informational services, and specific tools such as safety planning, journaling, and a guidebook to aid in talking to children about sexual abuse (stopitnow.org). Other useful Web sites are sponsored by the American Academy of Child and Adolescent Psychiatry (http://www.aacap.org); Pandora’s Box, found at http://www.prevent-abuse-now.com; and the Office for Victims of Crime, U.S. Department of Justice Report: Child Physical and Sexual Abuse: Guidelines for Treatment. This report can be downloaded from the National Crime Victims Research and Treatment Center at the Medical University of South Carolina at http://academicdepartments.musc.edu/ncvc/resources_ prof/OVC_guidelineS04-26-04.pdf.

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Summary Sexual abuse is a devastating type of child abuse that often poses serious physical and emotional consequences for the victims. The recognition or disclosure of such acts compels healthcare personnel to report the incident and to take other immediate steps to protect the child from future incidents. Since sexual abuse often occurs within the child’s home or other environment where the child should be cared for, nurtured, and protected, social service intervention will be a vital part of any plan for these victims.

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Appendix 7.1: Child Sexuality At Birth • • • •

Capacity to have an erection (male) Capacity for vaginal lubrication (female) All sex organs present In males, testes may or may not be descended into the scrotum

During First Year • • • •

Show genital guarding Manipulate own genitals Orgasm in boys from 5 months Orgasm in girls from 4 months

Two Years • • • • • • • • • • •

Rebelliousness, uncooperative, fiercely independent Know their own mind Differentiate between males and females Male or female gender identification is fixed Interest in posture of males and females when urinating Learn to name body parts Capacity to fantasize Love rituals regarding bedtime, bath, meals, and story time Emotionally stormy Don’t want anyone to touch their buttocks Develop positive and/or negative attitudes toward elimination and urination depending on toilet training • Self-esteem and trust in others first established

Three Years • • • •

Pleasant, initial shyness Girls attempt to urinate standing up Play at adult male-female roles Continue to masturbate

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Four Years • • • •

Bathroom slang and name calling—pooh face, shit head Interested in peeking at others eliminating and urinating May demand bathroom privacy for self Play nurse-doctor-patient games with peers; plays hospital and take rectal temperature • Enjoy nudity • Aware of gender and sex roles • Boys scornfully chauvinistic

Five to Seven Years • • • • •

Reinforcement of gender identity continues Identification with same-sex parent strengthens Mutual body exploration with same sex is common Sexually oriented daydreams and fantasies begin Feelings toward opposite sex become more ambivalent

Eight to Twelve Years • • • • • •

Best friend or buddy common Peer group begins to dominate in identity seeking Beginning of separation process from parents Early menstruation begins in some girls Secondary sex characteristics develop Strong feelings of modesty begin to be expressed

Thirteen Years and Older • • • •

Puberty and resultant body changes proceed in both sexes Menstruation begins in almost all girls by age 16 Ovulation usually established in girls 18–24 months after menarche Estrangement from parents as sexual authority figures becomes more pronounced • Masturbation and sexual fantasies become more integrated and common, especially among males • Sexual attraction to opposite (or same) sex becomes stronger

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• Mood swings develop in body image from extremely self-critical to overly vain • More attention paid to personal appearance and dress • Sex role expectations begin to be acted out according to culturally established patterns (dating, petting, etc.) Source: Received from Dr. Renee Ornelas; original source unknown.

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Appendix 7.2: Signs of Child Sexual Abuse Note: Fondling, oral copulation, vulvar or labial coitus, and sodomy generally have little or no physical signs 1. Child reports sexual abuse by a parent or other caregiver 2. Child has unusual or unexplained genital, anal, or oral injuries, bleeding, pain, or odor 3. Young child has difficulty sitting and walking 4. Child exhibits sudden withdrawal, fearfulness, or avoidance of familiar adults or places, development of phobias, unexplained depression, clinginess, or irritability 5. Child exhibits sexual knowledge or behavior that is beyond what is expected for the child’s developmental level; inappropriate displays of affection 6. Child shows avoidance of undressing or wearing extra layers of clothing 7. Child has onset of nightmares, bed-wetting, or other sleep disturbances 8. Child shows sudden change in appetite; eating disorders 9. Child has frequent psychosomatic GI or GU complaints 10. Adolescent promiscuity or prostitution 11. Child under the age of 14 becomes pregnant or contracts a sexually transmitted disease (STD) 12. Child is chronically running away from home, exhibits suicidal gestures or obsessive behavior 13. Child is isolated or caregiver severely restricts child’s contact with others, especially those of the opposite sex 14. Caregiver is unduly protective of the child; secretive, jealous, or controlling

References Aldrich, C. A. 1977. In Kempe, C.H. Sexual abuse: Another hidden pediatric problem: 1977 C. Anderson Aldrich lecture. Pediatrics. 1978; 62:382-389. American Academy of Child and Adolescent Psychiatry, http://www.aacap.org/ Botash, A. 2010. http://emedicine.medscape.com/article/800770-overview (accessed October 5, 2010). Child Abuse Prevention and Treatment Act of 1974 (CAPTA), reauthorized by Public Law No. 108-36. 2003. Office for Victims of Crime, U.S. Department of Justice http://academicdepartments.musc.edu/ncvc/resources_prof/OVC_guidelines04-26-04.pdf

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Kellogg, N. and the Committee on Child Abuse and Neglect. 2005. Clinical report: The evaluation of sexual abuse in children. Pediatrics 116:506-512 http://www. aap.org/pubserv/PSVpreview/pages/Files/EvalSA.pdf (accessed October 6, 2010) Office for Victims of Crime (OVC), USDOJ, U.S. Department of Justice Report: Child Physical and Sexual Abuse: Guidelines for Treatment. http://ovc_guidelines04-26-04.pdf or from http://ojp/usdoj/ovd/publications/infores/ca/welcome.html (accessed August 28, 2010) Pandora’s Box, http://www.prevent-abuse-now.com/ Patterson, C. J. 1995. Lesbian and Gay Parenting: APA Amicus Briefs, A Successor to Lesbian and Gay Parenting: A Resource for Psychologists. http://www.apa.org/ pi/lgbt/resources/parenting.aspx# (accessed August 28, 2010). Sexual Offender (Jacob Wetterling) Act of 1994. Enacted as part of the Federal Violent Crime Control and Law Enforcement Act of 1994, Public Law No.: 103-322 http://www.law.cornell.edu/uscode/uscode42/usc_sec_42_00014071----000-. html (accessed October 6, 2010). Overview at http://www.ojp.usdoj.gov/BJA/ what/2a1jwacthistory.html Stopitnow.org. http://www.stopitnow.org Wikipedia. Child sexual abuse, http:en.wikipedia.org/wiki/Child_sexual_abuse (accessed November 13, 2008). www.unicef.org/crc (accessed October 5, 2010)

Additional Resources http://www.familywatch-dog.us http://www.nlm.nih.gov/medlineplus/ency/article/007224.htm National Sex Offender Public Registry www.nsopr.gov http://www.sexualoffenders.com Darkness to Light hotline 1-866-367-5444 http://www.darkness2light.org

Youth Behaviors and Violence

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Violence toward children doesn’t always come from adults. Risky behavior patterns and violence perpetrated by and between children, adolescents, and young adults is on the increase. Teen gang violence is well known. Less notorious but of considerable concern is the violent behavior occurring within teenage dating relationships. Abduction of children by a stranger strikes fear in the heart of every parent, yet most abductions are perpetrated by persons known to the victim or the family. The impact of homelessness on children is unsettling and minimally studied.

Risky Behavior The leading cause of death for teens over age 15 is accidents, most of which are motor vehicle accidents. Suicide is the second leading cause of teen death. Homicide is third. Most deaths among our youth are preventable. Looking only a few years ahead, two-thirds of all deaths among persons over 25 years of age will be the result of three causes: cardiovascular disease, diabetes, and cancer. The associated risk behaviors are established during adolescence and they are, for the most part, entirely preventable (Eaton et al., 2007). Teens typically engage in high-risk behaviors such as experimenting with drugs and alcohol, fast and dangerous driving, or minor criminal activity. Violent behavior is another example of experimentation and challenge of social norms. As noted previously, teens who live with violence in their homes or social environment are more likely to be violent themselves (Healthy Youth, 2010; Join Together, 2008). The Youth Risk Behavior Surveillance System YRBSS, 2010 monitors six categories associated with health and violence risks among young people: careless or reckless behavior, tobacco use, drug and alcohol use, sexual practices, dietary habits, and physical activity. The results of this ongoing study are staggering. Although risky behavior among teens and young adults has decreased, the number of young people still involved in risky behavior is substantial. Behaviors contributing to unintentional injuries include failing to use seat belts in vehicles, failure to wear helmets when riding on a motorcycle or bicycle, and riding with a driver who has been drinking alcohol or using drugs. Violent behaviors include carrying a weapon, (CDC, MMWR, 2009) fighting on and off school grounds, dating violence, forced sexual intercourse, 243

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and threatening or injuring another person with a weapon. Behaviors begun in adolescence that place youth at risk for acute and chronic health problems later in life include tobacco use, alcohol and other drug use, use of inhalants, steroids, and other prescription drugs, unprotected sexual intercourse, poor dietary habits and eating disorders, and lack of physical exercise. Dietary behaviors, such as poor eating habits and inappropriate weight control practices are especially alarming. Over 10% of middle-school and high-school students are overweight or obese. Less than one-third of students eat fruits and vegetables on a regular basis. Some students went without eating for 24 hours or more to lose or keep from gaining weight. Some took diet pills, powders, or liquids, vomited or took laxatives in the 30 days prior to the survey. (YRBSS, 2010; NVAA, 2002). Clearly, these behaviors place our youth at risk for immediate and longterm health consequences.

Drug Use Drug use among preteens, teens, and young adults is endemic. As any child or teen will tell you, drugs are available on school campuses or minutes away on the street. A current fad among youth is abuse of stimulants such as Ritalin. Many parents are unaware of the potential for misuse of these drugs. Younger children, including elementary school children, are most interested in stimulants like Ritalin and Adderall because they think they’re “safe.” Unfortunately, over 1,400 Ritalin-related visits to emergency departments were made in 2001. The danger is twofold because children for whom Ritalin is legitimately prescribed are skipping doses. Other children seeing the money to be made selling prescription drugs are faking symptoms in order to get a prescription.

Dating Violence Dating violence occurs in the context of a courtship or dating relationship. Most young women are physically assaulted by someone they know. Dating violence is an act or threat of violence by one or both members of an unmarried couple against the other member. Dating violence, battery, illegal restraint, or intimidation are often accompanied by alcohol use (NVAA, 2002). Nonsexual violence occurring within a dating relationship is not a rare event. Research suggests as many as 65% of dating relationships includes violence or threats of violence. There is little research into dating violence.

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Risk factors may be due in part to immature thinking,* inexperience due to age, and choice of lifestyle. Behavioral indicators include an increased number of partners, acceptance of dating violence, and previous sexual assault victimization. Inexperienced young individuals make the unwise and unfounded assumption that a violent, controlling partner will improve after marriage. Physical and emotional abuse during a courtship is pretty much a guarantee of further abusive behavior. Without intervention, marriage, “love,” or children will not overcome a violent personality. Once a potential victim is aware of abusive tendencies in an acquaintance or partner, the only safe options are to (1) set limits on that person’s behavior and stick to them, or (2) leave the relationship. Regardless of age, individuals have the right to set limits on interpersonal behavior toward them. However, potential victims also have the responsibility to communicate those needs and rights to those around them. Although males are responsible for the majority of dating violence, not all perpetrators are male and not all victims are female. For simplicity, however, this text will refer to perpetrators as male and victims as female. Characteristics of dating violence perpetrators are similar to those who commit domestic violence and sexual assault. He abuses alcohol and/ or drugs, loses his temper easily, displays violent behavior toward objects, animals, and others, is jealous, watches his partner closely, and needs to know details of her activities, becomes enraged when things don’t go his way, demands excessive attention or time from his partner, exhibits a need to control (as might be seen in telling the partner how to dress, wear hair, makeup, etc.), demonstrates use of control by physical means (slapping, pulling hair, twisting arms, punching, shoving, or other physical aggressiveness), and is physically abusive or the recipient of physical abuse in his own home. Historically, sex role stereotypes have suggested that men are to be in control and women are to be passive. Such views of male dominance have been perpetuated in some families and have led to the belief that use of coercion or force is justified in sexual relationships. Parents and teachers should encourage preteen children to question such sex role stereotypes and teach more appropriate attitudes and behaviors about self-determination in intimate relations. Teens and naïve adults who are less sophisticated may not be adept at protecting their personal boundaries. The dominant partner or both individuals may be under the influence of alcohol or drugs, clouding * Dr. Jay Giedd, who studies brain development at NIH’s National Institute of Mental Health, explained that scientists have only recently learned more about the path of brain growth. One important finding, he said, “showed that the frontal cortex area—which governs judgment, decision making and impulse control—doesn’t fully mature until around age 25” (Giedd, 2005).

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personal judgment. Young adults should be alert to indicators that a partner might become abusive. These include: • • • • •

Disregard for what others are saying Becoming hostile when the other person says “no” Accusing the partner of being “uptight” Attempting to make the partner feel guilty Acting aggressively, possessively, or jealously

The bottom line: If a partner’s behavior doesn’t seem right, it probably isn’t. Trusting one’s intuition is a valuable tool in restraining a potentially unhealthy relationship. Like all victims of abuse, many feel isolated and alone. Dating violence is endemic. Previous victims and community resources are available to empathize with and support victims. As younger teens mature, particularly those who have experienced violence themselves, they become valuable role models and sources of support and guidance for more vulnerable peers and younger associates. The astute healthcare provider, especially in communities where people are better acquainted with each other, can facilitate positive interaction between older, more mature adolescents and young adults and their younger counterparts. Many youthful victims keep their violent relationships from parents or supportive adults. Teens believe such behavior is “not a big deal” and, unhealthy and dysfunctional as it may be, still desire the relationship with the abusive partner. Because of the secretive nature of teen interpersonal relationships and teens’ inability to remove themselves from unhealthy and unsafe situations, it is even more important for adults to be aware of changes in children’s behavior. Subtle signs of interpersonal teen difficulties are such things as changing friends, dropping activities, or becoming very secretive. When assessing adolescent or young patients, healthcare providers need to be aware of the possibility that their patient may be a victim of dating violence and interview him or her carefully. Providing a confidential setting is extremely important. Privacy and respect encourages victims to discuss their concerns. Bridging the communication gap between parent and child can make the difference in dissolving the dysfunctional relationship. If possible, find a way to include parents when providing information on developing a safety plan. Ways that a parent can help to protect their child from potential violent associations include promoting open communication, knowing where their child is, showing up or participating in the child’s activities, and using pagers or cell phones. Because of the communication gap between adolescents and adults, it may be helpful for parents to promote a “middle man,” such as a

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trusted relative or mature adolescent, to buffer the relationship. Trust by both the parent and the adolescent is crucial in developing these relationships, but they can help bridge the gap. Mike Domritz, in his book May I Kiss You? (2003), suggests that we rethink the approach of prevention and begin to think in terms of awareness. It is difficult to prevent another’s violent behavior, but it is possible to be aware of the risks involved in any given situation and take actions to minimize those risks.

Bullying Bullying is difficult to define because it includes a wide variety of behaviors, some of which are direct and easily observable, others of which are indirect and more subtle. Examples of direct bullying include hitting, threatening, intimidating, name calling, malicious teasing, stealing, damaging personal property, or deliberately running into the victim and then blaming the victim for the encounter. Examples of indirect bullying are spreading rumors or encouraging others to reject or exclude someone. Cyber-bullying—use of the Internet to bully—has escalated recently and has become a severe enough problem that some teens have committed suicide. It is estimated that approximately one-third of teens in the United States are involved in bullying either as perpetrator or victim. Although research is limited, it is thought that bullying is more prevalent among younger teens and preteens and diminishes as teens grow older. Not surprisingly, boys are more likely to be involved in direct bullying, whereas girls are more likely to be involved in indirect bullying. Some studies report that bullies act tough in order to cover up feelings of insecurity and inadequacy, while others report that bullies are confident, physically aggressive individuals with high self-esteem, a need to dominate, and a low tolerance for frustration. Male bullies often use a physical size advantage to overpower victims and have little empathy for the victim’s plight. These bullies are frequently physically aggressive in other aspects of their lives, get into trouble more often, perform poorly in school, and engage in troublesome behaviors such as smoking, drinking, and fighting. Extremes in parenting techniques may also increase the likelihood a student will become a bully. Children with too many or too few boundaries may rebel by taking out frustrations on those perceived to be weak or vulnerable. It’s all about power. Bullies seem to have little trouble making “friends.” Unfortunately, other kids see the bully as powerful. They share similar aggressive or problem behaviors and attitudes, yet are unwilling to go it alone. Teens who bully are also more likely to engage in other delinquent behavior such as

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vandalism, truancy, and shoplifting. Bullies are four times more likely to be convicted of crimes by early adulthood. Victims of bullying, especially if the bullying is repetitive, become tense, anxious, and fearful. The student’s ability to concentrate is compromised and repeated incidents may lead victims to avoid going to school. Victims’ self-esteem suffers, leading to depression, insecurity, and withdrawal from their peers. Some teens bring weapons to school for self-protection and may even engage in retribution, as was seen in the Columbine High School shootings of April 20, 1999. Others may surrender to despair and commit suicide. The effects of bullying can last a lifetime. Adults who were bullied as children have higher rates of depression and exhibit lower self-esteem than adults who were not bullied. Bullying also affects those who witness it. Feelings of guilt are common among friends or classmates, especially if they actively watched or supported the bullying. Others seek safety from being bullied themselves by blaming the victim, ending any relationship with the victim, or supporting the bully’s behavior. Nurses who suspect a child has been the victim of bullying can provide immediate support by encouraging the victim to discuss his or her feelings, contacting and involving parents, and referring both to support services. Nurses, particularly school nurses, can become more involved in reducing the frequency and severity of bullying by raising awareness regarding the signs of bullying, educating school administration on the effects of bullying, encouraging increased teacher supervision, and developing methods to reduce the incidence of bullying in their school. Taking a proactive stance against bullying can be the school nurse’s way to change the situation. Healthcare providers are role models. Firefighters, emergency medical care personnel, nurses, and others can be proactive by initiating a collaborative effort among students, parents, teachers, administration, and the school board to eradicate bullying in the school. A pledge is available for students, parents, and teachers on Dr. Phil’s Web site: http://www.drphil.com/. Victims of bullying can help protect themselves by talking to a parent or trusted friend or adult about the situation, developing a safety plan, and actively seeking emotional and psychological support. Confidencebuilding steps include finding and pursuing activities that provide personal rewards, cultivating new, positive relationships, and developing new talents and skills. Thoughts of retaliation are fairly common, so an open, honest discussion of the victim’s feelings should be encouraged. Victims of bullying should not focus on acts of retaliation and should never carry a gun or other weapon. There are more powerful means of combating bullying than retaliatory violence. Learning ways to stay calm, respond evenly and firmly, act and feel confident, make eye contact, and set limits on behavior are all ways to combat an aggressive individual. Schools, churches, social groups,

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and communities can set the standard that aggressive behavior is not the same as being assertive, and aggressiveness toward others is not acceptable in their community. Effective means to defuse a tense situation are the intentional use of humor or simply walking away. Encourage the victim to talk about their experience and feelings following a bullying experience. Those who witness bullying may feel guilty or experience fear of retaliation, or fear being targeted themselves. They may avoid contact with the victim in an attempt to avoid losing status or being seen as “weak.” If a bullying situation has overtones of violence, witnesses should not put themselves in harm’s way; rather, they should report it immediately to authorities.

Guns and Gangs Gun ownership is common, particularly in the United States. The risks associated with the possession and use of guns for self-protection have been established (Iannelli, 2009). The danger to families is exacerbated in homes where domestic violence occurs. Gun possession also poses a risk of injury and death due to accident. The tragedy of one child being shot by another is an event that has a lifelong effect on survivors. There are few laws imposing penalties on adults who leave guns unsecured. The healthcare provider is rarely in a position to learn of an accessible weapon in the home. However, once it is known that guns are unsecured within a child’s grasp, the healthcare provider can use the opportunity to educate parents and the child, and if appropriate, notify authorities. Federal law makes it illegal for anyone under the age of 18 to own or carry a handgun. Yet many teens have access to guns either at home, through friends, or by borrowing or stealing them. Guns are carried by teens for “selfprotection” or as a confidence booster in dispute resolution. On average, over 7,000 gun-related violent crimes were perpetrated against persons 12 to 17 years old at schools or on school property (Perkins, 2003). Problems of gang violence have become increasingly serious. Gang violence, particularly homicide, have become more deadly as dangerous weapons, especially high-caliber, automatic and semiautomatic handguns, have become increasingly accessible. According to C. Ronald Huff, Director of the School of Public Policy and Management at the Criminal Justice Research Center at Ohio State University, there are more than 16,000 gangs in the U.S. with at least a half million members (Huff, 1998). In 1994, there were 1.1 million violent victimizations perpetrated by gang members (Harrell, 2005). The Gangs Toolkit is available from the Community Oriented Policing Services (COPS), a division of the U.S. Department of Justice (USDOJ) and NCJRS (National Criminal Justice Reference Service).

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Dangers to Bystanders and Healthcare Workers Homicide by gang members is more likely to take place in public settings and may involve strangers, multiple participants, and the use of automobiles for drive-by shootings. Threats and intimidation by gang members are common. Fear of retaliation from gang members is a genuine reality. Healthcare providers are increasingly at risk from gang members entering the hospital, clinic, or nurse’s office or even reentering a scene in an attempt to “finish the job.” Female Gang Membership Little research has been done on female gangs and female gang members. Most research on youth gangs has focused on gang involvement, drug use and sale, criminal activities, and the cost of gangs. At present, very little is known about the general health of gang members. For instance, little is known about the incidence of sexual assault among gang members, partly because female gang members are reluctant to talk about it and partly because few researchers have considered female gang membership worthy of study. There is one constant, however; most female gang members have children. Male gang members may relinquish responsibility for their children but most females parent their own children. The impact on the healthcare system and society as a whole may be significant. Like their nongang counterparts, women and children do call 911 and do visit healthcare providers for reasons other than traumatic injury. Primary healthcare settings, including emergency response situations, provide an opportunity for healthcare providers to assess gang members’ overall health, health needs, health risks, and behaviors, and assist in the development of healthcare strategies. Effects of Gangs on Children Especially vulnerable to violence, child victims may become angry, withdrawn, and develop signs of posttraumatic stress. Over time, they may become desensitized to violence. The long-term psychological, emotional, financial, and legal effects of violence on nonparticipants can be significant. However, the immediate day-to-day effect of gun violence on children creates a basic feeling that they are not safe. Children at risk for psychological sequelae are those who are injured by violence, those who witness violent acts at close proximity, and those exposed to high levels of violence in their neighborhoods or schools. Gang-infested neighborhoods are an example of where a collaborative approach is most effective in helping children and their families cope with the violence engulfing their lives.

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Gangs in Rural Areas Gangs in rural areas have been largely neglected. A study by Slovak and Singer (2001, 2002) pointed out that rural areas are not immune to gang formation and violence. Gangs are not exclusively an inner-city phenomena. The stereotype that they are is an obstacle to identifying rural children and communities at risk and devising methods to combat gang creation and activity.

Homelessness The lives of homeless youth are unsettled and unsafe; their environment may change frequently, and at a moment’s notice. Basic necessities of life are often absent. The homeless witness asocial behavior on a daily basis. In addition to a lack of food, shelter, and clothing, educational opportunities, basic healthcare, and positive role modeling are minimal or nonexistent. Healthcare is often given a lower priority than immediate personal issues such as alcohol, drugs, cigarettes, or food and shelter, putting homeless youth at higher risk for communicable diseases such as HIV, sexually transmitted diseases (STDs), or tuberculosis.

Suicide Annually, approximately, 500,000 people seek treatment in hospital emergency rooms as the result of attempted suicide. The Centers for Disease Control and Prevention (CDC) reports teen suicide is the third leading cause of death between the ages of 15 and 24, exceeded only by unintentional injury (mostly motor vehicle and other accidents) and homicide. Surprisingly, it is the fourth leading cause of death for children between the ages of 10 and 14 (MMWR, 2007). More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined. Nearly three out of five suicides in 1999 were committed with a firearm. Hanging is also a popular method of committing suicide among teens. Over one-quarter of the youth surveyed reported feeling so sad or hopeless for two weeks in a row that they stopped doing some usual activity. Almost one-fifth of students surveyed seriously considered attempting suicide. Two-thirds of these students had made a specific plan to commit suicide, and half of those students had actually carried out a suicide attempt in the previous 12 months.

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Risk Factors for Suicide A combination of individual, relational, community, and societal factors contribute to the risk of suicide. Risk factors are those characteristics associated with suicide—they may or may not be direct causes. • • • • • • • • • • • • • • • •

Family history of suicide Family history of child maltreatment History of previous suicide attempts History of alcohol and substance abuse Feelings of hopelessness Isolation, a feeling of being cut off from other people Impulsive or aggressive tendencies History of depression or other mental illness Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts Barriers to accessing mental health treatment Stressful life event or loss (relational, social, work, or financial) Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma) Physical illness Local epidemics of suicide or exposure to the suicidal behavior of others Easy access to lethal methods Incarceration

There is also an increased risk for suicide among gay/lesbian/bisexually oriented youth, especially males. The Youth Risk Behavior Surveillance System (Eaton et al., 2008) found that in the 12 months preceding the survey, 1 in 13 high school students had attempted suicide. This ratio translates into an estimated 1.3 million students. Clearly, suicide among young people is a serious and preventable problem. Deterrents Strong connections with parents and family, a positive association with instructors and peers at school, and interest and participation in activities at school are the major deterrents to teen suicide. Intervention Healthcare providers can contribute to the reduction of teen suicide in many ways. As with other interpersonal trauma, they may be the first to recognize

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the signs of depression, substance abuse, mental illness, and hopelessness in their young patients. Healthcare providers are most effective when they use their skills and experience to listen to their patients, empathize with their pain, and help the patient plan a way to relieve their present despair. Healthcare providers know that suicide is a preventable public health problem. They know the basic elements of psychological and physiological origins of depression. As these elements are better understood, healthcare providers are in an ideal position to explain and translate the complicated psychological, biological, and chemical factors involved in depression, mental illness, and grief resolution. Suicide prevention requires a collaborative effort among private institutions, public institutions, individuals, and families. Because healthcare providers are on the front lines of healthcare, they are in an ideal position to screen the general population for suicidal attitudes and behaviors. Precipitating circumstances, personal characteristics, support and health services sought and/or received prior to the attempt, and the severity and cost of injuries are important clues to assessing individuals most at risk for suicide and preparing prevention strategies. The forensically aware healthcare provider can help train social service and other frontline providers in recognizing and responding to those at risk for suicide. They are in a position to know which agencies are appropriate for referral, initiate a referral, and begin follow-up care. Through collaborative efforts with schools, churches, members of the media, social service providers, and other ancillary professionals, healthcare providers can help their communities develop a cohesive suicide prevention plan. Public awareness of the risks and consequences of suicide lowers the incidence of suicide while reducing the stigma of attempted suicide. Early intervention for individuals who have been exposed to trauma or violence is critical. In addition, interventions have a much greater likelihood of success if they involve a variety of services and providers. Nurses, teachers, mental health practitioners, parents, friends, and family can help prevent further trauma to children who are exposed to violent or traumatic events. Community leaders must build effective coalitions across traditionally divided sectors, including private and public participation and the involvement of multiethnic and culturally diverse populations. First, of course, is to ensure the child’s physical safety, followed by the creation of a “safe haven” where further exposure is reduced or eliminated. In caring for children who have been exposed to traumatic events, it is important to protect them from interference by onlookers or members of the media, and ensure that interviews by law enforcement or healthcare providers are conducted in a neutral, nonthreatening setting, away from the incident itself.

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The nurse or other healthcare provider can identify children experiencing symptoms of acute distress and arrange for immediate care. Family and/ or friends may provide supportive care or the child may need to be taken to a professional setting until he or she stabilizes. It is important to provide supportive physical as well as verbal reassurance, especially to children in crisis. Touching, hugs, and a reassuring tone of voice are all helpful. Children recognize and respect the truth. When the crisis has subsided, explain the event in as clear, honest, and nonthreatening a way as possible. Encourage the child to express his/her feelings, but do not force communication. Listen to the child’s fears and concerns and let him or her know it is normal to be upset after something bad happens. Reassure the child that the event was not their fault and remind them that they are safe now. Allow children (and adults) to cry or vent. It is not appropriate to tell children to “be tough.” Most children will recover within a few weeks of the traumatic or violent event. Some individuals will require an extended period of time to recover. Children who continue to display avoidance behavior (refusing to go places that remind them of the event), experience repeated nightmares or sleep disorders, display emotional numbness, or have a tendency to be easily or over stimulated should be referred to a mental health professional for remedial help. Children and adolescents do experience posttraumatic stress disorders, but respond well to prompt intervention. It is important to remember that children are very sensitive to the emotional response of their parents, particularly the mother. A mother who is depressed or overly anxious following a traumatic event may need emotional support herself before the child can fully recover.

Stranger Danger Having one’s child abducted is a parent’s greatest fear. The thought of one’s child being tortured or murdered is unthinkable, and parents will do everything in their power to prevent such an occurrence. Such cases receive a great deal of media attention. It is important to note that over half the perpetrators in nonfamily abductions are known to the child (Rosas, 2003; Monteleone, 1998). These nonfamily members are frequently friends, neighbors, acquaintances, or other individuals in positions of authority. In almost half of nonfamily abductions, multiple perpetrators were involved. Streets, parks, wooded areas, and other public places, not homes and yards, are places where children are typically abducted (Suite 101, 2009; Yello Dyno, 2010). Abduction and harm of children by strangers make up a small portion of violence against children. Of the estimated 58,200 nonfamily abductions

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(those perpetrated by a stranger), 115 were classified as stereotypical kidnapping. (That is, the child was taken by a stranger or slight acquaintance, transported 50 or more miles, detained overnight, held for ransom or with the intent to keep the child permanently, or the child was killed.) Forty percent of child victims of stereotypical kidnapping were killed while 32% of these children received injuries serious enough to require medical attention. Nearly half of all victims of nonfamily abduction were sexually assaulted by the perpetrator. It is not surprising then that teenage girls are by far the most frequent victims of nonfamily abduction. The incidence of sexual assault and the percentage of victims requiring treatment puts these victims squarely within the domain of the healthcare provider. Making abduction and sexual assault prevention strategies (such as posters and support agency information) visible and easily available is one way the healthcare provider can help reduce the incidence of both crimes. In an attempt to thwart abductions, Amber Alert has been implemented nationally. Amber Alerts are posted along major highways advising motorists to be on the lookout for vehicles involved in recent child abductions (Amber Alert, 2010). Emergency Amber Alert bulletins are also made on television and radio stations. One way that parents can be cautious is to make sure they are aware of potential predators. Someone who “seems too good to be true,” offers exceptional assistance with childcare or other household responsibilities, or knows too much about your family and your children, is worth watching— especially if the person does not have a long history with you or your family. Children need to know that predatory individuals do not necessarily look scary or strange; in fact, they usually look pretty normal. Children need to know that they have the right to say “no,” especially to someone other than their parents. Communicating with children is the key. Discuss “stranger danger” with them as soon as they are old enough to understand, develop a plan of action, and rehearse it with your child. Encourage your child to teach other children. This helps to reinforce the behavior in your child and may save the life of another child.

Child Pornography Child pornography has been determined to be a crime by federal law (U.S. Code Title 18). In addition, many states have passed laws regarding child pornography and punishment of offenders. The photographs and other visual images are themselves evidence of a crime. They are a permanent record of the abuse of a child. Unfortunately, once published or shared, they are

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irretrievable and may circulate among those who indulge in viewing child pornography long past the child’s minority. Young teens are particularly vulnerable to becoming victims of the child pornographer. Most child victims are pubescent or prepubescent and are abused by someone who has legitimate access to them. Many perpetrators are the parents themselves, other relatives, family friends, or others with reasonable access to children such as neighbors, babysitters, teachers, coaches, and clergy. As with all forms of abuse of a minor, reporting by a healthcare provider is mandatory.

Summary Violence is the breeding ground of tomorrow’s perpetrator. Identification is the key to stopping the cycle of violence. Healthcare providers can take action in a couple of important ways. First, the healthcare provider must develop and activate a forensic antenna so he or she is aware of the forensic issues in children’s lives. Second, healthcare providers need to recognize that only a fraction of child victims need physical “medical” care; they need immediate and ongoing mental health intervention by a collaborative group of professionals and volunteers. The healthcare system can be instrumental in implementing this collaborative approach through public education strategies, networking with other agencies, and supporting aggressive prosecution of crimes by and against children.

References Amber Alert. 2010. http://amberalert.com or http://amberalert.gov/faqs.htm Bureau of Justice Statistics (BJS), Office of Juvenile Programs (OJP), USDOJ at http:// bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=695 Community Oriented Policing Services (COPS), a division of USDOJ, http://www. cops.usdoj.gov/ Domritz, Mike. 2003. May I Kiss You? Greenfield, WI: Awareness Publications. www. awarenesspublications.com Eaton, D.K., L. Kann, S. Kinchen, S. Shanklin, J. Ross, J. Hawkins, W. A. Harris, R. Lowry, T. McManus, D. Chyen, C. Lim, N. D. Brener, and H. Wechsler. 2007. Youth Risk Behavior Survey (YRBS) — United States, 2007. Morbidity and Mortality Weekly Review, 57(ss04): 1-131. June 6, 2008. http://www.cdc.gov. mmwr/preview/mmwrhtml/ss5704a1.htm Giedd, J. 2005. “Teen brains: Still under construction.” NIH News in Health. August 12, 2005. http://nihrecord.od.nih.gov/newsletters/2005/08_12_2005/story04. htm (accessed November 11, 2010).

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Harrell, E. 2005. Violence by Gang Members, 1993–2003. Bureau of Justice Statistics Crime Data Brief (NCJ 208875). Washington, DC: Office of Justice Programs. http://www.ncjrs.gov/App/Publications/abstract.aspx?ID=208875 (accessed November 14, 2010). Healthy Youth. www.cdc.gov/HealthyYouth/yrbs/pdf/us_overview_urbs.pdf accessed September 2, 2010. Also www.cdc.gov/HealthyYouth/yrbs/pdf/us_obesity_ trend_yrbs.pdf accessed September 2, 2010. Huff, C. R. 1998. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice, Research Preview. “Criminal Behavior of Gang Members and At-Risk Youths.” http://www.ncjrs.gov/App/Publications/abstract.aspx?ID= 200868 (accessed November 14, 2010). Iannelli, Vincent. 2009. Gun safety guide. About.com, http://pediatrics.about.com/cs/ safetyfirstaid/a/gun_safety.htm Join Together. 2008. http://www.jointogether.org/resources/2008/youth-risk-behavior.html (accessed November 15, 2010. Monteleone, J.A. 1998. A parent and teacher’s handbook on identifying and preventing child abuse. St. Louis, MO: G. W. Medical Publishing Inc. p. 52. Morbidity and Mortality Weekly Report (MMWR Weekly). September 7, 2007. Suicide trends among youths and young adults ages 10–24 years—United States, 1990–2004.56(35): 905–908, http://www.cdc.gov/mmwr/preview/mmwrhtml. mm5635a2.htm (accessed February 28, 2010). National Criminal Justice Reference Service (NCJRS). 2010. http://www.ncjrs.gov/ National Victim Assistance Academy (NVAA) Manual. 2002. Seminars held simultaneously at 1) California State University, Fresno, CA; 2) Medical University of South Carolina, Charleston, SC; and 3) Washburn University, Topeka, KS. The manual can be accessed at www.ncjrs.gov/ovc_archives/nvaa2002/aboutbook. html (accessed September 9, 2010). Individual chapters can be accessed at www. NVAAchapter/html/2002/chapter1_1.html. Perkins, Craig. 2003. U. S. Department of Justice, Weapon use and violent crime, National Crime Victimization Survey, 1993–2001 (September 2003). NCJ 194820, http://bjs.ojp. Rosas, A. 2003. Child Sexual Abuse. In Peterson, M. S. and Durfee, M. (eds.) Child Abuse and Neglect: Guidelines for Identification, Assessment and Case Management. P82. Volcano, CA: Volcano Press. Slovak, K., and M. I. Singer. 2001. Gun violence exposure and trauma among rural youth. Violence and Victims, 16, 389, 400. Slovak, K., and M. I. Singer. 2002. Children and violence: Findings and implications from a rural community. Child and Adolescent Social Work Journal, 19, 35–56. Suite 101, 2009. L. C. Deluca. http://www.suite101.com/content/statistics-on-childabduction-a147599 United States Department of Justice usdoj.gov/content/pub/pdf/wuvc01.pdf (accessed July 17, 2010). United States Federal Code, Chapter 18 (18 U.S.C.). Yello Dyno, 2010. Http://yellodyno.com/html/abductions_stats.html

9

Elder Abuse

Elder abuse is domestic violence visited upon the elderly. It is often a complex situation involving physical, psychological, social, and economic factors, both on the part of the abuser and the victim. Elder abuse occurs in a variety of settings, most commonly in a residential situation or elder care facility. The same basic forensic principles of assessment, documentation, evidence collection, and treatment that is appropriate for any victim of violence and crime is relevant to the elderly. The first National Elder Abuse Incidence Study, conducted by the National Center on Elder Abuse for the Administration for Children and Families and the Administration on Aging, U.S. Department of Health and Human Services, estimates that during 1996, at least one-half million older persons in domestic settings were abused and/or neglected, or experienced self-neglect, and that for every reported incident of elder abuse, neglect, or self‑neglect, approximately five go unreported. In almost 90% of the cases where the perpetrator was identified, it was found to be a family member or other person known to the victim.* Approximately two-thirds of the time the perpetrator was the spouse or adult child(ren) (National Center on Elder Abuse, 1998). Elders have many of the same characteristics and issues as victims of domestic violence and sexual assault. They minimize the abuse, blame themselves for the situation and the abuse, wait long periods of time before seeking healthcare, and experience depression, intense confusion, and posttraumatic stress disorder. The frequency and severity of abuse is a pattern of behavior that is likely to escalate over time. Many victims of elder abuse are killed by their abusers. Many people regard the elderly as forgetful, clumsy, easily bruised, and often less credible than those who are younger. When caring for an elderly patient, it is important to recognize that although those conditions may be symptomatic of senior citizens, all patients require that we listen to them, take the time to assess their condition, and keep our forensic antenna raised throughout the entire process. As with all potential victims of abuse, look for signs of adequate and appropriate food, water, healing, cleanliness, medications, safety, and availability of free communication. Be suspicious of any unexplained or unwitnessed traumatic events and/or injuries. Multiple * Although there is much publicity regarding nursing home abuse and neglect, perpetration of crimes against the elderly amounts to a very small portion of elder abuse cases.

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injuries in various stages of healing, unexplained delay in seeking medical care, injuries that are inconsistent with the account given, and patterned injuries or ligature marks are always suspicious. Because the aging process often leaves an elder at a general disadvantage, they have special needs, rights, and vulnerabilities (see Appendix 9.1, “Rights of Elders”). Physical limitations and mental infirmities may put elderly victims in a position where they are unable to protect themselves physically, emotionally, or financially. The characteristics unique to the elderly include: • • • • • • • • • •

Muscle mass atrophies and strength is diminished. Bones become brittle and more susceptible to breaking. Joints become stiff and painful, decreasing one’s mobility. The heart beats less forcefully, and arteries become more narrow and less elastic, reducing blood flow. The respiratory muscles become weaker and lung tissue becomes less elastic, making breathing more difficult and requiring more of one’s daily energy consumption. Kidney function decreases. Digestive juices are reduced, peristalsis diminishes, and the elder loses his or her appetite. The skin becomes dry and less elastic, hair becomes thinner and grays; nails become thick and tough or thin and brittle. Memory is diminished and senses are decreased, elevating the potential for confusion and uncertainty. Tissue atrophy, especially in the abdomen, makes internal organs more vulnerable to injury from blunt trauma.

Psychosocial factors also come into play as elders become aware that they are becoming dependent, are less valuable (important) to their families and the community, and essentially assume a state of decline and hopelessness. Factors include retirement, death of spouse and close friends, coping with physical and possible financial uncertainty, losing the ability to drive, and preparing for further decline and death. In addition to the loss of mobility and some cognition skills, two of an individual’s natural protective assets— hearing and eyesight—become so impaired that it adds to the vulnerabilities of the elderly. Many elders feel alone, unnecessary, and worthless, making them easy targets for abuse. Nonparticipating family members may not believe an elder’s accusations of abuse. Elders, especially those with longstanding membership in a community, are embarrassed to admit family members are capable of abusive behavior toward a spouse or parent and are therefore reluctant to disclose the abuse. An elder may not have the financial resources to reside in retirement or residential care housing. There may not be anyone else

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able or willing to assume the physical, emotional, and financial demands required to care for an elder. These circumstances can leave the elder feeling trapped, unable to report the abuse, and having no other option than to continue in the abusive situation. Crime statistics show that elders are less likely to incur physical injury as the result of violence and other crimes than younger individuals. However, when an elder is injured, the injuries tend to be more serious (broken bones and concussions) due to the fragility and vulnerability of the aging body and mind. When injured, the elderly person is more likely to be hospitalized and less likely to recover from their injuries than a younger person. They are more prone to develop subsequent sequelae such as pneumonia, thrombosis, and depression (NVAA, Chapter 14, 2002). Patterns of domestic violence in the elderly may be a continuation of lifelong spousal abuse, late onset abuse situations in which age-related behaviors and needs increase stresses on both partners, cases where an elder has married or remarried late in life to an abusive spouse, or instances where elders are battered by their adult children—some of whom had been battered themselves as children.* In domestic settings, however, neglect is the most common form of elder maltreatment and adult children are most often the perpetrators. Isolation and diminished mental abilities† expose elders to economic abuse, fraud, and other economic crimes. Even though they may live independently and function at a level where they can live alone, because of diminished eyesight, hearing, and cognitive abilities, they are more dependent on family and others for some aspects of daily life.

* The “cycle of violence” coming full circle from one generation to the next and back again. † The California Probate Code divides mental functions into four broad categories in which deficits may be found: Alertness and attention refers to a person’s level of arousal and orientation to person, time, place, and circumstances. It includes the ability to concentrate. Information processing includes short- and long-term memory recall; understanding and communicating, recognizing familiar objects and persons; understanding and appreciating quantities, reasoning using abstract concepts; and planning, organizing, and carrying out actions in one’s rational best interest. Thought disorder refers to disorganized thinking; rambling thoughts; non-sensical or incoherent thinking; auditory, visual, or olfactory hallucinations; delusions or uncontrollable, intrusive, and compulsive thoughts. Ability to modulate mood and affect refers to recurrent emotional states that appear to be inappropriate in relation to the person’s circumstances. These states may include anger, anxiety, fear, panic, euphoria, depression, hopelessness, despair, helplessness, apathy, or indifference. University of California, Davis. Identifying and Responding to Elder and Dependent Adult Abuse in Health Care Settings: Guidelines for California Health Care Professionals. September 2005. Davis, CA: UC Davis.

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Categories of Elder Abuse There are seven categories of elder abuse (USDOH, 1998). They are

1. Physical abuse 2. Sexual abuse 3. Financial abuse or material exploitation 4. Emotional abuse 5. Spiritual abuse 6. Abandonment 7. Neglect and self-neglect

The American Medical Association (AMA) has developed guidelines for the diagnosis and treatment of elder abuse (AMA, 1992). Those guidelines provide for routine questioning of all patients, including the elderly and those with mental/cognitive impairment. Questions include: • • • • • • • • •

Has anyone hurt you? Has anyone touched you without your consent? Has anyone ever made you do things you didn’t want to do? Has anyone taken anything that was yours without asking? Has anyone ever scolded or threatened you? Have you ever signed any documents that you didn’t understand? Are you afraid of anyone at home? Are you alone most of the time? Has anyone ever failed to help you take care of yourself when you needed help?

Of course, any positive responses need to be followed with further inquiry and direct quotes from the elder documented in the patient’s record.

Joint Commission Standards The facility must have objective criteria for identifying and assessing potential abuse or neglect patients throughout all of its departments. Initial screening includes assessment of physical and psychological well-being (American Institute of Forensic Education). Personnel must be trained annually on current information and procedures in detecting abuse and neglect, including providing appropriate referrals for treatment, interventions, and follow-up.

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The facility must have designated space for examining forensic patients and be equipped with locked cabinets for storage of evidence. Patient privacy must be assured and all evidence, including photographs, must be managed with a high level of security. Procedures for reporting and referral of abuse and neglect cases must be available to healthcare providers.

Definitions Physical Abuse* Physical abuse is the use of force that may result in bodily injury, physical pain, or impairment. Physical abuse may include such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. The inappropriate use of drugs and physical restraints, forced feeding, and physical punishment of any kind are also examples of physical abuse. Particularly alarming is the “hidden” nature of this physical abuse to the elderly. Incidence studies demonstrate that elderly helpers only report signs of physical abuse in one out of five of the cases examined. Sexual Abuse* Sexual abuse of the elderly is nonconsensual sexual contact of any kind with an elderly person. Sexual contact with any person incapable of giving consent also is considered sexual abuse. It includes unwanted touching; all types of sexual assault or battery such as rape, sodomy, coerced nudity; and sexually explicit photographing. Emotional or Psychological Abuse* Emotional or psychological abuse is the infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional and psychological abuse includes verbal assaults, insults, threats, intimidation, humiliations, and harassment. Treating an older person like an infant; isolating an elderly person from his/ her family, friends, or regular activities; giving an older person the “silent treatment”; and enforced social isolation also are examples of emotional and psychological abuse. * The definitions of these three different forms of domestic abuse of the elderly are derived from the National Elder Abuse Incidence Study conducted in 1996 by the National Center on Elder Abuse at the American Public Human Services Association. This research was jointly funded by the Administration for Children and Families and the Administration on Aging.

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Spiritual Abuse Spiritual abuse is characterized by an attitude of superiority and over-emphasis on authority, suppression of dissent, unquestioning acceptance of doctrine, or performance of spiritual requirements. It is the manipulation of person or group based on their spiritual beliefs by a family member, caregiver, spiritual leader or other individual to dominate, manipulate or coerce by using fear or mind-control tactics to further the perpetrator’s personal agenda or aims. In the context of interpersonal abuse against the elderly, everyday caretakers or other predatory individuals use these tactics in their quest for power and money. Group examples include the use of voodoo by Haitian rulers and doomsday cult leaders such as “The Reverend” Jim Jones. Neglect Neglect is the refusal or failure to fulfill any part of a person’s caregiving obligation or duties to meet the needs of an elder. Neglect may also include a person who has fiduciary responsibilities to provide care for an elder (i.e., pay for necessary home care services or the failure on the part of an in-home service provider to provide necessary care). Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in the responsibility to or agreement with an elder. Neglect, whether intentional or not, is a form of abuse. Neglect can be willful (intentional) or nonwillful (passive neglect). Neglect can include isolation of the victim, misuse, refusal or overmedication of the victim, or leaving the elderly victim to live in unsanitary living conditions (excessive dirt or odor, inadequate living conditions, or ability to maintain daily function). Self‑Neglect Self‑neglect is characterized as the behavior of elderly persons that threatens their own health or safety. Self‑neglect generally manifests itself in the refusal or failure of elders to provide themselves with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions. The definition of self‑neglect excludes a situation in which cognitive or mentally competent older persons (who understand the consequences of their decision) make a conscious and voluntary decision to engage in acts that threaten their health or safety as a matter of personal preference. Fraud, Theft, and Financial or Material Exploitation Fraud, financial, or material exploitation is the illegal, improper, or unauthorized use of an elder person’s funds, property, resources, or assets for

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personal gain (Tatara, 1992). Examples include cashing an elderly person’s checks without authorization or permission; forging an older person’s signature; misusing or stealing an older person’s money or possessions; coercing or deceiving an older person into signing any document (i.e., a contract, a will); and the improper use of guardianship or power of attorney. Fraud is defined as “a false representation of a matter of fact—whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed—that deceives and is intended to deceive another so that the individual will act upon it to her or his legal injury.” Typically, victims give money but never receive what they paid for (Alexander and Seymour, 1998; Legal Dictionary, 2010). In Rights, Roles, and Responsibilities: A Handbook for Fraud Victims Participating in the Federal Criminal Justice System, (Alexander and Seymour, 1998) published by the Police Executive Research Forum (PERF), the emotional impact of fraud victimization is described as follows: “Fraud crime is a personal violation. Trust in one’s own judgment, and trust in others, is often shattered. Victims may feel a sense of betrayal, especially if the perpetrator is someone they know.” The sentimental loss of possessions stolen during a burglary is often far greater for the elderly. Their grief and emotional trauma may be extreme. It may be helpful for victim assistance personnel to work with family members so they can understand the emotional ramifications of the burglary on the victim. The impact of burglary on elderly victims can result in profound harm that extends beyond the financial losses: The larceny of even a small amount of money means many elderly victims must go without food, medication, or other necessities, especially if the victim lives on a fixed income. Undue financial hardship may occur when paying for property damage resulting from a crime. Even with insurance, there may be large deductibles and depreciation on the items, making the replacement of stolen items difficult, if not impossible. The loss of items deemed insignificant to many younger people may have a life‑changing impact on the elderly. For example, the loss of a TV or radio can further restrict the elder person’s ability to stay in contact with the outside world and further isolates him or her from society. Abandonment Abandonment is the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder or by a person with physical custody of an elder.

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Risk Factors for Abuse • • • • • • • • • • • •

Shared living arrangements Caregiver stress, immature caregiver Family history of violence Lack of independence or dependence on others Mutual dependency syndrome Social isolation; lack of access to resources Stressful event(s) or life style Poor or deteriorating general health History of mental illness Physical or cognitive impairments Substance abuse Inadequate financial resources, low income

Signs and Symptoms of Physical Abuse • • • • • • • • • • • • • •

Untreated pressure ulcers Dehydration Malnutrition Unexplained falls; bone and skull fractures Open wounds, cuts, punctures, and untreated injuries, and injuries in various stages of healing Sprains, dislocations, and internal injuries or bleeding Physical signs of being subjected to punishment: bruises, black eyes, welts, lacerations, or broken eyeglasses/frames Signs of being restrained, such as control marks or rope marks on wrists, forearms, and biceps Laboratory findings of medication overdose or underutilization of prescribed drugs An elder’s report of being hit, slapped, kicked, or mistreated An elder’s sudden change in behavior The caregiver’s refusal to allow visitors to see an elder alone Patterned injuries; injuries to the face, ears, neck, and upper arms Bathing suit zone injuries (trunk, stomach, genitalia, buttocks, and thighs)

Signs and Symptoms of Sexual Abuse • Bruises around the breasts or genital area

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Unexplained venereal disease or genital infections Unexplained vaginal or anal bleeding Torn, stained, or bloody underclothing An elder’s report of being sexually assaulted or raped

Signs and Symptoms of Emotional or Psychological Abuse • Being emotionally upset or agitated • Being extremely withdrawn and noncommunicative or nonresponsive • Exhibiting unusual behavior attributed to dementia such as sucking, biting, or rocking • Reporting verbal or emotional mistreatment

Signs and Symptoms of Neglect • General but disproportionate deterioration in health • Dehydration, malnutrition, untreated bedsores, and poor personal hygiene • Unattended or untreated health problems • Hazardous or unsafe living conditions or arrangements (i.e., improper wiring, no heat, or no running water) • Unsanitary and unclean living conditions (i.e., dirt, fleas, lice on person, soiled bedding, fecal or urine smell, inadequate clothing) • An elder’s report of being mistreated

Signs and Symptoms of Self-Neglect • Dehydration, malnutrition, untreated or improperly attended medical conditions, and poor personal hygiene • Hazardous or unsafe living conditions or arrangements (i.e., improper wiring, no indoor plumbing, no heat, or no running water) • Unsanitary or unclean living quarters (i.e., animal or insect infestation, no functioning toilet, fecal or urine smell) • Inappropriate or inadequate clothing, or lack of the necessary medical aids (i.e., eyeglasses, hearing aid, dentures) • Grossly inadequate housing or homelessness

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Signs and Symptoms of Abandonment • The desertion of an elder at a hospital, a nursing facility, or other similar institution • The desertion of an elder at a shopping center or other public location • An elder’s own report of being abandoned

Signs and Symptoms of Financial or Material Exploitation • Sudden changes in bank account or banking practices, including an unexplained withdrawal of large sums of money by a person accompanying the elder • The inclusion of additional names on an elder’s bank signature card • Unauthorized withdrawal of the elder’s funds using the elder’s ATM card • Abrupt changes in a will or other financial documents • Unexplained disappearance of funds or valuable possessions • Substandard care or unpaid bills despite the availability of adequate financial resources • The forging of an elder’s signature for financial transactions and for the titles of his or her possessions • Sudden appearance of previously uninvolved relatives claiming their rights to an elder’s affairs and possessions • Unexplained sudden transfer of assets to a family member or someone outside the family • Providing services that are not necessary • An elder’s report of financial exploitation

Reasons Elder Abuse Isn’t Reported • Lack of knowledge on the part of the public and police about available resources • Lack of police involvement—nonreporting to police or lack of regard for domestic disturbances by police • Lack of successful prosecution • Unwillingness to report (fear of retribution or institutionalization) • The elderly may prefer the abusive relationship to long-term facility care • Lack of knowledge of criminal justice system • Lack of definition

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Reasons for Abuse or Neglect in Institutionalized Settings • Understaffed • Undereducated • Lack of preemployment screening

Assessment Physical Assessment Physical assessment of the elder does not differ that much from the physical assessment of a younger adult, except that the effects of aging, medication, and illnesses are more pronounced. An assessment tool is included as Appendix 9.2. Bruises and other skin abnormalities are not uncommon in the elderly, especially if they are on medication. Assess for normal conditions as well as signs of abuse. Perhaps the elder is on a blood thinner and is taking too high a dose or is using aspirin on a regular basis for arthritis or other pain. Consider what is normal and what is unusual. Key Point: Always undress elderly patients completely for physical assessment. Look at the patient’s general health and appearance. Is there evidence of poor hygiene or inappropriate clothing? Ask if the patient has experienced a recent weight loss. Note any bruises, welts, or patterned injuries (including immersion burns). Observe for signs of contracture, limited or painful movement, or gait abnormalities. Does the patient need or have assistive devices? Observe the skin for bruises, hematomas, abrasions, avulsions, pressure ulcers,* signs of dehydration, multiple skin lesions and whether or not they are being appropriately treated, bites, or burns. Bilateral, circumferential, or patterned injuries are always suspect as is evidence of multiple injuries, even minor injuries. Examine the head and neck for traumatic alopecia, traumatic tooth loss, signs of strangulation, petechiae, ligature marks, head and neck pain, difficulty swallowing, and dental neglect. * The Braden Scale is currently used to assess and predict pressure sore development. It is free online at http://www.bradensccale.com/braden/pdf. Clinical guidelines for treatment of pressure ulcers are also available online at http://www.ahcpr.gov/clinic/cpgonline.htm.

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Examine the genital area for vaginal, penile, or rectal bleeding or injury. Look for signs of infestation, rashes, or generally poor hygiene. Ask about fecal impaction. Mental Assessment Try to assess mental and emotional status, signs of depression, anxiety, signs of withdrawal, fearfulness, coping skills, interaction between caregiver and the elder. Does the patient make eye contact? If not, try to determine why. What appear to be the interactive patterns between the patient and caregiver? Does the patient look to the caregiver for support or shy away or appear indifferent? Does the caregiver insist on being present even if the patient is able to participate? History An elder who is suspected of being the victim of abuse should be separated from accompanying individuals and interviewed separately. Both interviews should be handled in a neutral, nonjudgmental, unrushed, matter-of-fact manner. Start with general questions such as name and address, continue into the reason the elder is in contact with healthcare services and move into questions of abuse and neglect as a matter of course. Communication is a key element in assessing an elder’s status. Exercise patience when interacting with the elderly. Ask only one question at a time, leaving plenty of time for the elder to assimilate and respond. Repeat or rephrase questions if necessary. Treat all patients, including those with dementia, with respect and courtesy. Do not interrupt; not only is it rude and disruptive, it discourages them from speaking freely and may cause the elder to forget what they were going to say. It is also important to recognize the elder’s need to feel they have some control, are being respected, and that their needs and feelings are being validated. Assess for competency and involve the competent elder in decision making and planning. Avoid lengthy, drawn-out interviews that may tire the elder. Provide a quiet setting, limiting distractions, interruptions, and excessive noise. Basic communication skills such as eye contact, being respectful of one’s personal space, listening carefully, and responding appropriately still apply. Because the patient is an elder, it is important not to make assumptions. It is valuable in establishing that all-important rapport, that assumptions not be made about a person’s sensory, cognitive, or physical capabilities. Ask the patient directly for clarification and preference regarding such things as personal space, touching, how they would like to be addressed (formally Mrs. X vs. informally by first name), and so on. For example, not all elders are hard of hearing, nor do they necessarily have diminished

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cognitive abilities. Give the patient options, summarize key information, keep instructions simple, and provide written follow-up in large easy-toread type, avoid use of jargon, and explain terms, treatments, and options clearly and concisely. Specific questions should be designed to help determine the mechanism of injury, substantiate claims of how the injury occurred, and help assess where there is consistency among accounts given by the patient, caregivers, and others in routine contact with the patient. Assess for functional status, including the ability to perform activities of daily living and try to determine any physical limitations that impair self-care or self-protection. Observe for and ask about history of previous fractures. Assess for coexisting conditions that may be caused or made worse by abuse or neglect. Assess cognitive abilities including general awareness, level of understanding, and logical thinking. Assess emotional status and general mood. Look for signs of depression, anxiety, fear or anger, and minimization or rationalization of tension or family conflict. Try to assess for coping mechanisms and skills, substance use, and abuse. Assess the patient’s living situation, including physical, emotional, financial, and societal status. Assess for activities of daily living including meal preparation, personal hygiene, medication usage and administration, and home conditions, including who lives in the home and their general activities and status. Look for evidence of intrafamilial and extrafamilial social support. Assess for general dependence versus independence.

Intervention Safety of the elder, of course, is the first concern. Temporary hospitalization may be the only immediate option, but it is not a long-term or even a short-term solution. Domestic violence shelters are often ill equipped to manage the needs of an elder, especially if he or she has mental or physical limitations. Elder care requires long-term intervention by a variety of supportive services and case managers. Once initial assessment of abuse has been made and the immediate physical and safety needs of an abused elder have been met, long-term planning needs to occur. A comprehensive assessment of the patient’s physical, emotional, mental, financial, and functional status needs to be made. As with all forensic cases, a comprehensive approach is needed. Arrangements need to be made to meet the patient’s basic needs, including transportation and social interaction needs. A case manager should be assigned by the local adult protective services and a schedule of reevaluation

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established so the patient’s changing needs can be addressed. Adult protective services, state and local agencies, law enforcement groups, veteran’s organizations, religious groups, social service agencies, advocacy and support groups, or other local resources need to be mobilized. In consultation with the patient and/or family, a comprehensive plan needs to be developed, implemented, and periodically reviewed. Education, training, community involvement, and outreach are longterm methods that will help attain the goals of supporting families and caring for the elderly among us. In cases of fraud, burglary, and financial mismanagement, the ultimate effect on the victim is often unseen and overlooked. Repairs to the home or replacement of lost items or stolen financial resources may be impossible for the elder on a fixed income. A television that cannot be replaced can be devastating to an elder because it not only restricts their opportunity for enjoyment and stimulation, it causes further isolation and despair.

Reporting In most states, specific professionals are designated as mandatory reporters of elder abuse and are required by law to report suspected cases of elder maltreatment. Healthcare providers should inform patients of their legal obligation to report abuse and describe possible ramifications of reporting. In 1994, 21.6% of all domestic elder abuse reports came from physicians and other healthcare professionals, while another 9.4% came from service providers, and family members and relatives of victims reported 14.9% of reported cases of domestic elder abuse.

Safety Planning Safety planning related to protection from a perpetrator of elder abuse includes measures such as identifying safe contacts, discussing safety measures with neighbors and trusted individuals including assigning a password in case of an emergency, deciding where to go in case of an emergency and how to get there, developing a list of phone numbers to contact for services, discussing and practicing how to get out of the residence safely, making sure the patient knows how to access healthcare providers, giving healthcare providers (including emergency responders) consent to get in touch with “safe” friends, family members, or associates, and arranging for follow-up visits to assess the patient’s status or progression. Safety planning involves more than separation from a perpetrator. Sensory changes and general confusion increase the elder’s risk for falling

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or failing to follow through on issues of safety such as gas leaks, electrical hazards, or exposure to extremes of heat and cold. The victim should be consulted prior to making any contact with the victim’s family or friends and should be shielded from contact with the news media. Law enforcement and victim assistance professionals can provide information about security options and, perhaps most important, ensure that the victim has a safe place to go after the medical exam. Because few of the 1,500 domestic violence shelters nationwide have special programs and services for elder spouse abuse victims, the Administration on Aging is funding several model projects to help shelters develop services for women 50 years and older (Administration on Aging, 1996).

Resources Many states have established 24-hour hotlines for victims of elder abuse. All healthcare provider organizations should have that number available. Adult protective services or the local department of social services are designated agencies to receive reports of abuse, investigate, and if abuse and/ or neglect is found, provide for protective services. Local and state law enforcement agencies and district attorney’s offices may investigate and prosecute cases of elder abuse and neglect. State attorneys general offices are required by federal law to have a Medicaid Fraud Unit that investigates and prosecutes Medicaid provider fraud and patient abuse or neglect in healthcare programs that participate in Medicaid. Under the 1975 Older Americans Act, every state has established a LongTerm Ombudsman Program to investigate and resolve nursing home complaints, including elder abuse and neglect. A nationwide elder care locator number (800-677-1116) is available to help locate services in or near the local community where an elder lives. See Appendix 9.3: Support Agencies for more informtion.

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Appendix 9.1: Rights of Elders* When a person lives in a nursing or board and care home, they keep the rights they have had all of their life, plus they gain special rights under federal and state law. Elders have the right to:

Fairness • Be treated with courtesy, respect, dignity, and compassion • Be free from discrimination because of their age, race, religion, physical or mental disability, gender, sexual orientation, financial status, nationality, family status, or source of payment • Exercise their rights as citizens • Receive information about all services and their costs, and written notice of any changes • Receive a written description of their legal rights and responsibilities as a resident of any facility • A safe and clean place to live

Freedom • • • • • • • •

Be free from physical and chemical restraints Be free from physical, emotional, and verbal abuse or exploitation Be free from neglect Be free from financial abuse Freely participate in religious, social, community, and other activities Be free to communicate in their native language Leave any facility freely and return without unreasonable restriction Be free from unjustified room transfers or discharge from a facility

* Adapted from “Rights of the Elderly,” a leaflet provided by Home Care of Metroplex Hospital in Texas and “Residents’ Rights,” a pamphlet distributed by the Ombudsman’s Office and the New Mexico Long-Term Care Ombudsman Program.

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Self-Determination • Refuse treatment • Voice grievances to the facility staff, public officials, the ombudsman, or any other person, without fear of reprisal, retaliation, restraint, interference, or coercion. • File complaints and have them promptly addressed and resolved. • Understand and participate in the plan for their care and treatment. • Choose their own doctor, pharmacist, and other healthcare providers. • Be given all information about their medical condition and health. • Have information about Medicare/Medicaid eligibility and benefits and written notice of services and charges not covered by Medicare, Medicaid, or other insurance. • Make their wishes known about their medical treatment, and have advance directives, such a living wills and durable powers of attorney for healthcare. • Keep and use their personal belongings without loss or damage. • Manage and control their personal finances, or be given a written record of all transactions made on their behalf. • Appeal before any unjustified or involuntary transfer or discharge. • Organize and participate in a resident association, and to recommend changes and improvements in a facility’s policies and services.

Privacy • • • •

Private and confidential medical care and records. Personal privacy, including private visits, and privacy in their room. Communicate privately and freely with any person. Have their mail protected.

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Appendix 9.2: Elder Abuse Assessment Tool Patient Name:               Date:           Date of Birth:               Time:           Address:                 Phone:           File Number:           Medical Record Number:        Name and relationship of person accompanying patient:           Reason for encounter (detailed description of events related to current injury or condition):                                                                                           Medical problems/diagnoses (incl. depression or mental illness):                                       Names and relationship of all individuals living with patient:                                        History of prior violence in the home? □ Yes □ No If yes, dates and type(s):                                                       Detailed description of home environment (incl. evaluation of quality and nature of the relationship with caregiver(s)):                                                                                                               Positive and negative aspects of patient’s living arrangement:                                        Any recent problems or difficulties encountered in the home or by those living in the home?                                                        Financial issues? □ Yes □ No If yes, explain:                  Who does the cooking?                       Laundry?                             Other chores?                           Does patient need help with: Medications? Who assists?                 Personal hygiene? Who assists?                 Bathroom activities? Who assists?                 Personal finances? Who assists?                Household expenses? Who assists?               

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What activities, hobbies, and social encounters does the patient enjoy?                                    What social activities does patient participate in?                                             Is there anything about your life or living conditions you would like to change?                                 Observations: General health issues (be specific):             Mental status:                         Emotional state or affect:                     General hygiene:                        Dress and appearance:                      Nutrition:                           Ambulation status:                       Evidence of trauma:                       Dental, vision, and hearing status/issues:               Skin problems:                         Compliance issues: Medications:                   Healthcare regimens, including keeping doctor appointments:      Date and time of interview:                                      Healthcare Provider Signature      

              

Healthcare Provider Name – printed

Notifications made (Name of person contacted): Adult Protective Services:          Law Enforcement:             Victim Advocacy:             Family Services:              Clinic:                   Religious Organization:           Other:                 

Date & time:        Date & time:        Date & time:        Date & time:        Date & time:        Date & time:        Date & time:       

Adapted from Office of Victims of Crime, National Victim Assistance Academy materials.

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Appendix 9.3: Support Agencies American Association of Retired Persons (AARP) Criminal Justice Services 601 E St., NW Washington, DC 20049 (202) 434-2222 Clearinghouse on Abuse and Neglect of the Elderly College of Human Resources University of Delaware Newark, DE 19716 (302) 831-3525 National Center on Elder Abuse 810 First St., Suite 500 Washington, DC 20002 (202) 682-2470 National Committee for the Prevention of Elder Abuse c/o Institute on Aging, the Medical Center of Central Massachusetts 119 Belmont St. Worcester, MA 01605 (508) 793-6166 Provides referrals to public and private national resource centers, state adult protective services agencies, and local organizations. Publishes the Journal of Elder Abuse and Neglect.

References Administration on Aging. 1996. Aging, No 367. Washington, DC: U.S. Department of Health and Human Services. Alexander, E., and A. Seymour. 1998. Rights, Roles, and Responsibilities: A Handbook for Fraud Victims Participating in the Federal Criminal Justice System. Washington, DC: Police Executive Research Forum. www.ojp.usdoj.gov/ovc/assist/nvaa2002/ Chapter16. American Medical Association (AMA). 1992. Diagnostic and treatment guidelines on elder abuse and neglect. Chicago, IL: American Medical Association. Bachman, R., and L. Salzman. 1995. Violence against women: Estimates from the redesigned survey. National Crime Victimization Survey. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. Bureau of Justice Statistics (BJS). 1987. Elderly victimization. Washington, DC: US. Department of Justice.

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California Department of Justice. 2002. A citizen’s guide to preventing and reporting elder abuse. Available online at http://www.ag.ca.gov/bmfea/pdfs/citizens_ guide/pdf (accessed January 20, 2004). Legal Dictionary. 2010. http://legal-dictionary.thefreedictionary.com/fraud (accessed October 4, 2010).€ Lynch, S. H. 1997. Elder abuse: What to look for, how to intervene. American Journal of Nursing, 97(1): 27–32. National Center on Elder Abuse, American Public Human Services Association. 1998. The National Elder Abuse Incidence Study: Final report. Washington, DC: Administration for Children and Families and the Administration on Aging, U.S. Department of Health and Human Services. www.ncea.aoa.gov/ncearoot/main_site/Library/Statistics_Research/National_Incident.aspx (accessed September 9, 2010). NVAA, 2002. Office for Victims of Crime 2002/2008 (NVAA/OVC). Victimization of the elderly, In National Victim Assistance Academy Manual, chapter 14. www. ojp.usdoj.gov/ovc/assist/vaa.htm. (Accessed March 3, 2010.) Tatara, T. (ed.) 1992. Understanding elder abuse in minority populations. Philadelphia, PA: Taylor & Francis. University of California, Davis Medical Center. 2005. Identifying and responding to elder and dependent adult abuse in health care settings: Guidelines for California health care professionals. Sacramento: University of California, Davis.

Death Investigation

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The purpose of investigating death goes much deeper than simply determining whether the deceased was a victim of homicide. Officially, the primary objective of death investigation is to establish the cause and manner of death. In addition to the legal reasons for death investigations, there are also several public health and safety benefits derived from the processes. Death investigations gather forensic information at the time of death, intervene on behalf of those left behind after the death, and help prevent similar deaths in the future (Wagner, 2009). In practical terms, death investigation in the United States is designed to protect the rights of the deceased while benefiting the living (see Appendix 10.1, “Deaths to be Reported to the Office of the Medical Investigator [OMI]”). In the healthcare setting, providers must be mindful of the rights of all involved—the decedent, friends and family, witnesses, and (if present) the perpetrator—must be safeguarded and all persons treated in a dignified and respectful manner.

Some Thoughts to Consider • In the case of a homicide,* was it justifiable or was the death the result of a criminal act? • Was the death a suicide and, if so, was it an act where the deceased felt he or she had no further options or was it part of an identifiable trend? • Was a motor vehicle accident the result of a faulty product, poorly designed roadway, inattention, losing control in an attempt to avoid hitting an animal, or did the driver suffer a heart attack or stroke while driving? What laws or practices might be implemented to help prevent accidental death?† • Was the death due to biological causes such as Legionnaires’ disease or exposure to the hantavirus, or was restaurant food intentionally poisoned, or was it the result of improperly kept food?

* Homicide is “the killing of one human being by another.” (Random House Dictionary, 1980.) † For example, the Back to Sleep program to reduce the number of SIDS deaths was developed based on death investigation results. Serotonin levels in the brain, which have been measured on autopsy, are currently being implicated in SIDS deaths. See Chapter 6.

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• What were the health consequences to responders of the September 11, 2001, attacks on the World Trade Center in New York and the Pentagon in Washington, DC, who died prematurely? What improvements might be made in building construction to mitigate those hazards? • How might we better identify human remains in a mass casualty incident such as an airline crash or disaster? • Are children, the elderly, or disabled dying from abuse or neglect? As you can see, the benefits of investigating unusual or sudden death go far beyond assigning criminal or civil liability. It is true, accumulation of data surrounding the circumstances of death may help lay the foundation for assigning criminal or civil liability, but it may also establish the identity of an unknown person facilitating notification of next of kin or providing surety to the grieving family. Positive identification of the body is important for several other reasons: • Families need certainty as to the victim’s identity in order to get emotional closure. • Property cannot be distributed or managed until identification has been certified. • Insurance companies may not pay on a life insurance policy until the cause and manner of death have been established. • Government benefits to survivors depend on certainty that the individual is truly deceased. • Criminal prosecution cannot proceed until a victim has been properly and accurately identified. Society benefits from information learned during the investigation of death. Current trends can be learned, providing opportunities for prevention. Death investigation also provides an important check on medical practices, incompetent medical practitioners, civil and human rights abuses, and design safety of the workplace, home, and the environs in general. The body is the single most important piece of evidence at the scene. Establishing and recording the decedent’s profile is a crucial step in determining cause and manner of death. This profile includes the history of circumstances of discovery and any medical intervention prior to death. The decedent’s medical history is important in determining the need for further investigation and the relationship between disease and injury. The decedent’s mental health and social history can also play an important role.

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History The concept of the coroner dates back to the ninth century during the time of Alfred the Great. In 1194, the Articles of Eyre formally established the Office of the Coroner in Great Britain. These articles set up a variety of judicial mechanisms, many of which were primarily fiscal in nature and were designed to ensure that all money owed to the king was collected. During this time, sheriffs were widely viewed as corrupt, so another major reason for establishing the Office the Coroner was to provide a counterbalancing presence. By 1887, when the Coroner’s Act was passed, the function of the coroner was no longer the protection of the Crown’s financial interests, but to investigate death on behalf of the community. From these royal beginnings, the office gradually evolved in many parts of the United Kingdom (except Scotland). The coroner system was brought to America during colonial times. Coroners were elected, opening the door to politicization of the office. The coroner decides when a person died, if a person had indeed died, and how they died. Yet he may have no real qualifications for the job. Eventually, the medical examiner (ME) system, e.g., Office of the Medical Investigator (OMI), was established in some states. This system is gaining prominence as coroner systems are being phased out. In general, the ME has the authority to investigate all deaths that are obviously the result of a crime, but also to look into suspicious deaths, possible suicides, accidents, and sudden, unexpected, or questionable deaths. One main advantage to the ME system is the removal of death investigation from political influence. Examples of suspicious death can be found in Appendix 10.2. Another advantage is that the chief ME is a medical doctor with a residency in pathology and a fellowship in forensic pathology. He or she has the knowledge and skills to perform a thorough autopsy. The chief ME investigates the circumstances surrounding a death, documents the findings, and collaborates with law enforcement, the judiciary, and defense lawyers.

Cause, Manner, and Mechanism of Death The main function of the ME is to determine the cause and manner of death. The cause of death is the original underlying medical condition that initiates the lethal chain of events culminating in death, that is, the proximate cause. Intermediate causes of death are the complications and sequelae of the underlying cause. Death may occur over a prolonged period of time (as in example 2 below). There must be clinical continuity between the initiating event (the cause of death) and the death.

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The following are not acceptable as causes of death: cardiac arrest or respiratory arrest (we all do that!); also natural causes, old age, sudden death, brain death, and unknown. These are mechanisms of death—the way people actually die. Cause of Death

Manner of Death May Be

Gunshot wound

Homicide Suicide Accidental

Multiple trauma (MVA)

Homicide Suicide Accident Natural Homicide Accidental Natural

Acute ethanol (ETOH) poisoning CO inhalation

Homicide Suicide Accidental

Blunt trauma

Homicide Suicide Accidental

Examples Intentionally inflicted by another person Intentionally self-inflicted Unintentional discharge of a weapon (kids handling or playing with a gun) Another person ran into or over victim Intentionally ran off road or into object Accidental—e.g., slick road, animal in road Driver had a stroke or heart attack while driving Another person gave or forced alcohol ingestion College student went on drinking binge Individual had an intolerance for increased ETOH level Person unable to flee due to being bound Intentionally left car running in a closed space Person fell asleep in garage before turning engine off Individual thrown off a cliff by another person Individual jumped off a cliff Individual fell off a cliff

Manner of Death There are five (and only five) types (categories or manners) of death. • Natural—The death is related to a disease process, including aging. • Homicide—The death of an individual who is killed either unlawfully or lawfully by another. • Suicide—The death results from the intentional actions of the decedent. • Accidental*—The death results from the unintentional or inadvertent actions of the decedent or another person. • Undetermined—The circumstances surrounding the death cannot be determined with reasonable certainty.

* Motor vehicle accidents (MVAs) may be suicide attempts; many may not be reported for lack of evidence (Peck and Warner, 1995).

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Mechanism of Death The mechanism of death refers to the mechanics of death—the final reason the body ceased functioning (death occurred), such as ventricular fibrillation, asystole, hemorrhage, kidney failure, cessation of brain activity, and so on. Example 1 Cause of death: Manner of death:

Liver failure Natural

Hepatitis caused by cancer of the liver. Cause of death: Manner of death:

Liver failure Homicide, suicide, or accident

Initiating event was a gunshot wound to abdomen leading to severe lactic acid acidosis. Example 2 Cause of death: Manner of death:

Pneumonia Natural

Patient with compromised immune system develops viral pneumonia. Cause of death: Manner of death:

Pneumonia Accidental

Initiating event was a fall off of a roof resulting in permanent damage to the spinal column and paralysis. This created a decreased ability to breathe. Subsequent obesity and immobility led to increased morbidity (illness, e.g., obesity, high blood pressure, metabolic syndrome, pressure ulcers, etc.), and eventual death.

Autopsy Done by a representative of the medical examiner’s office, an external examination is an in-depth exam of the body including taking of photographs and samples of body fluids for laboratory analysis. An autopsy is a surgical

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procedure performed by a forensic pathologist where all organs are examined at the same time. There are two types of autopsies performed: medical autopsy and medicolegal autopsy. Medical Autopsy Done at the family’s request Must have consent signed by next of kin* Family can restrict the autopsy in any way they want

May be done by court order if no family can be found The purpose is to confirm the diagnosis or effect of treatment Determine medical cause of death The family wishes to learn of genetic conditions (i.e., arteriosclerotic heart disease [ASHD], polycystic kidney)

Medicolegal Autopsy Done as a matter of law and by decision of the medical examiner. It is a legal order. The family has no choice, although some considerations may be given for religious or cultural beliefs. A legal request for identification and injury documentation. No restrictions; includes external examination and extensive internal exam where organs are looked at grossly and microscopically; tissues and fluids are sent to toxicology for testing. Family can request but must pay costs. OMI can refuse request. The purpose is to determine causes of injury and death. The state needs to correlate the death to natural or unnatural causes (cause + manner of death). The cause and manner of death need to be documented for a court of law or other legal proceeding.

* Next of kin (in order): spouse, children, parents, siblings—brother or sister, children of siblings—nieces and nephews, aunt or uncle.

There are three general categories of medicolegal autopsy: • Violent or traumatic—usually obvious. An autopsy is done to document injuries and determine which of multiple injuries was fatal. It is also used to rule out natural death. • Less traumatic—less obvious. Pending toxicology, an autopsy provides hints on such findings as petechiae (pinpoint hemorrhage in eye—a sign of suffocation), congestion and edema of lungs (heroin overdose), constriction of blood vessels and necrosis in the nose (cocaine use), and tattoos (may be used to cover needle tracks). • Nontraumatic such as sudden infant death syndrome (SIDS) or adult respiratory distress syndrome (ARDS)

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Usually by middle age there are various anatomical reasons for death, but whether these problems are related to the actual death can sometimes be questionable.

Role of the Death Investigator The death investigator takes physical possession of the body and is responsible for labeling, packaging, and removing the body to a secure location until a determination of cause and manner of death and disposition of the body has been made by the medical examiner or coroner. The death investigator maintains jurisdiction over the body until it is released to the medical examiner or coroner’s office for autopsy or to an authorized funeral director for burial or cremation.* The death investigator may also assist the family by providing information or protocols and a timetable for release of the body. Survivors, especially survivors of traumatic death, may face severe emotional distress requiring emotional support and/or psychological counseling. The death investigator may be helpful in providing information on community and professional resources available to the family. Establishing the time of death may or may not be made by the medical examiner, depending on local protocol. Goals of Death Investigation • • • •

Prevention of violent injury and death Forensic intervention at the time of injury or death Postincident care for victims, families, friends, and others Recognition of mechanism of death, look for possible cause, and determine manner of death

Implications for Healthcare Providers Death Investigation Basics • • • •

Determine scene safety Secure the scene Validate the death Identify the remains

* A sample Death Investigation Report was kindly provided by Dr. Patrick BesantMatthews and is included as Appendix 10.3.

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Photograph the scene and the body Conduct a physical exam of the body Document the scene Prepare descriptive report—tell the story

Evidence may be identified by the first responder or other healthcare provider. Identification and preservation of evidence should be done according to guidelines set out in Chapter 3. Goals of Evidence Collection at the Time of Death • • • •

Distinguish between personal property and evidence. Facilitate proper collection of evidence. Initiate and ensure chain of custody. Facilitate analysis of evidence. Ensure proper packaging. Suggest specific analysis based on scene observations.

The healthcare provider may be required to communicate with a variety of people including law enforcement (local, state, and/or federal), families, the media, and others. There are many reasons a healthcare provider may need to contact the family of a deceased person. These include: • Notification of next of kin • Obtaining medical and social history and (possibly) work history information • Explaining procedures • Reporting findings to the family and determining family requests • Preparing the family for viewing • Assisting the family with emotional reactions • Providing for follow-up referrals, if appropriate Handling the Deceased Remember that all patients—alive or dead—may subsequently be determined to be a victim or suspect in a forensic case. If a body is received that is dead on arrival (DOA), or if someone dies on scene, in transport, or in the emergency department during treatment, the following steps should be taken to ensure that evidence is not lost. • Secure the room and contact the medical examiner. Law enforcement may also be contacted in some cases such as an apparent violent crime, motor vehicle accident, suicide, or overdose. • Do not wash the body.

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• Do not remove any lines, wires, or tubes. • Save all medicine vials, IV bags, and bottles containing fluid, medications, or drugs. • Save urine, gastrointestinal drainage, chest drainage, and so on until it can be measured, examined, and preserved as a fractional or total specimen for qualitative analysis. In cases such as poisonings, overdose, or apparent suicide, quantitative specimens are often required. • Mark the sites of any IV attempts, blood draws, and so on with a skin marker. If any incisions were created during the course of treatment, these must also be annotated on the body as well as in the medical record to ensure that they are not confused with prehospital traumatic wounds. • Notify the laboratory to hold all specimens in their custody for evidentiary purposes. • Family members and other visitors should not be permitted without express consent of the medical examiner since they may inadvertently or intentionally alter physical evidence on the body or in the room. Even family members and other visitors who are permitted to view the body must be accompanied at all times by hospital personnel. • The body should be wrapped in a clean sheet before placement in a body bag to ensure that any evidence is preserved and not transferred to the interior of the body bag. • Leave all clothing on the body. The medical examiner will want to see the body as it was at the time of death before it is moved to the morgue. • Leave the body as it is at the time of death. Do not remove clothing, tubes, intravenous lines, and so on. • Do not wash any parts of the body. • Keep loose items and extra laboratory specimens, body fluids, and parts (including shaved hair) with the body. • Keep the body in a secure area with access limited to an identified few until transport to the morgue. • All items (clothing, wallet, jewelry, and other valuables, teeth, other evidence) should remain with the body. • If the medical examiner requests that the body be transported to the morgue, leave the body in the sheet on which it was lying and wrap the sheet around the body. Do not remove anything from around the body. The Office of the Medical Investigator will place the body in a body bag and transport it to the morgue.

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Assisting Survivors People grieve in a wide variety of ways. Not all members of a family or grieving group will react the same way. Become familiar with the stages of grief and the stress factors accompanying unexpected death. Allow survivors, especially survivors of a traumatic death, to grieve in whatever way they want for as long as they need. Provide survivors with a private place to grieve and to talk with law enforcement, clergy, or among themselves. Give survivors permission to cry and allow nonviolent expressions of grief. Be prepared for expressions of anger and try to channel their anger into productive activities. Validate their loss and need to grieve. Learn as much as you can about the deceased and the process before you speak with the family. In cases of traumatic death, especially homicide, the media will want to be involved. Prepare the family for the media’s involvement and facilitate their privacy. In cases of violent death, assess for ongoing safety issues for survivors and notify law enforcement immediately if safety concerns arise. Try to determine the family’s financial, emotional, and other needs. Recognize the difference between wanting to help and the survivor’s needs (or need to distance themselves from caregivers and well-wishers). Respect those needs. Be prepared with information on counseling services, support groups, financial assistance, and so on. Become knowledgeable about the investigation and criminal justice processes and offer information as needed. Try to discern survivor’s needs and desire for information and act accordingly. Facilitate communication between law enforcement, the medical investigator, and mortuary services.

Traumatic Grief Any death, including the expected death of an ill or elderly person, is difficult and gives rise to a variety of physical, emotional, financial, and social difficulties for the survivors. Traumatic death can exacerbate these issues. Traumatic grief is different from an anticipated loss. Traumatic grief occurs when there is an inescapable stressful event that overwhelms one’s coping mechanisms (van der Kolk, McFarlane, and Weisaeth, 1996). A complex neurochemical reaction occurs that is different than the normal stress reaction (Chapin, 1999). The event is recognized as a life-threatening situation, which triggers the fight or flight response. This type of grief can cause a chemical reaction within the brain that leads to severe emotional distress and lengthy recovery.

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Those who grieve a traumatic death often ask, “Why is it taking me so long to get over this?” The answer is complex, but it is known that the fight or flight reflex can be triggered by traumatic events—witnessed or not—and the chemical reaction that occurs in the brain delays one’s ability to get over the loss. Survivors of traumatic grief need to be reassured that an extended period of bereavement is not unusual, that there’s nothing wrong with them, that they may need to be patient with themselves, and that grief-counseling services are available. In some states, the Office of the Medical Investigator has special grief services programs to assist survivors of homicide, sudden loss of a child, or other traumatic death events. The impact of homicide on families can be enormous, particularly for children, the elderly, and the vulnerable. Healthcare providers should be aware of the impact of such events and have a list of services available for families, friends, and witnesses. It is also important for healthcare providers to utilize law enforcement to protect those individuals from undue exposure to the media.

The Consultation Autopsy The family or their attorney may request to have a medicolegal autopsy performed by the medical examiner. The cost of such an autopsy is usually paid by the requesting entity.

Organ and Tissue Donation Organs can be recovered for transplant from clinically brain dead patients whose organs have been oxygenated by ventilator support. Organs that can be donated include the heart, liver, kidneys, lungs, pancreas, and small bowel. There are no age limits for organ donation. In cases where organs were not perfused after asystole, tissues that may be harvested include the heart valves, bones, tendons, veins, skin, and corneas. Because vital organs rapidly lose viability without continuous blood flow, organs cannot be harvested after cardiac death. Effective August 21, 1998, the Healthcare Financing Administration (HCFA) required hospitals to report all deaths or impending deaths to the local organ procurement organization (Donor Services).* In cases of neurological brain injury, Donor Services must be called before terminating ventilator support. All patients must be evaluated for donor suitability by Donor * HCFA conditions of participation 42 CFR part 482.

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Services prior to the patient’s family being approached about donation. A Donor Services coordinator or designated requestor will approach those families for which a donation is a viable option. Basic Information Regarding Donation • Donor Services will pay for all costs related to the donation. • All major religions approve of organ and tissue donation and see it as an act of charity and gift of life. • An open casket or viewing is still possible after organ or tissue donation. • Organs are distributed according to the transplant waiting list based on blood type, size or tissue typing, region, medical urgency, and time on the waiting list. • Donor Services will determine medical suitability for donation prior to the patient’s family being approached regarding possible donation. Brain Death Criteria Principal findings leading to a diagnosis of brain death include coma or unresponsiveness, absence of cerebral motor responses to pain in all extremities, brain stem reflexes are absent (anaflexic), and there is no spontaneous respiration (apnea) (Sullivan, Seem, and Chabalewski, 1999). Simply put, it is defined as “the irreversible loss of function of the brain, including the brainstem” (American Academy of Neurology, 1994). For purposes of organ and tissue donation, additional criteria for brain death include: • • • •

There is a known mechanism of injury (i.e., trauma). The condition is irreversible. There is no toxic central nervous system (CNS) depression. There is no metabolic CNS depression.

Summary of HCFA 42 CFR 482 This final rule addresses only provisions relating to organ donation and transplantation. It imposes several requirements that a hospital must meet that are designed to increase organ donation. One of these requirements is that a hospital must have an agreement with the organ procurement organization (OPO), designated by the Secretary of Health and Human Services, under which the hospital will contact the OPO in a timely manner about individuals who die or whose death is eminent in the hospital. The OPO

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will then determine the individual’s medical suitability for donation. The hospital must also have an agreement with at least one tissue bank and at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of tissues and eyes, as long as the agreement does not interfere with organ donation. The final rule requires the hospital to ensure, in collaboration with the OPO with which it has an agreement, wherein the family of every potential donor is informed of their option to donate organs or tissue or not to donate. Under the final rule, hospitals must work with the OPO and at least one tissue bank and one eye bank in educating staff on donation of tissues and reviewing death records with Donor Services in order to improve identification of potential donors and maintain potential donors while necessary testing and placement of organs and tissue takes place. In addition, transplant hospitals must provide organ and transplant-related data as requested by the Organ Procurement Transplant Network (OPTN), the Scientific Registry, and the OPO(s). The hospital must provide, if requested, such data directly to the Department of Health and Human Services (NM Donor Services, 2010).

In Conclusion Death investigation is an important adjunct to the delivery of healthcare. Although most healthcare providers do not participate in death investigation activities directly, they play a crucial role in preserving evidence and facilitating the process. It is incumbent upon all healthcare providers to understand the basics of death investigation and whenever possible facilitate the process.

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Appendix 10.1: Deaths to Be Reported to the Office of the Medical Investigator (OMI) 1. Any death that occurs suddenly and unexpectedly, that is, when the person has not been under medical care for significant heart, lung, or other disease. 2. Any death suspected to be due to violence, that is, suicidal, accidental, or homicidal injury, regardless of when or where the injury occurred. 3. Any death suspected to be due to alcohol intoxication or the result of exposure to toxic agents. 4. Any death of a resident housed in county or state institutions, regardless of where death occurs. This refers to any ward or individual placed in such a facility by legal authorization. 5. Any death of a person in the custody of law enforcement officers. 6. Any death of a person in a nursing home or other private institution without recent medical attendance. 7. Any death that occurs unexpectedly during, in association with, or as a result of diagnostic, therapeutic, surgical, or anesthetic procedures. 8. Deaths alleged to have been caused by an act of malpractice. 9. Deaths suspected to be involved with decedent’s occupation. 10. Deaths unattended by a physician. 11. Any death due to neglect. 12. Any stillbirth of 20 or more weeks gestation unattended by a physician. 13. Any maternal death to include death of a pregnant woman regardless of the length of the pregnancy, and up to 6 weeks postdelivery, even where the cause of death is unrelated to the pregnancy. 14. Any death of an infant or child where the medical history has not established some preexisting medical condition. 15. Deaths that are possibly directly or indirectly attributable to environmental exposure not otherwise specified. 16. Any death suspected to be due to infectious or contagious disease wherein the diagnosis and extent of disease at the time are undetermined. 17. Any death occurring under suspicious circumstances. 18. Any death in which there is doubt as to whether or not it is a medical investigator’s case should be reported.

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Appendix 10.2: Suspicious Circumstances of Death • • • • • • • • • • • • • • • • • • • • • • • • • • •

Pills and alcohol, drugs, or toxic agents Death in a motel Death in a bathtub Death in a camper or RV Shallow grave Death in a car with or without a note Mutilation or dismemberment Human bones—exhumation Prisoners and inmates Occupationally related Alleged malpractice Unattended death Neglect Stillborn, unattended by an MD Any infant or child without a documented preexisting medical condition Any maternal death, regardless of length of pregnancy and including up to 6 weeks postpartum, even when the cause of death is unrelated to the pregnancy Nursing home and private institutions without recent medical attention—and maybe even then Environmentally related Exposure = cherry-red color to skin Carbon monoxide (CO) and cyanide = cherry-red color to skin Bad weather and drugs and/or alcohol Drowning Lightning Animal attack—wild or domestic (face and groin) Infectious or contagious diseases Acute alcohol poisoning Your gut tells you something is not right

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Appendix 10.3: Death Investigation Report COUNTY     CORONER NAME     CORONER PHONE     CORONER CASE #    POLICE AGENCY      POLICE CASE #     OFFICER(s)       PHONE #                                                 DECEASED                             SS#                   LAST         FIRST       MIDDLE AGE    RACE     SEX    WEIGHT    HEIGHT    RELIGIOUS PREFERENCE    ADDRESS                            PHONE #         OCCUPATION / RETIRED FROM       HOW LONG     EMPLOYER          NEXT OF KIN                        RELATIONSHIP       NEXT OF KIN ADDRESS                     PHONE #         NEXT OF KIN NOTIFIED (YES / NO)         BY         OF                                                    PLACE OF PRONOUNCEMENT                              DOA        EMERGENCY DEPARTMENT       _ OPERATING ROOM       INTENSIVE CARE / RECOVERY            NURSING HOME            HOUSE / APT      HOTEL / MOTEL      STREET / HIGHWAY / OPEN AREA      OTHER        LAST KNOWN ALIVE BY           DAY / DATE / TIME              DEATH OCCURRED (DATE / TIME)      WITNESSED BY        OF        FOUND DEAD (DATE / TIME)         BY               OF        PRONOUNCED (DATE / TIME)         BY               OF        CORONER NOTIFIED (DATE / TIME)      BY               OF                                                   LIKELY MANNER: NATURAL     ACCIDENT     HOMICIDE     SUICIDE      UNDETERMINED     DATE & TIME OF EVENT / INCIDENT / INJURY / OCCURRENCE               CITY / TOWN / PRECINCT     COUNTY     STATE     AT WORK (YES / NO)                                               FIREARM (MAKE, MODEL, CALIBER, BARREL LENGTH)                  AMMUNITION (MAKE, CALIBER, BULLET TYPE, BULLET WEIGHT)             OTHER WEAPON (TYPE, SIZE, WEIGHT, ETC.)                       MOTOR VEHICLE (TYPE, MAKE, MODEL, YEAR, COLOR)                  SAFETY DEVICES (USED / NOT USED, SEATBELT, AIRBAG, HELMET)             DECEASED WAS (DRIVER, PILOT, PASSENGER, PEDESTRIAN, BYSTANDER)                                                     IDENTIFICATION MADE BY (NAME / RELATIONSHIP)                   ADDRESS                        PHONE #             IDENTITY IS (CERTAIN / TENTATIVE / DOUBTFUL / UNKNOWN)             MEANS OF IDENTIFICATION (PASSPORT / DRIVER’S LICENSE / ID CARD, ETC.)                                                   FIRST AID GIVEN (YES / NO)       AID GIVEN BY          OF        TREATING (DOCTOR, PARAMEDIC, EMT, NURSE, RELATIVE, ETC.)             FUNERAL HOME (NAME)           PHONE #         PENDING                                                 DRUG / SUBSTANCE OR ALCOHOL ABUSE IS (PROBABLE, POSSIBLE, UNLIKELY, UNKNOWN)                                      SUSPECTED / POSSIBLE DRUGS / SUBSTANCES (OTHER THAN PRESCRIPTIONS)        MEDICATIONS IF KNOWN               SEE LIST ATTACHED                                                    BRIEF MEDICAL HISTORY AND/OR RECENT COMPLAINTS                                                           

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DOCTORS / CHIROPRACTORS / DENTISTS â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•… HOSPITALS / CLINICS â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•… RECENT OVERSEAS TRAVEL (YES / NO) â•…â•…â•…â•…â•…â•…â•…â•…â•… IF YES, WHERE â•…â•…â•…â•…â•…â•…â•…â•… â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…å°“â•…â•…â•…â•…â•…â•…â•… INDOOR CONDITIONS (TEMPERATURE, AIR CONDITIONING, FANS, HUMIDITY) â•…â•…â•…â•…â•… â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…å°“â•…â•…â•…â•…â•…â•…â•… OUTDOOR CONDITIONS (TEMPERATURE, VISIBILITY, HUMIDITY, WEATHER) â•…â•…â•…â•…â•…â•… â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…å°“â•…â•…â•…â•…â•…â•…â•… FIRST EXAMINATION OF BODY (STIFFNESS, BLOOD SETTLING, TEMPERATURE) â•…â•…â•…â•…â•… â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…å°“â•…â•…â•…â•…â•…â•…â•… CIRCUMSTANCES OF DEATH / INJURY / EVENT / DISCOVERY (WHO, WHAT, WHERE, WHEN, WHY, HOW!)

(ATTACH SEPARATE PAGES, DIAGRAMS & COPIES, ETC.) # OF ATTACHED PAGES â•…â•…â•…â•…â•… â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…å°“â•…â•…â•…â•…â•…â•…â•… BODY TRANSPORTED BY â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•… OFâ•…â•…â•…â•…â•…â•…â•…â•… PHONE # â•…â•…â•…â•…â•…â•… â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…å°“â•…â•…â•…â•…â•…â•…â•… REPORT COMPLETED BY â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•… BADGE ID # â•…â•…â•…â•…â•… DAY OF WEEK â•…â•…â•…â•…â•…â•… DATE â•…â•…â•…â•…â•…â•… TIME â•…â•…â•…â•…â•…â•… PHONE # â•…â•…â•…â•…â•…â•…â•… Courtesy Dr. Patrick Besant-Matthews. Used with permission.

References American Academy of Neurology: Practice parameters: Determining brain death in adults (Summary Statement). 1994. Report of the Quality Standards Subcommittee of the American Academy of Neurology. http://www.aan.com/ professionals/practice/guidelines/pda/Brain_death_adults.pdf (accessed March 15, 2010). Chapin, Carol. 1999. Personal communication. Discussion while working at the Office of the Medical Examiner, Albuquerque, NM. Clark, S. C., Ernst, M. F., Haglund, W. D., and Jentzen, J. M. 1996. Medicolegal death investigator. Big Rapids, MI: Occupational Research and Assessment, Inc. NM Donor Services (New Mexico Donor Services), 2715 Broadbent Pkwy. NE #J, Albuquerque, NM 87107-1618. (505 843-7672) http://donatelife.org Peck, D. L. and K. Warner, 1995. Accident or suicide? Single-vehicle car accidents and the intent hypothesis. Adolescence. Summer 1995, 30(118):463-72. Random House Dictionary, Concise Edition. 1980. New York. Sullivan, J., D.L. Seem, D. L., and F. Chabalewski. 1999. Critical Care Nurse, 19(2). American Association of Critical Care Nurses, http://www.aacnjournals.org/ (accessed March 15, 2010) Van der Kolk, B., A. C. McFarlane, and L. Weisaeth, (eds). 1996. Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York: Guilford Press Wagner, S. 2009. Death scene investigation: A field guide. Boca Raton, FL: CRC Press.

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Safety in the Workplace Forensic personnel work in environments posing serious risks to personal health and safety. In addition to the ever-present issue of infectious diseases, emergency workers and forensic personnel are faced with threats to their personal health and safety from patients and others at the incident location. Numerous environmental dangers may also be present. Altitude, weather conditions, released toxins, and caustic and explosive materials pose added hazards, often not recognized because of initial concerns about the victim(s). The formation of standardized practices to reduce the risk from blood and body fluids,* and airborne, contact, and droplet-transmitted diseases is a good general step to protect ourselves. In these high-risk circumstances, however, other things need to be considered. Emergency situations such as fires, vehicular accidents, industrial explosions, mass transportation disasters, and death scenes are inherently dangerous and chaotic. The need to act rapidly and to make prompt decisions in an unplanned event results in an “adrenaline rush” and concerns about personal safety are not at the top of the list for workers at the scene. The recent escalation of terrorism adds a whole new dimension to the dangers first responders face. Healthcare practitioners have very little influence on the creation of these scenarios or the risks they pose. Healthcare providers do, however, have opportunities to minimize those risks by taking preemptive actions such as wearing personal protective equipment (PPE), analyzing potential threats before “diving in,” and taking steps to minimize on-scene risks. This section will outline some important health and safety issues that should be recognized. Here are a few examples: • All scenes, including the patient himself or herself, should be assessed and cleared for safety issues.

* Major infectious risks include human immunodeficiency virus (HIV), methicillinresistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), multidrug-resistant mycobacterium tuberculosis (MD-RTB), Clostridium difficile (C-Diff), herpes, and all varieties of hepatitis.

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Chemical or biological hazards—weaponized or not Environmental exposure to toxic fumes and fluids Limited oxygen availability in the ambient air Caustic substances (hazardous materials, or HAZMAT) Extremes in heat, cold, or altitude Lice,* scabies,† insects, rodents, and animals (pets and wild animals) Unexploded devices, booby traps, or secondary explosive devices on scene

After initial assessment and the ABCs of initial treatment, evaluation and collection of evidence should be considered and begun. Especially where trace evidence is involved, cross-contamination is of high importance. It is imperative to avoid the introduction of trace evidence from ourselves, our clothing, and so forth. The best way to do this is to cover up—head to toe—so hairs, particles from our clothing, and other items do not become part of the scene and become confused with true “evidence.” Although sterility is not necessarily required, surgical attire—cap, mask, gown, and gloves—are a good way to prevent particles from the caregiver inadvertently contaminating the scene. Gloves should be powder free and latex free. If there is any risk of splash contamination, the mask should include a face shield. When assessing and examining a potential or obvious forensic case, the healthcare provider should avoid use of open boxes of gloves, which might contribute to cross-contamination when retrieving or replacing gloves. The Clean Room In many situations a clean room is a luxury. However, it is possible to provide a space free of biological materials or trace evidence from previous patients. Examples of trace evidence are hair, clothes, fibers, body fluids, soil, or debris from clothing, shoes, and so on. If possible, a ventilated empty cabinet where damp or wet clothing can be hung to air dry is desirable. In cases where DNA may be an issue, soap-and-water hand washing is preferred because alcohol-based sanitizers are known to degrade DNA. A sink should be inside the clean room and on–off accomplished by foot pedal or handles that can be manipulated with elbows or wrists instead of having * There are three types of lice: crab lice (live within pubic hair, axillary hair, or within beards or mustaches); head lice (live in hair on the head); and body lice (live on the body and are found on body skin and underwear). † Scabies is a commonly found mite on patient’s skin that causes intense itching, especially on the genitalia, in the axilla, and over the wrists. Nipple lesions can be found in adult women. Commonly found in the elderly and those who handle animals. They can easily be transmitted to healthcare providers.

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to be turned on and off with your hands. Jewelry, especially rings, should be removed before hand washing and donning gloves. If possible, drafts and direct air currents into the room should be kept to a minimum. High-efficiency particulate air (HEPA) filtration units may be used to remove allergens and particulates from the room air. Supplies should be kept to a bare minimum and kept behind closed doors in cabinets. Supplies can be prepackaged and brought into the room as a kit for each patient. Ideally, patient gowns, blood pressure cuffs, linens, and floor coverings should be individually wrapped and disposable. Items to consider for a forensic supply kit are listed in Appendix 11.1. If they have not been contaminated, unused materials can be returned to the general supply stocks. A sharps container and a container for biological waste should be available. A solidifying agent should be added to liquid waste before disposal. Contaminated instruments should be bagged and taken to another area for cleaning and/or sterilization. They should not be placed in the sink used for hand washing. If a computer is used, all data should be stored and transferred in a secure manner and the computer workstation wiped down after the exam. Equipment such as colposcopes, light sources, cameras, and exam tables should be covered at the point of contact with a disposable covering and discarded at the end of the exam. Any item containing possible trace evidence should be identified, bagged, and sent along with other items of evidence. Countertops should have no items left on them after the exam. Supplies should be stored in cabinets behind closed (and possibly locked) doors. Countertops and tables should be smooth and nonporous to accommodate a thorough cleaning after each use. All furniture and equipment should be wiped down with disinfectant wipes. Floors should be wet mopped and sinks cleaned. All trash and linen (if any) should be bagged and removed. Obviously, carpeting, upholstered furniture, and draperies are not suggested. The same concepts apply in ambulances and rescue units (see Appendix 11.2). Counters should be kept clear of unnecessary items, equipment and supplies should be stored in closed-door cabinets, and disposable linens used whenever possible.

Workplace Violence Formerly, individuals in public service, especially those in healthcare, were considered unlikely candidates for being a victim of a violent act while at work. Today, these individuals are “fair game” and must be prepared to protect

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themselves on their way to and from work and as they go about their daily duties. Threats to providers may be verbal, written, or simply threatening body language. Physical assault includes slapping, kicking, hitting, punching, shoving, and violent actions such as rape, homicide, use of a weapon, or mugging with intent to rob. Precipitating Factors Police officers, fire personnel, and correctional officers are typically thought to have dangerous jobs. More recently, however, healthcare personnel have become increasingly victimized. Situations predisposing individuals to violence include disgruntled patients and frustrated family, angry coworkers, sparring spouses, and others. Indications of individuals who may be prone to violence (OSHA, 2010) include: • Those with a history of violence against family and others. The more violence that was perpetrated in the past and the higher level of past violence is the best indicator of future violent behavior. • Individuals who demonstrate a lack of control over their emotions. Examples include temper tantrums, speaking before thinking, and sudden violent responses. • Those who are preoccupied with violence and show an unusual interest in violent events or acts and show a fascination with different types of violence. • Individuals who demonstrate a fascination with weapons and their ability to evoke “respect” or “show who’s boss.” • The mentally ill. Individuals suffering from hallucinations, depression, paranoia, or extreme anxiety, and those who exhibit irrational, delusional, or bizarre behavior. • Any individual who abuses drugs or alcohol, especially when their substance abuse interferes with their ability to reason or increases their tendency toward aggressiveness. These individuals may be encountered in prehospital settings, the emergency department or other healthcare units, within correctional facilities, or in forensic psychiatric settings. Most hospital violence is precipitated by patients, family, and other visitors. At present, there are relatively few restrictions on access to scenes, hospitals, clinics, and other environments where healthcare services are provided. With few exceptions, anyone can come and go at will. In addition to the normal stresses of illness, patients and families are also exposed to some of the same frustrations and issues experienced by caregivers.

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Unexplained and lengthy waiting times Lack of privacy Noisy, crowded, and uncomfortable waiting areas Patient’s and family’s increased general anxiety

The financial pinch in healthcare has led to increased stresses on staff. Understaffing, pressure to increase productivity, increased demands on staff to do more with less and less, inadequate and uncomfortable break areas, lack of privacy, working alone, decreased levels of security, poor building design, poor lighting within and outside facilities or in the field have lead to feelings of helplessness and hopelessness. Many feel trapped because they are afraid they will lose their job and not be able to get another. Understandably, but unfortunately, healthcare providers break down, too. Each individual who leaves the employ of a healthcare organization leaves a burden on fellow workers to pick up the slack. Those at Greatest Risk Risk to healthcare providers is greatest in situations where there is a lot of activity and a lot of patient contact, such as during mealtimes and visiting hours. Risk to healthcare providers is increased when patients and families feel frustrated, vulnerable, or out of control. Especially in emergency situations, this is pretty much unavoidable. Risks are exacerbated when firearms or other weapons are available or when there is minimal or ineffective security protection. Prevention Many healthcare providers have little knowledge regarding how to prevent violence. Unsuspecting personnel are often ill prepared to protect themselves, their coworkers, and innocent bystanders. Some healthcare workers accept that violence is just part of the job. They also have not developed the skills to take appropriate offensive and defensive actions. Knowledge of procedures, good listening skills, and excellent communications skills are the healthcare worker’s primary tools in de-escalating potentially violent situations and managing conflict. Reporting is one of healthcare’s greatest tools in preventing future violence in the workplace. Threats or acts of verbal or physical violence should always be reported regardless of the perpetrator. Organizational policies should strictly prohibit retaliation of any sort and violation of policy should not be tolerated.

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Awareness and Responses Unless premeditated violent situations often develop slowly over time. The “offender” usually becomes increasingly tense, troubled, and anxious. The offender eventually reaches a level where he or she becomes disruptive. If the situation is not handled appropriately at this stage, violent behavior may follow. If individual staff members can recognize when tension is building, they may be able to de-escalate the situation before the individual becomes overtly disruptive. Once an individual has reached a level where he or she is disruptive, security should be notified immediately before the situation further escalates into actual violence. Signs of Increasing Tension Signs of increasing tension in an individual include verbal expression of their belief that they are being threatened, deprived, manipulated, or ignored. Physical signs of increasing tension are defensive body language (such as tense muscles, closed posture, or excessive attentiveness) or aggressive body language (such as clenching teeth or jaw muscles, clenching fists, pacing, abrupt forward movements, and increased upright posture). Responding to Increasing Tension • Stay calm and quiet. • Act rationally and professionally. • Listen and ask questions, then summarize what you think you heard. • Apologize. Validate the person’s frustration and feelings by saying you’re sorry, even if you don’t think anyone did anything that was “wrong.” • Let the person know you will address the problem and take steps to do so immediately. Signs of Increasing Disruption • The person will not calm down. • The person does not think rationally or respond to rational discussion. • The person makes verbal threats of violence or other disruptive acts (including leaving against medical advice). • The disruptive individual may display rude behaviors and use impolite language or profanity. • The volume level of the voice may increase and the tone may be sarcastic, nasty, accusatory, and inappropriate. Response to Increasing Disruption • Remain calm. • Show that you understand and wish to help meet their needs and desires.

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• Choose your words carefully and wisely; use noninflammatory language. • Give clear instructions and ask for signs that the person understands. • Set reasonable limits on behavior. • Keep your distance. Both for safety reasons and to avoid further agitating the person, keep at least two arm lengths away. Never reach out or actually touch the person without their express approval. • Signal for help—preferably have someone call security. Types of Violent Behavior • Yelling or screaming are considered violent behavior. • Any attempt to become physical is considered violent behavior. • Display or use of a weapon—any weapon—is violent behavior. Responding to Violent Behavior • Your first and most important priority is to get yourself and others to safety. • Do not confront the person. • Do not attempt to restrain the person. • Call or have someone call security and local police, immediately. Every healthcare delivery system should have policies in place to deal with violence in their facility. All healthcare personnel should be educated and trained in standard violence prevention protocols. Prevention programs are most effective when management and staff are involved in developing a safety plan that is reviewed on a regular basis. Regular review helps ensure staff members are knowledgeable and proficient enough in dealing with a violent individual or situation to contain the situation until security or law enforcement can arrive. Review of safety plans is an attempt to identify weaknesses in both personnel and in protocols. The worksite atmosphere should be analyzed and critiqued by both staff and management. All employees should be educated in the goals, use, and follow-up procedures included in the safety plan. Whether or not an employee is a team participant, the process should be open to suggestions and strictly prohibit retaliation.* Safety plans must have the flexibility to change over time. * It is critical in preventing workplace violence for a safety plan to be in place before an incident occurs and that all employees understand that reporting violence or potential violence is the only way to identify and address workplace safety issues.

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Reporting Responsibilities Employers must not only encourage reporting, but follow up on incidents and safety suggestions. Staff must understand that they have a responsibility not only to themselves, but also to their fellow workers to report workplace violence or potential workplace violence. Security personnel must understand that safety in the workplace is their responsibility. Ultimately, security personnel are responsible to ensure a safe working environment. They must be an active participant in preventing workplace violence and must remember that they have the responsibility to respond when safety issues arise and that they have the authority to act in prevention of and response to workplace violence. Consequences for the Victim, Staff, Patients, and the Provider Organization The consequences of workplace violence extend beyond minor or major injury. Violent events can lead to temporary or permanent psychological as well as physical disability. Also important is the fact that any violent confrontation affects the organization as a whole. Morale goes down, and employees leave, creating an additional burden on those workers who remain. The overall work environment becomes more tense and hostile, workers and management lose trust in each other, and the organization’s finances are stretched—all leading to an increasing downward spiral in workplace safety, security, stability, and overall work satisfaction. OSHA Guidelines OSHA guidelines (OSHA, 1996) regarding workplace violence were published in 1989. Their goal was to eliminate and/or reduce worker exposure to violence in the workplace and minimize harm to employees and volunteers by identifying risk factors, implementing safety measures and devices, and designing safer workplace environments and practices. A sample violence incident report form is included as Appendix 11.3. Items to be considered when designing a report form include: • • • • • • • •

Type of incident (physical, verbal, bomb, transportation, or other) Date and time of incident Incident location Name of assailant (if known) Witnesses’ names, departments, and contact information Detailed but succinct description of the event Witnesses’ observations and status Number of people affected and status

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• • • • • • •

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Types of injuries inflicted If family was notified, when and by whom Equipment and/or weapons involved Lost work time Whether employee health and risk management were notified Environmental conditions (including weather) Other records that may have been filed (police reports, etc.)

Hostage-Taking Scenarios In addition to becoming injured or killed during a shooting, physical altercation, or other act of violence, healthcare personnel may be taken as hostages. Hostage-taking scenarios usually (but not always) develop as a spontaneous response when an individual feels he or she has no other options. The hostage taker uses control over another person (or persons) to gain an objective or to affect a way out when he or she feels trapped. In a preplanned event, the hostage or organization is targeted for some reason. Criminals, the mentally disturbed, and terrorists are typically implicated in hostage taking. Other situations involve domestic disputes, stressed family members of patients, and disgruntled coworkers. The best defense against becoming involved in a hostage-taking scenario is prevention. The following clues are useful in identifying those at risk for violent or previolent behavior. In combination with a healthy index of suspicion, the seasoned healthcare provider can divert the tendency for a violent offender’s behavior to escalate. An at-risk individual has an inadequate personality or has demonstrated difficulty in making decisions. The offender has a high need for control and may display an unusually large physical comfort zone (space) around them. They are uncomfortable when access or egress is limited and have a heightened perception of being “trapped,” demanding a fight or flight response. The initial sign of impending trouble is increased agitation or anxiety, pacing, fidgeting, raised voice, and so on. Another person of interest is the agitated patient or visitor with a minor complaint. These offenders might be looking for a venue to gain publicity. Or the individual(s) might wish to harass or embarrass law enforcement or other governmental entitles. The key to raising your suspicions about these individuals lies in experience, paying attention, subtle clues, and a gut reaction that something isn’t right. When your forensic antenna is raised—for whatever reason—it is wise to contact security or law enforcement and make them aware of your suspicion that something isn’t right.

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Sexual Harassment Sexual harassment is legally defined under Title VII of the Civil Rights Act of 1964 and complaints are handled by the Equal Employment Opportunity Commission (EEOC). Any unwanted conduct of a sexual nature in the workplace is considered sexual harassment. Perpetrators and victims of sexual harassment can be male or female and can be supervisors, coworkers, other employees, or even nonemployees. In some cases, employers can be held legally responsible for sexual harassment committed by their employees. Sexual harassment of victims can be direct (the victim is being harassed directly) or indirect (the victim is affected by ongoing harassment). Harassment can occur without specific job-related losses to the victim. Types of Sexual Harassment There are two basic types of sexual harassment in the workplace: quid pro quo and hostile environment. Quid pro quo sexual harassment is direct harassment, and the employee’s job status is directly dependent on how he or she responds to the unwanted sexual conduct. An example would be requesting sexual favors in return for job promotion or increased pay. Hostile environment sexual harassment is where unwanted sexual conduct interferes with an employee’s job performance. The work environment itself is hostile or intimidating and creates an offensive, possibly intolerable working atmosphere. An example of this type of sexual harassment would be when a coworker frequently “talks dirty” or tells offensive sexual jokes where others can hear it. Sexual Harassment Policy Employers should have a clear sexual harassment policy defining what is and what is not considered sexual harassment. It should also make it clear that reporting is mandatory and include a provision stating that harassers will be disciplined or fired. The policy should include how to file a sexual harassment report and to whom, how complaints are investigated, and should include a provision that retaliation is illegal under federal law and will not be tolerated. Victims of sexual harassment have a responsibility to confront the harasser directly and immediately and inform him or her that their conduct is offensive, unwelcome, and must stop immediately. Victims should also file a complaint with their supervisor, human resources department, or

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risk management as soon as possible. If the employer is not responsive, the injured person may appeal directly to the EEOC.* Employers are required to document all allegations of sexual harassment as well as investigation results and what actions were taken to stop the harassment immediately. The employer also has a duty to fully investigate sexual harassment complaints as soon as possible, ensure all involved employees are safe from retaliation, and provide guidelines for disciplinary action to be taken against perpetrators.

Electrical Hazards Although relatively uncommon, electrical mishaps do occur from time to time. Electricity is odorless, colorless, and tasteless—and depending upon the path the current takes, deadly. It is invisible, and for the most part, silent— until something goes wrong. Electricity can kill, even at low voltages. Key Point: Electricity can kill at 1/100th of the amps required to trip the lowest-rated circuit breaker. Circuit breakers are designed to prevent a fire; they are not designed to prevent electrical shock to humans and animals.

Definitions Electrocution is death by electrical shock. Electrical shock is the passage of electrical current through the body. This electrical current can create tissue damage or result in death. As a responder to an emergency or forensic event, it is impossible to know an electrical wire is live (charged) until it is tested by someone who is qualified to do so. Contact the local electric utility before touching or coming within “whip range” of a downed wire. Two Important Rules Firefighter Rule 1: Never turn off a circuit breaker except for the main breaker. Fire investigators will need to know the position of each circuit breaker to help determine the cause of the fire. Firefighter Rule 2: Never pull a meter! There is a very large risk of an arc-flash hazard. * Contact the EEOC at (800) 669-4000.

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Since electricity can be the underlying cause of a fire, all fire scenes should be managed as if there are inherent electrical hazards. Except for lightning, the two primary causes of an electrical fire are: (1) overload—more current than the wire can handle, and (2) poor connections—high-resistance connections (created by corrosion, etc.). Key Points: Never assume an electrical wire is dead. Never touch a person who is touching an electrical wire. Stay away from a downed wire—on the ground, touching a vehicle, etc. For example, most house wiring is now made of copper. During times of copper shortages, however, aluminum wire was used. Although aluminum does conduct electricity effectively, aluminum oxide, the corrosion that occurs due to oxidation, does not. Contrary to common assumption, circuit breakers are not designed to prevent shock to humans or other living organisms; they are designed to prevent an overload of current, thus preventing a fire. A circuit is measured in amps. An amp is the amount of current (volume or flow of electricity) passing a given point in an open circuit. Circuit breakers are usually 15 amps or more. The amount of electricity needed to affect a human with intact skin is expressed in milliamps (one one-thousandth of an amp—0.001 amp or 1/1,000 amp). Therefore, contact with any standard electrical current can be dangerous, and even lethal.

Toxins There are countless toxins that can be encountered by healthcare personnel. Even ordinary chemical solutions can be toxic to humans, especially when they are in higher concentrations or when two ordinary substances come together to form a toxic mix. These agents can enter the body through the mucous membranes, the respiratory tract, the gastrointestinal tract, or even intact skin. Personal protective clothing including coveralls, masks, and gloves can be vital for minimizing these threats. Carbon Monoxide and Oxygen Deprivation If first responders or healthcare personnel must work within a confined space, great care should be taken to ensure that they do not become victims of oxygen depletion or carbon monoxide poisoning. Initial assessment of a scene should always be done by someone wearing a self‑contained

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breathing apparatus (SCBA). Fire department or hazmat team officials will then advise other personnel regarding specific hazards and PPE required. Unconscious victims may be suffering from one of these circumstances. In these instances, high-flow oxygen should be administered immediately. It may not be immediately known whether the victim is unconscious because of the environmental situation or whether the environmental situation is the result of the victim’s state. In situations where the availability of breathable oxygen is in doubt, healthcare personnel should not enter the scene without an SCBA until a definitive cause of the unresponsiveness can be determined. Cyanide Poisoning Industrial fires can liberate high levels of hydrogen cyanide. Hydrogen cyanide can be inhaled, ingested, or absorbed through intact skin and mucous membranes. This toxin poses threats to life for all personnel who come into contact with it, including affected victims. Three vital rules for scene personnel are: • Flood any accidentally exposed skin or mucous membranes with copious amounts of water to minimize systemic effects. • Place clothing or other evidentiary items into impervious containers and clearly mark each as “hazardous” to prevent accidental exposure of others. • Wear recommended PPE to all fire scenes. If there is exposure, emergency medical assistance must be summoned. Definitive treatment includes respiratory support with supplemental oxygen and prompt use of the agents contained in a typical emergency “cyanide kit,” which includes nitrite, sodium nitrite, and sodium thiosulfate. Hydrogen Sulfide Hydrogen sulfide is a cellular asphyxiant capable of inducing rapid morbidity and death, especially when victims are in a small confined space. This poisonous substance is generated by the putrefaction of sewage or animal waste products. It is characterized by a rotten egg odor, and in living victims, visual impairment associated with blepharospasm, eye irritation, and pain may be experienced. Shortness of breath, confusion, cyanosis, and depressed level of consciousness are also common.

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Forensic pathologists may be accidentally exposed to hydrogen sulfide during autopsy. Greenish discoloration of the thorax muscles and the surface of the stomach should arouse suspicions that this chemical toxin may be present.

Altitude-Related Illness Unless acclimatized, when humans are exposed to altitudes above 7,000 feet, they can develop altitude sickness—a condition primarily due to the lack of oxygen in the circulating blood. Unless one is exposed to higher altitudes gradually (i.e., over 3 or 4 days), physiological processes cannot adapt to the reduced partial pressure of oxygen. Hypoxemia and alkalosis occur, and despite an accelerated heart rate, the cardiac output remains unchanged. Lethargy, headache, nausea, and other disturbing symptoms occur. In early stages, oxygen via a mask is the treatment of choice. Eventually, in certain individuals who are unable to adapt to the altitude due to chronic medical conditions or other limitations, high-altitude pulmonary edema (HAPE) can occur. This condition is life threatening, demanding prompt evacuation to a lower altitude and definitive, intensive medical care.

Bomb Threats A threat to “blow up the place” is often made by way of a telephone call. In addition to bombs, the caller may threaten to release a toxic gas or chemicals that could sicken or kill patients or staff. The intent of such calls is to threaten, intimidate, and disrupt normal activities. It is not uncommon for employees themselves to make a bomb threat. The chaos that accompanies the emergency provides an ideal window of opportunity to divert controlled drugs, steal hospital property, or perform malicious acts directed at coworkers or even patients within the facility. The healthcare professional’s use of their observational skills can play an important role in responding to a bomb threat. See Appendix 11.4, “Bomb Threat Report.” Most workplaces have specific checklists to follow in such instances. Recently, however, terrorists groups strike with little or no warning, such as driving a vehicle through a wall with explosives onboard, or in some cases, having explosives strapped onto their bodies and walking into a crowded area before blowing themselves up. Acts of this nature are more difficult to detect than the traditional poorly labeled, poorly wrapped, ticking brown paper box.

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In these instances, there is no time to plan and to react. The healthcare provider’s role is focused on caring for wounded victims, but they can also play an important role in using their powers of observation and forensic skills to assess the scene, patient needs, and possible evidence. Careful documentation of what they saw, heard, smelled, tasted, and felt at the scene may be important evidence for investigators.

Forensic Response Healthcare providers are in a unique position to participate in workplace violence task forces and response teams. They believe that violence takes many forms, and that verbal abuse directed toward patients or employees, arguments among family members, the presence of rival gangs in the treatment area, and outbursts from individuals under the influence of alcohol or certain drugs can trigger a lethal event. Elements of a response plan assume that all personnel know their specific roles and responsibilities in the event of workplace incidents. Healthcare providers can help isolate the scene and help move other patients, staff, and bystanders away from the danger zone. They can call for backup, if needed, and watch for secondary perpetrators, giving law enforcement and security personnel time and opportunity to control the situation at hand. In order to ensure that staff can confidently respond to workplace violence, education is a vital element of a successful plan. In addition, the facility needs to periodically practice responses to hypothetical scenarios to verify knowledge and skills. The critique of practice drills will be valuable for refining response plans and for ensuring a more predictable and consistent staff performance.

Regulations and Reporting Nurses and others who work in forensic settings are aware of their responsibilities for notifying agencies and authorities under specific sets of circumstances. These personnel also must be familiar with regulatory guidance, standards of practice, and mandatory reporting of occupational health and safety issues. In healthcare facilities, the occupational health nurse and the infection control practitioner will be able to provide advice and recommend courses of action in the event of accidents or injuries. Prompt reporting and precise response actions are important in mitigating the harm caused by breaches of safety in the healthcare setting.

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Appendix 11.1: Equipment and Supplies Healthcare settings should have a private designated room for all victim and suspect patients of crime. Suggested equipment and supplies include the following: ABFO No. 2 L-shaped scale measure (single use only) Anoscope Blood pressure cuff (single use only) Blood pressure machine Camera and related supplies (preferably digital with removable card) Chain of custody labels Clothing to replace confiscated clothes Cleaning supplies—disinfecting for counters, floors, and equipment Clear packing tape Coin envelopes Colposcope with clear point-of-contact cover Consent forms: Evidence collection Medical Photography Treatment Release of evidence to law enforcement Cotton swabs Cover sheets Covered bin with insecticide for non-disposable instruments Diagrams Body diagrams, anterior and posterior to document location of injuries Feet and hands diagram Head and neck diagram Female external genitalia Male external genitalia Examination table Fingernail cutter (sterile) Forceps (sterile) Forcep tip covers (protectors from central sterilization or suture boots from OR) Glass cover slips Glass slides Glass vials Hospital gowns (disposable) Labels Lock box for photographs Manicure sticks Marking pen (single use only) with labels

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Materials for blood draw: Lab forms for collecting toxicology samples Tourniquets Needles Vaccutainers (blood collection vials) Microscope—400 power Nonremovable write-on tape Non-alcoholic disinfectant wipes—benzalkonium chloride Normal saline Paper—clean white 8½ × 11 (for bindle) Paper towels Pens Plain labels Plastic bags for trash and non-disposable linens Portable stand for equipment and supplies Post-it notes Powder free, latex free, sterile gloves Rubber tipped forceps Scissors (sterile, preferably disposable) Sheets—disposable Small and medium cardboard boxes Small plastic combs or brushes Small, medium, and large envelopes Small, medium, and large gauze squares Small, medium, and large brown paper bags Small, medium, and large vaginal speculums Specimen containers (clean or sterile urine cups) Sterile forceps Sterile gloves Sterile small, medium, large paper bags Sterile water and distilled water Stethoscope Swabs—sterile Swab drying holder or box Tape—nonremovable evidence tape Tape measure Toothpicks Toluidine blue stain Ultraviolet light source White butcher paper or disposable paper used on examination tables; may be used for patient to stand on Adapted from materials from Janet Barber. Used with permission.

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Appendix 11.2: Minimum Required Equipment for Nontransport Medical Rescue Vehicles: New Mexico Administrative Code 2009 MINIMUM REQUIRED EQUIPMENT FOR NON-TRANSPORT MEDICAL RESCUE VEHICLES: All non-transport medical rescue agencies shall stock and equip non-transport medical rescue vehicles with the following minimum required equipment and supplies. Supplies shall be maintained in sufficient quantities to assure the safe and adequate provision of emergency medical services in response to one or multiple incidents. A. Forward compartment: (1)  vehicle registration; (2)  U. S. Department of Transportation Emergency Response Guidebook (most current edition); (3)  maps or navigational equipment; (4)  service specific protocols and resource guides; (5)  patient care reports or reporting system; (6)  hand sanitizer; (7)  flashlight (battery powered, hand crank, with mounted battery charging system); (8)  fire extinguisher (10 pounds, ABC type or functional equivalent, charged); (9)  spotlight or auxiliary lighting system; (10) roadway warning devices (safety flares, emergency lights, safety cones); (11) vehicle jack; (12) spare tire; and (13) tire wrench. B. Communications equipment: (1)  radio communications (portable or affixed); (2)  equipment sufficient to establish and maintain direct or repeated communications with area (7.27.10 NMAC 12) dispatch and secondary providers; and (3)  N.M. EMSCOM radio system capable of cellular and text/data transmissions (optional), spare batteries with charger system. C. Personal protective equipment (PPE): (1)  EMS turnout gear; (2)  helmets with face shield; (3)  gloves (work gloves or leather gloves); (4)  eye protection (glasses or goggles); (5)  hearing protection;

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(6)  safety vest/jacket (ANSI 2008 compliant; break-away, reflective, high visibility coloration); (7)  exam gloves (assorted sizes); (8)  disposable splash protection (gowns, scrubs, eye shielding, etc.); (9)  tyvex coveralls (optional); and (10) N-95 mask (or a mask better than a particulate mask). D. Diagnostic equipment: (1)  aneroid sphygmomanometer, blood pressure cuffs (with infant, pediatric, adult, and obese sizes); (2)  stethoscope (more than one); (3)  glucose monitoring instrument (portable); (4)  pulse oximeter (portable); (5)  end-tidal CO2 monitoring device (disposable, colormetric); (6)  penlights; and (7)  shears (trauma or equivalent). E. Cardiac equipment: (1)  semi-auto external defibrillator; (2)  defibrillator pads (extra); and (3)  defibrillator batteries (extra). F. Bandages/dressings: (1)  triangular bandages; (2)  universal dressings (approximately 10 × 30 inches); (3)  gauze pads (4 × 4 inches); (4)  bandages: soft roller (self-adhering); (5)  bandages: elastic (band aids, assorted sizes); (6)  occlusive dressings (sterile, individually wrapped); (7)  adhesive tape (various sizes: one inch, two inch), duct tape (medical, white); (8)  cold packs; (9)  heat packs; and (10) burn sheets. G. Respiratory equipment: (1)  mounted electric or manifold operation suction aspirator (that meets GSA standard); (2)  portable suction aspirator (as approved by the bureau); (3)  sterile suction catheters and tubing (rigid and soft, if applicable; assorted sizes); (4) bag-valve-mask resuscitator (BVM) (disposable, with transparent adult mask); the BVM shall be capable of operation in cold weather, shall be capable of use with an oxygen supply and shall be capable of delivering approximately 100% oxygen;

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(5)  p  ediatric bag-valve-mask resuscitator (disposable, with transparent child and infant mask); the pediatric BVM shall be capable of operation in cold weather, shall be capable of use with an oxygen supply, and shall be capable of delivering 100% oxygen; (6)  adult oxygen masks with reservoir (non-rebreather or partial non-rebreather); (7)  adult oxygen masks (simple); (8)  pediatric oxygen masks with reservoir (non-rebreather or partial non-rebreather); (9)  pediatric oxygen masks (simple); (10) nasal cannulas; (11) oxygen supply tubing; (12) oropharyngeal airways (with adult, child, and infant sizes); (13) nasopharyngeal airways (with adult, child, and infant sizes); (14) laryngeal, supraglottic, multi-lumen, or laryngeal airway devices (device not intended to be [7.27.10 NMAC 13] placed into the trachea); (15) oxygen: fixed system (minimum of two wall-mounted oxygen outlets and one flow meter); system shall include a yoke-type pressure reducer gauge and an approved cylinder retaining device that meets DOT standards; the system shall be capable of delivering an oxygen flow of at least 15 liters per minute; if oxygen source is of a size less than “M” cylinder, an additional full spare cylinder for the fixed system shall be carried in the ambulance; and (16) oxygen: two portable cylinders; each unit shall consist of at least a “D” cylinder or equivalent, yoke, pressure gauge, flowmeter and cylinder wrench; the unit shall be capable of delivering an oxygen flow of at least 15 liters per minute; cylinder holders with a quick-release fitting shall be furnished to allow the use of the portable unit outside the vehicle. [7.27.10.17 NMAC - N, 3/15/2010]

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Appendix 11.3: Violent Incident Report Form Specific Location:         Date:        Time:                       Day of week:            Assailant: □ Male □ Female □ Patient □ Visitor □ Staff □ Other      Assailant’s name:                          Armed: □ Yes □ No  Type of weapon:                Violence directed toward: □ Patient □ Staff □ Visitor □ Other       Factors involved: □ Intoxication □ Grief □ Dissatisfied with waiting time □ Prior history of violence □ Gang related □ Other            Type of Incident: □ Physical abuse □ Verbal abuse □ Other        Injuries: □ Yes □ No  Type & extent of injuries:             Description of Incident:                                                       Present at time of Incident: □ Security □ Police Witnesses (incl. department)                                                     Assistance called during or after incident: □ Security □ Police □ Other     Restraints used: □ Yes □ No  Type:                   Resolution: □ Incident diffused □ Police intervention □ Assailant arrested Disposition of Assailant: □ Stayed on premises □ Escorted off premises            □ Left voluntarily    □ Other          Report completed by:            Title:           Supervisor Notified:             Date and Time:        Adapted from Appendix D, Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers (OSHA 3148) 1996. U.S. Dept. of Labor, Occupational Safety and Health Administration.

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Appendix 11.4: Bomb Threat Report Name of Person Receiving Call:          Title:         Date:          Time:        Phone # / Ext:       As best you can, write the exact words of the caller:                                                                 Questions to ask caller: Ask caller to repeat message. Where is the bomb?                         When will it explode?                        What kind of bomb is it?                       What does is look like?                       Will it hurt anyone?                         Who are you?                           Why did you do this?                        Where are you calling from?                     Description of the caller’s voice: □ Male □ Female Age:    Was voice familiar?     If so, whose?                Voice: □ Raspy □ High Pitched □ Pleasant □ Intoxicated □ Soft □ Deep □ Loud □ High Speech: □ Fast □ Slow □ Nasal □ Stutter □ Distinct □ Slurred □ Distorted □ Muffled □ Lisp □ Intoxicated □ Other   Language: □ Good □ Foul □ Poor □ Other Accent: □ Local □ Racial □ Regional □ Foreign** □ Sure □ Unsure □ Joking □ Other **Explain:                            Manner: □ Calm □ Angry □ Serious □ Incoherent □ Righteous □ Deliberate □ Nervous □ Emotional □ Rational □ Irrational □ Laughing □ Tense Background Noise: □ Voices □ Music □ Trains □ Office Machines □ Factory Machines □ Street Traffic □ Animals □ Airplanes □ Quiet □ Other:          Phone Connection: □ Clear □ Pay Phone □ Static □ Long Distance Other:                              Time of Call:                Time Hung-up:       Remarks:                                                                                            

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References Alspach, G. 1993. Nurses as victims of violence. Critical Care Nurse 13(5): 13–17. Barber Duval, J. 2006. Forensic Nursing. St Louis, MO: Elsevier Mosby. Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH). 1992. Homicide in U.S. workplaces: A strategy for prevention and research. NIOSH #92-103. Kindle, S. L. 1993. Violence in the Emergency Department: How to stop it before it starts. American Journal of Nursing 93(7): 22–24. Koop, C. Everett. (1992). Violence in America: A public health emergency. Journal of the American Medical Association (JAMA) 267:3075-3076. New Mexico Register/Volume XXI, Number 5, 7.27.10 NMAC 12. March 15, 2010. http://www.nmcpr.state.nm.us/nmregister/xxi/xxi05/3.2.1amend.pdf New Mexico Register/Volume XXI, Number 5, 7.27.10 NMAC 13. March 15, 2010 from http://www.nmcpr.state.nm.us/nmregister/xxi/xxi05/3.2.1amend.pdf Occupational Safety and Health Administration (OSHA). 1996. Guidelines for preventing workplace violence for health care and social service workers (OSHA 3148). Washington, DC. Occupational Safety and Health Administration (OSHA). 2004. Guidelines for preventing workplace violence for health care and social service workers. (OSHA 3148-01R2004). U.S. Department of Labor. http://www.osha.gov.Publications/ OSHA3148/osha3148.htm (accessed November 4, 2010).

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Legal Issues

Testifying in Court Nurses who become involved in any medicolegal situation, whether it is civil or criminal, may have to testify in court at some point in their career. Testifying at a trial is similar to performing in front of a live audience. The backdrop of tension, expectation, and uncertainty is enhanced by an air of formality and possibly hostility. Add to this scenario the presence of various media representatives, numerous witnesses, family members, and other interested individuals from the opposing side, and you have a recipe for major stress. In an attempt to discredit the opposing side, it is not uncommon for an attorney to cast doubt on the credibility and professionalism of its witnesses. The O. J. Simpson trial in the 1990s was a good example of where the defense team was able to shift the focus of the trial away from Mr. Simpson and onto prosecution witnesses, police officers, detectives, crime lab personnel, and the prosecution itself. Fear Not The courtroom is a formal and intimidating place, and that is not necessarily a bad thing. Each citizen must live within the legal standards of the nation. The impact on individuals is huge. For these reasons, courts of law must be taken seriously and treated with respect. It is not surprising, then, that a prospective witness approaches the bench with some apprehension. The events that occur in a courtroom are serious business, but they need not be nerveracking. Understanding the process and knowing how to prepare will help the inexperienced witness testify without undue trepidation. What Is the Law? Civilized society is based on mutually agreed upon rules, ethics, and standards. A society’s values are exemplified when legislatures discuss proposed legislation and reach a compromise by passing a statute. The resulting laws are known as statutory law. The other method of making law is through the judicial process. Taken together, appeals of verdicts handed down at the end of trials create that body 323

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of law known as common law. Trial decisions may differ between various jurisdictions or with a different set of circumstances, but each verdict adds weight to precedent,* molding the form of judicial opinion. Be Prepared Regardless of the impression we receive from television, the primary function of witnesses is to educate the jury. Whether the witness is a fact witness (one who knows a certain fact or element regarding the issue at trial), or an expert witness (one who gives a professional opinion regarding a question or situation), understanding the role of witnesses and being fully prepared to testify will ease anxiety and improve overall testimony. Regardless of how familiar you are with the substance of your testimony, it is a good idea to review the applicable literature, standards of practice, relevant policies and procedures, as well as notes and sketches you have made. Remember that all emails regarding the case, and all notes made on records or correspondence are discoverable and can be placed into testimony. Most attorneys advise prospective witnesses to avoid writing on any documents that may be requested for review, or to incorporate facts or opinions into casual emails. In fact, it is imperative to avoid any discussion of the case with colleagues or others, despite how innocent the conversation might be. Attorneys invariably ask, “Have you discussed this case with anyone?” There is always concern that others may have influenced your thoughts or perceptions about the case. Before a deposition or a trial, witnesses should update their résumé or curriculum vitae, review their prior deposition, organize their thoughts, and be familiar with all terms or definitions associated with the case. This is vital since cases can be compromised merely because the witness does not fully understand fine details within the line of questioning. If precise timelines are pertinent to a legal scenario, these should be well established and confirmed prior to providing formal testimony. Typically, witnesses will have a pretrial conference with an attorney to ensure that they are well prepared. Visual aids are an important aspect of courtroom testimony. They should be prepared well ahead of time, appear professional, and be easy to understand by all parties in the courtroom. If possible, it is helpful to have one or two visual aids that the jury can examine closely and/or touch. Photographs for * Precedent is defined as follows: “In law, a judgment or decision of a court that is cited in a subsequent dispute as an example or analogy to justify deciding a similar case or point of law in the same manner. Common law and equity, as found in English and American legal systems, rely strongly on the body of established precedents.” Encyclopaedia Britannica Online, http://www.britannica.com/EBchecked/topic/474339/precedent (accessed April 5, 2010).

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the courtroom should convey facts in the case, but should not be unduly gruesome or offensive. Sensational graphic detail that unnecessarily exposes sexual anatomy or horrific wounds may not be deemed admissible by the judge. Arrival A subpoena to appear for a deposition or a courtroom appearance is a legal order and requires a formal response. Personal and work-related activities must be arranged to accommodate the court’s order. Stay in touch with your attorney and provide multiple ways for them to contact you in the event there is a new development in the case, a point that needs clarification or further discussion, or if there is a sudden change in court schedules. Make sure you know exactly where you are to appear and precisely what time you will be testifying. Determine details about parking, one-way streets, money needed for parking, and so on. Show up early. Notify the district attorney or your own attorney when you have arrived. Personal Characteristics We tend to forget that we are always observed by someone. Studies have shown that people believe you based on three things: your appearance, your demeanor, and your attitude.* These three things will take effect long before you begin to speak and remain long after you have ceased talking. Attire The courtroom is never a casual place. Dress appropriately—it demonstrates respect for the judicial system as a whole. Selecting the right clothing for the courtroom is an important factor in ensuring that you appear professional and businesslike. Military personnel or public servants may wear uniforms or badges. Jeans, short-sleeved garments, short skirts, lowcut blouses, and excessive jewelry are not appropriate. Suits, dresses, a conservative hairdo, and modest accessories will convey that you are mature, serious about the business at hand, and that you are there to testify, not to impress or provoke others. * People believe what they see: People believe someone 38% of the time based on how they present what they say—their method of delivery. People believe someone 55% of the time based on how they look and how they act—their appearance and demeanor. People believe someone 7% of the time based on what they say—the facts.

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Presence on the Stand The credibility of witnesses is highly influenced by appearance and demeanor. It is imperative that questions are answered thoughtfully and directly, without elaborating on trivia or embellishing responses. Yes or no answers are all that are required in many instances. Unnecessary details can lead to tedious follow-up questions and detract from central issues in the case. The most powerful testimony is delivered in a confident, strong voice. Despite the reality that witnesses have definite thoughts and feelings about the case, testimony should steer clearly away from emotions, criticisms of personnel, stereotyping suspects or victims, or making social statements that reflect bias. Just answer the questions! Rolling your eyes, smirking, grimacing, smugness, throwing up your hands, nodding, and laughing or smiling during someone else’s testimony are never appropriate in the courtroom. Body language conveys a lot about your attitude. A court of law is not a casual place. Seat yourself comfortably in an attentive manner, both feet on the floor with your hands in your lap. Sit up straight; do not slouch. Do not cross your legs or arms. Do not sit seductively, demurely (with undue modesty or reserve), or provocatively. Do not lean forward in a confrontational, aggressive, or hostile manner. Establish eye contact with the jury—each and every one of them. Members of the jury are the ones who are going to be making a determination in the case, not the prosecutor. Look at the attorney when he or she asks you a question; look at the jury when you answer it. Judges, attorneys, and members of the jury will maintain surveillance of your behavior and actions in the courtroom. Sit up straight with both feet on the floor. Avoid leaning forward which may be interpreted as confrontational or aggressive behavior. Pay strict attention to all details of the proceedings. Ensure that you turn off your personal digital devices. Cell phones and similar devices are banned in some jurisdictions. Although you may feel anxious, avoid accessing items in your handbag or briefcase, whispering, chewing gum, or engaging in other nervous habits. Do’s and Don’ts When Testifying Do’s • Above all else, tell the truth. • Be genuine. Do not try to be someone else; be yourself. • Be professional in every way possible. • Be polite. Use Mr., Mrs., your Honor, and so on. • Be comfortable with your own style. • Project confidence—remember you have the knowledge, skills, experience, training, and education to be there.

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• Allow the jury to see your interest, but not your bias. • Answer questions in a clear and concise manner. When speaking, use words and a tone that make it easy for the jury to understand what you are saying. Use simple, easy-to-understand terms.* • Define or explain any technical terms that you use. • Use analogies so that the jury can relate to what you are saying. If you make a mistake, acknowledge it immediately. Do not be afraid to say you have misspoken or made an error. If you are confronted with unfamiliar material, say so. Pause before answering. Pause and take a breath when you need to. Prepare, prepare, prepare—know your material. Practice good ethics every day. Your behavior may come back to bite you someday.† Don’ts • Do not discuss the case outside the courtroom! • Don’t elaborate! Don’t fill up the silence; wait for the attorney or judge. • Do not give an opinion and don’t ever express your personal feelings. • Do not make definite statements—Don’t use words like never and always. • Do not “invent” testimony just because it’s convenient or an embellished version sounds better. • Don’t make excuses. • Be respectful; don’t talk down to the jury. • Do not stop to talk to attorneys during break or when you leave—it implies favoritism or bias. • Do not remain in the courtroom once you have been excused—it implies that you have an interest in the outcome. Testimony Direct testimony is when your attorney (often the prosecutor) asks you questions. Cross-examination is when the opposing attorney asks you questions about issues that have already been raised. One of the reasons a defense attorney may not place their client on the stand is because that gives the prosecution an opportunity to cross-examine their client. Direct questions are those that are open-ended and straightforward. An example would be, “What did you observe when …” Leading questions are questions that are worded in such a way as to suggest a potential answer. These are “help” questions, which can lead the witness down a preferred path * KISS means Keep It Short and Simple. † Mark Furman, the policeman in the O. J. Simpson case, is an example.

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or influence the jury’s thinking in a certain way (e.g., “When you [saw, did, heard, etc.], did it [create a certain emotion]?”) An example of this type of question is, “When you saw the bruises on her face, did they upset you?” A direct question would have been: “What was your reaction when you saw the victim’s bruises and wounds?”

Depositions Depositions may be taken voluntarily or may be required by subpoena. There are two reasons a person may be deposed: • The attorney seeking the deposition needs to become informed regarding what the individual knows about a certain situation. • The attorney wishes to establish that individual’s version of the story so it can be countered or neutralized at trial. A deposition is a written, word-for-word recording of questions posed by an attorney and answers given under oath. A deposition is taken in the presence of attorneys for both the prosecution and the defense, or in the case of civil litigation, all interested parties. The recording is transcribed by a court reporter and a written transcript is prepared. The person being deposed will be given a copy to review and sign after verifying that the transcript is accurate.* The following are suggestions for responding during a deposition. Listen Carefully to the Question—Try not to think ahead. Rather, focus on each word of the question paying special attention to words that may have double meaning or are ambiguous. If you do not hear the question, or do not understand the question, or what is being asked is unclear, ask that the question be repeated, reworded, or expanded. Do not answer a question you do not thoroughly understand. Take Plenty of Time to Answer—Avoid the impulse to answer quickly. Think the question over carefully before you respond. It is better to be accurate than spontaneous! Pausing to consider the question being asked does not mean that you are dishonest, ignorant, or that you are not giving a good deposition. The transcript does not reveal pauses and the transcript is what is admitted at trial. It is permissible to write out the question or take notes before answering. After listening to and considering the question, answer in your mind before you do so verbally. * The person being deposed can make corrections to the deposition, but the original text remains even though it may be incorrect.

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Tell the Truth—A falsehood during deposition will come back to bite you at trial. Remember, you are under oath. If you don’t know the answer, it’s OK to say you don’t know. Answer the Question but Don’t Elaborate—Don’t give the other side any more information than they ask for. If you are uncomfortable answering a question, look to your attorney to object. Stay Calm—If you find yourself becoming agitated, ask for a time out to go to the restroom where you can regain your composure.

FORENSICS & CRIMINAL JUSTICE

Forensic Science in Healthcare Caring for Patients, Preserving the Evidence “The author has distilled the essentials for those who do not have the time to wade through a lot of peripheral ‘nice to know’ information to find immediate answers … . If you can have only one quick reference manual, it should be this one!” —Janet Barber Duval, Forensic Nurse

“. . . an excellent resource for all healthcare providers and right on target for our EMS colleagues.” — Philip J. Froman, MD, FACEP, EMS Medical Director First responders confronted by forensic cases are forced to consider the competing concerns of administering proper medical treatment while at the same time safeguarding vital evidence. Forensic Science in Healthcare: Caring for Patients, Preserving the Evidence presents precise on-scene protocol designed to ensure that the actions of the response team provide the necessary care and yet maintain the integrity of the evidence for legal purposes. Following an introduction to forensics, the book explains how to recognize and identify patients with forensic issues, offers guidelines on proper documentation, and provides tips on forensic photography and capturing critical images. It reviews basic principles of evidence collection before moving into specific case scenarios, including domestic violence, sexual assault, child and elder abuse, youth violence, and death investigation. The book also examines occupational concerns for forensic personnel as well as legal issues such as testifying in depositions and in court. Enhanced with photographs, illustrations, templates for documentation, and case-specific recommendations, this one-stop reference provides first responders with practical understanding of the steps that should be followed to ensure not only patient protection but evidence preservation.

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