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Law and Order in the ER 

Nurses are being trained to deal with the needs of both patients and police

Wednesday, Apr 18 2001
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It's 3 a.m. on the lightest overnight shift anyone at the S.F. General emergency room can remember, and nurse practitioner Lucretia Bolin looks a little bored. It's hard to blame her: An emergency room that's generally flooded with carnage has managed little in terms of excitement tonight. There was that one patient, the chiseled street kid who had taken something of a beating to the head, who livened the place up a bit with his constant screaming, swearing, and occasional lunging at doctors. He managed to keep most of the staff on its feet by somehow hurling himself (and the weighty backboard his legs, arms, and torso were tethered to) clean over a bedrail and onto the floor, which was good for a fresh whack on the head that necessitated his second $1,000 CAT scan of the evening.

But other than that, things have been almost startlingly ho-hum. Things got so slow at one point that Bolin -- one of six nurse practitioners who have been trained in forensics, as well as the techniques of dealing compassionately with the victims of rape and domestic abuse -- was helping a doctor drain a foot abscess.

Now Bolin, 39, is camped out in the triage window, which overlooks the dingy and disheveled waiting area, chitchatting and, mostly, trying to figure out where the team of specially trained nurses she belongs to fits in the emergency room. "In a year from now, when it's more defined, it'll be really exciting," she says. "It's cutting edge."

The notion that at least some hospital nurses should be trained in forensics is probably less than 20 years old. It was spawned by increasing sensitivity to the emotional trauma suffered by victims of violent crimes, particularly sex crimes. In such cases, the conflicting priorities of nurses, who wanted to treat the victims' medical problems, and police officers, who wanted to interrogate them on the way to catching criminals, often collided in a manner that was, to say the least, detrimental to the patient.

Virginia Lynch, a registered nurse who teaches forensic nursing at the University of Colorado's Colorado Springs campus, says she remembers working in emergency rooms where policemen charged with collecting genetic evidence from rape victims would tell the victims to take the evidence home to be stored in their refrigerators (thus rendering it legally useless). She also recalls seeing medical staff destroy key evidence, like clothing, in their zeal to help patients. And doctors, she says, have little or nothing in their formal training that helps them tend to the emotional needs of fragile victims of violent crime.

Common sense, Lynch says, dictated that nurses should be formally trained to identify the victims of crime, collect evidence from them, and tend to their emotional needs -- at the same time. Many hospitals -- including S.F. General -- added a nurse or two with such training to their staffs. At S.F. General, however, the nurses worked remotely, often from home. When a case came up requiring their skills, they had to be paged, and because they could seldom arrive immediately, patients' first contact continued to involve police or nurses without specialized training in handling crime victims. Sometimes, the recently traumatized victim would be confronted by nurses and cops simultaneously.

"Historically, cops are men, and if I'm a rape victim, I don't want 'em touching me," says Lettie Muller, an RN for 31 years, whose rising intonations while recounting scuffles past seem to suggest she's seen a few. "With the older cops, the inspectors, it's less of a problem. But sometimes the younger ones are a little, you know, "We need this right now.' And the nurses say, "No, you don't, the evidence is good for 72 hours.' And the cops say, "Yes, we do.' And so on. It gets pretty heated, especially considering ...

"And I understand their problem, but they need to understand that this person will carry this experience around with them for the rest of their life. If the patient gets threatened, the police don't get their story."

Recognizing the futility of the old arrangement, S.F. General hired a team of experienced nurse practitioners in February, sending them through a 40-hour crash course in forensics before putting them to work. Because the new nurses will constantly be on duty (and on site) at both the hospital and the victim recovery center, there should be an immediate impact not only on the quality of screening and treatment, but also on the number of prosecutions.

The forensic nurses are trained not only to collect evidence, but also to document crimes in a way that figures to have an impact on juries. One of the tools they'll be using is a large microscope called a colposcope, which provides images of injured areas enlarged up to 16 times. Considering the microscopic nature of many injuries related to sexual assault cases in particular, having a 16-times enlarged image of an affected genital area in front of a jury figures to be, in the words of Amy Tischler, the nurse practitioner heading up the forensics team, "pretty powerful evidence."

This type of training and evidence-gathering inside the hospital should make law enforcement's job easier, says Lt. Jerri Davis of the San Francisco Police Department's sexual assault unit: "We can't go forward without this kind of evidence. The more trained the nurses are, the more evidence we're going to court with."

But one prosecutor, who handles sexual assault and domestic violence cases, doesn't sound as certain.

"We're just hoping they're equally as well trained [as the current nurses]," says Deputy City Attorney Susan Etto. "[The hospital] is hoping they'll provide more services to victims. But the impact on prosecutions, I think, remains to be seen."

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Jeremy Mullman

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