MEDICOLEGAL ASPECTS OF TRAUMA MANAGEMENT

Dr T. Kombora

CONTENTS

• Completion of J88

• Wound Descriptions

• Doctor and the Law

COMPLETION OF THE J88Divided into 9 Sections

A. Demographic Information B. General HistoryC. General ExaminationD. History in case of Alleged Sexual Offence

E. Gynaecology Examination F. Samples Taken for Examination G. Anal Examination H. Male Genitalia I. Diagrams to show extent of injuries J. Annexure

A. DEMOGRAPHIC INFORMATION

• Police Station , Case number and Investigating Officer

• Use 24 hour notation for time

• Medical officer Details – name , registered qualifications, contact details in case of subpnoena

• Details of person examined- full name as on ID and DOB

B. GENERAL HISTORY

*State source of information1 . Relevant Medical History & Medication

- Any old injuries, medical illnesses eg DM, epilepsy, asthma, Psychoses

- Document if you find any medical condition

2 . Medication- Any that can aggravate/cause bruising , bleeding ,

influence mental awareness eg steroids , immunosuppressives , anti-convulsants, antidepressants , hypnotics

C. GENERAL EXAMINATION

1. Condition of Clothing - tears, missing buttons, torn or any stains like blood , mud , semen or vomit

2. Height in cm, weight in kg

3. General Body Build- Is it within normal limits for age, muscular, obese or emaciated? Can use BMI or weight for age scales

C. GENERAL EXAMINATION (CONT.)

4 . Clinical Findings- Document systematically- Avoid medical terminology unless no alternative- Use contrasting colour pen for sketch- Number each lesion (1)….(2) on sketch and describe

on form

C. GENERAL EXAMINATION (CONT.)

5 . Mental and Emotional Status- Is patient calm, crying, hysterical or just plain stuperous- Is there evidence of mental retardation, psychosis or mood

disorder

6 . Clinical Evidence of Drugs or Alcohol- Any obvious smell of alcohol or dagga- If necessary take blood and urine samples- Inspect injection sites for needle stick marks

C. GENERAL EXAMINATION (CONT.)

7 . Conclusion- Just a short history with the facts.- Never give name of accused- Avoid trying to narrate actual events as per person giving it

because it might not be the same as in police statement and these differences can be used by defence to dispute evidence in court

D. HISTORY OF ALLEGED SEXUAL OFFENCE

1 . Age of menarche, number of pregancies and deliveries. Is person pregnant at the moment and how many weeks?

2 . First day of LMP, duration of period and cycle3 . Contraception use, when last used and type4 . Date and time of last consentual intercourse and partners in

past week. 5 . Condoms?6 . Has person after alleged offence occurred, bathed washed

showered, douched , urinated or changed clothing

E. GYNAECOLOGICAL EXAMINATION

1 . Breast development use Tanner Stage 1 – 52 . Pubic Hair use Tanner Stage 1 - 5 - Tanner Staging best way to determine discrepancies

between apparent and chronological ages3. Examine external genitalia noting any injuries old or new4. Hymen- Use clock notation to describe position of injuries 5. Vagina - Use clock notation to describe injuries. Record any

vaginal delivery in past 6 months and if any lesions result of it6. Cervix and Perineum

TANNER STAGING- FEMALE

F. SAMPLES TAKEN FOR INVESTIGATION

1. Forensic Specimen taken2. Urine Pregnancy Test3. Seal number of Evidence Collection Kit4. Note name, rank, Force Number of person given Kit for preservation

on chain of evidence5. Conclusion

- Do not use term rape - if negative eg “ absence of injuries does not exclude forcible

penetration of vulva or vagina by penis or other object” - if positive eg “ injuries compatible with forcible penetration

past labia majora with bruising of hymen” - State if injuries confirm to time and date of alleged incident

G. ANAL EXAMINATION

. Use clock notation, state apparent age , degree & severity of lesions

. Measure lesions in mm

. Conclusion as for the Gynae exam

H. MALE GENITALIA

. For cases of male sexual abuse

. Note degree of genital development and pubic hair

. Determine nature , extent, anatomical position and apparent age of all injuries

CONCLUSION

. In young males use Tanner staging

. State if findings are comparable with history of alleged incident as provided by person examined

TANNER STAGING - MALES

J . ANNEXURE

. This is a declaration that said Medical Officer has done the examination on the person mentioned in the J88

PITFALLS IN COMPLETING J88

. Failure to do adequate exam and describe full extent of injuries and poor documentation

. Not signing on every written page

. Use of abbreviations like NAD and medicolegal terms ( layman terms to be used)

. sketches that difficult to note esp with use of pen of same colour with sketches

. Making a subjective diagnosis which is scientifically impossible

WOUND DESCRIPTION

• Open– Laceration– Incision wound– Abrasion– Puncture– Penetration wound– Gunshot wound – Entrance and exit wounds

• Closed– Contusion– Hematoma

LACERATION• Laceration – Irregular tear like wound caused by blunt trauma or

heavy edged weapons like axes or hatchet

ABRASION• Abrasion - Superficial with loss of epidermis. Caused by skin coming

into moving contact with a rough surface. If more traumatic with loss of all sin layers then its an avulsion

CONTUSION

• Contusion - Blunt force causes rupture of capillaries and venules with extravasation of blood into extracellular space

Haematoma

• Haematoma – Collection of blood under the skin

PUNCTURE• Puncture - Sharp thin object like a needle, nail or screwdriver

puncturing skin

INCISION WOUND• Incision Wound - regular margins cased by sharp edged object like

knife, razor or glass

PENETRATION WOUND• Penetration Wound – Sharp object entering body eg knife

GUNSHOT WOUNDS• BALLISTICS. Calibre – Approximate diameter of a bullet in inches, in a rifled

barrel this is the distance between consecutive lands or grooves

. A moving projectile has kinetic energy proportional to its weight and velocity KE= MV2/g

.Wounding effect due to transfer of KE from projectile to tissues

. The greater the angle of yaw with subsequent tumble and wobble the greater the damage the greater the loss of KE

. Calibre and mass of projectile influence the “drag effect”. Structure of projectile important

. The denser the tissue the greater the loss of KE

GUNSHOT WOUND. Several mechanisms of injury by bullets ; - Direct laceration with low velocity rounds forming single

permanent cavity - High velocity tend to form a large temporary cavity due to the

great KE, lasts 5-10 msec. If pressure of temporary cavity exceeds elastic limit of tissue then it will burst eg liver

- Shockwaves receeding from projectile can rupture hollow viscus like bowel

- Secondary projectiles eg shattered bone fragments - Discharge gases from muzzle of gun

GUNSHOT WOUND - ENTRANCE

Contact GSW

Intermediate Range GSW

Intermediate Range GSW

GSW EXIT WOUNDS

COLLECTING EVIDENCE FROM GSW

• Victim’s clothes may yield information on range of fire or distinguish entrance from exit wounds

• Package items of clothing separately to cross contamination and place in paper bags (to avoid the static electricity in plastic bags which would lift evidence from clothes)

• In suspected shooters wrap their hands in paper bags for later test of GSR

• When removing bullets cover haemostats/forceps with gauze to preserve the microscopic “fingerprint” of each bullet

• Bullets must be collected in breathable containers eg paper boxes or envelopes not airtight containers

• When in doubt over GSWs describe what u see not guessing

THE INTOXICATED PATIENT

. Issue of collecting bloods ; Section 37 of the Criminal Procedure Act of 1977 states that blood samples can be taken by medical officer of any prison or any district surgeon and also any registered MO or nurse can do so on request of police.

. It gives authority to do this against will of subject( provided he is lawfully arrested) and allows use of reasonable force without this constituting assault

. However in other 1st world countries it’s a bit different you need patient consent and its recommended that police surgeons do the collection

CONSENT

. Duty of treating doctor to advise and explain benefits and risk of any treatment to be administered to patient

. Done in two stages : 1) Assessment of legal capacity to consent 2) The process of obtaining that consent. On assessment age, consciousness and whether of sound mind

considered

UNAUTHORISED ADMINISTRATION

. Negates need for consent on basis of medical ‘necessity’

. There must be a real state of emergency

. The patient must be unaware of the fact that he is being medically treated, or must at least be incapable of properly appreciating the situation

. The treatment must not be against the will of the patient

. The treatment must be intended to be in the best interest of the patient

JEHOVAH’S WITNESSES

.First consider whether patient is competent to give or refuse consent

.Refusal of blood transfusion by a legally competent person is binding but it must be his own decision, free of undue influence

. If incompetent adult( eg unconscious) the views of relatives are not binding. However, we should respect a formal advance directive ,made when competent, that no blood may be given

. In cases of minors the issue might need to go before the courts which usually grant permission for the transfusion

REFERENCES

. Strauss S.A. Doctor, Patient the Law. 3rd Edition 1991. J.L Van Schaik. 357-358

. Montague A. Legal Problems in Emergency Medicine. 1996. Oxford University Press. 21-34, 35-36

. Olshaker J. Forensic Emergency Medicine 2nd Edition 2007.Lippincott, Williams and Wilkins. 55-70

. Guidelines for the Completion of the J88 in Kwazulu- Natal