11.02.16 examination of a injured person-converted

Mechanical injury Part 1 Forensic Medicine &Toxicology.

1. EXAMINATION OF A INJURED PE RSO N 8 / 6 / 201 6 1 Dr.Deshapande H.B (Asst.Prof.) Dept.Forensic Medicine &Toxicology Govt.Medical College &Hospital Latur.

2. WHAT IS AN INJURY REPORT? Injury report is a kind of medicolegal report. A medicolegal case is a case of injury or ailment where attending doctor after taking history and clinical examination of the patient thinks that some investigations by law enforcing agencies are essential so as to fix the responsibility regarding the case.

3. INJURY CERTIFICATE MLC No.: Name: Age: y e a r 4 . Sex: 5. Address: 6 .Occupation: Brought by: Date, place and time of examination: 9.Examined in presence of: 10.Consent: 11 . Signature: o f Examinee In presence of Identification marks: 1. 2. Brief history of the case: 14.General Examination • Built: Height Weight 15.Systemic Examination: 8 / 6 / 201 6 3

4. Sl no. 1 Nature of injury 2 Site of I nju r y 3 Size of I nju r y 4 Type of Injury 5 Type of infli c ting weapon 6 Age of injury 7 Remarks 8 8 / 6 / 201 6 4

5. IDENTIFICATION MARKS Two identification marks must be taken. They are necessary to identify the person in court One identification mark is more likely to lead to mistaken identification, as it can be duplicated in another person. Two identification marks are less likely to lead to errors. They should be on exposed parts, and not on hidden parts, so patient faces no embarrassment in court where these marks may be tallied.

6. IDENTIFICATION MARK Black mole present over left cheek, 8 cm front of left ear, 6 cm outer to left angle of mouth, 0.3cm in diameter, hairy, slightly raised above the surface. 8 / 6 / 201 6 6

7. GENERAL CONDITION OF THE PATIENT Whether the patient is conscious or unconscious. If conscious, whether anxious, tense, afraid, agitated. Bleeding from nostrils, ears, mouth, other natural orifices (vagina in case of sexual assault, anus in the case of buggery). Pulse rate, blood pressure, temperature, whether in a state of shock, paralyzed or not. If the police wants a statement from the victim, the doctor must first certify that the patient is compos mentis. 8 / 6 / 201 6 7

8. 1.Serial Number 8 1,2,3… Fi rs t colum n i s f or s e r ia l nu mbe r of injuries. A look at this column informs about total number of injuries over the body. 8/6/2016

9. 2 . Nature of injury 8 / 6 / 201 6 9 Stab injury [Example] This column is for recording the Nature of injury whether it is an - abrasion/contusion/laceration/ incised wound/ stab wound/chop wound / firearm wound/ fracture/ ………. etc.

10. (1) All injuries, however insignificant they may appear, should be recorded. Proper, adequate, and complete documentation is very necessary for all medicolegal work. Remember the maxim: Legally, only those injuries are present that have been recorded. Whatever has not been recorded was not present. Similarly, whatever procedures have been recorded were performed; whatever was not recorded was not performed. If necessary, photographic documentation should be performed. Although this is a common practice in the West, it has not yet caught on in India

11. (2) Even old injuries should be recorded. (3 ) Nature of each injury (e.g. whether it is an abrasion, contusion, laceration, incised wound, stab, burn, scald, fracture, dislocation of tooth etc.) should be noted. ( 4) Systematic entries - In order not to miss any injury, a systematic plan should be adopted. The best is to go round the patient in this manner; start with head and neck → right upper limb → right lower limb → left lower limb → left upper limb → front of the chest and abdomen → genitalia → back of chest and abdomen. 8 / 6 / 201 6 1 1

12. 5) Lens must be used in order to be able to differentiate between incised and incised looking lacerated wounds, or for noting other minute details such as singeing of hairs around firearm entry wounds. (6) Presence of any foreign material - (i) Note presence on the body or within the wound e.g. broken off point of a knife, bullets , coal, dirt, dust, fibers, glass, grass, gravel, grease, hair , metal, mud , oil, paint, pellets, powder, sand, shots, splinter of wood, synthetic materials, wads etc., These can often help identify the weapon , and indicate the manner in which injury was inflicted (e.g. Tip of a stabbing weapon may sometimes break when it strikes a bone [sternum, rib, skull, or when it gets lodged in a vertebra].

13. MIXED INJURIES Contused abrasion 1 3 8 / 6 / 201 6

14. 3. Site of injury 1 4 Front of chest on left side, 1 cm below nipple, 7 cm left to midline. [Example] This column is for recording the exact location of injury. Measurement should be taken from at least two anatomical landmark. 8/6/2016

15. 8 / 6 / 201 6 1 5

16. On what part of the body inflicted (1) Exact location of the injury in relation to important landmarks (e.g. midline, navel, nipple, outer canthus of the eye, a joint, a bony structure [e.g. knuckle]) should be noted. Distance from landmarks should be noted. (2) Avoid technical terms as far as possible (e.g. instead of writing "medial malleolus", write "inner bony prominence of the ankle"). There is nothing wrong in writing technical terms, and if the doctor cannot think of a suitable common name, he can use technical terms too.

17. Writing in layman's language makes it more comprehensible to judges and lawyers. A good alternative is to use the technical term and then common name within brackets, e.g. "Right anterior superior iliac spine (bony prominence on the right side of the waist)". (3) Concealed wounds - If the patient is unconscious (i.e. can't point to areas of pain), a careful search must be made for wounds in areas such as ears, nostrils, vagina, rectum, etc. Surgical wounds-reffered cases. 8 / 6 / 201 6 1 7

18. 4. SIZE OF INJURY 8 / 6 / 201 6 1 8 cm × 2 cm × chest cavity deep; both margins clean cut; both ends acute. [example] This column is to write down the size of injury. Normally any injury has three dimensions, length, width and depth but abrasion and contusion are to be described in two dimensions. The size should be measured and no guess work should ever be done.

19. Size, shape and direction of each injury (1) Size of each injury should be noted, after measuring them with a ruler. No reliance should be made on guesswork.:homicide-non accessible ( 2) Shape of injuries – whether linear, triangular, circular, elliptical, oval, irregular or any peculiar shape. :weapon ( 3) Direction of wounds - Whether horizontal, vertical, oblique or in any particular direction. Relationship with an organ is desirable (e.g. directed toward the heart, or away from the heart). Beveling of edges is particularly helpful in determining this. ( 4) Labeled sketches of all injuries should be made. This helps lay persons like judges and lawyers to understand the injuries better.

20. Cut Laceration

21. 5 . TYPE OF INJURY 8 / 6 / 201 6 2 2 Grievous This column is to point out the nature of injury. Legally injuries are of two types. They are:Simple injury ,Grievous injury Any injury that poses an imminent danger to the life of a person is termed as dangerous injury. It is the treating physician or the autopsy surgeon that has to decide the nature of a particular injury depending upon its type, site and involvement

22. Type of each injury (1) Against each injury, its nature should be noted (e.g. simple, grievous or dangerous) ( 2) If nature of injury is not immediately apparent, patient must be kept under observation and following entry made in the relevant column " patient under observation ." Similarly, if X-rays or other investigations have been ordered and their reports awaited, following entry should be made "Awaiting X-ray report."

23. Patient may have to be kept under observation in obscure head or abdominal injuries. After observation period is over, or when the lab reports and X-reports have come, and the doctor is ready to opine on nature of injuries, they could be given on a separate piece of paper . This is called " subsequent opinion ." Many hospitals have dedicated forms for giving such opinion. All precautions must be made as in the original injury report, e.g. making in duplicate, taking police official's signatures, etc., Serial number should be same as in the original MLC. 8 / 6 / 201 6 2 4

24. 6. Type of inflicting Weapon 8 / 6 / 201 6 2 5 Double edged sharp cutting weapon with a pointed tip [example] Depending upon the type of injury, the possible weapon/s that can produce the injury is to be mentioned in this column. One doesn’t have to name a particular weapon like sword/ lathi /knife etc. The opinion that can be given is that the type of inflicting weapon could be hard and blunt/sharp cutting/heat/cold etc

25. By what weapon inflicted Examination of wounds and clothes can indicate the nature of the weapon - whether sharp edged or blunt; or if sharp-edged, whether single-edged or double-edged. Blunt and sharp weapons - A weapon which when used with some force can cause fractures, is loosely referred to as a "heavy blunt weapon". In the case of cranial trauma, once the forensic doctor was shown a cricket bat in court and asked if it was a "heavy blunt weapon"? The answer was "yes". The lawyer asked, "if I take off 100 g from it, would it still remain a heavy weapon"? Answer - Yes. Q - If I take off another 100 g would it still remain a heavy weapon?

26.  Answer - You can remove as much as you want. The answer does not lie in weight. Rather if that weapon when used with force can cause a fracture or not. Show me such a weapon, and I will opine if it is a "heavy blunt weapon."  IN ANOTHER CASE , a lawyer showed the forensic doctor a single piece of paper and asked if it's edge was sharp. Answer - Yes. Qu. So, this means it is as deadly as a blade or dagger because they are also sharp? Ans - No. The answer does not lie in the sharpness of the edge but whether it can produce an incised wound. Since the edge of the paper cannot produce an incised wound, we cannot classify it as a "sharp 8 / 6 / 2 w 1 6 e a p o n " . 2 7

27. 7. AGE OF INJURY Fresh The column is to note down the age of the injury mentioned. It can be approximately inferred as follows; Age of abrasion • Fresh Red • 12-24 hours Bright red • 1-2 days Dark red • 2-3 days Red brown • 3-5 days Dark brown • 8/6/2016 5-7 days Fall off 2 8

28. AGE OF BRUISE Fresh- Red Few hours to 3 days - 3 – 5 days- 5-7 days- 7-12 days- Y ell o w Bl u e Brown (due to hemosiderin) Green (due to haematoidin) (due to bilirubin) 8 / 6 / 201 6 2 9

29. AGE OF LACER A TED, INCISED AND S T AB WOUNDS : Unsutured Inflamed skin edges- Up to 24 hours Appearance of infection- More than 36 Hrs Sutured Inflamed edges-Up to 24 hours Edges easily separated-1-3 days Edges difficult to separate- 3-7 days 1-4 weeks More than 4 wks Red, soft, tender scar- Pale, firm, nontender scar- 8/6/2016 3

30. 8. REMARKS ( TREATMENT REQUIRED, X-RAY, etc) On exploration, the wound was found to be entering the front of lower lobe of left lung through an injury of size 3 x 0.5 cm, 3 cm deep into the lung tissue 8 / 6 / 201 6 3 1

31. REMARKS This would include entries not covered elsewhere, e.g. condition of clothes (whether they are blood stained or stained by other body fluids like semen, saliva etc., torn, buttons missing, burnt etc., or not ). Whether wet, dry or show corrosion (if hot fluid was thrown on the body [as in scalds], they would be wet. In case of vitriolage, they would show corrosive marks). If blood stained, or if showing associated defects due to firearms, they must be sent to the forensic science lab for examination of gunshot residues (to enable estimation of distance of fire).

32. This column is for any remarks to be made by the examining doctor. If any investigation is to be advised, it is mentioned here and the report kept reserved till arrival of the investigation report. Injuries mentioned are consistent with RTA or ASSAULT or THE HISTORY GIVEN. Injuries mentioned are not consistent with RTA or ASSAULT or THE HISTORY GIVEN. 8 / 6 / 201 6 3 3

33. Treatment given: TT,dressing,iv fluids etc Investgations pending. Referred to which speciality? Like all other certificates, signature/left thumb impression of the examinee should be taken at the left hand corner with examining doctors’ signature at the right hand corner with seal of name and designation. 3 4 8 / 6 / 201 6

34. CLINICAL CONSIDERATIONS 8 / 6 / 201 6 3 5

35. PUNCTURED WOUND

36. PUNCTURED WOUND

37. Entry Vs Exit Wound

38. EXIT WOUNDS In SHOT GUN INJURIES Only if there is contact entry wound Fired tangentially to surface Thin parts of the body – limbs, Neck. Caused by rifled slugs

39. 8 / 6 / 201 6 4 2

40. Scrotal Contusion

41. DEFENCE WOUND

42. DEFENCE WOUND

43. 6 August 2016 Stab Wound

44. INCISED WOUND

45. 6 August 2016

46. 6 August 2016

47. ABRASION Injury to skin Simplest Types *Scratch *Graze *Impact/ p r essu r e / imprint 8 / 6 / 201 6 5 1

48. Impact/imprint abr Replica of the Object may be Produced 8 / 6 / 201 6 5 2

49. 8 / 6 / 201 6 5 3

50. 6 August 2016 Imprint Abrasion – Ligature Mark

51. 6 August 2016 Throttling – Nail Marks

52. CONTUSION/BRUISE Also in internal Organs Types: *Ectopic *Patterned *Come out 8 / 6 / 201 6 5 6

53. CONTUSION / BRUISE P A TTER N ED BRUISE 8 / 6 / 201 6 5 7

54. LACERATED WOUND Tear/split of skin. Mucus m,muscle or internal organs Types *Split *Stretch *Avulsion *Cut laceration 8 / 6 / 201 6 5 8

55. INCISED INJURY Clean cut Through tissue Length Ma r g i n s Width Depth 8 / 6 / 201 6 6

56. 6 August 2016 Stab Wound

57. 6 August 2016 Gunshot wound

58. 6 August 2016 Gunshot wound

59. 6 4 8 / 6 / 201 6