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CSI: Penn Medicine?

Forensic NursingRhonda Browning doesn’t play a forensics expert on TV, but she is training to be one in real life.

With the proliferation of crime dramas like Law & Order SVU, NCIS, and the CSI franchise, forensics has become a big topic – people are interested in it, self-declared Sherlocks around the world are joining in to solve real-life cold cases, and some people, like Browning, are seizing opportunities for professional development.

Browning is the Trauma Outpatient & Injury Prevention Coordinator at Penn Presbyterian Medical Center and, for the past three has been working toward earning a Master’s degree in Forensic Nursing from Duquesne University.

Forensic nursing is a subspecialty of trauma nursing and, like all trauma nurses, describes the role forensic nurses play as helping to “investigate crimes like sexual and physical assault, and accidental death. They are trained in medical evidence collection and the criminal justice system.” But unlike trauma nurses, the forensic nurse is specially trained in the legal aspects of criminal investigations, as well.

“Forensic nursing is the bridge between the legal and medical aspects of trauma care, so whenever there's something that may have a legal aspect to it, that's where this comes in,” said Browning, who is also certified in trauma and emergency nursing, will earn her advanced degree in June 2017. “A specialized degree will allow me to teach forensic nursing to the other nurses, and also teach classes at the police academies – specifically teaching law enforcement about the processes we have in place to ensure preservation of evidence that could aid in a criminal investigation.”

Trauma nurses (and forensic nurses, by extension) are charged with caring for patients who in many ways are more vulnerable than the average patient who arrives at the Emergency Department with an illness or injury. These patients may be the victims of assault, rape, gun violence, or another type of violent crime that requires special care to make them feel respected and protected. While all trauma nurses receive specialty training in treating patients who are victims (or perpetrators) of trauma – including evidence collection and preservation – the forensic nurse will more often provide medical testimony in court, consult with legal authorities, and receive explicit training in processes like injury documentation.

Documenting injuries is a critical part of a trauma nurse’s role. “If a patient is brought to the trauma bay with a gunshot wound (GSW), but also has a broken hand or a bruised face, we would document all those other injuries because they may have gotten in a fight, or maybe they jumped out a window. We have to document all injuries because details that like that can be critical in a police investigation,” Browning explains.

Beyond taking notes and reporting about injuries in a way that is, as Sgt. Joe Friday would say, “just the facts, ma’am,” trauma and forensic nurses rely on tried and true methods of evidence collection and preservation.

“Medical care always comes first – in everything we do, our focus is always on caring for the patient, and saving lives, but we are also cognizant of preserving evidence,” explains Janet McMaster, RN, Outpatient Practice Coordinator for Penn Medicine’s Trauma Program. “In some cases, victims of violent crime may have DNA on their body or clothes that would identify the perpetrator. But, when the patient is critically injured, their care needs to take precedent, even if that means sacrificing possible evidence. Whenever possible, we do what we can to both treat the patient, and preserve possible evidence.

McMaster explains that when a patient comes in with a gunshot wound, for example, immediately the care team is looking for holes in their clothing to help identify injuries. To treat the patients as quickly as possible, clothes are cut off. But, if there’s a hole in a shirt, the team cuts around it (never through it) because forensic investigators can tell things about the weapon by the shape of the hole. However, McMaster says “that's not for us to decide – that goes on to the police.”

And while one person is cutting around a hole in a shirt, someone else is taping paper clips on the injuries. Yes, when minutes matter and care teams are working to assess patients and save lives, the paper clip is a vital part of the process.

“It's very tricky to figure out trajectory, but we need to figure out what the bullet hit,” McMaster says. “It’s a very specific and well-oiled process – a hole on the front of the body gets a paper clip, and a hole on the back gets an opened paper clip, because on an x-ray you can't tell a patient’s front from back, it's just 2D.”

Paper clips_with labels

Not only do the trusty paper clips help identify internal injury, but also what might be missing. For example, Browning explains that in the example above, the x-ray shows one closed paper clip, one opened paper clip (indicating a hole in both the front and back), and two bullets. In this case, the team would know right away that something’s amiss. Two holes indicates a bullet entered and exited the body – there would need to be two more holes to pair with the bullets still present in the patient’s body. One possibility is that the bullets were leftover from previous gunshot wounds; unless easily accessible or causing harm, many times surgeons will leave bullets in place rather than risk further complication in surgery.

Bullets, clothes, and other evidence from trauma victims are also processed and protected in specific ways to ensure a “chain of custody.”

“When we retrieve a bullet, it's really important that we don't tamper with it, because if you grab it with a metal instrument, you're going to change it, or scratch it. We have special rubber forceps to grab it so we don't scratch it,” McMaster said. “There’s also a special chain of custody for bullets, drugs, drug paraphernalia, or other weapons – bullets go in a special cup that gets labeled and goes to security; clothes are placed into individual bags so any evidence such as gun residue or DNA won’t, for example, rub off of a shirt and onto a pair of pants. Everyone who touches evidence has to sign off because we have to make sure the chain of custody goes from the evidence, to security, to the police, so there's no chance that anybody tampered with it.”

In the case of patients who die from their injuries, special procedures are also followed to make sure evidence on the body is preserved. “If a patient was shot, we have to place paper bags on their hands because, we don't know, maybe they shot someone too, in which case there could be gunshot residue on their hands.”

Forensic nurses use paper bags – not so far off from the type used to pack lunches -- to preserve possible evidence because plastic makes the body sweat, which would cause residue to “wash off” or deteriorate.

Now, when you think evidence collection and preservation, you probably wouldn’t think it has anything to do with the patient’s family, but, managing the family of a deceased trauma patient is in fact another specific - and understandably tricky – part of a forensic nurse’s role.

“We have families that come in absolutely devastated, who want answers. But, we never really know the perpetrator was, or who might be a suspect – for all we know, that person could be in the waiting room, so we have to keep things separate, but also give these families information,” Browning explained. “It’s also very important that we provide an opportunity for the family to see and visit with their loved one in a way that won’t contaminate evidence. We're not going to put a piece of yellow tape around the body and say they can't see their loved one -- we have to do this with sensitivity. We want to make sure they're allowed to see their loved one because it's an important part of the grieving process, but we also need to preserve evidence.”

Paper clipping bullet holes, cutting clothes, and dealing with distraught family members might not sound like tasks that require highly-specialized training, but these examples merely scratch the surface of the intricacies involved in being a nurse who treats patients who’ve been involved in violent crimes.

“It's a specialized field that is continuing to evolve as more people become interested in the process,” Browning said. “Forensics is an extension of trauma nursing, and both areas are seeing a boom right now. A lot of nurses are really getting into it, I think because of how popular all the forensic TV shows are, but also because there’s an added level of involvement in the patient cases – we’re not just caring for them; we’re a part of the larger investigative team.”

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