Crit Care Nurs Q Vol. 38, No. 1, pp. 36–48 c 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

The Relationship Between the Forensic Nurse in the Emergency Department and Law Enforcement Officials Georgia A. Pasqualone, MSFS, MSFN, RN, CFN, FABFN This article describes the need for a collaborative relationship between the advanced practice forensic nurse in the emergency department and critical care settings with law enforcement officials. The relationship is necessary when working with victims and/or perpetrators in the context of the 27 categories of forensic patients. Key words: chain of custody, collaboration, emergency department, forensic nurse, HIPAA, law enforcement

Thank God for the forensic nurses! Now we won’t be losing all that evidence in the hospitals. Retired Sgt, David Rivers, Metro-Dade Homicide Bureau1 URSES, for the most part, have been historically linked to the hospital setting. Today, that setting is being constantly altered by new ideology, technology, and patients’ health requirements. Successful delivery of health care today requires coordination, cooperation, and collaboration among a myriad of professionals. This assemblage of personnel consists of nurses, physicians, emergency medical services (EMS), and a great variety of health services and technologists. With the latest recognized specialty of forensic

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Author Affiliation: Adjunct Faculty, Fitchburg State University, Graduate Forensic Nursing Program, Fitchburg, MA. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Georgia A. Pasqualone, MSFS, MSFN, RN, CFN, FABFN, Fitchburg State University, SON, 160 Pearl Street, Fitchburg, MA 01420 (Ltcgeorgia@ msn.com). DOI: 10.1097/CNQ.0000000000000047

nursing, criminal justice and law enforcement are additional specialists who directly and indirectly contribute to the patient’s health and well-being before, during, and posthospitalization. This array of participants confuses and perplexes most patients or clients and is often one of the underlying reasons for most patient complaints and lawsuits. Therefore, it is imperative that the forensically educated, advanced practice nurses (APNs), as well as nurses in all other nursing disciplines, be liaisons, catalysts, and in some cases referees to bring all these participants together into a cohesive, functioning group for the betterment of health care delivery. Because nurses have tried to be all things to all people throughout history, their job descriptions are frequently defined by default. Reality is such that nurses from merely 15 years ago would have difficulty in today’s complex, electronic, and fast-paced health care setting. Today’s nurses need a wider variety of skills, both technical and interpersonal, as well as extensive knowledge of medical procedures, protocols, medications and equipment, and the ability to interrelate all of these to ensure maximum use of the right resources in a limited amount of time. The economic environment in which health care finds itself in today is demanding change. Survival

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The Forensic Nurse in the ED and Law Enforcement means that risk management and quality assurance must assist in setting nursing’s priorities. Good patient outcomes should be a result of teamwork and collaboration. The forensically educated nurse is the effective cornerstone of these medical, social, economic, and litigious relationships. A COLLABORATIVE ROLE WITH LAW ENFORCEMENT The American Nurses Association recognized the specialty of forensic nursing in October 1995. It is “the application of the forensic aspects of healthcare combined with the bio/psycho/social/spiritual education of the registered nurse in the scientific investigation and treatment of the trauma or death of victims and perpetrators of violence, criminal activity, and traumatic accidents.”2 The forensic nurse has the opportunity to work in partnership with members of the criminal justice system, including police officers, detectives, and attorneys, as well as death investigators, coroners, and forensic pathologists in the medical examiner systems. It requires the assessment and achievement of patient care in a new and unconventional manner. Historically, injured victims of trauma would be interviewed primarily by police, firefighters, and paramedics, both at the primary crime scene and in the hospital’s emergency department (ED). Recognition of any forensic issues would be solely the realm of law enforcement, accompanied by the need for and the completion of a chain of custody. Furthermore, the photodocumentation of injuries by ED health care personnel has only been minimally performed, if at all, while written documentation, with the expectation of testifying in court, has not always considered. All of the aforementioned activities have often taken a backseat in the ED, at the expense of crime scene reconstruction and any future adjudication process. There were major communication gaps between nurses and law enforcement concerning forensic protocols. Evidence has been frequently mishandled or destroyed, resulting in a miscarriage of justice.

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Collaborative efforts must now involve and affect an array of participants in the medical setting. A few of the most important relationships that nurses can have in our litigious society include those with police officers, detectives, and any other criminal justice official who accompanies or subsequently follows a patient into the ED or critical care area. The nurse and law enforcement officials will, of course, have different expectations of each other within this collaborative effort, at every level of the interaction. However, the final goal for nursing should be that which is best for the patient, with the final goal for law enforcement being the safety of the public. When either of these participants becomes an impediment to the situation, collaboration may well prove to be near impossible. The similarities between nursing and law enforcement professions are not coincidental. Society depends on both nurses and police officers to protect their lives and property. Nurses and police officers both perform their duties in a variety of ways, depending on the size, type, and objectives of their respective workplace environments. Nurses and law enforcement officials are on duty “24/7” and each is considered a professional. “Nurses accept the fact that they will have to cope with people in tough situations. Similarly, law enforcement officers understand that they, too, sometimes will come into contact with people at their lowest of lows.”3 Education and understanding between the entities, combined with prudent compromise, will resolve many obstacles and result in a positive alliance. The sum of any accomplishment is expected to be greater when nurses and police officers work together. This is especially true when the collaborative process travels outside of the hospital setting and involves other than health care professionals. Alejandro del Carmen, PhD, associate professor of criminology and criminal justice at the University of Texas, states, It’s a natural fit. Both professionals give more than they receive. Both work under extreme duress and in challenging work environments where there can be reduced flexibility and little monetary incentive

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to make them do what they do on a daily basis. It comes from the heart. They are sustained by their ideals, the core of the similar realities they share. The differences between them are great, too. Nurses, unless they are in that specialty, generally are not obligated to enforce the law. They are there to heal, while cops are there to uphold the law. It’s a delicate balance.4

Collaboration is not and must not be exclusive to the hospital setting. The clinical forensic nurse must be able to think outside the hospital ED box and assume a very necessary collegial relationship with the local police department. The forensic nurse must also be especially astute to the necessity of incorporating a care plan of life-saving protocol while maintaining a logical and consistent gathering of evidence. Every nursing discipline may experience an action/reaction with forensic science at one time or another within its practices. All nurses must be able to recognize those situations that could eventually end up as a matter for an attorney. Nurses must also learn to detect situations that could otherwise be neglected or overlooked and, therefore, unreported, such as child maltreatment, elder abuse and neglect, as well as other situations of interpersonal violence. Law enforcement officers who are responding to a problem in a health care setting in which someone is ‘mad’ and/or ‘bad’ will be thinking of safety issues—officer safety, staff safety, and public safety. Ensuring that the individuals are in areas where they cannot injure others or themselves (and eventually the officers who address them) can be a good place to start. Nurses who can calm the individuals and deescalate the situation are worth their weight in gold.3

Forensic nursing includes hands-on care to victims as well as an application of psychosocial interactions and management of the surviving victims and family members. Victims of violent crimes and families who experience sudden or catastrophic death are especially needy of this new caliber of APN. The structure of the entire approach is predicated on the clinical forensic nurse’s investigation, interpretation, and dogmatic search for the facts and truth. In years gone by, management

of the surviving victims and family members had been carried out exclusively by the police tending to the incident. For a long time, law enforcement has recognized that a patient who comes through the doors of the ED is as much a crime scene as the geographic location of the incident. “An extant member of the hospital staff who can work hand-in-hand with law enforcement agencies is vital to protect victims of foul play when they are at their most vulnerable.”5 C. Michel, PhD, BSc (unpublished data, 2004) interviewed police in Western Australia with regard to their expectations of nurses in clinical settings. There was a pervasive sentiment that police and nurses needed to work together and exchange information in order to assist in each other’s particular job functions. In Australia, evidence collection was not seen as a nursing role. However, the police did concede that it would be helpful to have a forensic nurse liaison in the hospitals with whom the police could interface. In the United States, with the establishment of sexual assault nurse examiners, the police have come to expect most nurses in the clinical setting to have a basic knowledge of evidence recognition, collection, and preservation. It is not unusual today to find that some nurses have simultaneously completed police academy training and function as detectives. As a forensic nurse, I am able to identify, collect and preserve evidence from a victim at the hospital or crime scene that police officers without this training may overlook. For me, forensic nursing bridges the gap between law enforcement and traditional clinical nursing.6(p6-7) Nurses can use their observational and diagnostic skills and relay the facts of the situation to the officers. Law enforcement officers count on nurses to relay accurate information about what has occurred and any pertinent background information. For example, is the troubled person a psychiatric patient? If so, what can nurses tell the officers about the patient? Is the patient currently agitated and combative or sitting quietly, but obviously seething? Officers will attempt to evaluate whether a crime has occurred and whether an arrest is appropriate.3

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The Forensic Nurse in the ED and Law Enforcement One of the ultimate benefits for nurses with this relationship is the insured safety of staff, patients, and the entire ED environment. Nurses should not hesitate to tell the officers if the patient has threatened, pushed, shoved, struck, or otherwise assaulted them or other staff members. Individuals’ difficult or noncompliant behavior should not be accepted as ‘part of the job.’ Physical assault is a crime! This is helpful to remember in the decision-making process in which nurses and law enforcement officers should engage. Coordinating with law enforcement officers to determine the proper course of action will enhance the safety of all involved.3

COLLABORATIVE CHALLENGES Collection of evidence Dr Henry Lee7 stated, “virtually any type of material can become physical evidence. It may be as small as a pollen particle or as large as a train. It can occur in the form of patterns or be in the form of a particular physical object.” Physical evidence encompasses any and all objects that can establish that a crime has been committed or can provide a link between a crime and its victim or a crime and its perpetrator. But if physical evidence is to be used effectively for aiding the investigator, its presence first must be recognized at the crime scene.8

This concept, coupled with Locard’s principle, the foundation for crime scene investigation, initiates the forensic nursing process. Locard’s principle simply states that if there is “contact between two surfaces, there will be a mutual exchange of matter across the contact boundary.”9 Therefore, every contact that is made between another person, place, or object will result in an exchange of physical material. The forensic nursing process includes the recognition, documentation, photodocumentation, collection, evidence preservation, awareness of mandated reporting situations, as well as maintenance of the proper chain of custody for the evidence obtained from the patient. Realizing that the patient is the

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nurse’s crime scene, there is the expectation that the crime scene may be deluged with significant trace evidence. This is the first step in forensic nursing assessment. With the exception of sexual assault nurse examiners, who have been collecting evidence since at least the 1970s, the concept of evidence collection is fairly new to the nursing profession. What has been the primary objective in police crime-solving protocol for hundreds of years was secondary to nursing’s primary intention of providing patient care and comfort. With the main objective of rendering first aid and/or saving a life, clothing and the contents found within or on were cut off and cast onto the floor or into the trash. Blood spatter patterns and gunshot residue on hands or arms were quickly washed off in preparation for an intravenous line. Nurses must realize that evidence is not limited to the sexual assault or domestically abused patient. There are 27 categories of forensic patients who may present themselves to the ED at any time during a 24-hour period. Furthermore, each category has the potential for critical physical and/or communicative evidence to be recognized by the nurse.10 The forensic patient may be accompanied or pursued by a police officer at any time during this process. There is an expectation at this point that nurses become the liaison between the patient, the health care system, and the law enforcement arena. Not only should the forensic nurse in the ED be adept in the nursing process, the forensic nurse must also be proficient at recognition of crucial evidence that could be destroyed during any of the procedures carried out by the health care team. Exigent evidence, which is evidence that can be destroyed or lost very quickly, must be collected urgently and the chain of custody maintained. All evidence that is identified must be collected, properly packaged, labeled, and turned over to the jurisdictional authorities. On a great number of occasions, it is the law enforcement officer accompanying the patient into the ED who will be at the receiving end of both physical and communicative evidence. Communicative

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or nonphysical evidence is considered to be those declarations or statements made by the patient to the nurse or the police officer (Table 1). The trail of evidence and the chain of custody have the potential for being destroyed far too many times. Mistakes in forensic cases do exist. They are made and then compounded by ignorance of the correct procedures. By initiating a conscientious system, ED nurses can assist their patients, their local police departments, and the entire legal community by actually protecting their crime scene from all that may impact or influence the corruption of evidence. They must simply focus on following correct procedures and by detailing all evidence in the medical record. Table 1. Twenty-seven Categories of Forensic Patients Abuse of the disabled Assault and battery Burns >5% BSA Child abuse and neglect Clients in police custody Communicable diseases Domestic violence Elder abuse and neglect End-of-life decisions Firearm injuries Food and drug tampering Forensic psychiatric clients Gang violence Human and animal bites Malpractice and/or negligence Motor vehicle trauma Occupation-related injuries Organ and tissue donation Personal injury Product liability Questioned death cases Sexual assault Sharp force injuries Substance abuse Transcultural medical practices Toxic exposure (environmental hazards) Victims of WMD and/or terrorism Abbreviations: BSA, body surface area; WMD, weapons of mass destruction. From Pasqualone G.10

The establishment of comprehensive policies and procedures in all EDs delineating the proper handling of evidence will help alleviate some evidence collection errors. Some of the more obvious types of evidence that the ED nurse can expect to encounter include bloody and/or torn clothing, bodily fluids, hair, fibers, glass from automotive collisions, gunshot residue, blood spatter patterns, and bite marks. The ED nurse must know to first collect evidence that is the most fragile or most likely to be lost, flushed, damaged, or destroyed with antibacterial solution including paint chips, dirt, blood splatter, and body fluids. Evidence specifically collected from a victim of sexual assault is packaged into special kits that are complete within themselves and contain step-by-step instructions for the nurse to follow. All collected evidence is turned over to the police who have jurisdiction where the assault or the crime occurred. The presentation of a gunshot wound to the ED creates a variety of problems for the nursing and medical staff including wound management and documentation, handling of patient’s clothing, and reporting the injury to the proper authorities. Of all injuries presenting to the ED, the reconstruction of this crime can be either faultless or entirely flawed, depending on the techniques utilized by the personnel to recognize, collect, and document the evidence. The character of a wound produced by a gunshot depends upon several factors, including the distance between the victim and the muzzle of the gun, the caliber and velocity of the bullet, the angle at which the bullet enters the body (if it does), (and) whether the bullet remains within the victim or passes completely through, exiting the body.11

Whether the bullet is extracted in the ED or in the operating room, it must be handled with rubber-tipped forceps, wrapped in gauze, and packaged according to correct protocol. It should then be immediately handed over to the police with attention focused on maintaining chain of custody. It is not appropriate for a bullet to go to the hospital’s pathology department. The bullet or bullet fragments are part

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The Forensic Nurse in the ED and Law Enforcement of a crime scene investigation and the police have the authority to claim these as evidence. Without evidence, even a heinous crime may go unpunished. That’s why protecting the scene and the evidence is of paramount importance. In fact, the care (or lack of it) that is taken in handling evidence directly impacts law enforcement’s ability to successfully investigate and prosecute a crime. Evidence may be damaged, contaminated, or even lost, thus rendered useless to the crime lab and probably inadmissible in court. Even the most expensively equipped and sophisticated crime lab has little use for damaged or altered evidence. Regardless of who actually gathers evidentiary materials, those people nevertheless need to be well schooled in proper techniques.11

Chain of custody Chain of custody is a legal concept that applies to the handling of evidence. It is also “a foundational principle in emergency care 12(p102) Because evidence can be used forensics.” in court to convict people of crimes, it must be handled in a scrupulously careful manner to avoid later allegations of tampering or misconduct. An identifiable person must always have the physical custody of a piece of evidence. In practice, this means that a nurse, police officer, or detective will take charge of a piece of evidence, document its collection, and hand it over to an evidence clerk for storage in a secure place. This transaction, and every succeeding transaction between the collection of the evidence and its appearance in court, should be thoroughly documented. Chain of custody guarantees the identity, integrity, and chronological history of the specimen from collection through to testimony at trial regarding its association to the crime. Physical evidence is the best foundation for proving a case. The criminal defense attorney will closely examine the chain of custody, looking for errors and omissions along the way and, if found, will file a suppression motion to have that evidence against his or her client excluded from the trial. All of the people having had custody or control of the evidence may be required to testify in court. This includes nurses, physicians, law enforce-

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ment, and laboratory personnel. Their records and any documentation regarding the handling of the evidence will be subpoenaed. If there are errors or omissions in the chain of custody, the defense may argue that it was negligence and may also suggest that the rest of the case was processed in a negligent fashion. The judge is the person who rules on whether evidence is admissible into a court case. Compromise and contamination issues are less likely to occur when good crime scene control and chain of custody procedures are followed. Documentation on the specimen may not be sufficient in and of itself. The clinician should record in the medical record, or on special forms designed for evidence collection, what time the evidence was collected, by whom and how, and what was done with the specimens. For example, an easily used phrase is, “specimen remained in my control, care, and custody until personally delivered to Officer _______, Badge No. ______, of the __________ (name of law enforcement agency).” Prepackaged kits, such as rape kits, blood alcohol kits, and urine drug screen kits may contain sufficient documen12(p103) tation for demonstrating chain of custody.

If a nurse makes a mistake with evidence, he or she should put it into his or her documentation and let the police know that there was a mistake or error made. It is easier to explain an honest mistake than to excuse dishonesty, which may appear to or perceived by the jury as intentional concealment of the truth (Table 2). HIPAA As the field of electronic discovery has matured, and to protect privacy and curtail privacy infringements, the federal government enacted the Health Insurance Portability and Accountability Act (HIPAA) in 1996. HIPAA’s medical privacy regulations govern the use and release of a patient’s personal health information, also known as “protected health information,” or PHI. The HIPAA statute imposes serious criminal restrictions on dissemination of certain PHI. The Department of

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Table 2. Chain of Custody

Health & Human Services adopted regulations implementing HIPAA that took effect in April 2003. All health care providers, including hospitals, physicians, and emergency medical or ambulance personnel, as well as health plans and health care clearing houses that transmit PHI in electronic form are considered “covered entities” or providers of medical services. Business associates of these entities, such as accountants, consultants, or attorneys, are also required to keep PHI confidential.

In the 1950s, some newspapers used to list every hospital admission within the community in their social sections, including the diagnosis and condition of the patient. Now, patients must sign a HIPAA form before even being admitted to the hospital, as well as one for every EMS call that is associated with transfers between health care facilities. The patient has the right to determine the amount of information to be given out and to whom it is to be given.

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The Forensic Nurse in the ED and Law Enforcement Police, firefighters, other law enforcement agencies, and family members are not considered covered entities under HIPAA. HIPAA does not extend to police incident reports, fire incident reports, court records, records of agencies that do not provide health care or insure health care, autopsy, or any other records that an individual has authorized to be disclosed. Because of strict health care HIPAA regulations, the police find it more and more difficult to get any information about victims, suspects, or perpetrators once they are admitted to the hospital. Police are often not able to verify the whereabouts of patients, despite the fact that they could be suspects wanted for murder. In one case, nurses refused to tell detectives whether a shooting victim was alive and said that even if he was, he could not be questioned without his family’s approval.13 HIPAA specifically refers to situations when “a covered entity may disclose protected health information for law enforcement purposes to a law enforcement official if the conditions in paragraphs (f)(1) through (f)(6) . . . are met, as applicable (HIPAA §164.512(f).” In addition to responding to a search warrant, health care personnel may disclose limited information for the identification and location of patients, victims, and/or suspects; in response to a law enforcement request concerning victims of a crime; death of an individual (if it is suspected that the death could have resulted from criminal activity); criminal activity on the premises of the hospital; and reporting crimes in an emergency (HIPAA, §164.512(f). HIPAA specifically allows hospitals to release information if police believe a crime has been committed. The most practical way to deal with HIPAA is to create a proactive, team-focused approach between hospitals, EDs, critical care areas, and law enforcement agencies. Setting the stage in advance, prior to a crisis, will expedite and enhance the relationship between all providers, police, and prosecutors. Health care provider and law enforcement communities must brainstorm solutions to combat the PHI disclosure restrictions. Ultimately, the

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development of standardized tools could reduce the problems current restrictions have created. Some of the tools should include educational flowcharts, tables and matrix outlining issues surrounding subpoenas, search warrants, requests for information, evidence in DUI/DWI (driving under the influence/ driving while intoxicated) cases, mandatory wound reports, and the relinquishing of evidence to the police.14 An agreement must also exist for situations regarding contraband in the ED. Patients may be in the ED for unrelated issues and have contraband on their person. Should the nurse confiscate it, destroy it, or lock it up? Should he or she call the police and if he or she does, should the police be told where the contraband originated? If the amount of illegal substances is large enough, the patient may be considered a dealer. To prevent any confusion or staff anxiety about how such situations must be handled, hospitals and law enforcement should work out an agreement that does not defy either HIPAA or state regulations. An important aspect to remember is that state laws supersede and prevail HIPAA regulations and, in some situations, be even more protective of patients’ privacy than HIPAA. For example, HIPAA allows health care personnel to disclose information to the police regarding domestic violence or abuse situations. In Massachusetts, confidentiality laws require permission from the victim before disclosing such information. HIPAA allows health care personnel to disclose information to the police if they are investigating a homicide and the suspect might be in the ED. In this circumstance, Massachusetts also allows disclosure because health care personnel, under Massachusetts General Law, must not harbor a criminal. As long as law enforcement presents a warrant, they can get any information they need. However, because the threat of liability is so great, most hospitals are choosing silence under the umbrella of HIPAA. This results in frustration on both sides and could be easily and effectively resolved with the implementation of detailed protocols.

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There are certain disclosures that are required, not just permitted, by law. These disclosures may be made without a patient authorization and must be limited to only the information required by the law including identification and location of a suspect of a crime, a fugitive, material witness, or missing person. However, the nurse may disclose only the following details: name and address, date and place of birth, social security number, ABO blood type and Rh factor, the type of injury, date and time of treatment, date and time of death, and a description of any distinguishing physical characteristics such as height, weight, gender, race, hair and eye color, and presence or absence of facial hair, scars, and tattoos (American Hospital Association HIPAA guidelines). The aforementioned information must be given only to those officials or police officers authorized to receive the information under the law. Disclosures required by law include deaths from suspicious circumstances and may be made to the chief law enforcement official and/or the chief medical examiner or coroner in the city/town where the death occurred. For example: r deaths caused by violence, homicide, or suicide or appear to be accidental; r death resulting from drowning; r death resulting from presence of drugs or poisons in the body; r death resulting from motor vehicle collision or the body was found in or near a roadway or railroad; r death occurred in the hospital with no previous medical history to explain the circumstances; r death occurred while the person was in police custody, a jail, or other penal institution; r death resulted from fire or explosion; r death of a minor indicating child abuse, maltreatment, and/or neglect prior to death; r death of minor and no prior medical history to explain the death; r human skeletal remains were recovered or an unidentified deceased person was discovered;

r death was due to criminal abortion; r manner of death was from other than natural causes; r death was sudden and unexplained; r death occurred at a work site; or r death occurred in the home.15 If the nurse has a reasonable cause to suspect that a child, younger than 18 years, has been abused or neglected, he or she may disclose the medical records related to the abuse to the local department of child welfare or social services as well as law enforcement officials. Such reporting is mandated by law in all 15 states. Abuse or neglect of the elderly and disabled/impaired adults is also a mandated reporting situation, as well as reasonable cause to suspect that an adult living in a long-term care facility has been abused or neglected. The only categories of patients whose abuse may be reported without their consent are children, the elderly, and certain classes of vulnerable adults. If a competent adult who has been abused does not consent to having his or her health information shared with law enforcement, you may not disclose it. Nurses must familiarize themselves with the state statutes regarding mandatory reporting of domestic violence or interpersonal violence. Consent from an adult to report such crimes may be either verbal or in writing. Intentional infliction of knife or gunshot wounds, animal and human bites, and communicable diseases are all mandated reporting situations. Court orders, warrants, and grand jury subpoenas authorize law enforcement to obtain whatever is specified in the documentation. If you are uncertain about the type of disclosure that can be made under one of these documents, contact the national HIPAA Office.16 In 2007, a Louisiana federal court judge ruled that HIPAA does not bar law enforcement from having access to patients who are victims of alleged crimes. In this situation, a hospital caseworker cited HIPAA in order to prevent law enforcement from having access to and questioning an alleged victim of interpersonal violence. The judge ruled that police

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The Forensic Nurse in the ED and Law Enforcement had the right to arrest a hospital caseworker and charge her with obstruction of justice when she tried to stop police from questioning a patient.17 Photodocumentation Many health care providers are under the misconception that photodocumentation of patients’ injuries will breach confidentiality. On the contrary, photographs are considered as much a part of the medical record as is written documentation. All types of documentation remains together within the medical record and does not get released to outside agencies unless subpoenaed by the legal system.18 An elderly woman was brought into the ED from a nursing home with vaginal bleeding of unknown origin. When the patient was prepped for catheterization, the nurse observed massive swelling, contusions and bruises in the patient’s perineal area. There were no other injuries on the woman’s body. Was this a result of anticoagulation therapy, or was this a situation of elder sexual abuse? The nurse wanted to photodocument the injuries and report her observations to Elder Services, but was discouraged from doing either by the resident on call. The resident was under the impression that photographing the woman’s injuries, because they were on her genitalia, would not only be an invasive process, but would also breach her confidentiality.10

The truth of the matter is that by not photographing the woman’s injuries, health care personnel are committing an injustice to this patient. Photodocumentation provides visual representation of injuries present during an episodic health care visit. With time, injuries heal and without such photodocumentation, the wounds will lose the impact for adjudication of this potentially abusive situation. As with all narrative notes, documentation of physical findings, clinical procedures, and diagrams of patient’s injuries, photographs are included in the medical record. If a patient is unable to give consent for photography, there is an implied consent, as treatable injuries are considered exigent evidence. In other words, evidence that will

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eventually vanish or be changed in appearance through healing or treatment is considered exigent and must be captured through photodocumentation to complete the record. A well thought-out policy must, therefore, be in effect for photodocumentation prior to the arrival of any forensic patient. Ideally, consent for photodocumentation should be included in the blanket permission to treat, signed upon entrance to any health care facility. As with any treatment generated in the ED, the patient always has the option of refusing or declining. If a patient does not want photographs taken of his or her injuries, he or she still has that right to refuse. There will come a day when hospitals and health care providers will be sued for not photographing the injuries because of trauma and/or violent crime. This will be an act of neglect on the part of the clinicians.10 The police have been photodocumenting for many years. Their photographs lend to their investigative process, though, and are unfortunately not considered part of the clinical medical record. The photographs taken by police and other first responders create the most accurate depiction of what transpired in a fatal auto collision. What is included in those photographs is mostly dependent upon scene documentation and evidence. The court system is not the only entity depending on the police and EMS for expert photodocumentation of a crime scene. In cases of serious, nonfatal injuries, the police and EMS provide ED trauma physicians and nurses with photographs of both victims and their vehicles. These health care specialists need to visualize both the damage to the vehicle and how the injured victim was positioned in the wreck so that they can assess for injuries that may not be obvious when patients arrive in the ED. Mechanism of injury facilitates the appropriate treatment, as well as detailing the documentation for potential litigation. Health care providers, especially those in the ED, are in the ideal situation for visualizing injuries, recognizing them as evidence, and preserving them for any future litigation. In effect, they are advocating for their patients. The knowledgeable public is becoming more

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and more aware of the fact that photographs provide a tremendous impact in the courtroom. It is the proactive hospital and the educated health care provider with a vision toward the future not only treats the patient but also protects his or her civil rights (Table 3). CONCLUSION In a landmark article published in 1991, Lynch19 referred to “the communication gap that exists between criminal justice agencies and health care institutions.” She stated that it “continues to confound the systematic, effi-

cient, effective, and substantive processing of incidents of trauma. This weakness creates serious consequences in the lives of affected citizens and threatens the legal rights of victims, witnesses, relatives, suspects, and professionals.” Today, the need has been identified to place forensically educated, APNs and clinical specialists into our hospitals, our nursing homes, our schools, our criminal justice system, and anywhere else in our communities where nurses can act as the liaisons between health care and the law. Nurses need to be prepared to enter into this career field as medicolegal consultants for attorneys, insurance

Table 3. Consent to Photograph

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The Forensic Nurse in the ED and Law Enforcement companies, law enforcement agencies, medical examiner and coroner systems, school departments, and hospital EDs. Although the contemporary media has portrayed the forensic scientist as a death-investigating Gil Grissom or Gary Sinese, able to solve a murder in less than an hour, one can now appreciate the comprehensive involvement of forensic nursing and its far-reaching influence with this science of the 21st century. Nurses in our nation’s EDs must collect both physical and communicative evidence from their patients on a daily basis. The nurses must also be more aware of protecting their patients’ human, civil, and constitutional rights. Nurses must never place themselves in the position that they are functioning as law enforcement agents; however, it is vital that the recognition, collection, preservation, integrity, and chain of custody of evidence are strictly maintained at all times.12 It is not within nursing’s realm to draw conclusions not supported by facts. It is certainly not within nursing’s realm to make judgments. However, it is well within the forensic nursing scope of practice to collect both facts and evidence. As the nation struggles with health care reform, the success of any organization will depend on its recognizing and utilizing the full potential of the forensic APN’s talents. The collaborative role between the ED nurse and law enforcement can be viewed as a simple metaphor, representing both sides of a swiftly flowing river. The river represents the patient. One bank of the river is health care and the other, criminal justice. The collaborative APN role is the bridge that spans the river, connecting the 2 banks for multiple mutual crossings. Nursing and law enforcement run parallel to each other, never meeting, except for the bridging across the river. None of the entities can accomplish its goal without benefit

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of the other. All working together accomplish more than merely the sum of the 3 parts. In 1998, the Emergency Nurses Association developed a position statement on forensic evidence collection, updated in 2010. The Emergency Nurses Association based it on the rationale that “an emergency nurse helps preserve the evidentiary material collected in the emergency department; collaborates with emergency physicians, social service, and law enforcement personnel to develop guidelines for forensic evidence collection, preservation and documentation in the emergency care setting; is familiar with the concepts and skills of evidence collection, written and photographic documentation, as well as testifying in legal proceedings.”20 The critical positioning of the forensic APN in a collaborative ED role can strengthen, amplify, and enhance both patient care and the patient’s perception of the quality of care. The forensic APN should be established as an integral component of the staffing patterns in the ED. There is a need to place clinical forensic APN specialists “24/7” into our hospitals, nursing homes, schools, criminal justice system, and anywhere else in our communities where nurses can act as the liaisons between medicine and the law.10 As purveyors of health, (we) must not only treat the havoc man heaps on man, but we must also try to prevent that which threatens our mass destruction. We cannot barricade and hide, we must act. We must serve as examples. We must educate ourselves and those around us. We must be willing to speak up. How can we accept less when we expect so much from ourselves? Difficult choices may have to be made. Sacrifice is in order. Are we willing to pay for what is right? Individually? As a society? Only through the efforts of us all, can change for the better actually happen. Awareness, courage, action, change. It is possible.21

REFERENCES 1. Rivers D. Public Agency Training Council. Investigation Procedures. Miami, FL: Metro-Dade Police Department; 2004.

2. Lynch V, Duval J. Evolution of Forensic Nursing Science. Forensic Nursing Science. 2nd ed. Mosby, MO: Elsevier; 2011:5.

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3. Maxey W. Cops and nurses. Partnership for safety. J Psychosoc Nurs. 2003;41(6):6-7. 4. Pyrek K. Cops and nurses: Making the personal and professional connection. Forensic Nurse, Volume October/September 2002. 5. Sullivan MK. Clinical forensic nursing: a higher standard of care. Forensic Nurse. 2002;1:8. 6. Cabelus N. A law enforcement career: my sliding door. Forensic Nurse. Volume October/September 2002:16-17. 7. Lee HC, ed. Physical Evidence. Enfield, CT: Magnani & McCormick; 1996. 8. Saferstein R. Criminalistics: An Introduction to Forensic Science. Upper Saddle River, NJ: Pearson, Prentice Hall; 2014. 9. James S, Nordby J. Forensic Science: An Introduction to Scientific and Investigative Techniques. Boca Raton, FL. CRC Press. Taylor & Francis Group; 2009. 10. Pasqualone G. Forensic categories among patients in the ED. Forensic Nurse. Volume March/April 2003:14-16. 11. Lyle D. Forensic for Dummies. Hoboken, NJ: Wiley Publishing, Inc.; 2004. 12. Lee NG. Legal Concepts and Issues in Emergency Care. Philadelphia, PA: W.B. Saunders; 2001. 13. NBC.com. Medical privacy laws frustrate police. http://msnbc.msn.com/id/3077101/. Published 2003. Accessed October 23, 2014.

14. U.S. Department of Health & Human Services. Health information privacy. http://www.hhs.gov/ ocr/privacy/. Published 2014. Accessed October 23, 2014. 15. Chenault V, Westbrook A. HIPAA for emergency department. http://hipaa.uams.edu/HIPAA%20for% 20Emergency%20Department.pdf. Published 2014. Accessed October 23, 2014. 16. CMS.gov. Centers for Medicare & Medicaid Services. HIPAA—general information. http://www.cms.gov/ Regulations-and-Guidance/HIPAA-AdministrativeSimplification/HIPAAGenInfo/index.html?redirect=/ hipaageninfo/. Published 2013. Accessed October 23, 2014. 17. Sorrel A. HIPAA allows police access to patients, federal judge rules. http://www.amednews.com/ article/20070521/government/305219980/7/. Published 2007. Accessed October 23, 2014. 18. Pasqualone G. Capturing more than the moment. Forensic Nurse. 2002;1(premier issue):36. 19. Lynch V. Forensic nursing in the emergency department: a new role for the 1990s. Crit Care Nurs Q. 1991;14(3):69-86. 20. Emergency Nurse Association. Forensic evidence collection. https://www.ena.org/SiteCollectionDocuments/ Position%20Statements/Forensic%20Evidence.pdf. Published 2010. Accessed October 23, 2014. 21. John M. Silent violence. Arch Otolaryngol Head Neck Surg. 1992;118(6):573.

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