As Death Investigators, Nurses Pick Up on Crime-Scene Subtleties
By Kelly M. Pyrek

Members of the forensic science community have long known that dead men do tell tales. Just what they are trying to tell death investigators is up to the men and women who interpret crime scenes. Mary Fran Ernst, BS, a medicolegal death investigator for the St. Louis County Medical Examiner's Office in St. Louis, as well as director of medicolegal education and a professor in the Division of Forensic Pathology at Saint Louis University School of Medicine, tells her students that "dead people always come first." She says, "What is the dead person attempting to tell us? Dead people do talk to you; you just have to listen really carefully. Their bodies tell us what happened. The death investigator must be a medically knowledgeable person who anticipates the questions of the forensic pathologist who will perform the exam and autopsy. It might be the physical location of the body relative to the crime scene or the trace evidence on the clothing. We must know how the body got there; was it at the scene or brought to the scene? Was it moved? A death investigator is the first medical person with forensic training to be with the dead person so he or she must get as much information from the body as possible to try to establish time of death, what the medical condition of the person was before they died, and details about the incident that caused them to die."

Ernst believes forensic nurses make exceptional death investigators because they are quick to pick up on signs and symptoms related to medical conditions. "Not every jurisdiction has well-trained law enforcement so death investigators must know how to do everything, to be sure the dead person gets the best treatment possible. Nurses make phenomenal death investigators because they know the terminology and the techniques. The law enforcement part is easy; the medical stuff is hardest, so nurses often have an advantage over some law enforcement. For a long time I had to convince a medical examiner that instead of more law enforcement at crime scenes, we need people like forensic nurses, people with medical backgrounds who take histories all the time and who excel at finding out what happened."

And that often includes recognizing pre-existing medical conditions -- a cinch for nurses. While only a third of deaths are unnatural, defined as anything sudden, unexpected, violent or suspicious, two-thirds of all deaths reported are natural deaths, Ernst says. "It might be the 22-year-old running track in college who blows an aneurysm, or it might be an 18-year-old who has an allergy to nuts and dies from anaphylaxis. They are a picture of health, yet could there be more to it than that? That's why nurses are so good as death investigators; they see the signs and symptoms that lead them down the right path."

However, Ernst cautions that the nursing mindset of empathy could hinder an investigation unless the individual is cognizant of the need for scientific detachment.

"Nurses make outstanding death investigators but I always remind them that dead people come first," Ernst adds. "With infant deaths, for example, it might be hard for a death investigator with a nurse's background to step back and say, 'We have a dead child; the probabilities are high that if there are no immediate physical injuries, it might be SIDS or it might be shaken baby syndrome. I cannot just hand the baby right back to the parent.'"

The subtleties of death investigation are what intrigue most death investigators.

"It's easy to do an investigation on a guy who has 16 gunshot wounds to his back," Ernst says. "That's a no-brainer. It's the subtle cases that are the most challenging and rewarding."

Ernst recalls the time she was called to the scene of a decomposed dead body near a gun. "The police officer says it looks like a homicide of one person," Ernst says, but as I drive to the scene I get more calls that there are more people, and by the time I get to the scene there are five bodies in what appears to be multiple shooting deaths. The bodies were left in an enclosed garage in the summer heat for three days so they were in the worst physical shape in which to find anything. A systematic examination revealed the bodies didn't have any gunshot wounds or any physical defects but they had cherry-red nail beds. These people were dark-skinned, so it was difficult, but a closer inspection of the evidence showed us that someone had left a car running in the garage. So what appeared to be a massive homicide by shooting turned out to be death by carbon monoxide poisoning. Without a thorough knowledge of toxicology, a small detail might have been overlooked."

Ernst recalls another case in which a police officer was killed when he responded to a burglar alarm in a shopping center. "The officer had been beaten about the head with the butt of a revolver. He was lying face up but his right hand was underneath him, bent at the elbow. When I turned him over very carefully I saw he'd clenched his hand around a button that didn't match anything of his. The officer, knowing he was outnumbered 5 to 1, knew he had to grab some kind of evidence to help us catch his killers. He was able to grab hold of one of his assailants and knew he had to hide that button. It was the one thing that tied one of the assailants to the crime and he was sent to the electric chair. It was another example of a subtle piece of evidence. In the same manner, nurses do the little things right. Just like documentation. There's nobody better at documentation than nurses, and in our business if you don't document it, it didn't happen."

In the last decade, Ernst reports nurses comprise at least 10 to 15 percent of the students taking her courses.

"Most of them are there because they are trauma nurses or ER nurses and they are tired of being abused or not being respected for their wisdom," Ernst says. "They are looking for a field in which they can make a difference, and they truly can."

Opportunities Abound for Nurses, Medical Examiner Says

She is a widely respected medical examiner and forensic pathologist, but Mary Dudley, MD, MS, RN, also has the respect of the forensic nursing community for being a champion of nurses and a pioneer in forensic nursing education.

"I don't think forensics was even something nurses thought about that much many years ago, as far as seeing the importance of recognizing injury, preserving evidence and maintaining chain of custody," Dudley says. However, the majority of students in her medico-legal death investigation courses are nurses who want to broaden their skills.

To understand her support for nurses, one must know her background in which forensics and nursing are intertwined. Dudley received her diploma degree in nursing from the Hospital of the University of Pennsylvania and then picked up her bachelor's degree in nursing from Metro State University in Denver and her master's degree from the University of Colorado prior to going to medical school. Following medical school and residency abroad, she did a rotation in forensics that clinched her future as a medical examiner/forensic pathologist.

Along her complicated educational path of medical boards, rotations and residencies, Dudley found herself teaching at Beth El University's School of Nursing in Colorado Springs, Colo., helping the institution convert its diploma nursing program to BSN. She says right around that time, she first became acquainted with the concept of forensic nursing through her professional membership in the American Academy of Forensic Sciences (AAFS). A nurse introduced her to Virginia Lynch, who was conducting forensic nursing workshops with an emphasis on training sexual assault nurse examiners.

Dudley was approached by the school's dean who asked her to teach a forensic nursing course at Beth El. "At that point Virginia had a forensic nursing article published and interest in the specialty was growing," Dudley recalls. "I said, 'I'm a pathologist and a nurse, and I could probably do that.'"

A lack of college-level material on forensic nursing forced Dudley to craft the program herself, relying on her forensic knowledge from medical school and seeking the expertise of colleagues. A friend who was a psychologist, who in turn was married to an attorney, was interested in law enforcement and forensic psychology, and was instrumental in helping set up the Beth El forensic nursing program, Dudley says. The course offered instruction in introductory forensic nursing as well as criminalistics, investigation of injury, plus psychosocial and legal issues and a 60-hour clinical internship. Dudley says Lynch was a guest lecturer, and when Dudley passed her forensic pathology boards and accepted a position with the Maricopa County Medical Examiner's Office in Phoenix, she asked Lynch to teach her course. Dudley says she was eventually phased out of the program due to her need to commute between Arizona and Colorado, and decided to create her own medico-legal death investigation course, Forensic Medical Investigation, in . The four-day course covers everything from an introduction to forensic investigation, to injury recognition, sudden natural and accidental deaths, to child fatalities and domestic homicide, plus a forensic skills internship.

Since , Dudley has served as chief medical examiner/forensic pathologist and district coroner for the Sedgwick County Regional Forensic Science Center in Wichita, Kan. In her ongoing support of forensic nurses, Dudley reports she has hired her first forensic nurse to work in her office as a forensic photographer.

"I think nurses are ideal in death investigation," Dudley says. "When most people think of death investigation, they think about crime scene identification; yet crime scenes are a minor part. As much as 70 percent of cases referred to the ME's office are mainly natural deaths; the rest are motor vehicle accidents, suicides and homicides. The police department's concern is the crime scene; they don't want someone without training coming into 'their' crime scene and moving everything around. Death investigators don't want to do that either. They are there to be my eyes and ears, and to get the body out of the scene once they are able to process a path to it and bring it back so I can make a determination of cause of death. It's critical that at every scene, every time, certain things are done -- photos taken, information gathered and the scene secured. Nurses make excellent medico-legal death investigators because they have the science background. They just need to be cross-trained in criminalistics and legal issues to be expert witnesses."

Because crime scenes can be hospitals, Dudley says forensic nurses in a death investigator role have a big advantage. "They can interface with physicians, they can find the medical histories on individuals; they can look at the medications at the scene and have an idea of why the person may have died. That may be difficult for someone from law enforcement. They may see Dilantin and not know what that was for; a nurse will know this person must have had a seizure disorder. That's why I have no hesitation about hiring nurses to work as death investigators."

Dudley encourages forensic nurses who want to become death investigators to get the necessary training through independent courses as well as through the American Board of MedicoLegal Death Investigators, which offers standardized certification. "They need 30 hours of classroom content and then they need to be checked off on their skills by a preceptor who is a medical examiner or another registered death investigator. They must sit for the four-hour registry exam, and then to actually be certified, they must have 4,000 hands-on hours working with the ME's office. This credential may be challenging for some nurses to obtain, but it's worth working toward."

She says the majority of the individuals who attend her courses seek to broaden their scope of knowledge and see forensics as a dynamic specialty. "Many of the nurses I see have gone as far as they can in nursing and they are disillusioned; they don't feel part of a team anymore," Dudley says. "In forensics, they are a big part of the team. When I presented my course in Colorado Springs, nurses said they loved it, calling it the most interesting and stimulating course they have ever taken. They are just like sponges, soaking up information. My advice to them if they want to get into the field is to get credentialed and registered and take as many courses as they can to establish themselves as experts and be ready when new opportunities present themselves."

Dudley admits it can be difficult to break into death investigation, especially since it has been traditionally a male-dominated field. "There is a turf mentality until they are educated about how important it can be to have death investigators with special training to handle natural-death cases, which are not law enforcement's focus, on their team. Medical examiners need as much or more history when the case is a natural death, so we need investigators who can get that background information -- and nurses are a natural at it. We're not even at the tip of the iceberg yet as far as the potential of nurses in the field of death investigation."

Forensic Pathologist Creates Online Course for Forensic Nurses

Julie Brown's circuitous route to the world of forensics supplied her with the breadth and depth of clinical, business and legal knowledge it takes to have written the new online forensic nursing course offered in January by Kaplan College. Saying her career evolved naturally, Brown, a former registered nurse and MD, parlayed early nursing experience into her medical degree. A move from Illinois to Arizona was followed by a residency in pediatrics; however, marriage and family commitments caused Brown to search for a calling that allowed her some flexibility. Pathology seemed to fit the bill, so Brown completed her four-year residency in this specialty and knew she was hooked. Brown says she continually pestered the head of the residency program until she was allowed to visit the medical examiner's office.

"That's when I fell in love with forensics," Brown says. Her desire to work for the ME's office was sidelined when the county was hit by a budget crunch, but Brown was enterprising enough to earn her MBA from the University of Phoenix while biding her time for forensics work.

"Since I couldn't get on with the county right away, my business knowledge gave me the confidence to start my own private autopsy business," Brown recalls. "The autopsies I did for funeral homes weren't forensic autopsies but I got more experience. And then I got the magical phone call to work at the ME's office."

Brown says she trained there for two years, fulfilling the requirement of attending 50 death scenes. She says that because of the caseload at that time, few MEs went out into the field. As a result, Brown says she was the one sent to investigate the scene, even though death investigators weren't a part of the ME's office.

"Mary Dudley (see profile on page 19) was instrumental in getting death investigators to our office and training them," Brown says. "Most of the homicide detectives handled the death scenes, natural or otherwise, and there was some reluctance to allow our death investigators in. So they didn't go to homicides, just natural deaths. It was a real shift in thinking when death investigators eventually were called in on all cases. It wasn't necessarily a threat, it was just such a different approach to investigating a death scene."

While Brown was working for the ME's office in Phoenix, she joined DMORT to gain additional forensics experience. While her first several deployments -- including staffing the medical team sent to aid a Kosovo refugee camp in New Jersey and caring for disaster workers in Georgia -- she soon found herself in North Carolina, assisting with the identification of bodies that had been released from caskets by torrential rains and rising flood waters. "Many of the bodies had been identified by using information given to us by family members regarding appearance, artifacts that had been buried with them or through fingerprints," she says.

Brown also was deployed to the site of a plane crash off the coast of Rhode Island. "DMORT members do what's needed, so it doesn't matter what the job is," Brown says. "I worked in the antemortem records room; as information from families and dental X-rays came in I would help with filing and record keeping." Brown says she also assisted forensic pathologists in New York City in the wake of the September 11 terrorist attacks, as well as at the tri-state crematorium incident. Because she also is on the weapons of mass destruction (WMD) team, she is frequently called away for training on the decontamination of bodies in such an event.

Several years ago Brown began teaching criminal justice, a long-time interest of hers that brought her career full circle. "Much of our work as forensic pathologists has to do with homicides and crime scenes so we are involved in the criminal justice process. Brown studied under the administration of justice program at a local community college to understand the bigger picture and to assist her in her consultation work with attorneys on medical case. An inquiry with Kaplan College regarding their need for an online criminal justice program instructor led to her contract to write Kaplan's new forensic nursing program. Brown saw it as an opportunity to bring together all the disciplines in which she'd been involved for years.

"I thought of how my career had evolved through forensics and all of the obstacles I ran into, so I knew I could help nurses train in forensics and criminal justice," Brown says. "People don't like the idea of appearing in court, so I knew I could teach them how to testify, write reports, document death investigations, and I really wanted to emphasize communication skills and nonverbal cues." Brown points to the first case of child abuse she'd encountered at a large metropolitan hospital. "Having been a nurse in a helping profession who trusted everyone, I didn't question anything. A child who had been hurt was brought in for X-rays. I saw a fracture but at the time I didn't think anything of it. Someone more experienced said, 'That's not an accidental injury.' I had no clue the family was lying to me. As nurses, we're not like cops; we assume everyone is honest, but we need to pick up on nuances. The case ended up with a good outcome for the child's welfare, but I think had the child gone back into the home the abuse could have continued. It was a real eye opener. In writing the Kaplan course, I had to identify what I wasn't prepared for when I entered forensics and address those key points."

Brown's goal while writing the program was to translate everything she had learned in her world to the nursing world. "I've seen many situations where it would have been very helpful to have a nurse involved at the scene," Brown emphasizes. "The stereotypical role of forensic nurses is handling sexual assault cases, but there is a real need for uniform treatment of victims who present in the ER and at urgent care centers, where abused patients usually get whoever has time to see them. In these busy care settings you need a dedicated person who knows about chain of custody for evidence collection, who is trained in preserving evidence. There is such great reluctance on victims' parts because they are afraid of further trauma. If they have good care up front, they will be more likely to press charges and go to trial. I've seen situations where a person has been shot, been brought to the ER and the clothing has been lost or the bullet holes have been cut through. Ask ER folks what they saw and they say, 'I don't know.' I understand that their job is to save lives, but a forensic nurse will not get in their way and will document everything while they are saving lives. And they will save the forensic evidence needed to prosecute the case. Lives can be saved and the medico-legal process is not undermined." Brown adds, "No one wants murderers walking the streets so part of our job is to not to bust the bad guy but to seek the truth -- and the evidence will speak the truth. What we find can exonerate or convict. Forensic scientists and forensic nurse work together to find that truth."

To that end, Brown has placed great emphasis in the Kaplan course on preparing forensic nurses to feel confident about appearing in the courtroom.

"Nurses feel confident on their own turf in the clinical arena but can feel terror in court," Brown confirms. "Those with a medical background think court is horrible, and they forget that court is merely part of the criminal justice system. Understanding this system eases a lot of fears. Nurse must realize that attorneys who yell or try to defame them are trying to make then look confused or upset to plant doubt in the jury's minds. If you anticipate this behavior and remain calm and composed, you will look better to the jury. If you remain unruffled, the attorney comes off looking bad. If an attorney tries to make you look bad, that means your information is a threat to his case. If you are attacked you should never take it personally. Understand that you are only being attacked because you did a good job."

Click here to Subscribe

More News