Forging New and Exciting Trails as a Forensic Nurse

By Barbara Katayama, RN, BSN, LNC

For the hundredth time I was explaining to a new friend what I do for a living. I got the usual confused smile. I then launched into my prepared speech about forensic science. No, it’s not the same as CSI (the television show). It’s neither that glamorous nor that gory.

My current job is built around rebuilding the last days of patients that died or were injured under mysterious circumstances. Almost all of these cases are from long-term care facilities. The typical case involves an elderly person who dies while in the care of a nursing home. Somewhere along the line, the staff got distracted, negligent or outright mistreated the person. Typically, the elderly person is cremated quickly. The nursing home has orders to not resuscitate and to take no heroic measures, so they don’t. Sometimes family members are present, sometimes not. When the death is “expected,” the family is called; when it is unexpected, they may never show up at the facility. Mom or dad is disposed of, along with all of the evidence that law enforcement might need to build a case.

For example, Patient A, a 90-year-old with a history of confusion, poor eating habits and wandering through the facility, falls one day and fractures a hip. Following the fall he is placed in various types of restrictive devices that don’t work. He falls again, this time fracturing his pelvis; this goes undiscovered until right before he dies. He becomes more agitated due to the pain of both fractures and he is difficult to handle. He is still 6 feet tall and most of the aides who are female are tiny and can barely manage him. He calls for his wife often, and when she isn’t present he cries out for her and refuses care until she arrives. She is only slightly younger than he is, with her own medical issues and it takes a great deal of strength for her to come to the facility every day, sometimes twice a day. But she comes.

He likes to stay independent and still wants to go to the toilet by himself. Late at night his confusion increases, but the call to void is strong. He pushes the call light and no one answers, at least not soon enough. This ex-Marine and officer of a big company stands in a wet diaper, hoping someone will come. He pushes the bedrails down with his still-strong hands and climbs over. He can see the bathroom light just at the foot of his bed. As he clears the rail and his foot hits the floor, he slips and lies there until morning. When he is found, he is bleeding from a laceration on his forehead. He doesn’t recall anything. He is taken for stitches. In time he learns it’s easier to hold his urine than to wet his bed, or to try to get staff to take him to the toilet. He is diagnosed repeatedly with urinary tract infections. The last months of his life he is off and on antibiotics of every description to treat this problem. Finally he becomes septic, his system shuts down, and he dies.

His daughter, a nurse, is not satisfied with the facility’s statements regarding how her father died. She contacts the Department of Health Services to investigate. They find that the facility did fail to care plan and implement properly — a Class B citation and an $800 fine is levied. She contacts the Department of Justice and decides that perhaps law enforcement can do a thorough job of researching and bringing the person or persons responsible to justice. That is where I come in; my job is to receive volumes and volumes of medical records. I sit down and start at the beginning, as if reconstructing a life, and pinpoint each and every turn that might have been causal in terms of a patient’s decline and demise. I review the history, admission, documents related to any medication administered, physicians’ orders, nurses’ notes, and social service notes. If I am lucky I can interview witnesses; if not, I depend upon the special agents to do that work. I am supplied with the interviews. I am able to tell the agent that we could use an interview from the pharmacist and he/she will do that. Once I’ve reviewed and discussed everything, I write a report. The report is my opinion based on the documents I’ve reviewed. For instance, a doctor might write, “Patient died from pneumonia.” Nothing in the record really says the patient had even as much as a cough, but what the record might show is a lengthy history of urinary tract infections. It’s my job then to connect the dots. When was the first infection, how close was the last one to the demise? What did the patient’s vital signs look like? Any X-rays?

My reports are used by the agents to develop their cases and to present them to the attorneys. The attorney and I will confer with the agent and decide where the holes might be, what further evidence we might need, etc. At that point, typically the case is in the hands of the attorney and I don’t hear anymore until the case goes to court.

What prepared me for this role? I started my nursing career like most. I worked medical- surgical units to get good basic skills. On med-surg floors you see almost everything. I went from that to oncology. I soon grew bored, which is my personality. I needed more of a challenge and decided to try neonatal intensive care. I was hired at a local children’s hospital and trained to work level-three intensive care. I was also trained to do transport of critically ill infants. I learned a great deal about medicine and not just nursing. We had to understand ventilator settings, how to calculate drips, recognize when a baby was crashing and not depend on a physician to grab the reins and rescue everything. I developed nerve as well, and the ability to talk directly about my concerns and be a strong advocate for what I thought was right. We had a unique environment in which this type of attitude from a nurse was respected.

To make extra money I started working as a community health nurse for the local visiting nurses association. They had a fledgling newborn program and I fit in perfectly. I made visits to early-discharged mothers and taught them about infant care. I did assessments, started IVs and conducted phototherapy for jaundiced newborns. I sent many a new babe and mom back to the hospital when my senses told me something was wrong. I began to work with adults in home care as well, doing wound care, respiratory care, and the entire assortment. Soon I was being sought after to work in management. I was a home care supervisor and director of nurses. Office work was a welcome change from driving constantly and eating in my car, but it entailed intense review of every piece of paper in the place — employee files, bookkeeping, patient records, etc. In time I earned my lactation educator certificate and taught lactation to my home care-visit moms.

Later I took a class and became a certified sexual assault nurse examiner (SANE). I was uncertain at the time exactly what this would be like, but soon found it was the same as all other nursing disciplines — you deal with fear, shame and concern. You also deal with the police, social services, and hospital personnel who might resent your presence and sabotage your work. Most of the rape exams I did were at night and called for long lonely treks on dark highways to outlying hospitals. I often worried I would become a victim just trying to get to work. After this, I felt I needed to have another job. I was hired on at the state of California Department of Health in the licensing department. I was placed in an academy and was taught the art of surveying according to state and federal regulations. I was taught how to work as part of a team, and how to write reports and deficiencies. I did this for approximately four years before I began to tire of the routine of this job as well. I was invited to give a talk for some agents with the Department of Justice (DOJ) on sexual assault response teams (SART). I asked my then- SART director to assist me since I had never done this before. Together we did the presentation, which was well received. I was asked if I would be interested in working for DOJ. What I didn’t know was that DOJ was a law enforcement arm of the state, and had few, if any, nurses. I decided to jump in with both feet. I got more curious about forensic science while doing SART nursing, but realized that no one outside of a few nurses knew what forensic science was. Television hadn’t caught the forensic bug yet. Following September 11th, I believe the general public became aware of the importance of forensic science when it became necessary to identify victims — especially when there was little remaining to identify. Relatives were asked to produce anything — such as toothbrushes or combs — that might aid in DNA matching.

I received my certificate in legal nurse consultation recently to increase my knowledge of legal jargon, and how the courts work. Still, most people — including those I work with everyday — see me as “just a nurse.” They don’t understand what I do, and I am attempting to educate them.

At some point I predict that city and state governments will have forensic nurse job descriptions, and those nurses will work arm in arm with corrections, law enforcement, and auditing, etc. I feel privileged to be in such an exciting job with so many possibilities — and a job that can do so much to help those who can no longer speak for themselves. Preparation to be a forensic nurse can take you in many directions. Now, there are college courses; however you prepare, you are forging a new and exciting trail. It will grow and hopefully one day police departments and fire departments will employ forensic nurses as well.

Barbara Katayama, RN, BSN, LNC, is a resident of San Diego.

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