RAMS Clinical Forensics Roadmap

Clinical Forensics Clinical Forensic Emergency Medicine is a niche within the field of emergency medicine that addresses the result of criminal activities, and the legal ramifications of those actions, including firearm-related injuries, knife and blunt-object related injuries, motor vehicle collisions, sexual assault and abuse, child abuse, human trafficking, and domestic violence.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

background

Senior RESIDENT

Resources

AUTHOR: Aaron R. Kuzel, D.O., M.B.A. Contributors: Ralph Riviello, M.D., FACEP Welcome to the Clinical Forensic Emergency Medicine Roadmap, your definitive step-by-step guide on how to succeed in Clinical Forensics at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, and podcasts can be found in “Resources.”

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

insider Advice

1 - SENIOR MEDICAL STUDENT (MS3 and MS4) Congratulations for considering Emergency Medicine as your specialty and having an interest in serving victims of criminal activity. Forensics is a young field or niche in emergency medicine; with that, there are few tasks a student can complete to illustrate interest and learn more about career opportunities.

TIMELINE

FAQ

During MS3/MS4 Year: • Seek Mentorship: While there are few programs with forensicfocused faculty in Emergency Medicine, there are ways to be involved with forensic medicine while as a medical student.

Are there particular residency programs for which I should apply?

There are no definitive answers or determined benefits on whether to choose a three or four year emergency medicine residency in regards to a career in forensics. A four year program does allow for more elective rotations in residency to further explore forensic medicine opportunities, however.

– Th e ACEP Forensic Medicine Section is an active membership that meets each year at the ACEP Annual Meeting. Students can join the section and have access to mentors in the field.

• Shadow Mentors: If your hospital has a forensic emergency physician, forensic pathologist, or sexual assault nurse examiner, ask if you can shadow their work day.

• Rotations: Students interested in Emergency Forensic Medicine can schedule electives at the following institutions:

– State Medical Examiner’s Office

– F orensic Psychiatry Rotations offered at participating VSLO Programs

– O ther forensic based electives offered at a participating University or Community Program

• Involvement and Conference Participation: Students interested in forensics should seek out training with and possible certifications as a sexual assault nurse examiner. Students may also be able to arrange the following activities:

– A ride-along with law enforcement

– A ride-along with local or state evidence response teams.

– A ttend the Scientific Assembly of the American Academy of Forensic Science.

Most emergency programs, regardless of community or academic designation, have some degree of forensic operations including sexual assault nurse examiners or hospital committees devoted to child abuse, sexual assault, elder abuse and other forensic-related issues. Academic programs or trauma centers with forensic departments will usually offer more opportunities than a community program.

2 - JUNIOR RESIDENT TIMELINE As a Junior Resident, there are actions you can take to set yourself on the path to a career in forensic emergency medicine.

Identify a Mentor: • Identify a mentor in your program who has a working relationship with:

– Law enforcement or other front line city officials.

– Serves as a medical director to a sexual assault nurse examiner (SANE) department.

• W ork with your mentor to obtain educational opportunities and certification in forensic medicine, or determine opportunities for law enforcement education or research projects.

• I f your program has no mentors in forensic medicine, you can join the ACEP Forensic Medicine Section and seek mentors from experts in forensic emergency medicine.

Become involved in Forensic Projects or Research: • A project or research in forensics does not necessarily need to be an extensive project, but a project in improving forensic care or methods in:

– Child abuse

– Elder abuse

– Sexual abuse and Assault

– T raumatic Injuries related to criminal activity such as police-involved firearm injury, criminal or gang related firearm injury, and sexual assault.

• Junior residents should work with their mentor to identify areas of forensic research the resident can assist or use as a scholarly project.

3 - SENIOR RESIDENT As a Senior Resident, you should continue to work with your mentor to establish a plan in achieving an academic or community position where the senior resident can practice forensic emergency medicine.

TIMELINE Electives • You should perform an elective in forensic medicine, if available, or work with your mentor to participate in or develop activities that will increase your exposure to various aspects of forensic medicine, for example:

– Take call with a sexual assault nurse examiner (SANE) program.

– D evelop and give lectures of forensic topics or coordinate training programs with police and evidence recovery teams.

• I f your department does not offer electives with the forensic patient populations you might seek out electives or programs that have departments dedicated to forensic emergency medicine. Some programs that off forensic medicine electives include:

– D rexel University College of Medicine

– Th e University of Louisville School of Medicine

– W ellspan York Hospital Emergency Department

– Other emergency departments with designated forensic centers.

Certifications and Training: • You should consider achieving certification or training with different aspects of law enforcement. Residents interested in forensic medicine should consider receiving SANE certification or taking online courses offered from the International Association of Forensic Nurses. Additionally the California Clinical Forensic Training Center offers courses including a course on Forensic Photography which may prove useful for a forensic emergency physician.

Networking • You can seek opportunities to network:

– Network with the ACEP Forensic Medicine Section

– A ttend the annual ACEP Forensic Medicine Section meeting at ACEP.

– A ttend the annual SAEM meeting or SAEM’s regional meetings to meet physicians and programs that have established forensic departments or programs.

Continue Working on Forensic Project or Research: • You should continue with your mentor to identify or complete forensic medicine-related projects and research.

5 - BACKGROUND What is Clinical Forensics?

Emergency Physicians frequently encounter in their daily practice victims of criminal enterprise and events requiring investigation. These enterprises can be further divided into traumatic circumstances including gunshot wounds, stabbings, physical and sexual assaults, and motor vehicle collisions; and medical circumstances including child abuse, elder abuse, human trafficking, and domestic violence. Clinical Forensics combines the legal, medical, and law enforcement aspects of patient care to not only serve the medical needs of a patient, but the acquisition of justice for that patient. It includes the collection and preservation of evidence in a civil or criminal matter requiring detailed documentation, expert testimony, and collaboration with local, state, and federal law enforcement agencies.

The History of the Field

The field was developed because of the number of emergency department patients who are victims of criminal activity. In 1991, the Department of Emergency Medicine at the University of Louisville School of Medicine, in conjunction with the Kentucky Medical Examiner’s Office, created the first formal training program for emergency medicine residents in forensics. In 2006, the American College of Emergency Physicians (ACEP) established the Forensic Medicine Section to further address forensic issues in emergency departments. Previously, there existed a 1-year postgraduate fellowship in clinical forensic medicine for residency-trained emergency physicians. However, there are currently no ACGMEaccredited clinical forensic fellowship programs offered. Most forensic departments that exist are adjunct offices within departments of academic emergency medicine.

The Current Academic Track and Duties of a Clinical Forensic Emergency Physician

The academic track is a small niche within the Emergency Medicine community. Duties associated with the track include directorship of a sexual assault nurse examiner program, research in forensic procedures and medicine, providing courses for emergency residents and faculty on forensic procedures and forensic updates, child abuse teams, serving as medical director for crime lab or law enforcement.

The Future of the Academic Track and Fellowships

The field has remained stagnant since its conception in the 1990s and interest varies over the years. The academic track is dependent on selfmotivated students and residents who have an interest in the field. There does exist a program within the Philadelphia College of Osteopathic Medicine that provides a combined degree program of Doctor of Osteopathic Medicine with a Masters in Forensic Medicine. According to experts in the field, it is unlikely that a formal, ACGME-accredited fellowship will be established. However, for motivated residents, programs can develop a non-ACGME accredited fellowship with a Masters program in Forensic Medicine, but it is unlikely an ACGME-accredited fellowship will be established in the near future.

6 - RESOURCES Professional Societies

• A merican Academy of Forensic Science • A merican College of Emergency Physicians (ACEP) Forensic Medicine Section • I nternational Association of Forensic Nurses

Publications

• J ackson MC,Olshaker JS, JacksonMC, Smock WS. Forensic Emergency Medicine.

• P hiladelphia, Lippincott Williams & Wilkins, September 2006, 2nd edition. 305 pp.

• S ociety of Forensic Toxicologists

• R iviello, RJ. (Ed). Manual of Forensic Emergency Medicine: A Guide for Clinicians. India: Jones & Bartlett; 2009.

Journals

• R yan, MT. Clinical Forensic Medicine. Ann Emerg Med. 2000; 36(3):271-273.

• J ournal of Forensic Sciences

• S mialek JE. Forensic medicine in the emergency department.

Emerg Med Clin North Am. 1983;1:693-704.

• Th e American Journal of Forensic Medicine and Pathology • J ournal of Legal Medicine • J ournal of Forensic and Legal Medicine • J ournal of Forensic Medicine • J ournal of Toxicology • J ournal of Medical Toxicology and Clinical Forensic Medicine • J ournal of Medical Toxicology

Recommended Conferences

• A merican Academy of Forensic Sciences Annual Scientific Assembly • I nternational Association of Chiefs of Police Medical Track • I nternational Association of Forensic Nurses Annual Conference

Grants Related to Forensic Emergency Medicine • N o specific grants exist regarding forensic emergency medicine.

Researchers can investigate grants with the National Institute of Justice (NIJ).

• S mock WS. Clinical forensic medicine. In: Rosen P, Barkin R, eds.

Emergency Medicine: Concepts and Clinical Practice. 4th ed. St Louis, MO: Mosby; 1998:248-261.

• S mock, WS. Development of a clinical forensic medicine curriculum for emergency physicians in the USA. J Clin Forensic Med. 1994;1:27-30.

• S mock WS, Nichols GR II, Fuller PM. Development and implementation of the first clinical forensic medicine training program. J Forensic Sci. 1993;38:835-839.

7 - INSIDER ADVICE Ralph Riviello, MD- Director of Forensic Emergency Medicine, Drexel University School of Medicine: “Forensics touches Emergency Physicians in many ways from SANE, child abuse, elder abuse, trauma, police involved shootings, and human trafficking. Emergency Physicians do a great job taking care of the medical needs of the patient, but forensics is equally important in obtaining Justice for an afflicted individual. All Emergency Physicians should have a baseline knowledge of forensics or forensic tasks and procedures, as well as preservation of potential evidence.”

Mary T. Ryan, MD: “Physicians and nurses may be unaware, or at times misinformed, about evidence collection and preservation. Practitioners often assume that excessive time and effort are involved in evidence collection, preservation, and proper documentation.

Others may worry that collection of evidence is at the expense of patient care. Simple steps can be taken to preserve evidence without interfering with patient care. These steps involve small modifications of our current practice and can greatly assist the investigators, and ultimately the victims, involved in these cases.”

William S. Smock, MD- University of Louisville and Louisville Metro Police Surgeon: “Forensic emergency medicine is the application of forensic medical knowledge and appropriate techniques to living patients in the emergency department. Nowadays, most trauma patients seen in emergency room settings are victims. They are not victims of happenstance or accident, but of malice and intent at the hands of assailants ...Given that this is the new reality of our patient population, physicians must practice medicine in particular trauma medicine in a new way, with attention to details heretofore overlooked.” What was once considered confounding clutter that gets in the way of patient care takes on a whole new significance when recognized for what it really is, evidence.”