Mkgrady8 Gpmdc 3 Forensic Medicine

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the public health and legal responsibilities of clinicians

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to serve as an interface between pts and the state within the context of the public health, legal, and justice systems; to recognize potential epidemics or bioterrorist events, to report certain infectious diseases and certain injuries to state social services or law enforcement agencies

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what do we have to do legally

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Most states in the U.S. have laws that require health care providers to report injuries resulting from firearms, knives, or other weapons; Twenty-three states have reporting requirements for injuries resulting from crimes (intimate personal violence is a crime in all 50 states); Seven states have statutes that specifically require health providers to report injuries resulting from intimate personal violence; The specifics of the reporting requirements vary from state to state, and the adequacy of response by the police to reporting varies by jurisdiction; Inadequate or inappropriate response to the reports (e.g., informing the perpetrator of the report without providing for the safety of the abused individual) can increase the risk of harm to abused individuals; ED personnel should be aware of reporting requirements and police response in their area; Patients must be informed if there is an obligation to make a police report and should also be told about possible ramifications.

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in order to this this we must

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Must be aware of local public health and legal obligations; Must be able to recognize patterns of injury; Must be able to document observations appropriately; Must be able to process evidence in a manner consistent with legal standards

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what if the pt is dead? who needs to examine

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Emergency Department (ED) patients fall under medical examiner jurisdiction if they die suddenly and unexpectedly without a clear diagnosis; Any death that results from the deliberate dissemination of an otherwise natural disease is also a homicide and must be reported to the medical examiner or coroner

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what do we need to report on

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Reporting of SPECIFIC INFECTIOUS DISEASES with public health ramifications (sexually-transmitted infections, food-borneillnesses, others may be required); Reporting requirements usually centered on VULNERABLE PTS suchas children, the elderly, and victims of domestic violence; There may be obligations to report CERTAIN TYPES OF INJURIES like gunshot wounds, knife wounds, assaults, and burns

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what do we need to document

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Knowledge of wound mechanics and production, as well as wound appearance, can provide physicians with important clues to the forensic interpretations of injuries (Wounds and injuries should be diagrammed and/or photographed); The medical record should accurately document objective findings but should not speculate on the cause or mechanism (For example, do NOT state that a gunshot wound is an entry wound or an exit wound, Or that a stab wound was made with a double-bladed instrument); Any evidence collected in the course of treatment must be documented in the medical record, including to whom the evidence was given, in order for the chain of custody to be preserved

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inital evaluation

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Take a proper history from the patient and other reporting witnesses (Include information about the origin of the injury); Document the statements verbatim (In case contradictions arise later on, Such statements are of legal significance and are admissible in subsequent legal proceedings); Examine the injury and document the state of the injury BEFORE THE INJURY IS ALTERNED BY HEALING OR MEDICAL TREATMENT; Other diagnostic and documentary tools, such as photographs and radiographs, should supplement the physical examination

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abrasion definition

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forceful removal of epidermis; rug burn, road burn, road rash, ligature marks, impact with solid objects

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contusion definition

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hemorrhage into soft tissue due to forceful rupturing of blood vessels caused by force applied to the surface of the body (used interchangeably with bruise); if sufficient bleeding occurs to create a lump then the lesion should be a hematoma; a bruise or contusion that is dark red or purple with well defined margins is consistent with having been inflicted <48 hrs before examination; yellow or brown or whose margins have begun to fade is certainly >48 hrs old; if it is in the outline of a bite mark then it is probably a bite mark (swab for saliva)

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laceration definition

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splitting of skin due to blunt force (unlike an incision, lacerations have nerves, vessels, and strands of soft tissue, which bridge the wound); the tear may be confined to the dermis (overstretching) or may extend through the full thickness of the skin into the subq tissue and bone; BRIDGING by intact blood vessels may be eivdent

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incised wound definition

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sharp force injury (the wound is longer than it is deep and has no bridging); Knife blades, shards of glass, and fragments of metal; The sharp edge of these objects severs structures in the skin, leaving no evidence of bridging such as that seen in lacerations; Depending on the shape of the sharp object, the cut edges will be abraded accordingly, whereas the ends of the wound may be squared or pointed; Unique abrasions found around a stab wound may represent the effect of the hilt of a knife blade striking the skin; The location of specific stabs or cutting wounds may suggest the manner in whichthey were inflicted

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stab wound definition

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sharp force injury (wound is deeper than it is long)

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pediatric fractures

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Skeletal injuries maybe detected when a child presents with unexplained swelling of an extremity or refusal to walk or to use an extremity; Fractures may take any form, and most commonly are transverse in nature; Spiral fractures, caused by torsion (twisting) of a long bone, and metaphyseal chip fractures, referred to as classic metaphyseal lesions,suggest inflicted injury, especially when present in infants <6 months old; A skeletal survey should include films of all long bones, the ribs, the clavicles, the fingers, the toes, the pelvis, and the skull. May reveal Periosteal elevation secondary to new boneformation at sites of previous microfractures or periostealinjury, Multiple fractures at different stages of healing, Fractures at unusual sites such as theribs, the lateral clavicle, the sternum, or the scapula, or repeated fractures to the same site

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OI pediatric fractures

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curved, thin bones with diminished bone density and fracture of the middle third of the tibia; blue sclera

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burns

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Electrical energy, certain chemicals, extreme heat, heated objects; A thermal-pattern injury is a common form of abuse or assault, especially in children and the elderly= Flat iron burns, curling-iron burns, immersion burns, splash burns, A sharp or clear line of demarcation between burned and unburned tissue CHARACTERIZES IMMERSION OR DIPPING BURNS, Splash burns are characterized by an irregular or undulating line or by isolated areas of thermal injury

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hot liquid burns

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it takes several seconds to happen so Despite claims to the contrary, IMMERSION BURNS ARE REARLY ACCIDENTAL. Although the time may be slightly shorter for a child, normal children would, if they accidentally put a hand or foot into water higher than 120⁰F, withdraw it in afraction of a second after the tips of their fingers or toes made contact with the water, leaving them with only superficial burns of the tips of their fingers or toes

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mimics of scalds and burns

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Staphylococcal scalded-skin syndrome: sloughing and desquamation in this infant, painful, tender, diffuse erythema was followed by generalized epidermal sloughing and erosions. S.aureus had colonized the nares with perioral impetigo, the site of exotoxin production

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missile penetration

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High (e.g., bullet) or low speed (e.g., arrow) missiles; The entrance wound of a skin penetration caused by a missile is circular, oval, ortriangular, with a CIRCUMFERENTIAL RIM OF ABRASION; Outer skin edges of an exit wound do not come in contact with the missile, do not sustain friction damage, do not exhibit this rim of abrasion; Bullet, shotgun pellets, shrapnel may be visualized in wound by x-ray; Broken bones may be present

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preservation and collection of evidence

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Blood samples, missiles, and debris found in wounds may be extremely valuable in identifying a particular weapon and in tying this weapon to an assailant; Only useful if proper chain of custody is established= Identify the patient, Date the evidence was recovered–Where it was recovered from, To whom it was given, and signed by the physician is adequate for establishing the chain of custody, An appropriate receipt form documenting the transfer of this evidence

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reporting of death

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Notifying the local law enforcement agency, medical examiner, or coroner of a death that constitutes a medical examiner or coroner case; Enables one to determine whether an autopsy is necessary, which can then be carried out under the same statutory authority; cases that may require referral to the medical examiner/coroner= Traumatic death, Death due to natural disaster, Individuals in police custody or jail inmates, Death under suspicion of homicide or suicide, Suspicion of poisoning, Sudden, unexplained death not clearly related to preexisting disease; CAUSE(S) OF DEATH aka the chain of events resulting in death= Immediate cause of death is the final entity causing death, Underlying cause of death is the original condition or diagnosis from which the chain of events leading to death originated; MANNER OF DEATH= the circumstance under which the death occurred, Natural, Accident, Suicide, Homicide, Undetermined (no witnesses; skeletal remains) (this is for the medical examiner to determine NOT US); Atherosclerosis --> myocardial infarction/arrhythmia --> NATURAL DEATH; Self-inflictedgunshot wound to the chest--> pneumonia--> SUICIDE; Motor vehicle accident--> repairof aortic laceration--> aneurysm at site 10 years later--> ACCIDENTAL DEATH; Blunt force injury of head during robbery--> altered mental function--> aspiration--> pneumonia--> HOMICIDE; Aliving victim, whose injuries were a medical examiner case, remains a medicalexaminer case Regardless of length of time a patient has been in hospital, Regardless of the age of an injury

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underling cause of death, intermediate causes of death, immediate cause of death

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Gun shot wound to the chest (UNDERLYING CAUSE OF DEATH)--> Paraplegia--> Chronic urinary tract infection lasting months--> Septicemia--> severe sepsis andseptic shock- (ALL THESE ARE INTERMEDIATE CAUSES OF DEATH)-> End-organ failure (IMMEDIATE CAUSE OF DEATH)--> DEATH

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what is the MANNER of death for the individual just described? a. natural b. accidental c. suicide d. homicide e. undetermined

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d. homicide