The Forensic Nurse

By Serita Stevens

A Traumatic Introduction
How one nurse stumbled into forensic nursing.

Anytown Hospital, 1979

The ER had finally calmed down after a hectic night.  Two codes and one motorcycle accident on the freeway were among the admits. Patients spilled out into the hallway.  Bad news, but not unusual considering they were just inside the inner city area. 

Belinda Wallis, one of the team leader ER nurses, stood looking at the chalk board that kept track of what patient was where and what tests had been ordered.  There was still one room occupied and nothing was written on it.  “What are we doing here?”

“Oh, I don’t know, “ another nurse came to stand by her.  “Donna,“ Belinda asked the ward clerk, “who’s in 4?”

“Just a sec.”  The over worked ward clerk was busy putting together the chart from the patient that the attending physician had just admitted to ICU.  “It’s uh...a Miss James.”

“But what’s her problem?”  Belinda wanted to know.  The quicker they got the patients moving, the quicker more could come in and from the looks of things this Saturday night, they would have plenty more.  “Are we drawing blood? Doing X-rays?  What?”  She asked.

The clerk flushed.  “Come read the chart yourself if you want to know, B.  I’m no doctor.”

Belinda walked over to the circular desk in the middle of the room.  “Miss James is a rape victim.  She’s been here for nearly three hours.  It doesn’t look like we’ve done a damn thing.” 

“Well, Christ,” the other nurse responded defensively, “it’s not like we’ve been twiddling our thumbs.  There were just a few dying patients in here, you know.  And it is just a rape.” 

Those few words changed the whole attitude of the room. Belinda rolled her eyes.  Despite the advent of the woman’s movement, rape was still thought of by many as a sexual “thing” rather than a violent act against women.  The victim was blamed for the attack because of what she said, the way she was dressed, where she walked and what she had done that evening. 

Even among nurses and other medical professionals, victims of violence, especially rape victims seemed to take second place.  Belinda had experienced is plenty of times, but today was different.

“Yeah, I know we’ve been swamped. I also know that a rape victim, in her own way, is as fragile as that drunken driver we treated.  Maybe more so.  She didn’t ask for violence.  He, at least, chose to drink.”  She flipped through the empty pages of the girl’s chart. 

Belinda realized she was just as much at fault.  She had heard the officer stroll in and yell, “Hey, we’ve got a rape here.  Who wants her?”

No one had said or done anything to tell him that his attitude did not help.

Belinda learned that the advocate had been beeped twice and not yet responded. 

“And what about the detectives.  Have they been notified?”

“Uh. Yeah.  They said they’d be along when they could.”  Donna replied in a hurt tone. 

Belinda sighed.  “Did Doctor P check her out to make sure there were no physical injuries?” Again, she looked at the blank sheets.

“Oh, yeah.  He asked me to page the OB on call.”

“And?”

“What are you, girl? A one woman rape crisis center?”

“No, I just think we need to take care of these victims, too.  I can’t believe we haven’t done anything for her yet.  I’m going in to check on her.  Please page the OB resident again, Donna. Tell him that I will report him to the Chief if he’s not here in 15 minutes.  Call the cops.  Tell them that they need to come and make a report NOW.  Please.”  Belinda made an effort to smile.  “And please call the advocate and tell her she, too, is needed immediately.”

“You act like you’re blaming us for not doing our jobs.  We’ve been a bit busy you know.” The other nurse stood to her own defense, repeating the obvious.

“Yes, we all have been, but we need to recognize these victims, too. Something different has to be done with them.  I’m not crazy about taking care of rape victims either.  I know that we see the victim and think, “There but for the Grace of G-d go I.”  She knew that many nurses were afraid that by taking care of rape victims they opened themselves up for attack and/or that they would assign blame to the victim and not be impartial.

“The fact is we are nurses.  We are supposed to take care of everyone who comes to the ER. “

Belinda was right. There was away to take care of rape victims.  Only she wasn’t sure what it was. 

Like others newly inventing the wheel, Belinda struggled to find some way to mesh her skills with the needs of the victims.  She talked to police; she talked to the rape advocates.  Belinda, like others, was interested in changing the system.

She saw, however, that as nurses, she and her colleagues often saw the patient first, doing triage before the doctors even got involved.  They were the ones who most often talked to the victim and the family, learning facts crucial to the case that the doctors and police were not told.  They saw things and were the first to recover evidence, only they didn’t know how to handle it.

Despite being a well-educated medical professional, she had no inkling that what she was doing in the emergency room was forensic nursing. 

Belinda, as you may have guessed, is not a real person, but she is based on one.  More importantly, she is a composite of the many men and women who make up the profession of forensic nurse.   Her story has been repeated over and over in many places across not only the United States but the globe. 

Many of the forensic nurses started out in the emergency room, as our Belinda did, believing that the victims were not being taken care of in the best possible manner.  Seeing the rights of the victims violated by the poor (or absent) collection of evidence and then compounded by sloppy documentation, the nurses discovered stymied cases and victims, who could not heal from their psychic wounds.  Belinda, and those she is modeled on, knew there just had to be a better way to do things. 

From the emergency room, many trained on their own.  Eventually they branched out and specialized in sexual assault, child abuse, domestic violence, elder abuse, death investigation, legal nurse consulting, working with mass disasters, prison and forensic psychiatry and combinations of the above. 

Virginia Lynch has been responsible for turning a great many heads and focusing their sights toward forensics.  The lecture she gave the night “Belinda” listened was on The Forensic Insight of Trauma Nursing.   It made Belinda sit up and mentally examine the patients that she had seen that very day.  Not only did she realize that her emergency room needed a SART (sexual assault response team), she also realized that they had to observe more carefully how and what type of evidence they collected even for the “common” pedestrian or traffic accident.  Anything that had the potential of being a lawsuit, of going to court, was a forensic case. 

Propelled forth by a combination of curiosity and a sense of justice, a sense of herself as the patient advocate, “Belinda” sought out further education in forensics. 

She was surprised that there were not many classes around…at least in her county.  A SART had been started up in Santa Cruz, California, and there were a few others scattered around the country, but they all cost time and money to attend. 

Armed with the need of her patients, convinced that this would be a better thing for her hospital; she sought to take advantage of the department’s education grant system.   She was shocked when the denial came.  Despite arguments with her supervisor and with the hospital administrators, they stood firm by their refusal not only to fund her tuition, but also to give her the time off so she could take the course.  They did not see the benefits to the community, the police, or most important to their own bottom line.

The doctors in the ER, she found out, were threatened, believing that Belinda and her kind would take away their cases and hit their pocket books.  They did not want to admit that a nurse might be better at something than they were and accused her of overstepping her bounds by wanting to do pelvic exams. 

Belinda tried to explain that they would not be doing pelvic exams as the doctors did, rather they would be looking for injury and documenting it in a way that the physicians were unaccustomed.  Most, especially those doctors who belonged to the “old boy” network (even some of the female doctors) were unable to let go of their power. 

Nevertheless, Belinda started reading on her own.  She signed up for a class in criminology at the local community college and began talking to the police detectives about how to collect the evidence and what would help them the most. 

When it came time for the annual International Association of Forensic Nurses to have their seminar, Belinda took vacation time and her own funds to learn the basics.   Here she was introduced to the theories of the SART (sexual assault response team), nurses as death investigators, legal nurses, child advocates, and others. 

Given a simplistic understanding of the exit and entrance wounds from gunshots, she realized that the ER doctor who had recently identified a bullet entrance had been wrong.  What he thought was an exit wound had perhaps been an entrance.  That turned the whole scenario around.  Horrified, she knew that his ill informed opinion would end up throwing the case to the defense, exonerating the suspect.  

As a nurse, Belinda had been trained to see the whole patient and to look at the entire situation.  She discovered that many MD’s suffer from tunnel vision, seeing things that were relevant only to their own specialties.

She learned about chain of custody – how she could not, once she had collected the evidence, sealed and signed with her name, leave it out of her sight until she handed it over to the officer for processing. 

She discovered the importance of photography in documenting abuse and trauma since the courts often insisted that photos be taken both with and without the forensic ruler as a guide.

Returning from her five days of intensive training, she was fired up with the idea of forensics.  She realized just how valuable it could be not only for the police and the lawyers but the community at large.  The harder she tried to convince people, the more she was rebuffed. 

On her off duty time, Belinda began talking to the District Attorney, the Chief of Police and even the mayor of their small city.  She circulated petitions and spoke with advocates, trying to create a ground swell grass roots organization.

Successful to a point, she found herself continually struggling for acknowledgement and fair pay for her new knowledge. 

            The cases you will read about are real, contributed by many of “Belinda’s” colleagues.  They will show you how forensic nurses work with other medical professionals, with police, attorneys, and DA’s.  They will show you how you, as a private individual, can benefit by having a forensic nurse working on your case. 

At the hospital she started to teach the others what she had learned, admitting all the while that there was a whole lot more she did not yet know.

Some were receptive; others felt that she should mind her own business. They did not want interference with “their” patients.

She tried to get a class going so that she could impart the knowledge she’d acquired, but it was an uphill battle.  Mostly the other staff were concerned not only with getting their jobs done and getting the patients moved out, but with the fact that if they got involved in the legal process, they might have to go to court.  They might have to get up on the stand and testify while the defense tore them apart limb by limb – fodder for the crowd of the Roman circus. 

Their comments were, “Let someone else do it.”  They were too afraid; they didn’t want to be made fools of; or they “didn’t have the time.”

Going into one of the ER rooms where a shooting victim was being taken care of, Belinda showed the nurse there the necessity of bagging each article of clothing individually in paper bags and not plastic.  Plastic, she informed the other nurse, erodes the evidence.  Each item had to be packaged alone so as not to contaminate the evidence that was there.  

She was frustrated to see that the next time, they did the same thing, throwing all the clothes together in one pile.  That case, whatever it was, would be a lot harder to prove.

When the next rape victim came in, however, she was assigned to the patient and was informed, halfway through her exam, that she needed to hurry because there were other patients, more critical patients, wanting her attention.  Belinda continued with her exam, but felt it was not as good as it could have been. She was disappointed, if not surprised, to find that the evidence she had collected had been contaminated by the next shift.  The case for that victim was lost. 

In an effort to make the hospital see just how valuable forensic nurses could be and how they really needed to train nurses in the art of forensic collection and to have them available 24/7 as a specialty, she began tracking the types of clients in the ER. 

Her mentor mentioned more than once that Joint Commission on Hospital Accreditation (the organization that certifies hospitals) had, itself suggested that forensic nurses be hired for all units of the hospital.  Getting the hospital CEO’s to understand the benefit in prevention and saved money from civil suits as well as the good will of the populace was another issue.