Forensic Nurse Develops Bruise Detecting Technology For Dark Skin

Katherine Scafide, PhD, RN, a forensic nurse, scientist, and associate professor at George Mason University’s College of Public Health and School of Nursing has pioneered the use of technology using Alternate Light Sources (ALS) with specific wavelengths as a way to better detect bruises on dark skin, potentially leading to improved documentation, care, and legal justice for victims of violence who have dark skin tones. 

During her time as a forensic nurse in the ER, Dr. Scafide, Ph.D., RN, noticed a major problem when assessing victims of violence—individuals with dark skin often had injuries that were harder to detect to the naked eye. “I often would have patients who had dark skin who would report injuries and I wouldn't be able to see anything and the problem is if you don't see it can very limited in terms of what you can document it and if you can't document it, then there's very limited evidence to where you can testify to in court,” she explains. 

To combat that, Dr. Scafide is now developing and evaluating clinical guidelines to support the implementation of ALS technology into forensic nursing practice. Her work has the potential to have a significant impact on how violence is assessed, documented, and treated and Nurse.org got the chance to learn more about her work and how it will impact forensic nursing. 

The Bruise Scientist

Dr. Scafide began her career as a forensic nurse, then earned her Masters as a forensic clinical nurse specialist, and eventually focused on research in forensics as she earned her PhD at John Hopkins University. As a forensic clinical nurse specialist, Dr. Scafide explained that she ended up working exclusively with victims of violence, specifically children and adults who reported being sexually assaulted and those who were victims of intimate partner violence. In addition to her hands-on work with patients, she also worked as a death investigator for the medical examiner's office, identifying injuries that may not be visible to anyone not specifically trained. 

During her work as a forensic nurse and while earning her PhD, she specialized as a bruise scientist, which Dr. Scafide notes is someone who has had specific training in bruises and who investigates bruising. As a bruise scientist, Dr. Scafide also performed research on bruising. “I was trying to understand how we observed bruising and the physiology of bruising in the application of bruising in various fields,” she says. 

As a bruise scientist, Dr. Scafide explains that there are challenges to detecting—and thus documenting— injuries that don’t involve a break in the skin with more obvious damage. 

“The problem nurses face and other health care providers is injuries are often hard to see on patients for a variety of reasons, particularly bruises,” she notes. “Bruising involves discoloration to the skin that is due to crushing or squeezing force trauma, often without any kind of break in the skin and so without that breaking the skin sometimes it's very difficult to see their injury.”

Those challenges become magnified in dark skin because the injuries can be masked. “If you have dark skin pigmentation because the melanin that contributes to that pigmentation is actually located primarily above where the bruises are located in the layers of the skin. So if you have a lot of skin pigmentation, with darker skin, then it's going to be difficult to see the bruise,” she explains. 

She went on to add that there are even more challenges with older bruises. Bruises go through color changes, which can be hard to detect through skin pigmentation or with small bruises. Additionally, how visible the bruise is depends on several factors, such as:

• Where the bruise is located: “The connective tissue may not be able to support having bruises be really visible,” she says. “The neck is a great example. So strangulation injuries to the neck are often very difficult to see because the connective tissue support in the skin makes it difficult for the bleeding to collect and remain and become visible.”

• How much hemoglobin is released: Without a lot of hemoglobin released, the bruising will be very difficult to see. 

“There are a lot of factors that go into whether or not you're able to see a bruise,” she says. 

What That Means for Victims and Nurses

If you’re wondering how the science of bruises translates into a real-life application, Dr. Scafide explains that without being able to see and detect bruises properly, forensic professionals are unable to document them or testify on the extent and existence of injuries during criminal proceedings. 

However, early on in her career, she knew that there was technology utilizing specific light wavelengths that could help better detect bruises in skins of all colors. The only problem? There was no research to back up its use. “The difficulty is that when you're using technology in your practice, you have to testify to it,” she explains. “ And when we testify to it, there has to be research to support its use.”

Without the existing research to support the use of ALS technology, Dr. Scafide decided to create it herself. “I was very inspired by my own practice and also the experiences of other forensic nursing units and their experiences in terms of the challenges they were having in terms of using this technology,” she tells Nurse.org. “So that's what made me decide that you know what, if this technology seems to work, we need to have the research to support its use and so or we shouldn't be using it. So that's what prompted me to really invest my program of research on looking at this technology and others to see if we can come up with better approaches to documenting bruises.”

The ability to use the ALS technology is incredibly significant from both a medical professional’s perspective and a victim’s perspective because Dr. Scafide explains that many victims of domestic violence and assault are reluctant to come forward for a variety of reasons and often when they finally do, their bruises are very old or are located in hard-to-detect areas, like strangulation of the neck: “The skin of the neck doesn't allow you to see bruises very well because of its structure,” she notes. And that’s where technology such as this could come into play, making a significant difference in both being able to identify the injuries of the victim, allowing for proper treatment (Dr. Scafide adds that strangulation especially can lead to very serious medical complications), and accurately charge the assaulter with evidence. 

What is ALS Technology?

Not to be confused with technology for the degenerative disease of ALS, Dr. Scafide explains that ALS stands for alternative light source technology—it’s a technology that utilizes a specific wavelength of light to make bruises more identifiable. She adds that the technology actually has been used for a long time with crime scene investigations and has even been featured on crime shows like CSI: “You’ll see them shining a light looking for blood spatter, or, or other types of latent evidence that you can't see very well,” she says. 

Along with the lack of research into ALS technology, Dr. Scafide notes that not a lot of nurses are trained in using the technology, which has further limited its use. Fortunately, however, that is changing and as more forensic nurses become trained in the technology and it becomes more proven through research like hers, she explains that the light technology is another assessment tool. 

“So in addition to conducting a physical assessment, a forensic nurse does an interview with a patient to find out what happened and get an understanding of where they might find evidence,” she explains. After the patient interview, comes a physical assessment to look for injuries and then evidence and evidence, which is where the nurse can use the alternate light source. 

The ALS, she notes, can help enhance what the nurse is seeing in terms of looking for injuries that maybe they can't see very well or looking for areas of absorption that might be consistent with an injury that they can't see at all, based on the history that they're seeing and hearing. “It's a tool in their toolbox [and] other assessment skills they use to help enhance what they're able to see,” she says. 

What Comes Next?

According to Dr. Scafide, the research she and her teams have done has established that this technology is effective and improves the ability to detect individualized bruises on diverse skin tones. What they are working on right now, she says, is developing clinical practice guidelines to go along with that. “The technology requires the nurses to understand how light works and how it interacts with the skin and we have to make sure that what nurses are doing is evidence-based,” she explains. “And so as with any practice in nursing it does it has to be evidence-based.”

Evidence-based clinical guidelines will set strict requirements on the patient conditions, the technology that can be employed, how to do the assessment, what settings it can be used in, and provide guidance on how to do that assessment in conjunction with the rest of the medical forensic exam. The guidelines will also take into consideration the other people involved with these kinds of cases, including police and law enforcement. Fortunately. Her team does have a federally funded grant that they are using to develop those very guidelines, which they hope to be able to release sometime next year to the public.

Additionally, her interdisciplinary research team is collaborating with George Mason’s Health Informatics and Volgenau School of Engineering to investigate whether deep learning of the digital images can be used to model bruise age as well as develop a national repository for bruise images. 

As for what she hopes will happen in the future as a result of her and her team’s work, Dr. Scafide tells Nurse.org that she hopes the technology will become more widely adopted, along with the guidelines and learning modules that they are creating. “We're hoping that in the future, alternate light sources will be more accessible, more user more accessible and make it easier for forensic nurses to understand how to use it and how to interpret what they're seeing.”

“Interpreting and documenting what they see is really key,” she adds. “Because if you misinterpret or miss document what you're seeing, then that can obviously have a significant effect on the legal outcomes and medical outcomes. So we want to make sure that nurses are properly trained and educated on how to use it.”

If you are interested in forensic nursing, you can learn more at The International Association of Forensic Nursing or The Academy of Forensic Nursing.