Minutia matters Since the program's inception, about 60 nurses have participated. The four-hour class is held, on average, three times a month,
with the dates determined by the ME's schedule. Usually eight slots per class are open to nurses throughout the Memorial Healthcare
System. "Only so much physical room is available," Rice said. "But if someone calls me with a special request—like a major
upcoming OR case for which a nurse wishes to prep, or a post debriefing that allows closure—then I might make an exception."
While there is a great deal to consider in such cases, Cina made sure the course covered some of the more critical points.
"Nurses and EMS personnel often see patients in the most pristine state with respect to trace evidence. Potentially everything
about the person, from head to toe, has forensic value, which is why bodies should never be cleaned prior to transport to
the morgue. And although there is a temptation to remove tubes and lines before the family views their loved one, such actions
limit our ability to assess the efficacy of care and to rule out the possibility of iatrogenic artifacts. "For example, we need to know if a person has been esophageally intubated, but we cannot determine this if the ET tube has
been removed. Or, we need to know how many venipuncture attempts were made in order to find extra ones that may be related
to IV drug abuse. Additionally, any sites of injury need to be documented and relayed to the ME because medical intervention
can alter injuries. A thoracotomy incision, for instance, may inadvertently distort a stab wound." He noted, "Injuries should
be indicated on a body diagram. We realize it might be difficult to provide exact details while trying to save a life, so
generic descriptions may be appropriate." Careful preservation of blood, fluids, or other samples must also take place. "Biological evidence extracted by staff could
be extremely valuable," advised Cina. "We use urine for drug screens, preferably the very first sample taken. Similarly, we
want all blood available, including any sent to the laboratory for testing, even if the patient expires shortly after admission."
"If patients have to be volumized by IV fluids," added Rice, "then their blood is diluted and the medical examiner cannot
obtain accurate blood concentrations of toxins. Instructing the lab to hold onto the admitting specimens for the ME's office
could positively affect any investigation." Immediate application Kelley Feigen, RN, BSN, an administrative supervisor at sister facility Memorial Regional Hospital South, volunteered for
the forensic nursing class in April and almost immediately recognized where her department could make improvements in its
policies and procedures. "When we have ME cases, it is often my decision as to what we do with the patient," she said. "In the hectic pace of treating
patients, it is easy to lose track of who is touching this or touching that. Now I know to make sure everyone is following
the correct actions on the forensic level, so the medical examiners can do their job more effectively. "I already have spoken with my nurse educator about holding an in-service class on ways we can improve our procedures," Feigen
continued. "For example, I never realized how important it was to place paper bags, not plastic, on patients' hands to protect
potential evidence." Added Stibal, "These learning opportunities have given the nurses a new perspective on how to handle
forensic evidence and prepare them for one more challenge they will most likely face in their nursing careers."
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