When forensic nurse examiners work with survivors of violence -- sexual assault, child abuse, elder abuse or domestic assault -- they're painstakingly collecting and documenting evidence that can hold up in a potential court case. And they're taking care of a person who's just been traumatized, often by someone they know well. Forensic nursing takes a balance of objectivity, skill and compassion, and it's more than just a job for the professionals who do it.
Experts on the Stand
Whatever type of assault they've endured, survivors' first encounter with law enforcement or medicine "paves the way for their entire future," says Trisha Sheridan, a forensic nurse and clinical assistant professor at Texas A&M Health Science Center College of Nursing.
Victims face a higher risk of post-traumatic stress disorder, depression, suicide and medical problems in the aftermath, she says, and those who "have a positive experience with someone who's trained to deal with victims of violence" tend to not only have better legal outcomes, but better quality of life than others who receive standard emergency care. But in Texas, especially the more rural areas, forensic nurse examiners are few and far between.
Last year, Texas passed a law requiring emergency department nurses to undergo two hours of training in basic evidence collection, but that's far from enough, Sheridan says. And while most facilities "either have a specific room that's set aside in the ER or special private place for those patients," she says, "without a forensic program or a forensic nurse, it's just an ER bed."
While certified forensic nurse examiners undergo extensive skills training, Sheridan believes graduate programs can move forensic nurses to the next level, with a deeper understanding of the science behind the evidence they're collecting, helping them explain the pathology and ramification of victims' injuries in a courtroom. For instance, she says that information helped the jury "make a better-informed" decision when she testified in two recent cases of strangulation.
Taking On Domestic Violence
Strangulation is one of the most frequent injuries in domestic violence, yet symptoms are subtle and often downplayed, says Heidi Marcozzi, coordinator of the Intimate Partner Violence Program, started last year as a branch of District of Columbia Forensic Nurse Examiners, which also works with victims of sexual assault.
Forensic nurses look not only for bruises and scratches, but less obvious symptoms such as petechiae (small red or purple spots on the skin), voice changes, cough and headaches, Marcozzi says. They ask patients about loss of bowel and bladder function, which is a good indicator that they lost consciousness during the attack.
"Domestic violence is a huge issue" in the nation's capital, Marcozzi says. The program's 30 forensic nurses respond to these calls from MedStar Washington Hospital Center, anytime day or night. Within an hour of getting the call for a domestic violence case, the forensic nurse arrives at the hospital, where ER staff have already made sure the patient is in a quiet, private space rather than the waiting room.
Before the exam, the forensic nurse walks the patient through the whole process. "We see a fair amount of drug-facilitated sexual assaults, so we want to make sure it's very clear that the patient is able to consent," Marcozzi says. "Then we do a medical exam head to toe to make sure they're physically stable." Nurses pays close attention while patients describe the incident and use that account to guide where they collect evidence, including swabs that will later go to the crime lab for analysis.
The FNE photographs any injuries and examines the patient using a high-powered light source that can reveal hard-to-see signs like bruising. The light also helps the nurse locate "foreign secretions ... things will fluoresce under certain wavelengths -- semen, urine, saliva," Marcozzi says.
More Than Just a 'Rape Kit'
Victims of sexual assault go through essentially the same process, with the addition of a pelvic exam, which takes an additional 15 minutes or so. Examiners photograph the genitals for signs of injury, and then collect swabs as indicated. Treatment comes next. If appropriate, patients can receive Plan B emergency contraception to prevent unwanted pregnancy, or medications to protect against HIV and other prevalent sexually transmitted infections.
In sexual assault cases covered by DCFNE, an advocate with Network for Victim Recovery of DC accompanies the nurse to the hospital and helps patients with crisis management, discharge plans, crime victim's compensation and referrals for counseling.
Preventing the Worst
For domestic violence victims, the DCFNE program teams up with Survivors and Advocates for Empowerment, a nonprofit that provides advocacy and crisis intervention, and works to hold offenders accountable. SAFE runs the lethality assessment project for the District of Columbia -- trying to determine which victims are at highest risk for being killed by their abusers.
Advocates evaluate the victim's environment for cues -- such as whether the abuser has easy access to weapons, or even "if there's a child in the home who doesn't belong to him, which, believe it or not, increases the severity of the risk," says Natalia Marlow-Otero, SAFE director.
Of the 5,000 or so domestic violence cases SAFE sees each year, up to 1,900 are deemed high-lethality cases. Isolation is a "huge" factor among the women -- and some men -- who are victims of domestic violence. Isolation and abuse are even more prevalent among immigrant clients, Marlow-Otero says, so SAFE provides an English/Spanish helpline (1-866-962-5048). People can also call the National Domestic Violence Hotline at 1-800-799-7233 (1-800-799-SAFE).
Patients Before Police
Assault victims are not required to involve the legal system in their cases. "They have an absolute right to an exam whether they want to tell the police," Marcozzi says.
Sheridan says, "Yes, we want to collect the evidence if there's evidence to collect, we want to work with law enforcement, we want to successfully prosecute the perpetrator. But we don't work for law enforcement -- we're nurses first, and we're trained to treat the patient." In the District of Columbia, there's a 90-day window before an evidence kit is destroyed, although it won't be tested unless the patient decides to make a police report. In Texas, the kit will be held for at least two years.
Reclaiming Your Power
For some survivors, there's another intangible, but important benefit of requesting a forensic exam. "Sexual assault is specifically a crime of power, not sex," Sheridan says. "So if I can return any sense of control to that person, that's more important than anything else."
Marcozzi agrees that undergoing the exam can be empowering in itself. "For many people, it's the first step in their recovery," she says, "to know they were able to go through the process and start healing that way can be good for them."
On a personal level, Marcozzi says, the hardest thing about her job is leaving it behind. "When you hear the stories -- most of us are young women -- you can't help but be a little paranoid. Personally, it's increased my awareness of how I carry myself and interact with the world." In terms of safety advice, she says, "Pair up and look out for your friends is a good overall message."
For her part, Sheridan says that being raised along with three sisters by her mother, as well as seeing women receiving inadequate care after sexual assault, fueled her passion for forensic nursing. "It was a need," she says. "It changes your life. It's not something you go into saying 'yay' -- it's kind of like arming up for battle."