Clinical Guides

Court Testimony

Because it is the most popular topic on FHO, what follows is a clinical guide on issues related to testimony. Clinicians generally identify testimony (and specifically cross-examination) as the most intimidating aspect of their forensic practice, so what’s contained here is meant to help build capacity. Every attempt will be made to update this guide on a regular basis.

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Toluidine Blue Dye

There’s been very little written about TB dye in the peer-reviewed literature over the past 30 years, so I have included all of it (that I could find) here. Some discuss the utility of TB dye in greater depth than others. As with any research, it is imperative that you read these articles (particularly the older ones) with a critical eye toward the methodology used and the relevance of their findings in light of advances in the science.

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Peer Review

The issues of peer review, quality assurance/improvement, and competency are critical ones in forensic healthcare. Because of the potential legal ramifications of our findings, we have to be confident in our capacity as objective clinicians, and current in our knowledge and approach. Having some type of quality assurance process in place can ensure that we meet the highest practice standards, but implementing such a process can be daunting for many. What follows are tools and resources to help demystify this aspect of practice management. I have also included some QA information related to educators and educational offerings, since that’s also a big part of the quality process. Keep in mind this guide is not comprehensive, merely an introduction to current research and information (everything is from the last 10-15 years).

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Female Genital Mutilation

There isn’t a large amount of clinically-focused information out there on female genital mutilation/cutting, and much of it is specific to obstetrics. I rounded up what appeared to be the best and most current articles and clinical guidelines. As always, it’s not exhaustive (I opted to leave most of the obstetric-specific information out), but it should be useful.

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False Allegations in Sexual Assault Cases

Statistics surrounding false allegations in sexual assault cases are bandied about in our line of work, but rarely do we actually review the full breadth of the research. Generally articles are cherry-picked, and older studies with frequently scrutinized methodology are often brought up when I teach. What follows is the current research on this topic.

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Evaluating Research

For anyone who’s ever heard me speak on the issue of providing ethical and effective court testimony, one of the main topics of discussion is always about being able to support your opinions with credible scientific information. That, of course, leads into a discussion of how you actually do that. Fortunately, many smart people have addressed this topic.

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Determining the Age of Bruises

I receive a lot of questions about determining the age of bruises. Although the research has shown that determining the age of bruising by clinicians based on color provides consistently inaccurate results, with poor interrater reliability, I still find that some are loathe to turn their backs on this highly unreliable assessment technique. So I have provided an overview of the literature below, with articles split into 2 categories: those that address the attempt to age bruises based on color in a routine clinical environment (Clinical Assessment of Bruises) and those that have a much more high-tech approach (Laboratory Assessment of Bruises). These articles address aging bruises using equipment and mathematical models not typically seen in our routine clinical practices. It’s important to note that studies in the latter category found greater success at determining the age of bruises, which further emphasizes the unreliability of visual assessment alone.

The articles below address bruising in a wide range of populations. Some specifically address pediatrics; one specifically addresses older adults.

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Consensual Sex Injury

The original research grid I created on consensual sex injury while writing the book chapter on this topic has been updated many times. It’s been refreshed again, as I try to do regularly. If you want the word doc with links to the abstracts, please note it is available for purchase now at Scribd ($0.99), as it is incredibly labor intensive. Otherwise, you can click the link to download the PDF of the research grid.

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Compassion Fatigue

It seems like compassion fatigue (and its sisters, vicarious trauma and burnout) don’t get nearly enough attention in our professional circles. But really, they should–a recent study found that 85% of emergency department nurses surveyed reported moderate to high levels of compassion fatigue. I’d be interested in what the results would look like if they surveyed a group of forensic clinicians.

Many people have read and liked Trauma Stewardship; I personally enjoyed parts, could leave other parts entirely. But it’s a worthwhile read (and I think if you ever wanted to have a book discussion with your team, this would be a good selection). If you’re not talking about it with your colleagues (and not just clinician colleagues), it’s time. Chances are good someone you know is struggling with this. And it might be one of the top 3 issues impacting staff retention in our programs right now.

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Bite Wounds

Periodic requests come down for information on bite wounds in living patients. However, there are caveats to this one— research is only included that was applicable to the work of clinicians. Any of the research on bite mark impressions and the challenges to that science are not included here (no disrespect to our forensic odontology colleagues, but that’s a very different area of science). Contained here are articles related to identifying, managing, sampling and documenting bite wounds in the living patient.

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Alternate Light Sources: Part I (Identifying Fluids on the Body)

The issue of Wood’s Lamps and other alternate light sources (ALS) in sexual assault medical forensic exams comes up at courses and conferences regularly, which makes me reflect on how often we do things because we were taught we should, and not because they’ve been shown to be particularly useful or effective. So what follows is an overview of the literature on ALS in the detection of semen on the bodies of sexual assault patients.

The general gist of the literature is that Wood’s Lamps are ineffective for consistently identifying semen in the medical forensic exam; other types of ALS seem to be more effective. That being said, being able to document the presence of a glowing substance (since many things fluoresce under ALS) may still be of limited value for the forensic healthcare professional. Review the following articles for research and information on the subject. To be clear, the amount of research done on the subject is not overwhelming–there’s a definite need for more data as related to detection of semen on the human body with the tools generally found in clinical practice.

An important note: If you are using any type of alternate light source, you must be able to articulate how it works and the science to support its use. Should you go to court, this line of questioning is fair game.

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Alternate Light Sources: Part II (Identifying Subclinical Bruising)

There is little research that supports using ALS for identifying subclinical bruising, so from an evidence-based standpoint you are out in the weeds if you are using this tool for such purposes. However, because people seem to be particularly fascinated with the technique (and alarmingly, it’s being taught in some parts of the country as a best practice) I have done a round up of the existing science. Remember: just because an article is published in a peer-reviewed journal doesn’t mean it’s quality research or generalizable to a broader population. Read all research critically. And perhaps familiarize yourself with some key research terms, like sensitivity and specificity, because this is what is at issue with the current state of this science.

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Adverse Childhood Experiences

The Adverse Childhood Experiences (ACEs) research is some of the most important in our field. There’s little related to forensic healthcare that isn’t impacted by the results of Dr. Felitti, Dr. Anda and their colleagues. It would be virtually impossible to include all of the information available on ACEs, but I have tried to provide a good sampling of resources. If all else fails, follow the PubMed search at the bottom of this guide for the most comprehensive and current science.

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Social Media Use for Forensic Clinicians

Social media use is ubiquitous at this point, but there’s much we simply don’t discuss: about its appropriate use; left and right limits of what should be posted online; and the type of training and policy creation that should be happening on the subject. What follows are resources to assist with all of these. Note that this is really focused on the ethics of using social media when you are a clinician who can fully expect to end up in court. This doesn’t touch nearly so much on using it for clinical practice or research. As always, the guide isn’t exhaustive, just a place to begin.

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