Recent mass casualty incidents in the United States, including the movie theater shooting in Aurora, Colo., the school shooting in Sandy Hook, Conn., and the Boston Marathon bombing have highlighted the important role emergency medicine plays in our nation’s health system. These incidents have also highlighted and brought attention to another important need in emergency medicine, clinical forensic emergency medicine.

In an article just days after the Boston Marathon bombing, Dr. Louis Alarcon, medical director of trauma surgery at the University of Pittsburgh, highlighted the importance of forensic evidence collection.

“We collaborate closely with forensic pathologists and law enforcement,” he said

“Our first priority is to save the patient’s life – life and limb over everything. Once we achieve those goals, we also have a strong duty to the evidence.”

Dr. Alarcon went on to say, “‘At Tufts Medical Center in Boston after Monday’s marathon bombing, doctors worked with law enforcement to collect and save fragments of shrapnel that became projectiles with the force of the bombing,’ Robert Osgood, M.D., told Boston’s WBUR-FM.”¹

Dr. Alarcon added, “Emergency physicians painstakingly search for bullets, metal, wood, plastic, or other substances that become projectiles in bombings or other events.” His hospital formalized that search with a standard process for evidence collection and preservation, a process so detailed that it stipulates when plastic versus metal instruments should be used for collection.¹

Clinical forensic emergency medicine (CFEM) is defined as the application of forensic medical knowledge and appropriate techniques to living patients in the emergency department.²

CFEM is the link for survivors of crime and violence to the criminal justice system. Victims who do not survive the violence have the voice of the coroner or medical examiner, but survivors have to rely on emergency physicians and trauma surgeons who have had little or no training in forensics.

Several studies have shown that emergency department personnel do not do an adequate job at handling the forensic needs of their patients. Smialek wrote that evidence from crimes was disappearing from emergency departments because of lack of staff knowledge and training.³ A study of 100 charts from a Level I trauma center found that documentation in 70% was poor, improper, or inadequate. In 38% of cases potential evidence was improperly secured, incorrectly documented, or inadvertently discarded.⁴ In 1983 a paper in the American Journal of Nursing emphasized the importance of evidence recognition and preservation in the emergency department.⁵