Gunshot wounds, stabbings, and drug overdoses are common here in this large metropolitan hospital. So is domestic violence, child abuse, elder abuse, traffic accidents and work related accidents, though they are not always recognized as such.

One victim, a walk-in patient, is a young woman in a blood-spattered dress with bruises covering her whole face and body. Her story: she fell down a staircase in her home.

The admitting physician, an intern, assisted by a nurse, interviews her briefly, examines her and orders X-rays. He finds no life-threatening injuries but does observe evidence of earlier abrasions and contusions. Visibly upset and nervous, the patient explains away these injuries by saying they were from household accidents, the most recent one happened when she tripped such as tripping over a child's toy.

At least a dozen patients wait for the doctor's attention. Ambulances bring in more. The intern treats the woman and discharges her. Has he, perhaps, under the pressure of a crushing caseload inadvertently released a victim of domestic violence without taking the appropriate follow-up?

Probably so. If the assisting nurse had been a forensic nurse, this would not have happened. According to different studies, between 20-50% of all emergency admits are a result of domestic violence. 20-30% of all murders are from a spouse or partner.

In fact, all of these patients in the emergency room have one thing in common. They are cases of forensic nurses.

Forensic challenges are faced by every nurse. The bulk of these challenges are presented by living patients. Because the nurse frequently is the first health care worker encountering living patients, successful arrest, prosecution or perpetrators or crime and violence may depend on the nurse's recognition of the problem and documentation.

Any time a nurse treats a victim or suspect of criminal acts, the survivor of a catastrophic accident or any liability related bodily injury (living or dead) she is involved with a forensic case that requires investigation.

Ignorance of problems and ignorance of what data means and of what evidence needs collecting have resulted in the inability to prosecute perpetrators of abuse and violence. They are permitted to continue and even escalate their acts.

The sad fact is most doctors and nurses do not know anything about collecting evidence. The doctors have been trained to look for disease but not for injury and trauma resulting from rape. They know nothing about the collection of data or how to properly preserve it.

Who is the forensic nurse? She is the new detective on the block. Not the fictional Cherry Ames, she is law enforcement's secret weapon.

Increasingly more valuable in the investigation of crimes, the nurse, more specifically the forensic nurse, is a unique combination of law, nursing and criminalistics.

The term itself is relatively new. But forensic nursing has been around for centuries, it is only now being recognized as a nursing/legal specialty. Recognized by the American Association of Nurses in 1996 it has quickly become one of the fastest growing specialties.

Briefly put, the forensic nurse links the health care profession to the criminal justice system providing her unique expertise where the victim or perpetrator has the first contact after the crime: a hospital.

Taught to maintain a high degree of suspicion, skilled in forensic techniques as identification of injuries consistent with weapons, interviewing victims and collecting and preserving evidence, she is a liaison with the police and medical examiner. Often, later she serves as an effective expert witness.

There has always been forensic nursing only it was never acknowledged as such. From the moment we student nurses entered school we were warned that anything we did or said involving the patient could wind up in court. Back then few of us nursing students sought out court as an avocation. In fact, we were petrified of being called on the stand and questioned about our abilities and our competence.

Many of us are so fearful of being called to the stand, of being chewed up and spit out by the defense attorneys questioning our very breathing that we avoid getting involved. We look the other way even when the evidence is screaming at us.

Getting involved means listening to the patient, something, that despite our training as medical professionals many us do not. If a victim says that the perp kissed her breast than that means we need to look for evidence there.

Even now, only a lucky few of us get training in courtroom tactics or have a DA who will go ov

er the case with us so that our testimony is understood. And if the victim, perhaps an elderly person, afraid of being sent to a nursing home and so chooses to put with the violence, does not complain, how much harder is our job at listening to their silent language.

No one when I was in nursing school and very few even now have any training as to what forensic care means or how we as forensic nurses can put an end to some of the violence plaguing society.

As a child I had been an avid reader of Cherry Ames, student nurse, camp nurse, cruise nurse, etc. Cherry had solved crimes in the course of her nursing duties and that was exactly what I had wanted to do. So I entered nursing school, but after nearly 25 years of flittering from nursing specialty to specialty, I had helped a lot of patients, but solved very few crimes except that of inept or poor quality medical care.

The ad for the "Bone Collector," a movie had Denzel Washington convincing a cop that she had to do forensic work. Not so long ago I would have thought nothing wrong with that statement. Now I knew it was redundant. After all, anything a police officer, one who does law enforcement, is forensic since the definition of the word forensic is "anything to do with the legal system." But few people realize this.

Growing up with TV's popular Quincy, like many, I assumed the word forensic meant death or working with death since Dr. Quincy had been a forensic pathologist. The forensic world encompasses not only medicine but also nursing, dentistry, anthropology, archeology, chemistry, and many other disciplines�anything, in fact, that might be called in on a legal case.

Forensic cases include the living as well as the dead. Victims of rape, abuse, and trauma as well as relatives and friends of the dead are the living/clinical forensic cases.

Today, victims of violence and trauma occupy 1:8 hospital beds. Daily 16,000 violent crim

es are committed or attempted in the United States. (Reiss, 1993). Stumbling onto a web address, "SleuthRN", I questioned the owner what that meant.

"SleuthRN", aka Sondra Goldstein, a sexual assault nurse examiner (SANE) in the Santa Cruz area directed me to the International Association of Forensic Nurses (IAFN.)

Attending their third Scientific Assembly in Louisville, Kentucky, I heard distinguished speakers such as doctors Henry Lee, Michael Baden, Patrick Beasant Matthews and James Starr. I learned what forensic meant as it applied to everything-- including nursing.

These specialized nurses fill a void that historically existed in the emergency room where the doctors had little or no forensic training.

With training, even I could become Cherry Ames alter ego.

In 1976 the first SANE program was developed as a multi-disciplinary victim centered response to sexual assault. Like most infants, it struggled to survive and find its place in society and had plenty of growing pains.

In 1991 when the Journal of Emergency Nursing first published it's list of SANE programs, there were only 20 identified.

Today, there are over 117 programs in the US and Canada but not nearly enough to serve the hundreds of thousands of children and adults raped or assaulted each year.

The organization, IAFN (International Association of Forensic Nurses) which brings forensic nurses together with pathologists, criminologists, and others who can help us perfect our skills is only a few years old but now has already over a thousand members and growing daily.

Founded in 1992 by 74 pioneers, spearheaded by Linda Ledray, Ph.D., who started the Minneapolis SART, it was an exploration into unknown territory. Linda had been writing about sexual assault exams for the Journal of Emergency Nursing. She wanted to discover who else was out there doing sexual assault exams and how they were doing them. What successes they had, what failures and why? The only way to grow was to learn from one another as a community.

Meeting in Minneapolis the summer of 1992, the 74 nurses compared notes of how they worked. The majority of those attending considered themselves SANE nurses since they did rape exams of both the victim and the perpetrators.

Many who attended found themselves being renewed and rejuvenated in their passion for justice, their desire for seeing the victims properly taken care of and held hands through the judicial system. One nurse described, "It was like finding your long lost best friend."

Like the invention of the wheel, different groups in different states had come up with the best way, they thought, for examining rape and other victims of trauma. Each had found their own way despite numerous obstacles because they believed with all their hearts that there was a better way to help victims and survivors.

Other pioneering nurses braved the "old-boy network", stumbling and pushing forward with the courage of Florence Nightingale. They entered the realm of death investigation as nurse coroners or deputy coroners and proved themselves to their male colleagues. In Wisconsin and in Texas nurses fought to use their medical-legal skills to assist the survivors of trauma as well as investigation of deaths.

Still a third major group dueled the Bar Associations to become accepted as nurse-attorneys or legal nurse consultants.

No matter what hyphen they put after their nursing degrees all of them remained nurses. They found that they looked at rape, death, trauma and law from a unique nursing problem solving perspective.

It didn't take long to realize that as nurses, our abilities and skills could help the victims in ways law enforcement had never contemplated.

The body of the crime, the corpus delicti, is often the body, itself. The body is the crime scene and needs to be treated as such.

Those victims that manage to come to the ER will often do so before talking to the police. Some don't even comprehend that a crime has been committed on them. Some are too young or too infirmed to understand.

Since nurses staff the emergency rooms, it is the nurse who will first come into contact with the victim and assess what is going on. She is also the first to talk to the family of the victim.

Crime victims and other forensic cases compromise the majority of the urgent care patients. Besides rape and death, these can include workman's compensation, accident liability, child abuse, elder abuse, domestic violence, food and drug tampering, environmental hazard contamination, automobile accidents, survivors of attempted suicide. One of the oldest areas of forensic nursing is forensic psychiatry (working with those who have been declared not guilty by reason of insanity) and jail nurses.

"There isn't a department in the hospital that doesn't come into contact with forensic victims," says Virginia Lynch, former IAFN president. "It's up to the forensic nurse to identify what is going on, to listen to the silent language and put the pieces of the puzzle together."

Children, for example, are not going to come in and identify themselves as crime victims. Yet a large number are admitted to the ER as victims of abuse or neglect. You can't expect the parent to identify the child as a victim. In most cases, the parent is the perpetrator.

Battered women are either too embarrassed or intimidated to admit that the person they believe they love is beating them.

The same is true for the elderly who are infirmed and being abused. They fear retaliation by their caretakers who are mostly family. Yet many would prefer to remain abused rather than being put in a long-term care facility.

In order to see and properly listen to the silent language of these victims, we have to believe that something might have actually occurred because we can just as easily put our blinders on and look passed what to someone else who has chosen to believe might seem obvious.

As a result of our lacking forensic expertise and the loss of evidence, we received constant criticism from law enforcement officials and crime labs. Virginia Lynch was determined to do something about this.

"I went to the local crime lab," she continued, "to find out what we could do to better protect the patient's legal rights and properly preserve evidence. Inside the lab, the door of forensic science opened. I realized the tremendous void between the health and justice systems.

"I saw how victims were often treated in a less than empathic manner both by law officials and health care professionals who due to time constraints or lack of necessary skills felt uncomfortable with the emotional trauma surrounding crime victims as well as their family."

She was determined to add that human touch with crisis intervention and grief counseling, a major component of recovery, that only a nurse could add and only one that was especially skilled in the art of forensic investigation.

Virginia Lynch served as first president of the budding organization. Soon this nurse-death investigator turned into a PR whiz marketing the concept of forensic nursing around the world. Because of Virginia's charisma, word of the new specialty spread around the globe. Not only to Canada but also to England, Japan, Africa, and South Africa, whose rate of murder is one the highest in the world. The Caribbean, Central America and Singapore joined the forensic nursing family and even Russia was included.

Law enforcement took some notice but not enough. Our services and resources were still underused.

Word spread. Changes continued but slowly. More and more the art of forensic nursing was accepted in the major cities. Still battles had to be fought. Turf wars broke out. Just so many little skirmishes here and there, many times without logical reasoning behind them�many times misguided or misunderstood myths fueling the fires.

The hospital administrators had difficulty budgeting money to fund the SART (sexual assault response team) clinic. Skilled forensic nurses were not paid at all, or poorly paid for call time. Often only one or two nurses served the 24-hour on call status for a whole community. Standard accepted equipment was often not supplied. Many hospitals did not see the need to have the SART clinic in an area separated from the emergency room.

This meant the rape victims had to sit in the waiting room for the police or advocate or SANE to arrive. During this time she would be ogled by the other patrons and staff. Often not triaged as being medically unstable, she would have to wait hours and hours before she could be seen.

The nurses, though skilled in forensics, often had to work both general hospital jobs and the sexual assault teams. Money was a problem. Few of the SART teams could afford a full time nurse. Many of the nurses worked two and three jobs to keep their passion for justice fed. But money was not the only difficulty.

Despite their training very few were awarded full time positions for their efforts. Some days they would go from a 3-11 p.m. shift back into one or even two middle of the night rape exams and then back to work once more. Weeks would pass without a single day off. Many burned out.

In the trauma center nurse-managers and fellow staff became irate when the SANE left them with "her patients" to perform a time consuming forensic exam. In a hectic center where it was "band-aide, shot, and thank you Ma'am," an exam that took upwards of four to eight hours to complete, including evidence collection, was not well accepted. Equally irritating was that the SANE had to be scheduled off for court time but at whose expense? And then even she had to go back because they had not yet called her in or they wanted to continue their questioning of the nurse.

Who was to fund the SART stations? Hospitals trying to make a profit, but who saw a loss? Or law enforcement? Some centers found funds from the Violence Against Women (VAW) Project. Others received grants from the Department of Justice. Even then it was seldom enough for the state-of-the-art equipment needed and to pay the nurses for their time.

Doctors became upset when the nurses had the audacity to do pelvic exams or use the colopscope on their own. The nurse's standards of practice was called into play. In Arizona and Kentucky, the forensic nurses are just beginning a new phase of their battle to do the exams, which the doctors did not want to do in the first place.

The colposcope, an instrument originally used for magnification of cells to identify vulvae cancer, was later found useful as a weapon in photographing child abuse injuries. But the medical establishment had yet to use the colposcope as standard practice on adult victims of sexual assault for differentiating forced sexual contact with consensual sex.

The medical practitioners had been taught to see signs and symptoms of diseases, and to differentiate from the norm but they had not learned to identify patterned injuries or distinguish blunt from sharp force trauma.

It was assumed that doctors, because they had gone to medical school, could treat trauma. They could. But very few of them understood the difference that forensic trauma treatment required. Their education neglected identifying wound patterns, sexual injuries, and collection of evidence that could be used in court. Lacking proficiency, the doctors often feared being called into court and questioned by a hostile defense attorney attacking them on their lack of training and/or experience. Many refused to perform the medical evidence exam. And many doctors, while flattered at being called expert witnesses, were not.

Doctors became upset when nurses, not working for their hospital, were called in to do the rape exams. Yet they were relieved that they did not have to deal with the courts.

The average ER doctor has no training or skills when it comes to doing a forensic exam or collecting evidence. In fact, often doctors and untrained nurses, in an effort to help the patient throw away or destroy evidence without understanding what they are doing.

It's not that the doctors purposely discard the evidence but overwhelmed with the sheer number of cases especially in the major trauma centers they often did not have time to stop and think about collection and preserving evidence like clothing, body fluids and trace materials.

Medical and nursing schools in the United States and elsewhere simply do not teach forensic medicine. Sometimes the students can take it as an elective. Mostly, it's not even available.

Frequently, fear of an inadvertent violation of the patient's confidentiality or constitutional rights will prevent evidence from being reported or recovered.

Even when it comes to death investigations nurses are indispensable. While its true pathologists make great coroners and medical examiners, there just aren't enough of them around any more. There are fewer than 400 certified forensic pathologists in the United States and only a fraction of these are willing to do the work of the medical examiner.

Seeing the lack, many agencies turned to the nurses who, because they understood the functioning of the body, could make swifter determinations of natural vs unnatural deaths. They could tell if the medications a patient had taken had hastened their death or had something to do with it; they knew when something looked suspicious and when it did not. Almost as important, they knew how to help the real victims�the survivors who were left behind to grieve.

This is something Dr. John Butts, former chief medical examiner of Edmonton, Calgary, Alberta, Canada found out. As a result Alberta's nurses and now Nova Scotia's nurses, since Dr. Butts relocated there, are hired as death investigators. But not all of Canada has wised up. Neither has the States.

Within the United States, only a handful of the medical examiners have made the same discovery. Those that did prefer to hire nurses to work as their investigators trusting their instincts to help with the investigations and crime scene reports.

Many police, district attorneys, prosecutors and judges did not know how to use this new weapon. In court, they still turned to doctors as experts rather than the nurses who had taken additional training and were skilled in forensic exams.

The courts neglected nurses who had actually seen the wounds and could correctly identified them. They turned to the standby doctor who had probably never before seen an entrance or exit of a bullet wound. Making his judgment on something he did not understand, the doctor's verdict often altered a whole trial.

Seeing only the stereotype of the nurse and the bedpan, the courts forgot that the nurse, who has always been the liaison between the doctor and the public, is a skilled translator of medicalese. Patient teaching is one of the basic nursing skills. As a by product of their nursing education, they know how to educate and persuade a jury, talking to the jury in their own language not medical jargon.

Moreover, the public, itself, unaware of the forensic nurse's potential in helping fight crime did not seek out SANE nurses neither did they know how to use the resources the forensic nurse had, which would have made their recovery from trauma and grief so much easier.

Nurses, being taught to use their knowledge and skills to treat the whole person and to see the whole picture, often found themselves working as the resource person or center wheel spoke pulling together the various disciplines or puzzle pieces to help the victims of trauma heal.

It is the nurse who is at the forefront of trauma treatment and death investigation. She sees the victims as they flood the emergency rooms seeking help for their wounds and ills. Not only does she work in the ER doing rape and wound exams but also she attends crime scenes as an adjunct to the medical examiner. She investigates the unnatural deaths, works as a triage person with the paramedics, as a consultant to lawyers and district attorneys both in criminal and civil cases, as a nurse attorney, herself, or as an expert witness.

Often it is the nurse who photographs the evidence and notes the wound patterns.

Working as a police liaison, she is often the first to see child abuse and domestic violence.

Assisting with mass tragedies and fatalities forensic nurses as members of the DMET (disaster medical emergency team) assist not only with overwhelmed medical resources but also in identifying pieces of bodies from crashes and hurricanes.

Armed with the knowledge of wounds, ballistics, rape examinations and more, nurses in forensics have increased the apprehension of rapists and killers. Her observations have freed those falsely accused. The nurse has been used as expert witnesses, uncovered fraud, investigated accidents both work related and vehicular and in teamwork with the police solved many cases of unnatural or suspected deaths.

Another group of forensic nursing specialists work in prisons and jails.

More than 80% of the rapes where a SANE is involved have been successfully prosecuted.

Who is the forensic nurse? She is any nurse who cares enough to be aware of both the medical and legal side of the exam; she is someone with a passion for justice, someone who likes making a difference in people's lives.

Rampant violence and its consequences has been and is a public health problem that needs addressing. An effective answer to violence in America and the world at large needs to include many disciplines. Nursing is just one of them who seeks solutions to the problem.

The motto of IAFN is Nursing "Beyond tradition�" We forensic nurses are no longer the bedpan pushers our mother Florence Nightingale was. While we still hold the patient's hand, and we are concerned about the psychosocial aspect of the events the patient/victim is going through, we can also help go beyond tradition and put a stop to the violence.

Working together, nurses, doctors, law, science and the public, we can make a difference in our lives and in our society.

This book is written not only for other nurses who might want to pursue forensics in their careers, but it is also for the doctors and other medical professionals to understand who we are and what we do and how they can learn forensic skills. As a team we can accomplish so much more.

In recent months, forensic nursing has been clouded with misunderstandings. Our scope of practice has been questioned more than it has in the twenty-five years since the sexual assault teams began.

We need to have a forensic nurse on all State Boards of Nursing so that our evaluation of victims, our doing exams with speculums and our use of the colposcope to find evidence is not questioned.

It is for the law enforcement officers and courts to know what we can do so that they can use our skills to win their cases and get the perpetrators off the streets.

As forensic nurses, we are advocates not for the patient but for justice. We are witnesses only for justice.

Our work as forensic nurses focused on a variety of issues such as domestic violence, sexual assault, homicide, death investigations, child death review, child abuse, civil rights, workman's comp, vehicular injuries, elder abuse and neglect�to name a few.

And it is for you, the public. Should trauma, death or sexual assault happen to you or someone you know, you will be aware of what the forensic nurse can do to aid you and to bring closure to your situation.

Most members of juries, even though they are intelligent men and women, have very little knowledge of what a sexual assault nurse examiner does and how different she is from the nurse with the lamp who changes the bed pans and wipes the sweat with the towel. They do not know how nurses are being used in rape cases, homicide and natural death cases, in workman's comp and other legal cases because we have not told them.

It's not easy being a forensic nurse but for the nurses in this book the hardest part is seeing the victims failed by the system.

This book will, hopefully, give you information to help you change this. Many of my friends and colleagues in forensic nursing have contributed cases to this book and to the interview material.

While the facts are consistent, because of legal and ethical considerations, names, locations and minor details have been changed. Some of it might read like fiction but it's not. The most important facts are there. The passion with which these nurses work has not and never will change.

Join us, help us, in defeating the violence. Let us make this a society we can be proud of.

To further the efforts of forensic nursing, a portion of the proceeds from this book will be given to the IAFN for research.

A glossary at the back makes an effort to fill in for those reading this that lack the medical knowledge.

Because most nurses are female the pronoun "She" is used commonly throughout the book though there are both male victims and male nurses.
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