Championing the Medico-legal Process

By Kelly M. Pyrek

Georgia A. Pasqualone, MSFS, MSN, RN, CEN, DABFN, has assembled an impressive list of credentials thus far in her career, but she isn't one to rest on her laurels. This Massachusetts forensic nurse consultant -- who balances her time between her work as a certified emergency nurse, a national and international lecturer, a death and crime scene investigator, a forensic photographer, a legal nurse consultant and a lieutenant colonel in the USAR Nurse Corps -- is an advocate of lifelong learning and is constantly attending courses, conducting research and sharing her hard-won knowledge with her colleagues and students.

This champion of the medico-legal process says she learned one of the most valuable lessons ever from one of her graduate school professors. Pasqualone was earning her first forensic master's degree in the crime scene investigation track at the University of New Haven, and a research project required her to radically adjust her way of thinking. It was an unexpected thought process that has stayed with her throughout her career.

"At the time of this project, the O.J. Simpson trial was all the rage," Pasqualone reflects. "Our entire program dealt with trial issues and the investigative process. Because I was a nurse, my professor told me I was to deal with the medical evidence within the trial, such as the stomach contents, the DNA, the blood, etc. I said, 'That's easy.' He said, 'But you are to research the medical evidence and present it to me as though you were preparing a brief for the defense.' I stopped dead in my tracks. I was forced to think objectively about everything I had learned; everything is not as it seems, I cannot take everything at face value, and not every defendant is guilty. I could still tell the truth about that evidence but I had to present it as he had asked. I had to analyze what the defense and the prosecution did with the evidence and how Johnny Cochran could have used it as a defense for his client. By being objective and letting the evidence speak for itself, you can get to the truth. However, many things were messed up in that case and that evidence, although it does not lie, could have been used and abused by the attorneys."

That mind-bending experience, and subsequent forensic training, has sharpened her clinical skills, Pasqualone reports, but both areas of expertise have substantial crossover ability.

"My forensic training has made me a better nurse, but my nursing skills have helped me be a good investigator," she says. "As a nurse, I was taught to be a fact finder. There is no one in the world better at getting the facts than a nurse. We can ask people questions they don't realize they are answering. I have been able to develop these psychosocial skills even more with my forensic training. I am much more aware of what I am looking at; what I am smelling on someone's clothing, on their breath or about their person; I am more aware of what they are wearing, if there is foreign debris on their clothing or under their fingernails; I am better at looking for injuries and trying to detect a pattern; so forensic science education is critical. It has developed my nursing skills so that I am better attuned to my patients. I'm not sure I would be half as good a forensic investigator if I didn't have the nursing background."

Pasqualone likes to describe forensic nursing as a state of mind, a detective process and an analytical way of thinking that kicks into high gear when a potential forensic case presents.

"Unless you are employed in a job where you can be called a forensic nurse consultant, a sexual assault nurse examiner or a legal nurse consultant and are doing that 40 hours a week, forensic nursing is something that is incorporated into your practice," she explains. "You can be an ER nurse and suddenly a child comes in and you suspect child abuse, or an elder comes in and you suspect elder abuse. Something should click in your head and suddenly you are wearing the hat of a forensic nurse; all the things you learned about being a forensic specialist now kicks in and you think about injury patterns, photo documentation and evidence collection. It may not be a hat you wear all the time but it is a sense of knowing that exists below the surface."

Pasqualone points to home-health as an example of a nursing specialty that deals with potential forensic patients. "Home-health nurses would not describe themselves as forensic nurses yet they are the nurses going to what could be a primary crime scene. They are the ones who first see the environment, the people in it, and they are the first to see if there has been neglect or mistreatment in the home." Pasqualone adds the emergency department (ED) or the intensive care unit (ICU) also are prime arenas in which forensic cases present.

"A nurse may be caring for a patient in the ICU and discovers she has been sexually assaulted, or a child is brought into the ED for a tonsillectomy but the nurse sees bruises and isn't sure what to make of them. That's when forensic training kicks in. Forensic nursing isn't necessarily one hat you put on continuously; it's a role you fall into when the moment presents itself."

The continuum of the medico-legal process often includes building a case and taking it to trial--a component that makes even the most brave forensic nurse quake in his or her shoes. Pasqualone, a veteran of the courtroom, says stage fright is natural, but forensic professionals must keep their fears in check and focus on presenting the evidence.

"You must have strength of conviction to get in front of a group of people and be able to speak your mind," Pasqualone says. "Very little, besides ongoing experience, can prepare you to face judges and juries, as well as opposing attorneys who continuously badger you. They try to trip you up by saying things like, 'Ms. Paqualone, you would say anything you could to protect your patient, wouldn't you?' That's a loaded question, so no matter what you say, yes or no, you are backed up against the wall. Then you start stuttering and you feel you have lost all credibility. All you ever wanted to do was get up there and tell the truth. Nurses shake in their boots at the thought of going to trial as a fact witness because they don't want to be subjected to that kind of humiliation. They get rattled and say things they never meant to say or maybe they say too much because they are trying to backpedal to get out of the hole they know they are falling into."

Pasqualone has survived her share of painful courtroom proceedings and shares with her students effective techniques to avoid being nailed to the wall by cross examination.

"I give them examples of the times I fell flat on my face. I say, 'This is what happened to me, and in retrospect, let's talk about how I got in this position and what to do to prevent this from happening to you.' Forensic nurses have not had enough opportunity to be educated by other veteran forensic nurses; there aren't enough of us around yet. They haven't been taught how to act in a court of law -- what you say to attorneys, how you behave, how you dress, how you present yourself and what you don't say."

Pasqualone recalls the first time she went to court. "It was a hearing so my job description that day had not been delineated. I was going in as a fact witness because I was acting as a nurse investigator for a criminal defense attorney and I had interviewed witnesses and I knew what was going on with the case. The judge allowed me to testify as a fact witness but because I was also a nurse, he allowed me to give my opinions as they related to adolescent behavior and sexual child abuse. The assistant DA ripped me apart. It was the first time I had ever been to court to testify in that kind of capacity and I was reduced to rubble. The attorney I was working for said he couldn't even look at me on the stand because it was too horrible. At the end of the session, this attorney must have spent an hour with me in the back of the courtroom after everybody cleared out. He said, 'You know she was paid to do that; it was nothing personal. You have to be more aware of and anticipate the hole they try to push you into. It has nothing to do with you as a nurse.' I thought everybody loved a nurse because we are angels of mercy. But here's this woman pulling me apart and blowing holes into my testimony. The attorney pasted me all back together again like Humpty Dumpty and said, 'When this is over, you will never do that again.' He was right."

Pasqualone says nurses' outgoing, communicative nature often is the very characteristic that gets them into trouble.

"Nurses do talk too much because we try to put our patients at ease," Pasqualone says emphatically. "It's a communication pattern among healthcare professionals. Nurses talk too much because they are very social, they want to educate. It gets us into trouble in court when it should be 'just the facts, ma'am.' Nurses need more classes on how they should conduct themselves in court, more mock trials and more nurses who have been to court should share information with other nurses."

Most forensic nurses who find themselves on the stand are fact witnesses, who go to court to tell the story, Pasqualone explains. "A patient comes into the ED and the nurse cares for him/her. Whatever transpires, whether the patient has injuries or has said something to the nurse, everything is documented. In court, the nurse is a fact witness to the way the patient presented his/her injuries, and a fact witness to the nursing notes, to the photo documentation, and to what they saw, heard and documented."

Pasqualone says the number of nurses testifying as fact witnesses continues to grow, while the number of nurses considered knowledgeable enough to be expert witnesses is still small--a source of contention between doctors and nurses.

"In the past, physicians have been the ones asked to testify as expert witnesses, even to nursing processes," Pasqualone says. "Physicians have no business testifying about nursing; they don't know what we are all about. They haven't been to nursing school and they know nothing about what we do and how we care for patients. Attorneys are wising up. They are starting to call nurses as expert witnesses in fields where nurses have a great deal of experience. I have 32 years in critical care and emergency nursing so I think I am well equipped to have an opinion about nursing care and what nurses should or should not be doing. With my graduate studies in forensic science and forensic nursing, I feel I can have an opinion about patients that fall into my forensic categories. SANEs are entitled to have an opinion about what they see, how patients present and all the psychosocial ramifications of rape trauma syndrome. Attorneys are realizing that nurses are doing more in their clinical practice that the physicians aren't privy to."

Pasqualone says a factor contributing to her first humiliating courtroom appearance was that the judge had never encountered a forensic nurse and was interested in her opinions. She cautions that the best of intentions can backfire and that forensic nurses must realize every word that comes out of their mouths has significant impact and can trap them.

"I will never be backed into a corner like that again and all nurses must learn this valuable lesson," Pasqualone says. "After a horrible experience nurses must go into court knowing it's not personal; you expect a battle, realize they are going to try to discredit you and you can't get angry. They will try to find all the buttons to push. You just have to take a deep breath, try to out-think them, and try to find the most neutral answer that prevents you from going down that slippery slope."

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