CHAPTER 14. Evidence Collection in the Emergency Department
Catherine M. Dougherty
Forensic Focus in the Emergency Department
The first article to appear in U.S. emergency medicine literature regarding forensic medicine in the emergency department came in 1983 (Smialek, 1983). In Emergency Medicine Clinics of North America, Smialek stated, “medical care of the critically ill in the emergency department has a significant impact on the practice of forensic medicine. Many victims of homicide or accidents receive some degree of medical or surgical treatment prior to expiration.” Smialek recognized that evidence, necessary to accurately reconstruct the event, prove guilt, or establish innocence, was disappearing in the emergency department. This evidence was being destroyed, either by commission or omission, in the provision of patient care. That same year, Roger Mittleman, a medical examiner for Dade County; Hollace Goldberg, an emergency nurse; and David Waksman, a state attorney for Florida, published “Preserving Evidence in the Emergency Department” in the American Journal of Nursing (Mittleman, 1983). This article emphasized the importance of recognizing and preserving evidence on patients presenting to the emergency department.
The need for nurses to be involved in evidence collection in the emergency department was first mentioned in literature in 1986. Harry C. MacNamara, the chief medical examiner for Ulster County, New York, proposed to provide forensic training to emergency nurses and physicians. Principally, MacNamara recognized that evidence was being destroyed or discarded; wounds were being cleaned, repaired, and surgically altered without adequate description or documentation; and statements in records were being recorded without factual basis (MacNamara, 1986). These factors often complicated the work of the medical examiner and created ambiguity and confusion within courts of law. Richard Carmona, a trauma surgeon and U.S. Surgeon General, reported that a review of 100 charts of trauma patients who presented to a level 1 trauma center in California revealed poor, improper, or inadequate documentation in 70% of the cases. Additionally, in 38% of cases potential evidence was improperly secured, improperly documented, or inadvertently discarded (Carmona & Prince, 1989). The message from the medical and law enforcement communities was clear: a patient’s evaluation must be adequately documented narratively, diagrammatically, and photographically, in the patient’s chart for possible use in future legal actions. The failure to do so may have far-ranging consequences for the hospital, the patient, the accused, and potentially the treating physician. The Emergency Nurses Association (ENA) acted promptly to formally define the role of nurses in evidence collection and initiated special education and training for its members. However, even now, the American College of Emergency Physicians (ACEP) has not issued a position statement regarding the role of forensic physicians or police surgeons in emergency departments (EDs) in the United States. Even so, the organization has issued forensic policy statements and training guidelines related to evidence collection in cases of sexual assault and has recommended that residency curricula include training in the recognition, assessment, and interventions in child abuse (ACEP, 2000). The ACEP also acknowledges the benefits of sexual assault nurse examiners (SANEs) and strongly supports their use in the emergency department for the benefit of patient care.
Emergency nursing adopts forensic role
An article titled “Forensic Nursing in the Emergency Department: A New Role for the 1990s” charted the course for forensic nursing during the 1990s (Lynch, 1991). Lynch recommended the inclusion of forensic nurse examiners (FNEs) as a functional component of emergency department care. In addition to performing sexual assault examinations, these nursing specialists would provide other services such as formal assessments for abuse and neglect, forensic photography, wound identification, evidence collection, and expert testimony.
In October 1998, the U.S. ENA initially issued its position statement that clearly outlined the responsibilities of ED nurses in evidence collection. The most recent revision of this document was approved by the ENA board of directors in 2003. The position statement clearly states that performance of forensic procedures is a component of emergency nursing practice (ENA, 2003).
By the time that the ANA’s Congress of Nursing Practice recognized forensic nursing as a unique and specialized area of nursing in 1995, many emergency nurses had already been expressing their interest in this new specialty and were seeking ways to educate themselves in forensic theory and practice. They were enrolling in postgraduate courses, participating in online offerings, and attending workshops and professional meetings to learn more about forensic nursing. Motivated by personal goals and enticed by a desire to participate in an exciting, challenging new area of clinical practice, nurses pursued forensic education.
In some states, forensic nursing practice is being driven by local, state, or federal agencies, and sometimes pressure or support from advocacy groups. The state of Texas recently passed legislation with provisions for mandatory forensic education for nurses working in the ED as well as for medical students. In 2007, Connecticut considered legislation that would require the state’s 31 acute care hospitals to make forensic nursing services available to patients. Additionally, The Joint Commission (TJC) also has established guidance that states that hospitals must educate their staff regarding the identification of forensic patients and have policies and procedures in place to ensure that they are properly managed and referred to ensure their human rights. This includes the collection and preservation of forensic evidence (TJC, 2009)
The Joint Commission guidelines emphasize that patient assessment must be conducted within the context of the requirements of the law to preserve evidentiary materials and support future legal actions (TJC, 2009).
A study published in the National Institute of Justice Journal (NIJ, 2009) demonstrated that jurors sitting on criminal cases fed nightly on both fictional and reality television shows about forensic science have developed an awareness and
• 46% expected to see some kind of scientific evidence in every criminal case.
• 22% expected to see DNA in every criminal case.
• 36% expected to see fingerprint evidence in every criminal case.
• 32% expected to see ballistics or other firearms laboratory evidence in every criminal case.
In forensic nursing literature, you will find many experts advocating the use of specially trained and educated nurses, commonly referred to as FNEs, to do the work of identifying, collecting, and preserving forensic evidence. This is a sound proposal, but in reality, it is not always practical. When human resources and economic resources are constrained, hospital administration is reluctant to create new positions and expand services within the facility. As a consequence, all nurses are expected to have basic understandings about forensic patients and the issues related to the recognition and preservation of evidence. The Joint Commission, the legal system, and the public have affirmed their expectations that healthcare personnel must behave in a responsible manner when caring for victims and suspects of crime. The explosion in “ CSI” media has fueled the public’s expectation of forensic science’s role in the outcome of legal proceedings. The criminal cases presented emphasize that successes and failures for both the prosecution and the defense rest squarely on the shoulders of those responsible for the collection and custody of forensic evidence.
Forensic Patients in the Emergency Department
The ED is the portal that funnels victims and perpetrators of violent crimes into the healthcare system. These and many others who enter for care are, by definition, forensic patients.Hoyt (1999) suggested that a forensic patient is any client or that person’s significant others whose nursing problems bring him or her into actual or potential interaction with the legal system. Further, according to Pasqualone’s research, a large number of emergency department patients require collection and preservation of evidence (Pasqualone, 1998).
Pasqualone determined that there were at least 24 types of forensic categories among patients seen in one community hospital ED. Pasqualone’s 60-day survey of 914 patients presenting to that hospital’s ED revealed that 27% were forensic patients. She identified the following categories of patients:
1. Occupational injuries. Typically, at a minimum, patients referred to the ED for treatment of occupational injuries are required to provide a urine specimen for toxicology. These specimens must be handled using strict chain of custody to protect both the injured employee and the employer.
2. Transportation injuries. Transportation injuries can run the gamut from a pedestrian struck to the mass disaster scene of a derailed train, all of which will undoubtedly have interaction with the law.
3. Substance abuse. Substance abuse with all its inherent medical complications also carries with it potential for legal involvement secondary to the illegal use of scheduled drugs or buying and selling of these drugs.
4. Personal injury. Attempts at or succeeding in taking one’s own life is not illegal but is often considered to be a criminal case.
5. Child abuse and neglect. Any suspicion of these acts is reportable by law.
6. Forensic psychiatric admission. Psychiatric patients who may be sent to psychiatric facilities by order of protection or otherwise involuntarily must have their rights protected.
7. Environmental hazards. Cases of environmental hazards such as exposure to hazardous waste may result in the endangerment of an individual or community’s health and may be subject to jurisdiction according to the U.S. Environmental Protection Agency’s Resource Conservation and Recovery Act.
8. Assault and battery. Interpersonal violence is familiar to ED personnel and often requires police involvement. Knowledge of local and state laws is of paramount importance in dealing with these patients.
9. Abuse of the disabled. Abuse or neglect of any disabled individual may necessitate legal intervention.
10. Human and animal bites. Human bites often constitute a form of interpersonal violence, and animal bites may require public health surveillance as well as involve animal control.
11. Questioned death cases. Any death within less than 24 hours of hospitalization becomes a medical examiner case and will require special handling of the body.
12. Elder abuse and neglect. Many states have mandatory reporting requirements that protect the elderly.
13. Domestic violence. Laws vary from state to state as to how domestic violence is handled and reported.
14. Clients in police custody. Patients in custody requiring restraint provide a challenge for the practitioner. Consider the effects that stressors, legal medication, and drugs of abuse have on the cardiovascular system, which puts these patients at risk for death by excited delirium syndrome.
15. Sexual assault. Forensic nurses have been identifying, collecting, and preserving evidence from sexual assault victims for years.
16. Sharp force injuries. Sharp force injuries can range from the stab wounds of interpersonal injuries to impalement by a javelin at a high school track meet.
17. Product liability. Products representing a potential public health hazard may be subject to multiple federal statutes.
18. Transcultural medical practices. Many cultures in the United States use methods of healing that may mimic abuse, such as cupping or coining. Use of these practices may, in fact, constitute abuse in some states.
19. Organ and tissue donation. All deaths in hospitals must be reported to local or regional organ/tissue banks to ensure that survivors have the right to donate organs or tissues if that is their wish.
20. Burns over 5% body surface area . Burns involving 5% or more of body surface area must be investigated thoroughly to determine if there was intentional harm or possibly product liability.
21. Firearm injuries. In many states every firearm injury, even accidental, must be reported to local police.
22. Food and drug tampering. Any threat to the general public may be considered a federal offense as well as a public health issue.
23. Gang violence. Any incident of gang violence may be treated as organized crime.
24. Malpractice or negligence. An obvious legal term with legal consequences, any findings of malpractice or neglect must be carefully handled.
Although this is by no means an exhaustive list, it highlights the most common forensic presentations to the ED. It is imperative that the emergency nurse understands the various classifications of forensic patients to ensure that forensic evidence is identified and properly managed. For a complete summary of Pasqualone’s quantitative findings, see Table 14-1.
| *Data based on a yearly ED population of 22,500. | ||
| From Pasqualone, G. (1998). An examination of forensic categories among patients seen at a community hospital emergency department. Unpublished master’s thesis, Fitchburg State College, Fitchburg, MA. | ||
| Sample Population Based On A 60-Day Survey (N = 3436) | ||
|---|---|---|
| 914 Patients (27%) Qualified As Forensic Cases | ||
| Forensic Category | Frequency | Percentage (%) |
| Occupation-related injuries | 289 | 8.41 |
| Transportation injuries | 193 | 5.62 |
| Substance abuse | 160 | 4.66 |
| Personal injury | 125 | 3.64 |
| Child abuse and neglect | 464 per year | 2.06* |
| Forensic psychology | 49 | 1.43 |
| Environmental hazards | 25 | 0.73 |
| Assault and battery | 22 | 0.64 |
| Abuse of the disabled | 130 per year | 0.58* |
| Human and animal bites | 90 per year | 0.40* |
| Questioned death cases | 10 | 0.29 |
| Elder abuse and neglect | 56 per year | 0.25* |
| Domestic violence | 6 | 0.17 |
| Clients in police custody | 2 | 0.06 |
| Sexual assault | 2 | 0.06 |
| Sharp force injuries | 7 per year | 0.03* |
| Product liability | 1 | 0.03 |
| Transcultural medical | 1 | 0.03 |
| practices | ||
| Organ and tissue donation | 6 per year | 0.03* |
| Burns >5% BSA (body | 3 per year | 0.01* |
| surface area) | ||
| Firearm injuries | 7 per 3 years | 0.01* |
| Food and drug tampering | 0 | |
| Gang violence | 0 | |
| Malpractice and/or negligence | 0 | |
Evidence Recovery Processes
Once the nurse has identified a forensic patient, directions for a systematic approach to the identification, collection, and preservation of evidence must be in place. Any shortsightedness can usually be avoided if the nurse follows established hospital policies and protocols, which are based on the principles of forensic science as well as the recommendations of law enforcement, legal counsel, and the medical examiner or coroner.
Evidence defined
What is evidence? The word evidence can have many meanings. In the usual everyday use of the word, it is something that tends to prove, that which makes another thing evident. It is facts and data. In relation to the law, evidence may be the statement of a witness, the testimony of an ED nurse, or an object that bears on or establishes a point in question. There are several distinct types of evidence. Examples include admissible, circumstantial, documentary, and real evidence. For the purposes of this section, the discussion will be limited to physical evidence. Physical evidence is any matter, material, or condition, large or small, solid, liquid, or gas, that may be used to determine facts in a given situation. Therefore, items such as clothing, hair, nails, bullets, contusions, lacerations, and other wounds are classified as physical evidence. What is critical in medicolegal cases is to ensure that any and all evidence is appropriately managed using precise forensic procedures. Physical evidence is the concern of the criminalist who will identify and analyze the materials submitted to the crime laboratory. For the evidence to be used, it is imperative that it has been properly collected and preserved. It is hoped that the evidence will link a victim to a suspect, link a suspect to a crime scene, identify an assailant, establish an element of a crime, or corroborate or disprove an alibi.
Emergency personnel need to understand the legal procedures required in handling physical evidence, the types of physical evidence, and the value of that evidence. They must also know proper methods for collecting, documenting, and preserving forensic evidence. Education should include the identification of specific wounds and how their interpretation may provide critical information regarding the type of weapon and circumstances surrounding the injury. In the absence of a specially educated forensic physician or nurse clinician, potential liability exists. Search and seizure become complex. It is recommended that healthcare professionals seek legal counsel or information about forensic procedures when questions arise concerning the legality of evidence recovery. Once medical personnel are taught the value of physical evidence and the proper procedures for handling it, they generally support police requests for assistance and do not inadvertently hinder progress of the investigation.
Most trauma EDs have some type of cooperative program established with the local police when evidence collection is required. However, many rural or smaller EDs do not handle evidence collection often and therefore may not be aware of the specifics regarding recovery and documentation. Forensically trained nurses can assist patients and other ED personnel by sharing their education and training and by assisting in the development of policies, procedures, and protocols for other facilities. It is recommended that the forensically trained nurse work in conjunction with the local crime lab and district attorney’s office to ensure strict compliance to guidelines within the jurisdiction.
Establishing Priorities
A forensic patient is first and foremost a patient, and caring for the physiological and psychological needs of the patient are paramount. Airway, breathing, and circulation are the first order of business but can usually be addressed with minimal loss of evidence. Being prepared and equipped to identify, collect, and preserve evidence will enable the nurse to act quickly and efficiently and to provide nursing care while maintaining medicolegal standards protecting the patient’s civil and human rights.
Forensic Examinations in the Emergency Department
Space and equipment considerations
Unfortunately, few emergency departments have a dedicated room for forensic examinations and evidence collection. Obviously when other nonforensic patients share the space with those requiring evidentiary examinations, there is a risk of “foreign” biological materials that could potentially confuse findings in evidentiary specimens. Hair, clothes fibers, body fluids on surfaces of an exam table, or any materials left behind by previous patients could be problematic. To avoid concerns about cross-contamination of evidence, the nurse ensures that all items from a previous patient’s care and treatment are removed from the room. This includes the emptying of all trash containers and linen receptacles (Barber Duval, 2006).
Efficiency demands that all supplies needed for forensic patients be easily available to the nurse. See item 12 in Box 14-1 (Eisert, et al., 2009).
Box 14-1
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Model “Forensic Evidence Collection Guidelines for the Emergency Department” were developed for the York Hospital WellSpan Health System, York, Pennsylvania, by Eisert, P. (PI), Eldredge, K., Hartlaub, T., Huggins, E., Keirn, G., O’Brien, P., Rozzi, H., Pugh, L., & March, K.
I. Purpose
A. To establish guidelines in the collection and handling of forensic evidence from patients who have gunshot or stab wounds, or were assaulted, requiring treatment in the emergency department.
II. Guideline Statement
A. The medical needs of the patient are paramount. The next concern, however, must be the recognition, collection, and proper handling of forensic evidence from patients that received gunshot or stab wounds, or were severely assaulted. These are guidelines for the collection and handling of forensic evidence.
III. Equipment
A. Forensic Evidence Collection Kit
B. Containers for Clothing
IV. Procedure
1. Evidence Collection
A. General Recommendations
a. Always wear gloves and other personal protective equipment, as appropriate, when handling evidence. 1,4,8,9,10,12,15,16,22
4Brown, K. Evidence collection and preservation in a healthcare setting. Nursing Spectrum Continuing Education. Available at: http//:nurse.com/ce/print.html?CCID=4249. Accessed January 29, 2008.
d. Place each piece of evidence in separate paper bag or bindle (piece of folded paper) and label with patient’s name, collector’s name, date/time of collection, contents and where it came from.
f. Do not lick envelopes to seal. Moisten them with a gloved finger or use patient label. 12
g. Bags/envelopes/containers should be sealed with evidence tape and labeled with patient’s name, the date and time, and printed name and signature of person collecting and securing evidence. 14
h. Do not staple bags closed. 16
i. Body cavity searches, if requested by law enforcement, should be done by physicians and must be fully documented with the signature of the physician and accomplished in front of a witness the same gender of the patient. 16
2. Assessment
3. Body Fluids
A. Blood
a. Wear personal protective equipment.
b. Draw red-, 16 purple-, 1,16,20 and gray-1,16,20 topped blood tubes and label with patient’s name, collector’s name, date/time of collection. Blood tubes are to be placed in an envelope labeled with patient’s name, collector’s name, date/time of collection, sealed, and chain of custody followed as it is transferred to the lab. This blood work should be drawn on all gunshot and stabbing victims, and assaults that are life threatening.
i. Draw labs prior to transfusion of blood products, because it alters DNA for several months post-transfusion. 24
c. Use Povidone-iodine to prepare the venipuncture site; do not use alcohol. 16
d. Circle venipuncture sites. 11
e. Follow the chain of custody.
4. Bullets
A. General
a. Wear personal protective equipment.
b. Handle bullets, pellets, wadding, or casings with rubber-tipped forceps or regular forceps with gauze over ends to prevent marking. 1,4,9,11,12,15,16,17,24 Do not mark any bullet fragments. 1,4,9,11,12
c. Do not place in metal container. 15
d. Store in a plastic specimen cup with gauze. If wet, allow to air-dry before sealing lid, then close and seal with evidence tape, printed name and signature of collector, and date. Place patient identifier on container. Document location of the recovered bullet (e.g., left shoulder) on container. One bullet per container.
e. If any trace evidence exists around the wound, follow the trace evidence recommendations (section #10).
f. Follow the chain of custody.
5. Chain of Custody/Evidence
A. General
a. Use the chain-of-custody/evidence form when handling any evidence. 123 and 46789101112 and 1317 This procedure ensures that evidence is always accounted for.
c. Patient Information
i. Name
ii. Patient medical record number and/or trauma identification number
d. Name of person collecting evidence (printed and signature)
e. Transferring of evidence
f. Evidence cannot be left unattended and must be in plain view of the collector. If it cannot be observed, it must be secured in a locked area. 4,7,9
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