FORENSI C INTENSIV E CARE Dr. Miada Mahmoud Rady Lecture 1 Topics I. the rule of EMS in forensic medicine .

II. Important vocabulary III. Areas of forensic interest IV. Crime scene

V. evidence The rule of EMS in forensic medicine EMS called to evaluate and transport victims: i. Gunshot and stab wounds. ii. Physical assault. iii. Sexual abuse and assault.

iv. Domestic violence. v. Motor vehicle crashes. All may have injuries or conditions with criminal or civil forensic medical implications. The rule of EMS in forensic medicine So assessment and appropriate treatment of injuries is not the only responsibility , protection of potential evidence during medical evaluation is also crucial .

Whats important to know Vocabulary. Protecting evidence at crime scenes. The nature of evidence.

Forensic emergency medicine: application of forensic medical knowledge and appropriate techniques to living patients Forensic science: systematic methodologies of associating people , places, and things involved in criminal activities to assist in investigating and solving crimes.

Areas of forensic science Criminalistics Forensic Pathology Forensic Anthropology Forensic Odontology Forensic Engineering Toxicology Behavioral Sciences Questioned Documents Crime Scene

while examining crime scene the following should be taken in consideration: 1. Primary task of first investigator in crime scene is to secure the scene and prevent destruction or alteration of the contents of crime scene . 2. Normal items can be evidence 3.

Simple mistakes can occur that affect an entire case and many peoples lives. 4. Each scene is unique. 5. Situations demand flexibility and creativity. Evidence

Real evidence : most evidence is real; generated as part of the crime e.g. blood, hair, semen, saliva, urine

,clothing ,condoms, bedding ,fingerprints, shoe prints , weapons, bullets, restraints, gags. Trace evidence: Broken glass, paint, environmental debris. Other evidence : Medical documentation ,patient statements/excited utterances ,photographs. Documentation Greater significance than in non-criminal case.

Criteria : 1. Legible, clear, objective observation. 2. Describe behavior 3. Record excited utterances. Excited Utterances Definition : statements made by victim immediately or shortly after experiencing traumatic event

Presumed Narrative to be true, often admitted into court as evidence often admitted into evidence as it is used for medical diagnosis and treatment . Chain of custody Written trail of possession of evidence . Should be clearly documented for each item of clothing, body fluids,

debris. Document receiving person. Maintaining chain of custody can make or break a case. Evidence preservation and integrity Key focus of the paramedic is evidence preservation , following should be followed : 1. Avoid cross contamination 2. Evidence that is fragile or small presents challenges and has to be handled

with care. 3. Wet evidence should be air dried 4. Plastic packaging should be avoided Patients as the crime scene The role of EMS with respect to evidence preservation can be crucial. Trace evidence can be lost when transporting victims/patients. Preserve possible evidence on skin, clothing, wounds, or body fluids.

Emergency Assessment ABCs. Assess and treat injuries. Protect potential evidence. Provide safety, security, support. Patients are more likely to cooperate with complex medical and legal procedures if they feel safe and secure. Objective Assessment and Documentation

Appearance. Behavior. Clothing.

Injuries. Evidence collection Penetrating trauma A. Documentation of number, location, size ,shape and characteristics of wounds. B.

Misinterpretation of entrance and exit wounds occurs frequently , differentiation depends on : I. Size. II. Shape. III. Configuration. IV. Velocity of bullet and the characteristics of the impacted tissue.

Penetrating trauma C. Clothing: Helps to distinguish entrance v. exit and range of fire via : 1. Direction of fibers. 2. Deposit of soot and gunpowder residue. Do not cut through defects in clothing. Package separately in paper bags : 1. Minimizes risk of static electricity lifting fragile evidence. 2. Reduces cross contamination and degradation of evidence. Gunshot residue (GSR) test :

1. May determine if person was in the location where the weapon was fired. 2. Sensitivity of test decreases with time, washing, placement of tape, rubbing the skin, placement of plastic bags or gloves 3. Place paper bags over the hands early in treatment. D. Bullets : The following precautions should be followed: 1. Handle with gloves, if hemostats are used, cover with gauze to preserve marks.

2. Collect separately if multiple bullets, in breathable containers. 3. Placement in airtight container results in contamination and degradation of the evidence due to moisture and bacteria so should be avoided . Sharp force trauma wounds Types of wounds : 1. Cut ( incised ) wound : caused by drawing motion; longer than it is deep , straight edges. 2. Stab wound : caused by penetrating trauma , deep than long , straight edge .

3. Contused wound : blunt trauma , irregular edges . Wound characteristics provide information about weapon: single or double edge, sharp or serrated . Self inflicted wounds : 1. Usually superficial, linear, uniform, often parallel on non tender parts of the body in accessible areas . 2. Wounds from sharp objects such as knives, scissors, razor blades are most common.

Motor Vehicle Trauma Who was driving? Can you tell what type of vehicle hit the pedestrian? High risk of evidence destruction while delivering emergency care . Documentation of pattern injuries is important 1. Seat belt abrasions 2. Air bag abrasions

3. Steering wheel contusions 4. Cuts and lacerations Motor Vehicle Crashes Clothing: collect in paper bags if possible. Broken glass from wounds can be collected.

Body map injuries. FORENSI C INTENSIV E CARE Dr. Miada Mahmoud Rady Lecture 2 Forensic Evaluation of Injured Pedestrians Many Most

incidents involve hit and run drivers . victims are struck by front bumper and will show signs of : 1. Primary impact injuries 2. Secondary impact injuries 3.

Tertiary impact injuries Other injuries include crushing body wide injuries with or without bumper injuries The following should be followed on handling Injured Pedestrians 1. Trace Evidence on injured Pedestrians are collected from clothing or wounds and includes Headlight glass , Windshield glass Grease, oil,

and paint chips 2. Clothing should be collected 3. Body injuries map should be done Sexual Assault Sexual Assault : Nonconsensual sex acts which can include vaginal, anal, or oral sex that is unwanted, painful, humiliating .

Usual legal time limit for collection of evidence us 72-120 hours (3-5 days). If more than established time, victim should still have physical exam with treatment of STIs. Some states and some situations require mandatory reporting Pre hospital Physical Assessment of rape victim 1. Focus on complaints or injuries without disturbing clothing. 2. Gather only needed information to provide medical care. 3. Detailed questioning about assault is usually unnecessary. 4. Severe trauma is rare, wounds usually minor.

5. Preserve evidence on clothing and injuries . 6. Stabilize medically. 7. Activate SANE if appropriate : Sexual assault nurse examiner ( SANE ): is program designs to fill the gap between sexual assault victims legal and medical care . Nurses involved in this program are highly trained to :

1. Care for victims emotional needs 2. Collect forensic evidence and assist in reporting , 3. Give STDS prophylaxis and develop proper follow on medical plan in case of pregnancy or suspected STDs exposure evidence collection Should not be delayed, greatest amount of evidence can be collected within hours of assault. Medical stabilization is priority. Oral evidence If report of oral assault is made within 6-8 hours the following is done :

1. advise patient not to eat, drink, smoke, or chew gum. 2. Report to SANE so swabs and or dental floss can be collected immediately. 3. Patient can then brush teeth and have oral fluids. Urine as Evidence If necessary to void prior to transport from scene or discharge from ED the following must be done : 1. Instruct the victim not to wipe 2.

Save tissue if patient wipes 3. Instruct patient not to wash hands 4. Collect urine sample. 5.

Instruct patients not to dispose of personal care products if they need to urinate Tampons, pads, panty liners should be preserved as evidence. Clothes as evidence Clothes of rape victims are usually : 1. Torn or ripped 2. Soiled , Wet 3. Missing buttons , Missing items

4. Stretched areas 5. Inside out items , partially clothed . Clothes as evidence While collecting clothes from rape victim the following should be followed: 1. Preserve evidence, collect in paper bags if possible. 2. Document any modifications: clothing backwards, debris, grooming. 3. Ensure that clothing is worn or brought to SANE unit or hospital. Words :

1. Use the language the victim uses. 2. Clarify what it means. 3. Dont act shocked or disgusted. Absence of Injury Lack of contact. Delayed Non

reporting. aggressive perpetrator/nonresistant victim. Lack of training or experience of examiner. False allegation.

Normal to be Normal Children Acquaintance/intimate Fear, partner intimidation, manipulation, coercion DFSA ( drug facilitated sexual assault ).

Strangulation Take report of choking, strangulation seriously. Document associated injuries: 1. Petechiae above level of strangulation 2. Swelling to face, tongue. Intimate Partner Abuse Documentation of injuries, body maps documentation of patient

statements/excited Photographs Associated utterances of injuries trauma can include traumatic alopecia, strangulation, slap injuries, bite marks,

and firearm injuries. Child Abuse/Assault When caregivers provide history that is inconsistent with extent of injury or condition, child abuse must be considered : 1. Head injury

2. Failure to thrive 3. Chest and Abdominal trauma 4. Multiple bruises, fractures, soft tissue injuries or burns

5. Bites wounds 6. Neglect EMS rule in forensic cases 1.

Victims may refuse care other than from prehospital care providers so what you do and what you say is critical 2. Victims are more likely to cooperate with the multifaceted medical and legal proceedings if their first contacts are positive and encouraging 3. EMS should focus on helping victims maintain a sense of control and safety after a traumatic event. 4. Explain options, respect decisions.

5. Offer choices, resource information, or referral numbers. Summary Rule of EMS team in forensic area is growing beyond medical acre. Knowledge of the proper way of dealing with accident with

forensic nature is crucial. Empathy and compassion is important in handling victims of sexual assault.

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