Beth called her sister and asked her to take her to the closest hospital. At the hospital, Beth met a sexual assault forensic examiner who was able to retrieve semen from Beth’s vagina and was able to obtain a toxicology screen that revealed the use of a date rape drug. Law enforcement collected evidence from the hotel room. The presence of the drug in Beth’s system, the retrieval of e-mail between the perpetrator and Beth, and DNA matching the new Internet friend led to a plea bargain agreement.

Two youth gangs reside in neighborhoods that are conjoining. In the past few months, graffiti from the two groups indicated that a fight between the gangs was about to take place. Law enforcement believed the two gangs were fighting over “turf” and the right to sell drugs on certain corners. One afternoon, after high school was dismissed, shooting broke out in the street near the high school that members from both gangs attended. Two gang members and one bystander were shot in the exchange of fire. All three victims were transported to a level-one trauma center. All three victims survived.

The word forensic means “pertaining to law.” The goal of a forensic examination within a healthcare setting is to identify and collect evidence that has transferred from the perpetrator to the victim. When a crime involves close contact between the victim and the perpetrator, in such crimes as assault, sexual assault, and physical abuse, evidence transfers to the crime scene and to the victim from the perpetrator. While law enforcement personnel preserve and collect evidence from the crime scene, healthcare personnel can preserve and collect evidence from victims of crime.

Evidence must be collected systematically and comprehensively without inducing psychological or physical harm to the victim. The system for evidence collection and preservation involves a careful search of the entire body, requiring careful identification and retention of all evidence from the victim.

Healthcare personnel can play an important role in assisting in the investigation of crime, while providing healthcare to the victim. However, the forensic work of collecting and preserving evidence should never compromise the safety of a patient, the first priority. And members of the healthcare community should be able to handle forensic evidence without compromising healthcare.

Interview

Whenever possible, healthcare personnel interview the victim, with or without a law enforcement person present. The interview guides the forensic examination by revealing what aspects of the body require the most attention. This process is similar to ED triage in which a member of the ED team asks questions that help focus the episodic visit.

A victim’s account of what occurred during the commission of the crime, in as much detail as possible, is most helpful for guidance in evidence collection and preservation. For example, in a sexual assault case, knowing where the suspect placed his mouth on the victim is likely to enhance the accuracy of the search for saliva. In cases of domestic violence, knowing exactly what areas of the body were injured makes the search for early bruising and patterns of bruising more likely to be successful. Knowing that the victim was restrained in any way during an assault allows the examiner to carefully search for signs of restraint, such as bruising and tape marks.

Healthcare personnel should record what the victim recalls in his or her own words as often as possible. An ideal victim interview is a series of quotes, in quotation marks, of what the victim recalls about the crime committed. Statements made by the victim can be used in court. The role of the healthcare provider is not to analyze or place judgment on the words of the victim, but simply to record them, in writing, exactly as stated, such as “I have been shot,” “I was raped,” or “I was beaten up by John.” The victim’s description should not be sanitized or interpreted, just recorded with as many exact quotes as possible. No interpretation of the victim’s comments or judgments about the victim’s comments should be included.

An interview conducted with law enforcement present saves the victim from retelling the account. Law enforcement must determine what crime or crimes were committed, gather information related to the crime scene, and obtain as much information as possible about the suspect(s). Healthcare workers seek information about possible injury and possible evidence transfer from the suspect to the victim. Information desired by law enforcement and by healthcare personnel can be derived from the victim’s description of the events preceding his/her entry into the healthcare system.

Because healthcare concerns are always a priority, the interview may be delayed until the victim is medically stable; examination, evaluation, and treatment may proceed without interview. The interview may also be delayed if the victim is unconscious or semiconscious, and/or under the influence of alcohol or drugs. Evaluation, treatment, and testing should proceed in these situations without an interview, which can be conducted at a later time. When the victim cannot speak for himself or herself, careful documentation of any and all observations of the victim by healthcare personnel becomes crucial.

If at all possible, consent to collect forensic evidence and submit the evidence to law enforcement, as well as for photography, should be obtained. This consent is different from consent for medical treatment.

Preservation of evidence

Law enforcement is responsible for investigating all criminal cases. Investigation requires that as much information as possible be available to law enforcement for evaluation. If the victim has been shot or stabbed, evidence must be handled properly.

For example, if a bullet is recovered from the victim, it should be handled as little as possible. Metal forceps can damage the exterior of a bullet, making matching of the bullet to a particular gun difficult for ballistic experts. If a bullet must come in contact with forceps, the teeth should be covered with a plastic shield. A bullet removed from a victim should be wrapped in gauze and placed in a cup or envelope. Markings should never be applied directly to the bullet. The container to which the bullet is transferred should be marked with what it is, from whom, and who removed it as well as date and time. This is called “indirect marking” and is most appropriate to the type of evidence healthcare personnel collect. The bullet, in its container, is given directly to law enforcement personnel.

Only an expert in gunshot wounds should determine entrance versus exit gunshot wounds. If the victim can describe entry versus exit, this should be recorded. If healthcare personnel determine entrance versus exit incorrectly, a discrepancy will appear when the expert is consulted. Conflicting reports can mislead investigators and confuse investigation and prosecution.

If the victim is shot at a close range — less than three feet — gunshot powder will be found on the skin. Photographs of the wound with surrounding gunpowder should be taken before removal of the gunpowder. After the photographs, the powder should be removed by scraping some of it onto a piece of paper and placing the paper into an envelope. Gunpowder can also be removed with tape that is then placed into a clean, labeled envelope.

In cases of suicide, gunshot powder will be found on the victim’s hands. If suicide is suspected, the victim’s hands should be covered in paper bags until a forensic expert examines them.

Stab wounds should never be used for treatment access, such as insertion of tubes or catheters. New insertion sites should be chosen. If the victim has been stabbed, each wound is important to the investigation. The appearance of wounds determines the type of weapon used. Angle can be determined at times by visualizing wounds. Each wound should be photographed before medical intervention whenever possible. Medical intervention may distort the appearance of injury sustained during an assault.

Clothing worn by a victim during the commission of a crime can be vital to the investigation. Staff from the police crime lab inspect clothing, looking for trace evidence. They also analyze bullet holes, stab holes, rips, and tears. Clothing can provide important keys to understanding criminal events. For example, if the stab holes are in the back of the shirt, the victim was not facing the offender during the attack.

Clothing worn during the crime must be collected. A gloved examiner should remove clothing from the victim and place it into clean paper bags. Any clean paper bag is sufficient. Each item of clothing should be placed in a separate paper bag to prevent transfer of evidence. Each bag should be sealed with evidence tape obtained from law enforcement. The tape should be labeled as to the item of clothing. The victim’s name, the collector’s name, and the time and date of collection must also be included. If clothing worn during the crime must be cut for removal, cutting should avoid altering any evidence, such as rips, tears, cuts, and holes that occurred during the assault. Healthcare personnel should not mark the clothing directly. A more detailed inspection and marking will occur in the police crime laboratory. If clothing worn during the crime has been removed before the patient arrived at the healthcare setting, it should be retrieved and placed in paper bags by law enforcement personnel, who will deliver it to the forensic science laboratory for analysis.

In medical emergencies, the clothing is often forgotten and discarded. Investigators of crime would appreciate healthcare personnel tossing the clothing aside, at the very least, rather than losing it to the trash in the ED. Tossed aside clothing can be collected by law enforcement after the medical emergency.

Evidence collection

Three kinds of forensic evidence are collected in healthcare settings: evidence identifying the perpetrator, evidence indicating if force was involved, and evidence placing the victim at the crime scene.

Identification: Physical evidence collected from the victim of a crime is called trace evidence. The amount of each specimen is small and includes such items as hair, fibers, and any secretions. Forensic evidence collection and analysis identify important links between the suspect and the victim. It also assists in fact finding that can help convict an offender or exonerate someone who has been falsely accused.

Changes in the ability to analyze trace evidence are occurring in forensic science laboratories throughout the country. DNA, undoubtedly the most significant finding, can now be extracted from sample sizes smaller than the head of a pin. It can be isolated from any sample that contains cell nuclei. DNA can be found in blood, sperm, semen, saliva, skin cells, and even from dandruff and perspiration stains on clothing.

The extraction is achieved in a crime laboratory through analysis called short-tandem repeats (STR). The laboratory process for extracting DNA involves first identifying the specimen as blood, semen, saliva, or other sources. This is called presumptive testing. The laboratory must positively identify the specimen as blood or semen or saliva from a human being. After the specimen has been identified, the STR process is performed.

In 1998, the FBI requested that STR be the method of analysis of DNA for admission into its CODIS data bank. CODIS stands for Combined DNA Indexing System. The FBI uses the indexing system to assist in solving crimes and to link serial offenders to crimes. DNA retrieved from a crime scene or a victim is submitted to the data bank. To date, all states have passed laws that require submission of DNA for selected categories of convicted felons. CODIS requires 13 loci – points of attachment for genetic material – for admission. Identification using 13 loci via STR is extremely accurate. The use of 13 loci results in a probability of a random match that is less than one in three trillion, making it more probable that no two people will be the same.

A blood sample or cell scraping from inside the cheeks from the victim should be submitted to the police crime laboratory as a control sample for DNA analysis. The laboratory must be aware of the victim’s DNA while searching for DNA from the suspect.

Evidence should be collected whenever possible before it is disturbed by medical intervention or cleaning. “Cleaning up” the victim removes valuable evidence and should occur after evidence collection, if at all possible. Cleaning the victim’s body can remove valuable sources of DNA from the suspect.

For forensic examiners, the skin is the most important organ of the body. Slow and careful examination of the victim’s skin for any transfer of evidence from the suspect is critical to evidence retrieval. Saliva and semen can be difficult to see even with a high-intensity light or Wood’s lamp. Any secretions located on the victim’s body will fluoresce under a Wood’s lamp.

The entire body must be carefully inspected for trace evidence. Any random hair, fibers, or debris must be collected. Interview guides collection whenever possible. Any evidence found should be placed onto a piece of paper, which is then folded druggist style. A clean piece of paper is folded in thirds with the evidence in the center aspect of the paper. The paper is turned 90 degrees and folded in thirds a second time. The upper third is tucked into the lower third after the second fold to prevent loss of evidence and then placed into an envelope. Any clean white envelope is appropriate. A separate envelope should be used for each piece of evidence. Each envelope must be labeled with the victim’s name, the examiner’s name, and the date and time of collection. Each envelope must also be labeled with its possible contents and where it came from, for example, “possible fiber removed from left knee.”

To remove evidence from the victim’s body, gentle scraping with a clean glass slide can be used, or a piece of evidence can be lifted from the body with a pair of forceps that has plastic-coated tips. Evidence that cannot be lifted in either of these manners is collected by reconstituting it with sterile water on a swab or gauze pad. Any moistened swab or pad must be dried before being placed in an envelope.

Skin cells from the suspect may be obtained by scraping or swabbing under each fingernail while allowing the debris to fall onto a piece of clean paper. If a nail is broken, it should be clipped and placed onto a separate piece of paper. Again, the paper is folded druggist style and placed with the swab or orange wood stick in an envelope. A separate, labeled envelope should be used for each hand.

If victim interview reveals that saliva from the suspect could be present on a body part, this area should be swabbed for saliva using gauze or swabs moistened with sterile water. Semen can be retrieved from anywhere on the body. If the victim can recall areas that may contain semen, these areas should be swabbed. The face, including glasses, should be swabbed, if oral assault occurred. Swabs collected from the mouth should be obtained from the gum areas. If semen is present, it will most frequently collect there. Swab between the gums and the cheek and under the tongue. If the victim wears dentures, the dentures should be removed and swabbed for evidence. The mouth should be inspected carefully for injury with the dentures removed.

The external genitalia and the inner thighs of the victim should be swabbed routinely after sexual assault. A gynecology table is not necessary for evidence collection; a bed or a stretcher is adequate. External genitalia are inspected first with a high-intensity light or a colposcope for visualization. Good visualization of the external genitalia can be accomplished in a lateral or side-lying position, although assistance may be needed to support the victim’s legs.

Swabs collected from the vagina are easily obtained with a speculum. A speculum can be inserted on a bed or stretcher in lithotomy or side-lying position. A high-intensity light or colposcope is needed for visualization. If the victim cannot tolerate speculum insertion, swabs can be obtained without visualizing the vagina. Swabs are moistened with vaginal secretions and dried before packaging. Rectal examination and swabbing should also be performed, if sexual assault has occurred.

Careful searching of the body may reveal semen, saliva, or blood that should be retrieved for analysis. This evidence can be collected by scraping with the side of a glass slide or by applying moistened swabs or gauze pads. Each specimen should be packaged separately. The examiner must wear gloves and change them often; any instruments used must be cleaned between collections. All evidence, including swabs, scrapings, and clothing, must be dry before submission to a police crime laboratory. Swabs should be dried at room temperature separately from each other to prevent transfer of evidence. Test-tube holders in a test-tube rack can be used to keep swabs separated. Each swab or scraping must be labeled with the anatomical site from which collection occurred. All evidence submitted to the police crime laboratory is submitted in paper, not plastic. Plastic can allow the decay of biological tissue and prohibit analysis.

The examiner should remain in control of the collected evidence at all times. Nothing can be left unattended. All evidence must be in plain view of the collector. Evidence that is to be used in court must be appropriately packaged and given to law enforcement to maintain a continuity or chain of custody. In an ideal situation, the examiner maintains custody of all evidence, until it is collected by law enforcement. All personnel who handle or examine evidence must be acknowledged to establish its integrity for presentation in a court of law. If evidence cannot be maintained in the sight of the examiner, it must be locked in a secure area at room temperature away from anyone not in the chain of custody.

A suspect can be positively identified through DNA analysis conducted by a forensic science laboratory. If a specimen contributed to the laboratory via a healthcare setting is of good quality, nuclear DNA can be obtained and the suspect identified via CODIS or via a DNA sample from the suspect. Good quality specimens allow the laboratory to identify at least the thirteen loci required for CODIS. The better quality the specimen, the more likely positive identification of the suspect can be achieved.

Fiber, hair, and debris collected from a victim of crime in a healthcare setting is also analyzed by a forensic science laboratory. These trace items will be reported by the crime laboratory as class characteristics. Class characteristic evidence is not considered unique and cannot be utilized to positively identify. However, class characteristics reveal that the evidence is part of a limited class and can be very helpful in the investigative process.

The ballistic section of the forensic science laboratory analyzes bullets retrieved from a crime victim. The marks on a fired bullet can be utilized to determine if the bullet was fired from a particular weapon. Firearms examiners are able to perform microscopic comparisons and perform other examinations on a firearm retrieved from a crime scene. When analysis is complete, the firearms examiner can accurately reconstruct the circumstances of a shooting and testify to the exact firearm used in the shooting.

Evidence of Force: Detection of injury is important to the investigation of a crime. Any injuries the victim sustained during the commission of a crime, regardless of whether they require medical intervention, must be noted and recorded. Injuries are photographed and described in the medical record, both in a narrative and drawn on a traumagram or body map.

Determination of the cause of injury is important in criminal cases. For example, investigation may be facilitated by differentiating cut wounds versus blunt trauma. A cut wound is created with a knife or something sharp. Cutting divides the tissue as it penetrates. The wound created has distinct clean edges. A wound inflicted by blunt instrument creates tears. The tissue is hit with enough force that the tissue breaks apart. This wound does not have clean edges; rather it has ragged edges and often has pieces of tissue that are still connected between the edges. The tissue that remains connected to the edges is called tissue bridging. Tissue bridging — thin, delicate bridges of soft tissue — is apparent in blunt-force injury and is not present in cutting injury.

Blunt trauma, created by items such as a hammer, a pipe, or a fist, creates contusions, lacerations, and abrasions. Contusions, or bruises, are the result of a blow that breaks underlying vessels, but does not break the skin. Examples are black eyes and black and blue marks. Abrasions are the scraping or removal of superficial layers of skin. Abrasions are also called grazes, scratches, or brush burns. Lacerations are tears produced by blunt trauma, depending on the amount and direction of force used.

Blunt-force trauma sometimes creates a pattern in the design or shape of the injury that resembles the weapon, such as a shoe, a pipe, a baseball bat, a hand, or a tire. At other times, the weapon can be inferred from the location, distribution, and relationship of the injury. Patterns, either directly visualized or from photographs, can often assist in reconstructing the cause of the injury.

A bite mark is a form of patterned injury. A bite mark is composed of contusions and lacerations that correspond to the suspect’s dental arch, tooth characteristics, and jaws. A forensic dentist can compare bite-mark patterns to a suspect’s dental alignment and characteristics. Forensic dentists, who should evaluate full bite marks, can be contacted through the office of the medical examiner.

Although description and drawings of injuries help investigations, it is photography that preserves the appearance of the victim in the immediate aftermath of the crime. One photograph is worth a thousand words of narrative. And photographs of injury have a powerful effect on the law-enforcement community. Photographs preserve evidence. Victims can use them in matters of restraint orders, divorce, and custody arrangements. Photography can be used to assist rape and sexual assault victims in the investigative and judicial process. Photography can be used to protect children who are victims of physical or sexual abuse. Photographs can assist in the analysis of shootings.

Photographs of the victim should be taken with digital cameras before collection of trace evidence. These photographs document the appearance of the victim upon arrival at the healthcare setting. Photographs must be taken before the victim is “cleaned up,” or washed. The entire body should be carefully inspected for signs of injury, which then should be photographed. Fresh injury can be difficult to detect, which is why the interview may be important to guide the search. If possible, take an initial overall picture of the victim as identification as well as documentation of the overall appearance before any medical intervention.

When injuries are fresh, light purple, and difficult to see in initial photographs, they may be rephotographed at a later time deemed appropriate by law enforcement and healthcare personnel. But, if at all possible, photograph the injury before treatment ensues. If this is not possible, photograph immediately after intervention.

Photographs should be taken with a scale in place to indicate the size of the injury. Take at least one photograph that includes the area of injury including anatomical land marks. Place a scale in the picture that does not cover any portion of the injury. The scale should be as devoid of advertising as possible. An ideal scale identifies the victim with a case or medical record number. A picture should be taken with and without the scale if possible. Photographs taken at a 90-degree angle reduce the probability of distortion. Photographs will be accepted in court if the distance from the injury allows for accurate evaluation, the photograph is clear and in focus, and the scale is placed to allow for good visualization and measurement of the injury.

In a medical emergency, careful attention to photography strategies may not be possible. Also, healthcare personnel are not photographers. However, whenever possible, take a picture of any and all injuries whether the injury requires medical intervention or not.

In the scenario about Beth described above, force was applied without apparent physical injury. A drug was administered to Beth rendering her helpless. Blood and urine obtained via healthcare personnel can be submitted to a forensic science laboratory via law enforcement. A forensic toxicology team at the forensic science laboratory analyzes the specimens for all possible drugs following a proper chain of custody. Forensic toxicology analysis is extensive and time consuming, making it useless for clinical work. Forensic toxicology is the examination of all aspects of toxicity that may have legal implications. Clinical work requires a “tox” screen result from a hospital laboratory. The hospital laboratory produces a quick result noting the more commonly utilized drugs that create clinical emergencies. Beth had a clinical toxicology test done in the hospital laboratory and blood and urine were submitted to the forensic laboratory for analysis. Clinical testing guided Beth’s immediate care in the emergency department. Testing from the forensic science laboratory produced results several weeks after the crime was committed. The forensic results were utilized in the legal arena.

Connection to the Crime Scene: Debris found on the victim can connect him or her to the crime scene. If the crime occurred in a parking lot, gravel may be found on the victim’s body. If the crime occurred in the grass, grass may be found on the victim’s body. Collecting this debris can be important to investigators who may be able to connect the victim to the crime scene. At times, the crime scene is unknown and finding debris from the scene on the victim is crucial to discovering the crime scene.

Documentation

Documentation of cases involving a crime requires legible handwriting. The need for testimony can sometimes be eliminated if the record can be read by others. Documentation should be clear and legible with drawings incorporated, when appropriate. Documentation of any injury created by a treatment process is also helpful to law enforcement. If the victim does not survive, leaving tubes, catheters, and any other devices used for treatment in place assists law enforcement in differentiating injuries created by medical personnel from injuries created prior to treatment.

Healthcare personnel can assist law enforcement in the investigation of crime without compromising the delivery of healthcare. Forensic evidence collected by healthcare personnel in Beth’s case and in the neighborhood shooting assisted law enforcement in the apprehension and conviction of two violent offenders. Collection and preservation of forensic evidence in a healthcare setting assists law enforcement and, therefore, assists the victims of the crime who are seeking justice.