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Forensic Medicine WHAT THE PERIOPERATIVE NURSE NEEDSTO KNOW
Carol A. Schramm, RN Mors gaudet succure vita (Death rejoices in helping 1ife)l
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n our increasingly violent society, assaults and murders have become a daily part of our existence. Accordingly, there are more emergency department admissions of both the victims and perpetrators of such crimes. Because many of these patients will require surgical intervention, perioperative nurses are being summoned into what Justice Harry Blackmun called the “unavoidable intersection [of law and medicine where] . . . Cooperation and understanding, rather than distance and isolation, should be [the] way of life.”2 The role of the nurse has expanded from singular patient advocate, to advocate for the community at large. Because of this, the nurse must have a fm understanding of certain aspects of forensic medicine, the science that studies the application of medical facts to legal problems. As professionals and responsible citizens, perioperative nurses need to know how to assist in properly securing, handling, and documenting forensic evidence that enters the operating room. Like physicians, nurses must provide timely care for injured patients while simultaneously recognizing and preserving evidence. As nursing becomes more independent, the individual nurse’s level of practice will be subjected to greater scrutiny.
From Sheriff to Coroner
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he earliest application of forensic medicine dealt with suicide, generally regarded as a crime against public interests since
classical times. Initially, suicide became a crime because occasional communities, even then, suffered epidemics of suicide.3 The criminality of suicide probably correlated with the primitive belief that an individual who took his or her own
Carol A. Schramm, RN, MSN, CNOR, is a clinical nurse specialist in the OR at Thomas Jefferson University Hospital, Philadelphia, and a clinical instructor in the School of Nursing, College of Allied Health Sciences at Thomas Jefferson University, Philadelphia She earned her bachelor of science degree in nursing at Bowling Green Ohio State University and her master of science degree in nursing at the University of Colorado, Denver. The author wishes to thank Lewis Brennec MS, supervisor of the CriminalisticsLaboratoiy of the Philadelphia Police Department for his help, and Paul J. Hoyer, MD, Assistant Medical Examiner, Philadelphia, for supplying the photographs that accompany this article. 669
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life was possessed by evil spirits and might pass them on to other members of the community! The penalty for suicide usually consisted of denying funeral rites to those who had offended. In 1184, the Roman Catholic Church made condemnation of suicide part of canon law, prohibiting the burial of suicide victims in hallowed ground. Forensic medicine evolved, then, from the medicolegal need to determine a cause of death, so that the decision to impose a suicide penalty could be rendered? Most decisions as to the manner of death were made solely by investigation of the circumstances and without a specific examination of the body. The value of autopsy was first espoused in China in the mid-thirteenth century.6 The earliest directions on postmortem examinations, the Chinese handbook Hsi Yuan Li, specifically addressed the types of wounds inflicted by sharp versus blunt instruments, death by drowning versus submersion in water after death, and death by fire versus burning after death. So complete was this initial text, that it was published with amendments up to the nineteenth century? Historical development of medicolegal investigation in the United States can be traced to the English coroner system. In England, suicide officially became a crime under common law in the tenth century. The Charts of Privileges mentioned in English historical sources include a grant of the coroner’s office in the year 925.* In 1194, the office of coroner was formally described, along with the mechanism whereby appointment was to be made. The role of coroner in medieval England was broader than simply investigating deaths. Because there was no income tax, much of the crown’s revenue was produced via unnatural death or crime. Before the existence of coroners, sheriffs collected this money. Although sheriffs generally enjoyed good standing within the community and were usually wealthy, many were highly corrupt and pocketed much of the money due to the crown. Initially, the oftice of coroner was created to stop the loss of revenue, and coroners were 670
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occasionally given the authority to arrest the sheriff. The coroner was elected by knights and freeholders of the county, and heavy fines were imposed on those who did not perform their appointed duties. The prospect of these fines, and the fact that it was an unpaid position, made the office of coroner rather unpopular. Nevertheless, the early coroner could be considered somewhat analogous to a revenue officer. With time, the coroners became as corrupt as the sheriffs, and by the end of the twelfth century coroners were relieved of any major responsibility for collecting monies due to the crown? In place of revenue collection, the coroner eventually became concerned with felonies that resulted in homicide or suicide, felonies resulting in crown pleas, and mandates by the monarchy which required enforcement. An interesting example of enforcing a crown plea is “outlawry.” If an accused felon failed to appear and surrender to justice after four separate public demands for him to do so, the authorities would declare him an outlaw. This declaration meant that the individual’s property and possessions were forfeited to the crown, and he could be beheaded by anyone without punishment.1O The coroner was to be summoned by the “first finder” to examine the body for external marks of violence whenever a sudden or unnatural death occurred. He would then summon a jury of all males over 12 years of age from at least four neighboring towns, conduct an inquiry, and arrive at a verdict. If the verdict was guilty, the accused was committed to prison for further trial. The word murder originated near this time. After the Norman Conquest of England in 1066, ethnic animosities often resulted in the murder of the new French masters when opportunities presented themselves. In an effort to deter this, the Normans passed LexMurdrorum, a law which imposed crippling fines upon the lord of the region in which death of a Norman nobleman occurred, regardless whether it was a sudden, unexpected death or a documentedhomicide.1’ The lord would then transfer the fine onto the community over which he had jurisdiction. Other death-related factors that influenced the
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The widespread belief that death was “natural” if there were no external injuries thwarted the investigation of sudden death for centuries. fines imposed on a community was time and place of death. If the murder took place during the day and the community did not arrest the murderer or become adequately alarmed, an additional fine was levied. If the murder took place during the night, however, it was assumed that the murderer could escape in the darkness, and the community was not liable. It is not surprising, then, that many murders were determined to have occured at night. With such liberal usage of Lex Murdrorum, many communities were faced with fines that they could never meet. Consequently, the law and its fines were modified to apply only to Norman homicides. As Anglo-Saxon-Norman intermarriage blurred ethnic differences, it became increasingly difficult for the deceased to be determined as either French or English. The law was eventually repealed in 1340, but by then the word murder had entered the English language as a term for homicide.l* Physical exams conducted by coroners during the high Middle Ages were limited solely to external examinations. Autopsies were rarely performed, and a common cause returned in cases of natural death was ex vhitatione divina, or visitation of God.13 Although court proceedings became more sophisticated and jurors were more perceptive, the widespread belief that death was “natural” when there were no external injuries or a strong suspicion of poisoning thwarted the investigation of sudden death throughout the centuries.14 In the mid-nineteenth century, the great medical centers of Europe recognized the value of autopsies in medical training. Soon postmortem examination was used to validate the accuracy of a diagnosis or cause of death.’5 The first recorded autopsy in the New World was performed in Haiti, in 1533, for the purpose of determining whether Siamese twins had two souls or one. Although contemporary theory favored the heart or brain as the seat of the soul, 672
various other organs had at times been implicated as well, and so a complete autopsy was performed. “Everything that is to be found in two human bodies” was present, thus the priest proceeded to baptize each twin separately.16 The Medicolegal Investigation of Death describes the evolution of forensic medicine in America.” Postmortem examinations were recorded in Massachusetts in 1647 after the colony’s General Court authorized the teaching of medical students by autopsies performed on the bodies of criminals. Early American colonists adopted the seventeenth century English coroner system and Talbot County, Maryland, was the first site of medicolegal application of autopsy in this country. The coroner’s report absolved a Mr Francis Carpenter of the murder of a servant, Samuell Yeoungman. The book describes how the coroner system in the United States began to incorporate medicine in the latter part of the nineteenth century. The first colonial coroner’s ruling was recorded in New England in 1635. Two years later, Maryland‘s governor appointed Thomas Baldridge to “Doe all and everything . . . the office of sheriff and coroner of any county in England doe . . .” Two centuries later, in 1860, Maryland authorized the coroner or his jury to require the attendance of a physician in causes of violent death. Baltimore became the first city to have a physician as sole coroner in 1868. Massachusetts authorized a statewide system, which required that the coroner be replaced by a physician known as a medical examiner, but which restricted examinationsto bodies that were presumed to have met a violent death.
Modern Trenh
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he United States today is moving away from the coroner system and toward the medical examiner system, with every
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Medical examiners commonly have the authority to investigate cases of sudden death and to determine the cause and manner of death. county and parish being served by one or the other. Coroners remained common throughout the country until 1915, when New York State abolished the coroner system and established a system of medical examiners.’g Medical examiners are pathologists who have specialized in forensic medicine, and they have become the principle forensic officers in most states and large cities. Of interest, the chief investigator in the St Louis, Missouri, medical examiner’s office is a registered nurse.’g Coroners continue to preside predominantly in rural areas, and serve exclusively in Alaska, Idaho, Nebraska, and North and South Dakota.20 In contrast to most medical examiners, coroners often possess more legal power, with the ability to subpoena witnesses.21 State laws also vest medical examiners with powers to investigate in the public interest the deaths of individuals under certain circumstances. In New York City, for example, the chief medical examiner has the responsibility to investigate deaths occurring from “criminal violence, by casualty, by suicide, suddenly when in apparent health, or in any unusual or suspicious manner,” as well as deaths of persons whose bodies are to be cremated.22 Although specific laws vary from state to state, they commonly endow the medical examiner with the authority to investigate those cases of sudden death and unexpected death in his or her jurisdiction and to determinethe cause and manner of death. By this legal mandate, the medical examiner does not need additional permission to conduct an investigation or to perform an autopsy if either is deemed necessary. Most state investigation systems are county or parish-based, while some others, such as Maryland‘s, are singular and statewide. Some people in the United States have called for the development of “police surgeons.” These individuals are physicians trained in forensic medicine who may be called upon to provide
information for documentation and possible presentation during criminal and civil cases. They examine living people in addition to performing autopsies. Police surgeons are well-established in most European and British Commonwealth countries, in much of Asia, in Mexico and in areas of Latin America.23 They commonly receive general training in medicine as well as advanced training in forensics and traumatic medicine, and provide most of the legal testimony for the courts. In Mexico, Brazil, and Venezuela, for example, “medicos forenses” may treat victims shortly after the incident and determine whether or not there is a basis for legal action. The intent is to facilitate rapid case evaluation in order that a more accurate settlement and compensation may be obtained for the injured per~on(s).2~ The development of the forensic physician role in the United States would be very difficult. Under the European educational system, applicants go to medical school directly from secondary school, and enter medicolegal institutes almost immediately upon medical school completion. They are, therefore, channelled directly into working with the courts as they are trained in their medical subspecialty. Few courts and lawyers in this country would be satisfied with the clinical backgrounds of such specialists, compared to the board-certified physicians who presently te~tlfY.2~ Additionally, the European legal system is different from the US adversary system of fact-fmding. Much European work is done by deposition and reports without extensive courtrcom appearances, save for very important cases. In most instances, the forensics physicians are the only ones who are called, in contrast to the US expert witness system available to both sides. Regardless of the adaptation of the role of forensic physician to the United States’ system, there is clearly a need to expand beyond the traditional coroner’s duties.
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Fig 1. Close range entrance wound with black gunpowder soot on surrounding skin.
As the focus of forensic medicine is broadened to encompass living patients, nurses will increasingly be presented with the medical and legal responsibilities of caring for these patients.
Forensics in the Operating Room
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he perioperative nurse becomes involved when the cause of injury requiring surgical intervention is unknown or crime-related. In such instances, it becomes extremely important for the nurse to assist in properly securing, handling, and documenting any forensic evidence that may accompany the patient into the OR. Unquestionably, the nurse’s first duty is to provide nursing care for the trauma victim. Nevertheless, the patient and society are best served when the nurse can recognize and preserve evidence that may later be used in a medicolegal investigation, especially when a death is involved. Determiningcause of death. Whenever there is a suspicious or crime-related death, the autopsy is of prime importance. The autopsy remains a 616
laboratory test and is simply one piece of the puzzle.26 A medical examiner or coroner may be able to determine a cause of death, and if the manner of death was natural, accidental, suicidal, homicidal, or of undetermined nature. All manners of unnatural death are reportable to the medical examiner or cor0ner.2~ Any evidence that can be properly identified and preserved will help to more accurately reconstruct events in determining the manner and cause of death. It is essential for the perioperative nurse to be able to recognize several patterns of injury among patients coming to the OR. Knowledge of specific patterns will enable the nurse to identify evidence moie readily, to preserve it more completely, and to document it more accurately.
Patterns of Injury
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irearm injuries, stab wounds, incised wounds, and blunt injuries often require surgical intervention. These injuries should
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Fig 2. Entrance wound with surrounding ring of damaged skin.
alert the OR team to the possibility of forensic evidence. Fireurm injuries. These injuries result from either smooth bore or rifled weapons. Smooth bore weapons, such as hunting or sporting guns, almost invariably fire a large number of small lead pellets that diverge as they leave the end of the barrel. Rifled weapons include pistols, other handguns such as revolvers and automatic pistols, rifles, and military or self-loading automatic weapons. Rifled firearms are described by their internal barrel diameter,expressed in inches or metric units. Rifled weapons propel projectiles through a spiralled barrel designed to keep the projectile on course over a given trajectory. The science of the firing characteristics of a firearm or cartridge is termed bulfistics. The study of ballistics enables a fired cartridge or projectile to be matched with a specific firearm. More important to medical personnel than the details of the weapon, however, are the characteristics of the entrance and exit wounds and the nature of the projectile and propellant. Entrance wounds are usually inverted and may
be stellate, cruciate, triform or in rare instances, linear in nature (Fig 1). The sue of the entrance wound gives no direct measurement of the size of the weapon, except for shotgun Gross splitting of the skin may be seen in the case of a contact or near-contact wound because high pressure gases emitted from the muzzle press into the wound, thereby distending the subcutaneous tissue. Tissue damage will also be more marked whenever hard structures, such as the skull or sternum, are located immediately below the skin. Additionally, abrasions or bruising may be present at the entrance site. These injuries may show a ring of skin damage due to longitudinal or rotary movement of the projectile (Fig 2), a wider zone of bruising due to general tissue trauma in the area, or a bruised imprint of the muzzle, if it was in contact with the skin (Fig 3).29 Shotgun wounds may exhibit variable patterns, depending on the size of the pellets involved and the distance from which the weapon was fired. In near-contact wounds, the presence of stippling around gunshot holes is a very useful indicator of the proximity of the gun muzzle to the body. Stippling consists of gunpowder particles
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Fig 3. Entrance wound with bruised imprint of gun muzzle.
embedded in the skin around a bullet hole (Fig 4).The diameter of the distribution and the particle density provide information on muzzle-to-body distance, especially important in discriminating homicide from suicide. Most gunpowder falls away beyond a distance of 3 ft, although some newer types of ammunition have a fall-off at less than 2 ft.30 Thus, if surgery is planned, observation of the presence of gunpowder and measurement of the diameter of the distribution pattern should be documented in the patient’s record before such information is lost during prepping and scrubbing the patient. Similarly, it is essential that the clothing of the victim be retained for further laboratory analysis of muzzle-to-target distance.3l Equally important, one must refrain from cutting through the convenient starting point of the bullet hole or knife slit for purposes of removing the clothing because disruption of the clothing wound site will destroy evidence. In addition, the areas of clothing and
skin near wounds should be thoroughly searched for pieces of plastic or cardboard shotgun wadding or fragments of weapons, which must also be documented and saved for e~idence.3~ In contrast to entrance wounds, exit wounds are usually everted but are not always present. As with entrance wounds, the appearance of exit wounds varies, although they commonly are larger and have a more ragged slit-like or stellate appearance (Fig 5). An important exception to this occurs when the exit area is well-supported by tight clothing (eg, a waistband) or when the victim was pressed against a firm surface. In such circumstances, the exit wound may not differ markedly from the entrance wound in either size or shape.33 Often there will be no exit wound because the projectile’s energy is spent as the bullet fragments and, thus, the bullet remains in the body. In some instances, disturbance of the gyroscopic pathway and subsequent tumbling through the tissues 679
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Fig 4. Entrance wound with stippling.
dissipates the projectile’s energy more quickly, and increases damage as the projectile travels forward. Projectiles may fragment against solid organs such as the liver, heart, kidneys, or bone, which themselves can splinter into secondary missiles. Because the skin is second only to bone and cartilage in resistance to penetration, projectiles may become lodged beneath its surface. Shotgun pellets frequently may be palpated under the skin, and it is exceptional for them to emerge on the far side of the body anywhere other than the head, neck, or limbs.34 Certain features of gunshot wounds can assist in the forensic determination of suicide versus homicide. A homicidal firearm wound may be anywhere that causes a mortal injury. Wounds that are suicidal or accidental usually are in accessible sites, such as the head or trunk, although this factor alone is never relied upon to indicate the nature of the shooting. Of interest, suicide victims tend not to shoot themselves through their
clothing, but usually pull it aside to place the muzzle against bare skin. It is uncommon for women to shoot themselves, an observation in line with the general rule that women tend to destroy themselves by less violent means than men.35 Distinguishing between entrance and exit wounds is of critical importance in documenting a firearm injury. Such distinction may be highly significant during future legal proceedings for purposes of corroborating or refuting testimony. Unless one is an expert in examining such injuries, it is better to describe the wounds and avoid calling them entrance or exit wounds unless there is no doubt.36 Whenever a victim has sustained a large defect that requires debridement, the wound may be distorted or completely obliterated by the surgery. In such instances, adequate preoperative documentation by photographs or hand-drawn diagrams is crucial for preservation of evidence. 681
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Fig 5. Exit wound with slit-like appearance. Whenever projectiles are removed surgically from the body, their integrity must be maintained as much as possible for subsequent ballistic testing. Therefore, bullets and other projectiles should not come into contact with metal or any other surface which might mar the object, especially the longitudinal axis. Because inadvertent scrapings might completely destroy the item for laboratory analysis, the projectile should be placed on a gauze sponge until it can be sealed into an envelope, plastic s p i m e n container, or other appropriate receptacle. The container or envelope should be annotated with the date, time, location of the wound, and the person’s initials. Tamper-proof seals should be used whenever possible. Sharp injuries. These injuries include stab wounds and incised wounds. Incised wounds or cuts extend along the skin surface more than they extend inward, and yield little information regarding the nature of the sharp object. Stab wounds are caused by fairly long, usually sharp objects, and generally penetrate more deeply than the length of the surface defect3’ While incised wounds tend to bleed freely, stab 682
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wounds often are more serious because of unknown internal injury and hemorrhage. When impaled objects accompany patients to the OR, they should be handled as little as possible before turning them over to the appropriate authorities, and preferably should be secured in something rigid such as cardboard, to avoid injuring others. Stab wounds usually have a characteristic appearance that can yield important information about the type and sue of weapon used to inflict them (Fig 6).For optimal preservation of evidence, it is best that stab wounds be left intact rather than being incorporated into the incision or used as a drain site. A diagram indicating the sites and sizes of stab wounds can be invaluable during postmortem examinations.38 Blunt injuries. These injuries may result from homicidal attacks, assaults, various forms of abuse, accidents, or resuscitative measures. Abrasions, contusions, lacerations, and fractures are blunt injuries. They all result from the crushing impact of a surface against a portion of the body. Abrasions, which may be described as scratches or grazes, indicate the exact point of impact. If there is a characteristic pattern, it should be carefully documented and photographed, if warranted. Contusions, or bruises, indicate leakage of blood from capillaries or other small vessels into soft tissue. Although contusions heal at variable rates, it is safe to assume that those of a given color and location have occurred at about the same time (Table 1).39 Lacerations are injuries due to the crushing, shearing, tearing or pulling apart of tissues, and do not result from contact with sharp surfaces. Because many lacerations are due to crushing impact, a thorough search of the wound and surrounding areas, as well as clothing, must be made for such items as paint chips, glass fragments, wood, hairs, and fibers. Any trace of debris should be collected carefully on clean paper and sealed in an envelope or container. Motor vehicle accidents. People involved in motor vehicle accidents may sustain particular patterns of blunt injuries, depending on whether they are drivers, passengers or pedestrians. Drivers and front-seat passengers often sustain dicing
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Fig 6. Large stab wound.
injuries, which are multiple cuts and lacerations averaging about 5 mm in length, caused by contact with shattering tempered glass. Splinters of this glass may be found in the wounds. Drivers may have unique injuries if they are unbelted when an airbag deploys. Careful notation of burn or scrape marks on the face due to an airbag and burn marks on the legs from the hot gas of the accelerant in the airbag may be important in determining the cause of injury. Pedestrians who suffer serious or fatal injuries are usually struck by the front bumper in a headon collision or are side-swiped. When a person is struck by the front of the automobile, one of the characteristic identifiable injuries is known as a “bumper injury.” This is a fracture of the tibia, fibula, or both, at the height of the bumper. The height of the bumper and the subsequent injury will vary depending on whether the vehicle was traveling at a constant speed or if the driver was braking. The site of the impact will be lower if sudden braking occurred, which would cause the bumper to naturally dip. Side-swiping injuries result in shearing and crushing of subcutaneous
tissue and muscle. Injuries of people who are run over by motor vehicles are generally crushing in nature. Whatever the mode of injury, extreme care must be taken with the victim of a hit-and-run accident to preserve all possible evidence. If possible, after resuscitative measures, the victim should be undressed on a clean sheet, with all clothing left on the sheet after the patient is moved. The sheet should then be folded carefully and wrapped so any evidence can be removed in the crime laboratory.40 The garments of victims of run-over motor vehicle accidents may harbor other important evidence, such as tire impressions or debris from undercarriages. Because clothing fibers may adhere to the vehicle, notations of torn or damaged clothing should be made as carefully as possible. Even careful preservation of a shoe might be helpful in determining if a driver was trying to stop or if the driver was intent on suicide. In the former case, the imprint of the brake pedal may remain on the sole of the shoe; in the latter, the imprint of the accelerator might be on the sole.4l
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Table 1
Dating of Bruises Age (days) 0- 2 0- 5 5- 7 7 - 10 10 - 14
Color red, swollen red-blue, purple green yellow brown
The age of bruises can be estimated from changes in physical characteristics due to resolution of tissue edema and subsequent breakdown of hemoglobin. ~~
Chain of Evidence
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egardless of the mechanism of injury, proper documentation of the “chain of custody” is man&ted whenever there is forensic evidence. Chain of custody rules apply to everything taken from the patient, including laboratory specimens, clothing, and personal property.42 The admissibility of evidence can be affected by the manner in which evidence is handled and how it is documented, therefore, state laws regarding the handling of forensic evidence should be carefully reviewed when drafting policy and procedure. Handling specimens. All items should be placed in appropriate containers that can be sealed and labeled with the patient’s name, hospital number, and contents of the container. The container should be initialed or signed, dated, and timed by the person originally handling the item. Ideally, the container should remain in that person’s possession at all times until it is transferred to the appropriate authorities. If transfers of evidence m u r within the operating room, they should be documented in the record and on the container. To ensure smooth handling of laboratory specimens, the law presumes that no hospital or government employee has removed the seal and tampered with the item as long as proper documentation is done by the person who breaks the seal and performs the test.43 686
Defense attorneys frequently attempt to attack the chain of custody to cast doubt on the validity and integrity of the evidence in an effort to defend the accused. To prevent this occurrence, the penoperative nurse must take measures to identify the specimen as one which was handled on a specific date, to state from which patient it was collected, and to document that it was in the same condition when it went into the container as it was when it came into his or her possession.44 If these stipulations are met, it then becomes the burden of the challenger to prove the probability of tampering. A “paper trail,” such as a specific form or some type of log, should be used to document items taken from the patient. If the trail is properly recorded, hospital personnel may not be needed for court testimony, especially in instances when testimony is required simply to establish the chain of custody. Minimizing the times that a piece of evidence changes hands or location assists in protecting the integrity as well as the credibility of the evidence. Life-sustaining measures supersede the need to handle, secure, and document forensic evidence, however, and in most cases the court will recognize this priority.4* Victimr’ bodiks, personal eflects Whenever criminal activity as a cause of death or accidental death is suspected, the patient’s body should be sent to the morgue exactly as it was at the time of death. While most nurses are well aware of the need to leave lines and tubings intact, they may not recognize that evidence may be washed away in the cleaning of the body before family viewing. If there is any indication that the victim’s hands could be soiled by gunshot residues or that there could be fragments of skin and hair beneath the fingernails, the hands should not be washed. Rather, they should be enclosed in small paper bags, and secured around the wrists by rubber bands or tape. Plastic bags are not as desirable because condensation or moisture may cause evidence to dissolve.46 All clothing should be forwarded to the police or, in the event of death, to the coroner or medical examiner. Clothing should be enclosed in paper bags to aid air circulation and drying, then enclosed
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Table 2
Thomas Jefferson Operating Room Care Handling of Definition. Proper handling, labeling, and disposition of any material removed from the patient in the OR which is or could be considered forensic evidence (eg, knives, bullets, personal effects). I
Procedure 1. When it is anticipated that forensic evidence will be removed during the operative procedure, the perioperative nurse will notify security. 2. The perioperative nurse will inform security of the patient’s name, ID numbers, type of injury, and geographic location of the crime, if known. 3. The perioperative nurse will inform security of the estimated time of evidence availability. 4. Security will notify the appropriate police authority for claiming the evidence.
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2. Security needs this information to determine the correct jurisdiction and locate the appropriate authorities. 3. The OR phone extension will be provided to security for return calls. 4. Informing security of a forensic case allows security better control of personnel accessing the OR area.
5. Security will contact the OR to confirm the holding area location for evidence pickup and will provide the name of the police officer or other representative. 6. Clothing or other large items, will be 6. Universal precautions will be adhered to. contained within paper bags, then wrapped in a plastic bag. 7. Evidence tape will be used to properly seal 7. Unbroken evidence tape will indicate that evidence. Seal evidence to ensure that tampering has not occurred. tampering will not go undetected. Enclose sharp objects in rigid material such as cardboard.
in a plastic bag to comply with universal precautions. If clothing remains on the body, do not remove it before wrapping the body. Whenever others are allowed to view a body, a responsibleperson must remain present to ensure that tampering or alteration of the body or evidence does not occur.” Charting. A recent study retrospectively reviewed 100 consecutive trauma service admissions to a university-affiliated, level I trauma 688
Points to be Emphasized 1. For elective cases, the booking surgeon is expected to indicate if the procedure is a “police case.”
center!* This study created an ideal patient chart that would include minimal information necessary to provide medicolegal protection for physicians, provide essential information regarding the reconstruction and/or investigation of accidents, civil or criminal complaints, or crimes, and allow physicians, when subpoenaed, to be
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University Hospital Program Policy and Procedure Forensic Evidence
Purpose: Proper preservation of evidence; to reduce the amount of time before forensic evidence is picked up by authorities; to reduce the number of persons involved in the chain of custody. Procedure Points to be Emphasized 8. The surgeon and the circulator will 8. Documentation should be as precise as possible. document in the chart the type@)of evidence obtained. 9. Evidence will be surrendered to the 9. A security officer will stay with the receiving receiving police officer identified by security. police officer until the transaction is In the progress notes, document the name of completed. receiving officer, officer’s badge number, district number if uniformed officer, and date and time. 10. The receiving officer will document and sign for receipt of evidence in the chart. 11. If a receiving officer is not available, evidence will be stored in the evidence locker, and storage documented in the chart and OR Log Book. 12. If a receiving officer is not available to claim evidence, the OR will ask security to recontact the authorities. If there is no evidence pickup by end of shift, the nursing care coordinator or OR administrator-oncall will be notified. 13. When evidence is claimed, procedure for its surrender remains the same as above. (Adapted with permksion from ThomasJefferson University HospituL) able to reconstruct the condition and care of the patient based on the notes charted and evidence secured immediately postinjury. The study revealed widespread lack of knowledge and compliance with adequate forensic documentation. All admissions reviewed had possible forensic medical implications. Sixty-two admissions involved potential criminal charges, and 38 involved potential civil action. Seventy
percent of charts contained documentation that was considered poor, improper, or inadeq~ate.4~ Documentation deficits included illegible entries, no mention of restraint devices or helmets, if applicable, no mention of the patient’s mode of arrival, no notation of prehospital care, no charting of the patient’s general appearance or condition, 689
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failure to include mechanism of injury, poor or subjective terminology, inadequate documentation of the chain of custody, and unclear or unstated final disposition of the patient. The authors noted that, given the litigious nature of society, physicians can not afford to expose themselves because of a lack of knowledge or disregard for proper forensic principles. Two recommendations of this study were to incorporate educational programs in forensic medicine into residency and fellowship training, and to regularly supplement the basic curriculum with continuing education. It is reasonable that nurses also increase their knowledge and awareness of the principles of forensics as they apply to individual areas of practice. At Thomas Jefferson University Hospital, Philadelphia, we have recently reviewed and revised our policy and procedures for the handling of forensic evidence (Table 2). Input was solicited from the Risk Management, Surgical Pathology, and Security departments as well as legal counsel. To reduce the chain of custody to the fewest number of people and departments, we installed a locked evidence box in the main patient holding area. The key to the evidence locker is kept in a locked key cabinet to which the charge nurse has access. A roll of evidence tape, supplied to us by the Philadelphia Police Department for properly sealing evidence, is stored in the locker. Because obtaining evidence is not a routine occurrence, hospital security personnel are involved to relieve the nursing staff of the burden of verifying the identity of the receiving officer. Our policy is intended as a guideline only, as laws regarding the processing of evidence vary from state to state.
Conclusion
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s crime rates increase across the country, it becomes increasingly essential for operating room departments to implement procedures for the preservation of evidence accompanying trauma victims.
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Moreover, it is imperative that the perioperative nurse acquire and use a firm understanding of basic forensic principles in the care of trauma patients. 0 Notes 1. R B Hill, R E Anderson, The Autopsy-Medical Practice andPublic Policy (Boston:Butterworth’s, 1988) xvii. 2. C G Tedeschi, W G Eckert, L G Tedeschi, eds, Forensic Medicine: A Study in Trauma and Environmental Hazards, 3 vols, (Philadelphia: W B Saunders Co. 1977) forward. 3. W U Spitz, R S Fisher eds, Medicolegal Investigation of Death, second ed, (Springfield, 11: Charles C. Thomas, 1980) 3. 4. Ibid 5. Ibid 6. Hsi Yuan Lu (Instructions to Coroners), as cited in F E Camps, A E Robinson, B G B Lucas, eds, Gradwohl’s Legal Medicine, third ed, (Chicago: Yearbook Medical Publications, 1976) 7. 7. Spitz, Fisher, eds, Medicolegal Investigation of Death, second ed, 4. 8. Ibid. 9. A K Mant, “Forensic medicine in Great Britain I 1 The origins of the British medicolegal system and some historic cases,” American Journal of Forensic Medicine and Pathology 8 (December 1987) 354-361. 10. Spitz, Fisher, eds, Medicolegal Investigation of Death, second ed, 5. 11. Mant, “Forensic medicine in Great Britain 11: The origins of the British medicolegal system and some historial cases,” 355. 12. Ibid 13. Ibid, 356. 14. Ibid 15. Hill, Anderson, The Autopsy-Medical Practice and Public Policy 19-20. 16. A P Chavarria, P G Shipley, “The Siamese twins of Espanola: The first known post-mortem examination in the New World,” Annals of Medical History (1924) 297-302, as cited in Hill, Anderson, The Autop~yMedical Practice and Public Policy, 38. 17. Spitz, Fisher, eds, Medicolegal Investigation of Death, second ed, 6. 18. Ibd, 7. 19. R Kowalski Chief Investigator, Medical Examiner’s Office, St Louis, Mo , personal communication with the author, Philadelphia, 9 August 1990. 20. M F Goldsmith, “US forensic pathologists on a new case: Examination of living persons,’’ Journal ofthe American Medical Association, 256 (October 3, 1986) 168.5-1691. 21. R Kowalski, personal communication with the author, 9 August 1990. 691
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22. Office of Chief Medical Examiner, New York, NY, “General Information,” (pamphlet) 1. 23. W J Curran, E D Shapiro, eds, Law, Medicine, and Forensic Science, second ed, (Boston: Little, Brown & Co, 1970) 16. 24. Ibid 25. Ibid 26. R E Mittleman, H S Goldberg, D M Waksman, “Preserving evidence in the emergency department,” The American Journal of Nursing 83 (December 1983) 1653. 27. P Besant-Matthews, Gunshot and Stab Wounh: A Medical Examiner’s View (Lewisville, Tex: Barbara Clark Mims Associates, 1987) unnumbered page. 28. C G Tedeschi, W G Eckert, L G Tedeschi, eds, Forensic Medicine vol 2 (Philadelphia: W B Saunders, 1977) 510-511. 29. B i d 30. Mittleman, Goldberg, Waksman, “Preserving evidence in the emergency department,” 1654. 31. J E Smialek, “Forensic medicine in the emergency department,” Emergency Medical Clinics of North America 1 (December 1983) 687. 32. Ibid 703. 33. Tedeschi, Eckert, Tedeschi, eds, Forensic Medicine, vol2, 516. 34. Ibki 517. 35. Tedeschi, Eckert, Tedeschi, eds, Forensic Medicine, vol 2, 5 11. 36. Smialek, “Forensic medicine in the emergency department,” 695-696. 37. Besant-Matthews, Gunshot and Stab Wounds:A Medical Examiner’s View 2. 38. Smialek, “Forensic medicine in the emergency department,” 697. 39. E F Wilson, “Estimation of the age of cutaneous contusions in child abuse,” Pediatrics 60 (November 1977) 750. 40. Smialek, “Forensic medicine in the emergency department,” 70 1. 4 1. Mittleman, Goldberg, Waksman, “Preserving evidence in the emergency department,” 1654. 42. Ibid 1655. 43. Ibid 44. Ibid 45. Ibid 46. Besant-Matthews, Gunshot and Stab Wounds:A Medical Examiner’s View 22. 47 Ibid 24, 48. R Carmona, K Price, “Trauma and forensic medicine,” Journal of Trauma 29 (September 1989) 1223. 49. Zbid
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Medical Students Prefer Controllable Life-styles Medical students increasingly are choosing residencies in specialties that offer controllable life-styles. These specialties are those that typically have shorter training time and higher income. Students also tend to choose specialties in which they can limit work time. The two most popular specialities with controllable life-styles are ophthalmology and radiology, according to an article in the Nov 16, 1990, issue of American Medical News. Other specialties perceived as having controllable life-styles are anesthesiology and emergency medicine, followed by dermatology, neurology, otolaryngology, pathology, and psychiatry. Specialties with noncontrollable life-styles include internal medicine, family medicine, pediatrics, and obstetricsigy necology. The training time for these is relatively short, but the pay is relatively low and patient care can involve unpredictable hours. Surgery specialties fall into a third category. The income is higher, but the training time is relatively long. Midcareer changes also favor controllable life-styles. According to the article, the impact of hours is more of a deciding factor than other factors such as educational debt load. Young physicians also like health maintenance organizations and large group specialties because of the predictable hours.
Correction The article on abdominal aortic aneurysms in the January issue of the Journal contains an error. On page 44, the text should read “Our experience indicates that 15% of aneurysms 5 cm in diameter and 30% to 50% of aneurysms 6 cm in diameter may rupture in a year.” The Journal regrets the error.
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Forensic Medicine WHAT THE PERIOPERATIVE NURSE NEEDSTO KNOW
Carol A. Schramm, RN Mors gaudet succure vita (Death rejoices in helping 1ife)l
I
n our increasingly violent society, assaults and murders have become a daily part of our existence. Accordingly, there are more emergency department admissions of both the victims and perpetrators of such crimes. Because many of these patients will require surgical intervention, perioperative nurses are being summoned into what Justice Harry Blackmun called the “unavoidable intersection [of law and medicine where] . . . Cooperation and understanding, rather than distance and isolation, should be [the] way of life.”2 The role of the nurse has expanded from singular patient advocate, to advocate for the community at large. Because of this, the nurse must have a fm understanding of certain aspects of forensic medicine, the science that studies the application of medical facts to legal problems. As professionals and responsible citizens, perioperative nurses need to know how to assist in properly securing, handling, and documenting forensic evidence that enters the operating room. Like physicians, nurses must provide timely care for injured patients while simultaneously recognizing and preserving evidence. As nursing becomes more independent, the individual nurse’s level of practice will be subjected to greater scrutiny.
From Sheriff to Coroner
T
he earliest application of forensic medicine dealt with suicide, generally regarded as a crime against public interests since
classical times. Initially, suicide became a crime because occasional communities, even then, suffered epidemics of suicide.3 The criminality of suicide probably correlated with the primitive belief that an individual who took his or her own
Carol A. Schramm, RN, MSN, CNOR, is a clinical nurse specialist in the OR at Thomas Jefferson University Hospital, Philadelphia, and a clinical instructor in the School of Nursing, College of Allied Health Sciences at Thomas Jefferson University, Philadelphia She earned her bachelor of science degree in nursing at Bowling Green Ohio State University and her master of science degree in nursing at the University of Colorado, Denver. The author wishes to thank Lewis Brennec MS, supervisor of the CriminalisticsLaboratoiy of the Philadelphia Police Department for his help, and Paul J. Hoyer, MD, Assistant Medical Examiner, Philadelphia, for supplying the photographs that accompany this article. 669
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life was possessed by evil spirits and might pass them on to other members of the community! The penalty for suicide usually consisted of denying funeral rites to those who had offended. In 1184, the Roman Catholic Church made condemnation of suicide part of canon law, prohibiting the burial of suicide victims in hallowed ground. Forensic medicine evolved, then, from the medicolegal need to determine a cause of death, so that the decision to impose a suicide penalty could be rendered? Most decisions as to the manner of death were made solely by investigation of the circumstances and without a specific examination of the body. The value of autopsy was first espoused in China in the mid-thirteenth century.6 The earliest directions on postmortem examinations, the Chinese handbook Hsi Yuan Li, specifically addressed the types of wounds inflicted by sharp versus blunt instruments, death by drowning versus submersion in water after death, and death by fire versus burning after death. So complete was this initial text, that it was published with amendments up to the nineteenth century? Historical development of medicolegal investigation in the United States can be traced to the English coroner system. In England, suicide officially became a crime under common law in the tenth century. The Charts of Privileges mentioned in English historical sources include a grant of the coroner’s office in the year 925.* In 1194, the office of coroner was formally described, along with the mechanism whereby appointment was to be made. The role of coroner in medieval England was broader than simply investigating deaths. Because there was no income tax, much of the crown’s revenue was produced via unnatural death or crime. Before the existence of coroners, sheriffs collected this money. Although sheriffs generally enjoyed good standing within the community and were usually wealthy, many were highly corrupt and pocketed much of the money due to the crown. Initially, the oftice of coroner was created to stop the loss of revenue, and coroners were 670
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occasionally given the authority to arrest the sheriff. The coroner was elected by knights and freeholders of the county, and heavy fines were imposed on those who did not perform their appointed duties. The prospect of these fines, and the fact that it was an unpaid position, made the office of coroner rather unpopular. Nevertheless, the early coroner could be considered somewhat analogous to a revenue officer. With time, the coroners became as corrupt as the sheriffs, and by the end of the twelfth century coroners were relieved of any major responsibility for collecting monies due to the crown? In place of revenue collection, the coroner eventually became concerned with felonies that resulted in homicide or suicide, felonies resulting in crown pleas, and mandates by the monarchy which required enforcement. An interesting example of enforcing a crown plea is “outlawry.” If an accused felon failed to appear and surrender to justice after four separate public demands for him to do so, the authorities would declare him an outlaw. This declaration meant that the individual’s property and possessions were forfeited to the crown, and he could be beheaded by anyone without punishment.1O The coroner was to be summoned by the “first finder” to examine the body for external marks of violence whenever a sudden or unnatural death occurred. He would then summon a jury of all males over 12 years of age from at least four neighboring towns, conduct an inquiry, and arrive at a verdict. If the verdict was guilty, the accused was committed to prison for further trial. The word murder originated near this time. After the Norman Conquest of England in 1066, ethnic animosities often resulted in the murder of the new French masters when opportunities presented themselves. In an effort to deter this, the Normans passed LexMurdrorum, a law which imposed crippling fines upon the lord of the region in which death of a Norman nobleman occurred, regardless whether it was a sudden, unexpected death or a documentedhomicide.1’ The lord would then transfer the fine onto the community over which he had jurisdiction. Other death-related factors that influenced the
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The widespread belief that death was “natural” if there were no external injuries thwarted the investigation of sudden death for centuries. fines imposed on a community was time and place of death. If the murder took place during the day and the community did not arrest the murderer or become adequately alarmed, an additional fine was levied. If the murder took place during the night, however, it was assumed that the murderer could escape in the darkness, and the community was not liable. It is not surprising, then, that many murders were determined to have occured at night. With such liberal usage of Lex Murdrorum, many communities were faced with fines that they could never meet. Consequently, the law and its fines were modified to apply only to Norman homicides. As Anglo-Saxon-Norman intermarriage blurred ethnic differences, it became increasingly difficult for the deceased to be determined as either French or English. The law was eventually repealed in 1340, but by then the word murder had entered the English language as a term for homicide.l* Physical exams conducted by coroners during the high Middle Ages were limited solely to external examinations. Autopsies were rarely performed, and a common cause returned in cases of natural death was ex vhitatione divina, or visitation of God.13 Although court proceedings became more sophisticated and jurors were more perceptive, the widespread belief that death was “natural” when there were no external injuries or a strong suspicion of poisoning thwarted the investigation of sudden death throughout the centuries.14 In the mid-nineteenth century, the great medical centers of Europe recognized the value of autopsies in medical training. Soon postmortem examination was used to validate the accuracy of a diagnosis or cause of death.’5 The first recorded autopsy in the New World was performed in Haiti, in 1533, for the purpose of determining whether Siamese twins had two souls or one. Although contemporary theory favored the heart or brain as the seat of the soul, 672
various other organs had at times been implicated as well, and so a complete autopsy was performed. “Everything that is to be found in two human bodies” was present, thus the priest proceeded to baptize each twin separately.16 The Medicolegal Investigation of Death describes the evolution of forensic medicine in America.” Postmortem examinations were recorded in Massachusetts in 1647 after the colony’s General Court authorized the teaching of medical students by autopsies performed on the bodies of criminals. Early American colonists adopted the seventeenth century English coroner system and Talbot County, Maryland, was the first site of medicolegal application of autopsy in this country. The coroner’s report absolved a Mr Francis Carpenter of the murder of a servant, Samuell Yeoungman. The book describes how the coroner system in the United States began to incorporate medicine in the latter part of the nineteenth century. The first colonial coroner’s ruling was recorded in New England in 1635. Two years later, Maryland‘s governor appointed Thomas Baldridge to “Doe all and everything . . . the office of sheriff and coroner of any county in England doe . . .” Two centuries later, in 1860, Maryland authorized the coroner or his jury to require the attendance of a physician in causes of violent death. Baltimore became the first city to have a physician as sole coroner in 1868. Massachusetts authorized a statewide system, which required that the coroner be replaced by a physician known as a medical examiner, but which restricted examinationsto bodies that were presumed to have met a violent death.
Modern Trenh
T
he United States today is moving away from the coroner system and toward the medical examiner system, with every
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Medical examiners commonly have the authority to investigate cases of sudden death and to determine the cause and manner of death. county and parish being served by one or the other. Coroners remained common throughout the country until 1915, when New York State abolished the coroner system and established a system of medical examiners.’g Medical examiners are pathologists who have specialized in forensic medicine, and they have become the principle forensic officers in most states and large cities. Of interest, the chief investigator in the St Louis, Missouri, medical examiner’s office is a registered nurse.’g Coroners continue to preside predominantly in rural areas, and serve exclusively in Alaska, Idaho, Nebraska, and North and South Dakota.20 In contrast to most medical examiners, coroners often possess more legal power, with the ability to subpoena witnesses.21 State laws also vest medical examiners with powers to investigate in the public interest the deaths of individuals under certain circumstances. In New York City, for example, the chief medical examiner has the responsibility to investigate deaths occurring from “criminal violence, by casualty, by suicide, suddenly when in apparent health, or in any unusual or suspicious manner,” as well as deaths of persons whose bodies are to be cremated.22 Although specific laws vary from state to state, they commonly endow the medical examiner with the authority to investigate those cases of sudden death and unexpected death in his or her jurisdiction and to determinethe cause and manner of death. By this legal mandate, the medical examiner does not need additional permission to conduct an investigation or to perform an autopsy if either is deemed necessary. Most state investigation systems are county or parish-based, while some others, such as Maryland‘s, are singular and statewide. Some people in the United States have called for the development of “police surgeons.” These individuals are physicians trained in forensic medicine who may be called upon to provide
information for documentation and possible presentation during criminal and civil cases. They examine living people in addition to performing autopsies. Police surgeons are well-established in most European and British Commonwealth countries, in much of Asia, in Mexico and in areas of Latin America.23 They commonly receive general training in medicine as well as advanced training in forensics and traumatic medicine, and provide most of the legal testimony for the courts. In Mexico, Brazil, and Venezuela, for example, “medicos forenses” may treat victims shortly after the incident and determine whether or not there is a basis for legal action. The intent is to facilitate rapid case evaluation in order that a more accurate settlement and compensation may be obtained for the injured per~on(s).2~ The development of the forensic physician role in the United States would be very difficult. Under the European educational system, applicants go to medical school directly from secondary school, and enter medicolegal institutes almost immediately upon medical school completion. They are, therefore, channelled directly into working with the courts as they are trained in their medical subspecialty. Few courts and lawyers in this country would be satisfied with the clinical backgrounds of such specialists, compared to the board-certified physicians who presently te~tlfY.2~ Additionally, the European legal system is different from the US adversary system of fact-fmding. Much European work is done by deposition and reports without extensive courtrcom appearances, save for very important cases. In most instances, the forensics physicians are the only ones who are called, in contrast to the US expert witness system available to both sides. Regardless of the adaptation of the role of forensic physician to the United States’ system, there is clearly a need to expand beyond the traditional coroner’s duties.
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Fig 1. Close range entrance wound with black gunpowder soot on surrounding skin.
As the focus of forensic medicine is broadened to encompass living patients, nurses will increasingly be presented with the medical and legal responsibilities of caring for these patients.
Forensics in the Operating Room
T
he perioperative nurse becomes involved when the cause of injury requiring surgical intervention is unknown or crime-related. In such instances, it becomes extremely important for the nurse to assist in properly securing, handling, and documenting any forensic evidence that may accompany the patient into the OR. Unquestionably, the nurse’s first duty is to provide nursing care for the trauma victim. Nevertheless, the patient and society are best served when the nurse can recognize and preserve evidence that may later be used in a medicolegal investigation, especially when a death is involved. Determiningcause of death. Whenever there is a suspicious or crime-related death, the autopsy is of prime importance. The autopsy remains a 616
laboratory test and is simply one piece of the puzzle.26 A medical examiner or coroner may be able to determine a cause of death, and if the manner of death was natural, accidental, suicidal, homicidal, or of undetermined nature. All manners of unnatural death are reportable to the medical examiner or cor0ner.2~ Any evidence that can be properly identified and preserved will help to more accurately reconstruct events in determining the manner and cause of death. It is essential for the perioperative nurse to be able to recognize several patterns of injury among patients coming to the OR. Knowledge of specific patterns will enable the nurse to identify evidence moie readily, to preserve it more completely, and to document it more accurately.
Patterns of Injury
F
irearm injuries, stab wounds, incised wounds, and blunt injuries often require surgical intervention. These injuries should
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Fig 2. Entrance wound with surrounding ring of damaged skin.
alert the OR team to the possibility of forensic evidence. Fireurm injuries. These injuries result from either smooth bore or rifled weapons. Smooth bore weapons, such as hunting or sporting guns, almost invariably fire a large number of small lead pellets that diverge as they leave the end of the barrel. Rifled weapons include pistols, other handguns such as revolvers and automatic pistols, rifles, and military or self-loading automatic weapons. Rifled firearms are described by their internal barrel diameter,expressed in inches or metric units. Rifled weapons propel projectiles through a spiralled barrel designed to keep the projectile on course over a given trajectory. The science of the firing characteristics of a firearm or cartridge is termed bulfistics. The study of ballistics enables a fired cartridge or projectile to be matched with a specific firearm. More important to medical personnel than the details of the weapon, however, are the characteristics of the entrance and exit wounds and the nature of the projectile and propellant. Entrance wounds are usually inverted and may
be stellate, cruciate, triform or in rare instances, linear in nature (Fig 1). The sue of the entrance wound gives no direct measurement of the size of the weapon, except for shotgun Gross splitting of the skin may be seen in the case of a contact or near-contact wound because high pressure gases emitted from the muzzle press into the wound, thereby distending the subcutaneous tissue. Tissue damage will also be more marked whenever hard structures, such as the skull or sternum, are located immediately below the skin. Additionally, abrasions or bruising may be present at the entrance site. These injuries may show a ring of skin damage due to longitudinal or rotary movement of the projectile (Fig 2), a wider zone of bruising due to general tissue trauma in the area, or a bruised imprint of the muzzle, if it was in contact with the skin (Fig 3).29 Shotgun wounds may exhibit variable patterns, depending on the size of the pellets involved and the distance from which the weapon was fired. In near-contact wounds, the presence of stippling around gunshot holes is a very useful indicator of the proximity of the gun muzzle to the body. Stippling consists of gunpowder particles
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Fig 3. Entrance wound with bruised imprint of gun muzzle.
embedded in the skin around a bullet hole (Fig 4).The diameter of the distribution and the particle density provide information on muzzle-to-body distance, especially important in discriminating homicide from suicide. Most gunpowder falls away beyond a distance of 3 ft, although some newer types of ammunition have a fall-off at less than 2 ft.30 Thus, if surgery is planned, observation of the presence of gunpowder and measurement of the diameter of the distribution pattern should be documented in the patient’s record before such information is lost during prepping and scrubbing the patient. Similarly, it is essential that the clothing of the victim be retained for further laboratory analysis of muzzle-to-target distance.3l Equally important, one must refrain from cutting through the convenient starting point of the bullet hole or knife slit for purposes of removing the clothing because disruption of the clothing wound site will destroy evidence. In addition, the areas of clothing and
skin near wounds should be thoroughly searched for pieces of plastic or cardboard shotgun wadding or fragments of weapons, which must also be documented and saved for e~idence.3~ In contrast to entrance wounds, exit wounds are usually everted but are not always present. As with entrance wounds, the appearance of exit wounds varies, although they commonly are larger and have a more ragged slit-like or stellate appearance (Fig 5). An important exception to this occurs when the exit area is well-supported by tight clothing (eg, a waistband) or when the victim was pressed against a firm surface. In such circumstances, the exit wound may not differ markedly from the entrance wound in either size or shape.33 Often there will be no exit wound because the projectile’s energy is spent as the bullet fragments and, thus, the bullet remains in the body. In some instances, disturbance of the gyroscopic pathway and subsequent tumbling through the tissues 679
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Fig 4. Entrance wound with stippling.
dissipates the projectile’s energy more quickly, and increases damage as the projectile travels forward. Projectiles may fragment against solid organs such as the liver, heart, kidneys, or bone, which themselves can splinter into secondary missiles. Because the skin is second only to bone and cartilage in resistance to penetration, projectiles may become lodged beneath its surface. Shotgun pellets frequently may be palpated under the skin, and it is exceptional for them to emerge on the far side of the body anywhere other than the head, neck, or limbs.34 Certain features of gunshot wounds can assist in the forensic determination of suicide versus homicide. A homicidal firearm wound may be anywhere that causes a mortal injury. Wounds that are suicidal or accidental usually are in accessible sites, such as the head or trunk, although this factor alone is never relied upon to indicate the nature of the shooting. Of interest, suicide victims tend not to shoot themselves through their
clothing, but usually pull it aside to place the muzzle against bare skin. It is uncommon for women to shoot themselves, an observation in line with the general rule that women tend to destroy themselves by less violent means than men.35 Distinguishing between entrance and exit wounds is of critical importance in documenting a firearm injury. Such distinction may be highly significant during future legal proceedings for purposes of corroborating or refuting testimony. Unless one is an expert in examining such injuries, it is better to describe the wounds and avoid calling them entrance or exit wounds unless there is no doubt.36 Whenever a victim has sustained a large defect that requires debridement, the wound may be distorted or completely obliterated by the surgery. In such instances, adequate preoperative documentation by photographs or hand-drawn diagrams is crucial for preservation of evidence. 681
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Fig 5. Exit wound with slit-like appearance. Whenever projectiles are removed surgically from the body, their integrity must be maintained as much as possible for subsequent ballistic testing. Therefore, bullets and other projectiles should not come into contact with metal or any other surface which might mar the object, especially the longitudinal axis. Because inadvertent scrapings might completely destroy the item for laboratory analysis, the projectile should be placed on a gauze sponge until it can be sealed into an envelope, plastic s p i m e n container, or other appropriate receptacle. The container or envelope should be annotated with the date, time, location of the wound, and the person’s initials. Tamper-proof seals should be used whenever possible. Sharp injuries. These injuries include stab wounds and incised wounds. Incised wounds or cuts extend along the skin surface more than they extend inward, and yield little information regarding the nature of the sharp object. Stab wounds are caused by fairly long, usually sharp objects, and generally penetrate more deeply than the length of the surface defect3’ While incised wounds tend to bleed freely, stab 682
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wounds often are more serious because of unknown internal injury and hemorrhage. When impaled objects accompany patients to the OR, they should be handled as little as possible before turning them over to the appropriate authorities, and preferably should be secured in something rigid such as cardboard, to avoid injuring others. Stab wounds usually have a characteristic appearance that can yield important information about the type and sue of weapon used to inflict them (Fig 6).For optimal preservation of evidence, it is best that stab wounds be left intact rather than being incorporated into the incision or used as a drain site. A diagram indicating the sites and sizes of stab wounds can be invaluable during postmortem examinations.38 Blunt injuries. These injuries may result from homicidal attacks, assaults, various forms of abuse, accidents, or resuscitative measures. Abrasions, contusions, lacerations, and fractures are blunt injuries. They all result from the crushing impact of a surface against a portion of the body. Abrasions, which may be described as scratches or grazes, indicate the exact point of impact. If there is a characteristic pattern, it should be carefully documented and photographed, if warranted. Contusions, or bruises, indicate leakage of blood from capillaries or other small vessels into soft tissue. Although contusions heal at variable rates, it is safe to assume that those of a given color and location have occurred at about the same time (Table 1).39 Lacerations are injuries due to the crushing, shearing, tearing or pulling apart of tissues, and do not result from contact with sharp surfaces. Because many lacerations are due to crushing impact, a thorough search of the wound and surrounding areas, as well as clothing, must be made for such items as paint chips, glass fragments, wood, hairs, and fibers. Any trace of debris should be collected carefully on clean paper and sealed in an envelope or container. Motor vehicle accidents. People involved in motor vehicle accidents may sustain particular patterns of blunt injuries, depending on whether they are drivers, passengers or pedestrians. Drivers and front-seat passengers often sustain dicing
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Fig 6. Large stab wound.
injuries, which are multiple cuts and lacerations averaging about 5 mm in length, caused by contact with shattering tempered glass. Splinters of this glass may be found in the wounds. Drivers may have unique injuries if they are unbelted when an airbag deploys. Careful notation of burn or scrape marks on the face due to an airbag and burn marks on the legs from the hot gas of the accelerant in the airbag may be important in determining the cause of injury. Pedestrians who suffer serious or fatal injuries are usually struck by the front bumper in a headon collision or are side-swiped. When a person is struck by the front of the automobile, one of the characteristic identifiable injuries is known as a “bumper injury.” This is a fracture of the tibia, fibula, or both, at the height of the bumper. The height of the bumper and the subsequent injury will vary depending on whether the vehicle was traveling at a constant speed or if the driver was braking. The site of the impact will be lower if sudden braking occurred, which would cause the bumper to naturally dip. Side-swiping injuries result in shearing and crushing of subcutaneous
tissue and muscle. Injuries of people who are run over by motor vehicles are generally crushing in nature. Whatever the mode of injury, extreme care must be taken with the victim of a hit-and-run accident to preserve all possible evidence. If possible, after resuscitative measures, the victim should be undressed on a clean sheet, with all clothing left on the sheet after the patient is moved. The sheet should then be folded carefully and wrapped so any evidence can be removed in the crime laboratory.40 The garments of victims of run-over motor vehicle accidents may harbor other important evidence, such as tire impressions or debris from undercarriages. Because clothing fibers may adhere to the vehicle, notations of torn or damaged clothing should be made as carefully as possible. Even careful preservation of a shoe might be helpful in determining if a driver was trying to stop or if the driver was intent on suicide. In the former case, the imprint of the brake pedal may remain on the sole of the shoe; in the latter, the imprint of the accelerator might be on the sole.4l
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Table 1
Dating of Bruises Age (days) 0- 2 0- 5 5- 7 7 - 10 10 - 14
Color red, swollen red-blue, purple green yellow brown
The age of bruises can be estimated from changes in physical characteristics due to resolution of tissue edema and subsequent breakdown of hemoglobin. ~~
Chain of Evidence
R
egardless of the mechanism of injury, proper documentation of the “chain of custody” is man&ted whenever there is forensic evidence. Chain of custody rules apply to everything taken from the patient, including laboratory specimens, clothing, and personal property.42 The admissibility of evidence can be affected by the manner in which evidence is handled and how it is documented, therefore, state laws regarding the handling of forensic evidence should be carefully reviewed when drafting policy and procedure. Handling specimens. All items should be placed in appropriate containers that can be sealed and labeled with the patient’s name, hospital number, and contents of the container. The container should be initialed or signed, dated, and timed by the person originally handling the item. Ideally, the container should remain in that person’s possession at all times until it is transferred to the appropriate authorities. If transfers of evidence m u r within the operating room, they should be documented in the record and on the container. To ensure smooth handling of laboratory specimens, the law presumes that no hospital or government employee has removed the seal and tampered with the item as long as proper documentation is done by the person who breaks the seal and performs the test.43 686
Defense attorneys frequently attempt to attack the chain of custody to cast doubt on the validity and integrity of the evidence in an effort to defend the accused. To prevent this occurrence, the penoperative nurse must take measures to identify the specimen as one which was handled on a specific date, to state from which patient it was collected, and to document that it was in the same condition when it went into the container as it was when it came into his or her possession.44 If these stipulations are met, it then becomes the burden of the challenger to prove the probability of tampering. A “paper trail,” such as a specific form or some type of log, should be used to document items taken from the patient. If the trail is properly recorded, hospital personnel may not be needed for court testimony, especially in instances when testimony is required simply to establish the chain of custody. Minimizing the times that a piece of evidence changes hands or location assists in protecting the integrity as well as the credibility of the evidence. Life-sustaining measures supersede the need to handle, secure, and document forensic evidence, however, and in most cases the court will recognize this priority.4* Victimr’ bodiks, personal eflects Whenever criminal activity as a cause of death or accidental death is suspected, the patient’s body should be sent to the morgue exactly as it was at the time of death. While most nurses are well aware of the need to leave lines and tubings intact, they may not recognize that evidence may be washed away in the cleaning of the body before family viewing. If there is any indication that the victim’s hands could be soiled by gunshot residues or that there could be fragments of skin and hair beneath the fingernails, the hands should not be washed. Rather, they should be enclosed in small paper bags, and secured around the wrists by rubber bands or tape. Plastic bags are not as desirable because condensation or moisture may cause evidence to dissolve.46 All clothing should be forwarded to the police or, in the event of death, to the coroner or medical examiner. Clothing should be enclosed in paper bags to aid air circulation and drying, then enclosed
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Table 2
Thomas Jefferson Operating Room Care Handling of Definition. Proper handling, labeling, and disposition of any material removed from the patient in the OR which is or could be considered forensic evidence (eg, knives, bullets, personal effects). I
Procedure 1. When it is anticipated that forensic evidence will be removed during the operative procedure, the perioperative nurse will notify security. 2. The perioperative nurse will inform security of the patient’s name, ID numbers, type of injury, and geographic location of the crime, if known. 3. The perioperative nurse will inform security of the estimated time of evidence availability. 4. Security will notify the appropriate police authority for claiming the evidence.
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2. Security needs this information to determine the correct jurisdiction and locate the appropriate authorities. 3. The OR phone extension will be provided to security for return calls. 4. Informing security of a forensic case allows security better control of personnel accessing the OR area.
5. Security will contact the OR to confirm the holding area location for evidence pickup and will provide the name of the police officer or other representative. 6. Clothing or other large items, will be 6. Universal precautions will be adhered to. contained within paper bags, then wrapped in a plastic bag. 7. Evidence tape will be used to properly seal 7. Unbroken evidence tape will indicate that evidence. Seal evidence to ensure that tampering has not occurred. tampering will not go undetected. Enclose sharp objects in rigid material such as cardboard.
in a plastic bag to comply with universal precautions. If clothing remains on the body, do not remove it before wrapping the body. Whenever others are allowed to view a body, a responsibleperson must remain present to ensure that tampering or alteration of the body or evidence does not occur.” Charting. A recent study retrospectively reviewed 100 consecutive trauma service admissions to a university-affiliated, level I trauma 688
Points to be Emphasized 1. For elective cases, the booking surgeon is expected to indicate if the procedure is a “police case.”
center!* This study created an ideal patient chart that would include minimal information necessary to provide medicolegal protection for physicians, provide essential information regarding the reconstruction and/or investigation of accidents, civil or criminal complaints, or crimes, and allow physicians, when subpoenaed, to be
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University Hospital Program Policy and Procedure Forensic Evidence
Purpose: Proper preservation of evidence; to reduce the amount of time before forensic evidence is picked up by authorities; to reduce the number of persons involved in the chain of custody. Procedure Points to be Emphasized 8. The surgeon and the circulator will 8. Documentation should be as precise as possible. document in the chart the type@)of evidence obtained. 9. Evidence will be surrendered to the 9. A security officer will stay with the receiving receiving police officer identified by security. police officer until the transaction is In the progress notes, document the name of completed. receiving officer, officer’s badge number, district number if uniformed officer, and date and time. 10. The receiving officer will document and sign for receipt of evidence in the chart. 11. If a receiving officer is not available, evidence will be stored in the evidence locker, and storage documented in the chart and OR Log Book. 12. If a receiving officer is not available to claim evidence, the OR will ask security to recontact the authorities. If there is no evidence pickup by end of shift, the nursing care coordinator or OR administrator-oncall will be notified. 13. When evidence is claimed, procedure for its surrender remains the same as above. (Adapted with permksion from ThomasJefferson University HospituL) able to reconstruct the condition and care of the patient based on the notes charted and evidence secured immediately postinjury. The study revealed widespread lack of knowledge and compliance with adequate forensic documentation. All admissions reviewed had possible forensic medical implications. Sixty-two admissions involved potential criminal charges, and 38 involved potential civil action. Seventy
percent of charts contained documentation that was considered poor, improper, or inadeq~ate.4~ Documentation deficits included illegible entries, no mention of restraint devices or helmets, if applicable, no mention of the patient’s mode of arrival, no notation of prehospital care, no charting of the patient’s general appearance or condition, 689
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failure to include mechanism of injury, poor or subjective terminology, inadequate documentation of the chain of custody, and unclear or unstated final disposition of the patient. The authors noted that, given the litigious nature of society, physicians can not afford to expose themselves because of a lack of knowledge or disregard for proper forensic principles. Two recommendations of this study were to incorporate educational programs in forensic medicine into residency and fellowship training, and to regularly supplement the basic curriculum with continuing education. It is reasonable that nurses also increase their knowledge and awareness of the principles of forensics as they apply to individual areas of practice. At Thomas Jefferson University Hospital, Philadelphia, we have recently reviewed and revised our policy and procedures for the handling of forensic evidence (Table 2). Input was solicited from the Risk Management, Surgical Pathology, and Security departments as well as legal counsel. To reduce the chain of custody to the fewest number of people and departments, we installed a locked evidence box in the main patient holding area. The key to the evidence locker is kept in a locked key cabinet to which the charge nurse has access. A roll of evidence tape, supplied to us by the Philadelphia Police Department for properly sealing evidence, is stored in the locker. Because obtaining evidence is not a routine occurrence, hospital security personnel are involved to relieve the nursing staff of the burden of verifying the identity of the receiving officer. Our policy is intended as a guideline only, as laws regarding the processing of evidence vary from state to state.
Conclusion
A
s crime rates increase across the country, it becomes increasingly essential for operating room departments to implement procedures for the preservation of evidence accompanying trauma victims.
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Moreover, it is imperative that the perioperative nurse acquire and use a firm understanding of basic forensic principles in the care of trauma patients. 0 Notes 1. R B Hill, R E Anderson, The Autopsy-Medical Practice andPublic Policy (Boston:Butterworth’s, 1988) xvii. 2. C G Tedeschi, W G Eckert, L G Tedeschi, eds, Forensic Medicine: A Study in Trauma and Environmental Hazards, 3 vols, (Philadelphia: W B Saunders Co. 1977) forward. 3. W U Spitz, R S Fisher eds, Medicolegal Investigation of Death, second ed, (Springfield, 11: Charles C. Thomas, 1980) 3. 4. Ibid 5. Ibid 6. Hsi Yuan Lu (Instructions to Coroners), as cited in F E Camps, A E Robinson, B G B Lucas, eds, Gradwohl’s Legal Medicine, third ed, (Chicago: Yearbook Medical Publications, 1976) 7. 7. Spitz, Fisher, eds, Medicolegal Investigation of Death, second ed, 4. 8. Ibid. 9. A K Mant, “Forensic medicine in Great Britain I 1 The origins of the British medicolegal system and some historic cases,” American Journal of Forensic Medicine and Pathology 8 (December 1987) 354-361. 10. Spitz, Fisher, eds, Medicolegal Investigation of Death, second ed, 5. 11. Mant, “Forensic medicine in Great Britain 11: The origins of the British medicolegal system and some historial cases,” 355. 12. Ibid 13. Ibid, 356. 14. Ibid 15. Hill, Anderson, The Autopsy-Medical Practice and Public Policy 19-20. 16. A P Chavarria, P G Shipley, “The Siamese twins of Espanola: The first known post-mortem examination in the New World,” Annals of Medical History (1924) 297-302, as cited in Hill, Anderson, The Autop~yMedical Practice and Public Policy, 38. 17. Spitz, Fisher, eds, Medicolegal Investigation of Death, second ed, 6. 18. Ibd, 7. 19. R Kowalski Chief Investigator, Medical Examiner’s Office, St Louis, Mo , personal communication with the author, Philadelphia, 9 August 1990. 20. M F Goldsmith, “US forensic pathologists on a new case: Examination of living persons,’’ Journal ofthe American Medical Association, 256 (October 3, 1986) 168.5-1691. 21. R Kowalski, personal communication with the author, 9 August 1990. 691
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22. Office of Chief Medical Examiner, New York, NY, “General Information,” (pamphlet) 1. 23. W J Curran, E D Shapiro, eds, Law, Medicine, and Forensic Science, second ed, (Boston: Little, Brown & Co, 1970) 16. 24. Ibid 25. Ibid 26. R E Mittleman, H S Goldberg, D M Waksman, “Preserving evidence in the emergency department,” The American Journal of Nursing 83 (December 1983) 1653. 27. P Besant-Matthews, Gunshot and Stab Wounh: A Medical Examiner’s View (Lewisville, Tex: Barbara Clark Mims Associates, 1987) unnumbered page. 28. C G Tedeschi, W G Eckert, L G Tedeschi, eds, Forensic Medicine vol 2 (Philadelphia: W B Saunders, 1977) 510-511. 29. B i d 30. Mittleman, Goldberg, Waksman, “Preserving evidence in the emergency department,” 1654. 31. J E Smialek, “Forensic medicine in the emergency department,” Emergency Medical Clinics of North America 1 (December 1983) 687. 32. Ibid 703. 33. Tedeschi, Eckert, Tedeschi, eds, Forensic Medicine, vol2, 516. 34. Ibki 517. 35. Tedeschi, Eckert, Tedeschi, eds, Forensic Medicine, vol 2, 5 11. 36. Smialek, “Forensic medicine in the emergency department,” 695-696. 37. Besant-Matthews, Gunshot and Stab Wounds:A Medical Examiner’s View 2. 38. Smialek, “Forensic medicine in the emergency department,” 697. 39. E F Wilson, “Estimation of the age of cutaneous contusions in child abuse,” Pediatrics 60 (November 1977) 750. 40. Smialek, “Forensic medicine in the emergency department,” 70 1. 4 1. Mittleman, Goldberg, Waksman, “Preserving evidence in the emergency department,” 1654. 42. Ibid 1655. 43. Ibid 44. Ibid 45. Ibid 46. Besant-Matthews, Gunshot and Stab Wounds:A Medical Examiner’s View 22. 47 Ibid 24, 48. R Carmona, K Price, “Trauma and forensic medicine,” Journal of Trauma 29 (September 1989) 1223. 49. Zbid
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Medical Students Prefer Controllable Life-styles Medical students increasingly are choosing residencies in specialties that offer controllable life-styles. These specialties are those that typically have shorter training time and higher income. Students also tend to choose specialties in which they can limit work time. The two most popular specialities with controllable life-styles are ophthalmology and radiology, according to an article in the Nov 16, 1990, issue of American Medical News. Other specialties perceived as having controllable life-styles are anesthesiology and emergency medicine, followed by dermatology, neurology, otolaryngology, pathology, and psychiatry. Specialties with noncontrollable life-styles include internal medicine, family medicine, pediatrics, and obstetricsigy necology. The training time for these is relatively short, but the pay is relatively low and patient care can involve unpredictable hours. Surgery specialties fall into a third category. The income is higher, but the training time is relatively long. Midcareer changes also favor controllable life-styles. According to the article, the impact of hours is more of a deciding factor than other factors such as educational debt load. Young physicians also like health maintenance organizations and large group specialties because of the predictable hours.
Correction The article on abdominal aortic aneurysms in the January issue of the Journal contains an error. On page 44, the text should read “Our experience indicates that 15% of aneurysms 5 cm in diameter and 30% to 50% of aneurysms 6 cm in diameter may rupture in a year.” The Journal regrets the error.
