FORENSIC MEDICAL ASSESSMENT

When a patient presents to the emergency department and reports being sexually assaulted, medical treatment always takes precedence over evidence collection. All patients are first evaluated for pain, bleeding, and safety. The CDC also recommends baseline testing of patients who may have been sexually assaulted for sexually transmitted infections (STIs) and pregnancy. Any patient who reports being strangled or who has sustained a head injury should be seen by a physician prior to or while collecting evidence (U.S. DOJ, 2013; Texas A&M, 2019).

The forensic medical exam consists of obtaining the history; a physical assessment; and collection of potential biological, physical, or trace evidence.

Patient History

The nurse explains to the patient that the history is intended to document what happened in order to offer appropriate treatment and to determine what parts of the body to collect evidence from. For adolescent or adult patients, the examiner asks them to describe what happened from just before the sexual assault occurred to when they arrived at the facility. For prepubertal children, the nurse avoids extensive interviewing if not a trained sexual assault nurse examiner, specially trained medical forensic professional, or specially trained forensic physician.

Physical Assessment

The forensic medical assessment includes assessing and documenting any injuries that may have resulted from blunt or penetrative trauma, suction, bites, cuts, lacerations, abrasions, burns, bruises, or contusions. It is important to use the correct term when documenting findings. Common terms as described in the Texas Evidence Collection Protocol include:

• Abrasion: Scraping type of injury that is superficial damage to skin or mucous membrane
• Bruise: Bleeding beneath the surface of the skin; an accumulation of blood in the tissues outside of the blood vessels
• Contusion: A bruise (see above)
• Cut: An opening in the skin that occurs when a sharp object comes into contact with skin or tissues with enough pressure to divide it; not the same as a laceration or tear
• Laceration or tear: Injury that occurs when the skin is broken and disrupted by blunt force such as tearing, ripping, crushing, overstretching, pulling apart, over-bending, or shearing of tissue
• Petechiae: Multiple hemorrhagic spots, pinpoint to pinhead in size
• Scar: Fibrous tissue that replaces normal tissue after the healing of a wound
  (James et al., 2014; Faugno et al., 2012; U.S. Army, 2017)

Physical Evidence Collection

Physical evidence consists of articles that can be collected for analysis of a crime. Types of physical evidence may be:

• Biologic (e.g., blood, skin, hair, semen, saliva, vegetation)
• Trace evidence (e.g., fiber, glitter, glass, soil, sand, adhesive, gravel, oil)
• Gross (i.e., visible to the eye) (e.g., soil under the fingernails)
• Invisible (e.g., DNA on the skin surface)

Following are some important guidelines for the collection of physical evidence for forensic purposes:

• Bring all necessary equipment into the room before beginning the physical assessment.
• Always maintain Standard Precautions when obtaining biological evidence. This means always wearing personal protective equipment (PPE) such as gloves and gown (or clean lab coat) and a facemask and eye protection if there is any potential for droplet splatter.
• Treat all biological evidence as a biohazard to prevent possible exposure to HIV or other pathogens.
• Best practice is to use two swabs held together when swabbing each sample.
• Use a least-invasive to most-invasive procedure process.
  (Texas A&M, 2019)

Detailed instructions and a flowsheet for both the Adult/Adolescent Assessment and Prepubertal Pediatric Assessment are found in the Texas Evidence Collection Protocol (see “Resources” at the end of this course). The table below provides a summary.

EVIDENCE COLLECTION PROCESS

Items	Collection Procedure
(Adapted from Texas A&M, 2019)
1. Clothing collection	Follow the procedure outlined in the “Clothing Evidence” section later in this course. Collect the underpants that are worn at the time of the exam, even if they were not worn at the time of the assault. If clothing is wet, refrigerate as soon as possible.
2. Debris and foreign material collection	Collect any external evidence found during physical examination, such as blood, semen, saliva, debris, or other materials that might be associated with the crime scene.
3. Observation of skin surfaces	Observe skin surfaces with natural light for findings. Observe skin surfaces with an alternative light source and swab positive findings to collect dried body fluids that may otherwise be invisible. Photograph injuries following the procedure described later in this course.
4. Oral and buccal specimens	Collect 4 oral swabs from the inner surfaces of the gum lines and around teeth surfaces. Wait 15–20 minutes or have patient swish mouth with water and wait 15–20 minutes. Collect 2 buccal swabs by vigorously rubbing the swabs inside the cheek for reference DNA. Air dry for 60 minutes in a swab holder tray at room temperature or in a swab dryer* with a cool stream of air for 60 minutes. If a swab dryer or swab holder tray is unavailable, swabs may be inserted directly into the paper boxes included in the SAEK. (*A swab dryer may aerosolize COVID-19 particles; check local protocols to determine if it should be used.)
5. Blood and urine specimens	Collect blood to test for rapid plasma reagin (RPR), HIV, hepatitis B surface antigen (HBsAg), and human chorionic gonadotropin (hCG); blood tubes should not be sealed in the SAEK. Collect a urine specimen for toxicology analysis; consider collecting more urine for a GC and chlamydia RNA test. Use a voided specimen (dirty), not clean catch. Use a sterile urine collection container; package separately from the SAEK.
6. Head hair combings and head hair controls	Collect dried secretions by clipping hair around the area and collecting in an evidence envelope. Comb top, back, front, and sides of head hair over a piece of paper to collect any loose hairs or fibers. Include both the loose hairs and the comb in the evidence envelope. Cut, do not pull, hair controls for reference.
7. Additional swabs	Swab any area that was licked or bitten during the assault, any area that lights up with an alternate light source (i.e., positive ALS), or any source that may have dried semen. If the area is dry, lightly moisten tip of the swab with sterile water and swab the area by rotating the swab fully. Dry 60 minutes at room temperature. If a swab dryer or swab holder tray is unavailable, swabs may be inserted directly into the paper boxes included in the SAEK. Include location.
8. Fingernail swabs	Follow the procedure outlined in the “Fingernails” section of this course.
9. Pubic hair combings	Place a paper towel under the buttocks, and comb pubic area for loose and foreign hairs. Include both the pubic hair and comb in the evidence envelope. Collect a dried secretion by clipping around the area and collecting in an evidence envelope. Pulling hairs for controls is not recommended.
10. External genitalia swabs	Swab inner thighs and external genitalia with two lightly moistened swabs. Air dry for 60 minutes at room temperature. If a swab dryer or swab holder tray is unavailable, swabs may be inserted directly into the paper boxes included in the SAEK. Place air-dried swab in swab box and then in a paper or manila container. Swab external surfaces of penis and scrotum in male patients using four swabs that each have been lightly moistened with sterile water, and air dry for 60 minutes at room temperature.
11. Orifice swabs (vaginal/cervical/rectal)	Obtain four swabs from each orifice, swabbing from the outside in. Air dry for 60 minutes at room temperature. If a swab dryer or swab holder tray is unavailable, swabs may be inserted directly into the paper boxes included in the SAEK. Obtain all four swabs simultaneously. Coordinate with the attending physician to insert a speculum or anoscope for the swab collection. Swabs should not be inserted into the vagina of prepubertal children nor should anoscopy be performed on children.

Preserving Sample Integrity and Security

In order to preserve the integrity of the samples:

• Maintain the individuality of the sample. Preserve each sample separately to avoid contamination. Individual samples for a single case are to be separated, as are samples taken from multiple cases. Maintaining a physical boundary between simultaneous evidence-collection processes among more than one patient in a busy emergency department will reduce the likelihood of a mix-up. A nurse should never simultaneously collect evidence from more than one patient, since cross-contamination could occur and jeopardize any criminal case. Only exhibits from a single case are to be packed together in an external container (TXDPS, 2017).
• Label each sample. All evidence should be labeled with the patient’s name, date of birth, and identifier number; description of the contained evidence and where it was recovered; and the examiner’s initials, date, and time (Texas A&M, 2019). In addition, any evidence containing blood or other body fluids must be labeled as a biohazard. Glass or other sharp objects should also be identified on the outside of the container.
• Maintain evidence security. Collected evidence should remain in plain view of the nurse or in an established location in the emergency unit. Never leave evidence unattended and accessible to tampering. Document custody transfer to the police on the appropriate forms when releasing the SAEK and clothing to law enforcement.

Detailed instructions for preparing and sealing a nonreport SAEK for mailing are included in the Texas Evidence Collection Protocol (see “Resources” at the end of this course).

CHAIN OF CUSTODY

The chain of custody is a process used in forensic evidence collection that provides accurate information about who collected and transported physical evidence. A good chain of custody preserves the evidence against possible contamination or tampering. This process tracks the places the evidence has been kept and the people who have had contact with the evidence, in chronological order. The nurse assures that the evidence has been secure throughout the process of obtaining, labeling, packing, sealing, and processing in order to be defensible in the criminal justice system.

The chain of custody documentation includes:

• Receipt
• Storage
• Transfer of evidence
• Printed name and signature of each person in possession of and transferring or receiving custody
  (Texas A&M, 2019)

EVIDENCE STORAGE

Biological evidence may need to be stored before shipment to a crime laboratory for analysis. Check with the local crime lab for specifics. Follow these basic guidelines for storing biological specimens:

• Completely dry wet or moist items before packaging them in a sterile and secure environment. If items cannot be completely dried before the exam is finished, refrigerate as soon as possible.
• Package in paper, not plastic. Plastic is nonporous and therefore allows for moisture retention, resulting in possible growth of bacteria, mold, and/or mildew.
• Refrigerate sexual assault kits. The refrigerator should be locked or located in a locked room that is dedicated to evidence storage.
• If in doubt about how to store biological evidence, refrigerate it while awaiting further instructions or transport.
  (TXDPS, 2017)

Photographic Evidence

Photographs can be an important part of forensic evidence and may be used in some legal proceedings to demonstrate physical findings. Facilities must have policies in place to guide collection and appropriate secure storage of digital images, and written informed consent must be obtained prior to taking photographs.

Patients have the right to know how photographs will be stored and utilized and should be reassured that photographs are for medical forensic purposes only. Patients may decline the use of photography (DOJ, 2016).

Personal photography equipment/phones are not used because chain of custody and confidentiality of photographs cannot be maintained.

Basic photographic guidelines include:

• Take a picture of the patient’s demographic information (name, date of birth, age, etc.). A hospital-generated patient label works well for this purpose. This photo should be the first photo of the series and serves to identify the set of photographs. A professional color card may also be considered if color quality of photos is questioned later.


Photo of patient demographic information and color card. (Source: Sheree Goldman.)

• Whenever possible, include a photo of the patient’s face as the second photo in order to establish identity. This will help the examiner recall the patient at a later time if the case goes forward.
• In the photo of an injured area, always include an object of measurement (a scale) such as a ruler, paper measuring tape, or swab wrapper with centimeters printed on the side. Photograph the injury with and without the scale.
• Take a series of three photos for each injury: 1) a regional photo to show the anatomic location (e.g., middle of the back, right shoulder, etc.); 2) medium range photo, capturing a closer view of the injury; and 3) close-up of the injury. Each close-up of the injury should be photographed with and without a scale beside it (Texas A&M, 2019).
• Include a written report that describes the findings depicted in the photographs. Add a notation that states who took the photos, what type of camera was used, and details such as the magnification used.


A regional photo depicts an abrasion on the patient’s left knee. (Source: Sheree Goldman.)



A medium-range photo shows the abrasion on the left knee. (Source: Sheree Goldman.)



A close-up photo of the abrasion without a scale. (Source: Sheree Goldman.)



A close-up photo of the same abrasion with a scale. (Source: Sheree Goldman.)

Clothing Evidence

The clothing worn by an individual often contains physical or biological evidence that must be preserved. If the patient is still wearing the clothes they had on during the event, all items can be considered evidence. If the patient has changed their clothes, the nurse should collect the underpants that the patient wears to the exam since transfer of internal evidence from a sexual assault may be present on the fresh underpants. Examine the patient’s clothing and document any obvious stains or tears (Texas A&M, 2019).

Clothing evidence is gathered and packaged for further evaluation as described below:

1. Begin by covering the floor with a layer of exam table paper or a folded hospital sheet. The purpose of this bottom layer is to prevent collecting evidence from the emergency department floor; this layer will not be collected. When collecting wet evidence, a waterproof pad may be used as a bottom layer.


Bottom layer of paper. (Source: Sheree Goldman.)

2. Cover with another layer of paper. A large paper sheet for this purpose is found in some SAEKs, or exam table paper may be used. This layer will catch any debris that may fall from the patient’s clothing, such as hair, vegetation, etc., and will be folded into a bindle and collected after the patient has undressed. If the patient has many clothing items, this area will need to be fairly large.


Second layer of paper. (Source: Sheree Goldman.)

3. Have the patient slip off their shoes and step directly onto the paper with bare or stocking feet.


Patient stepping on paper with stocking feet. (Source: Sheree Goldman.)

4. The patient may remove clothing from the top of the body first and drop it onto the paper below. After the patient has removed all of the clothing from the top of the body, they can dress in a hospital gown and then remove the clothing from the lower part of the body, following the same process.


Patient beginning to disrobe and dropping articles of clothing onto the paper. (Source: Sheree Goldman.)



Patient donning hospital gown and continuing to drop articles of clothing onto the paper. (Source: Sheree Goldman.)

5. Using a clean pair of gloves for each item of clothing, inspect the clothing for tears and stains. Place a hospital sticker on the item of clothing after marking the sticker with the time the clothing was collected and the nurse’s initials.


Nurse labeling articles of clothing. (Source: Sheree Goldman.)

6. Package each article of clothing separately. Be sure to seal the bag with tape over the edge of all openings. Write the time, date, and nurse’s initials across the seal. Mark the bag with the patient’s name, what clothing is in the bag, any information about the clothing, who collected it, and when it was collected.


Nurse labeling the bag. (Source: Sheree Goldman.)



Sealed bag with nurse’s initials, date, and time written across the seal. (Source: Sheree Goldman.)

7. After the clothing is collected, be attentive to any debris that might be shaken from the clothing. This material should be packaged as trace evidence. Be careful to keep items separated for packaging.


Trace evidence (hair) that has fallen from the patient’s clothing onto the paper. (Source: Sheree Goldman.)

8. Fold the top layer of paper, if debris is visible, into a bindle. Label with the patient’s name and the collector’s initials, and package in a separate clean paper evidence bag as described for clothing above.


Folded paper bindle.



Evidence packaged in a paper bag and properly labeled. (Source: Sheree Goldman.)

To avoid transferring evidence from one piece of clothing to another, place each piece of clothing in a separate evidence bag. Only the underwear is sealed in the SAEK. Air dry any wet clothing before packaging, and use paper evidence bags. If it is not possible to dry the clothing, refrigerate as soon as possible (Texas A&M, 2019).

Collecting Other Evidence

Other evidence may include hair, fibers, and foreign material such as leaves, dirt, sand, or glass. This evidence can create a link between a victim, a suspect, and a crime scene and may be important for law enforcement in piecing together what has happened.

HAIR

Hair is present in a wide variety of forensic situations. For instance, during an assault, hairs may transfer from one individual to another.

Use an evidence comb from the SAEK, and place a paper towel under the patient’s head or buttocks to collect the loose hairs that result from the combing. Include the comb, paper towel, and any hairs that are collected in a bindle, which is sealed in an envelope that is appropriately labeled and sealed. If foreign hairs are collected, control hairs from the patient may be collected by cutting and sealing in an envelope that is appropriately labeled and sealed. Pulling hairs is no longer recommended (Texas A&M, 2019).

FINGERNAILS

Fingernails may contain foreign DNA in the event the patient describes scratching the suspect. It may also contain DNA from the victim or trace evidence such as fiber, dirt, or vegetation. Lightly moisten two small swabs with sterile water, and swab under and around the fingernails, holding both swabs together. Use one set of swabs for each hand, swabbing all five fingers on each hand with the same two swabs (Texas A&M, 2019).

DEBRIS

Bindle any other debris (e.g., tape residue, vegetation, sand, glitter) and place in an envelope that is labeled with the collection site and description. Seal the envelope with the examiner’s initials and place in the SAEK (Texas A&M, 2019).

TOXICOLOGY

The TECP suggests collecting urine when a toxicology study is indicated, such as in cases that include drug-facilitated sexual assault. Urine should be frozen or refrigerated. Document in the medical record any toxicology specimens obtained. Label specimen containers and document the exact collection time. Although blood can also be used for toxicology, it is no longer recommended because of the instability of storing and transporting liquid in glass vials (Texas A&M, 2019).