Body of Evidence: The Sequel: “Sir, will that be paper or plastic?”

A review of the answers to the last PPQ follows.

1.Clothing and personal effects can be released to the family in homicidal deaths.

False.

Clothing and personal effects should never be discarded or released to anyone when the death circumstances are homicidal or suspicious for foul play. These items can harbor evidence such as foreign DNA, gunpowder residue, or defects that correspond to body wounds. Recovery with analysis of foreign DNA may lead to a suspect. Analysis for gunpowder residue may assist in range-of-fire determination. Comparison of clothing defects to gunshot wounds and other penetrating or perforation wound types is an essential task in forensic cases. Another example in which clothing is vitally important involves the death of a pedestrian struck by a motor vehicle that fled the scene (hit/skip). Materials from the vehicle or tire tread marks may be on the clothing and have very high evidentiary value. Clothing and personal effects are considered evidence and must be handled according to established protocol of the medical facility in conjunction with local law enforcement. This handling includes storing items in sealed and labeled paper bags kept in a secured monitored location.

2.  A victim of a single stab wound of the chest expires despite surgical intervention. Blood-soaked clothing accompanies the victim. The clothing should be handled in which of the following manners:

c.The clothing should be sealed in a paper bag labeled with the patient’s identifying information, signed and dated, and placed in a secured, monitored room within the hospital (or medical facility).

Clothing must never be washed are otherwise manipulated in any way as this can alter, dislodge or destroy evidence.

 

3.A patient expires as a result of multiple gunshot wounds and is pronounced dead in the emergency room. A handgun is found in a pocket of the patient’s clothing. The best practice would be to

c. Refrain from handling the gun and notify law enforcement immediately

Handling a gun may lead to unintended discharge and possible bystander injury. If it’s found in its holster, leave it there. If in the treatment field, removal using a gloved hand, holding only the grip (and not touching the trigger), and without pointing it at anyone is a good plan of action. It is considered evidence and must be handled according to established protocol of the medical facility in conjunction with local law enforcement. Under no circumstances should it be given back to family members or acquaintances. Instead, notify police ASAP!

4. A patient with a known history of viral hepatitis is the victim of homicidal violence and is pronounced dead 2 hours after arrival despite therapeutic intervention. The patient’s hands are bloody with adherent debris . The best practice would be to:

b. Secure paper bags over the hands to contain any potential foreign material

The skin surface of hands as well as fingernails can be high-yield areas of biological and other types of evidence and therefore paper bags must be placed and secured over them to preserve any evidence to be collected and analyzed later. Paper is always preferable to plastic as plastic coverings placed on a cooling body can lead to condensation that can favor the proliferation of mold and bacteria and an environment less favorable to human DNA, foreign or otherwise. The hands of the deceased should never be cleaned as this may remove any evidence.

5. An 8-month old infant is brought to the emergency room unresponsive by a frantic caretaker. Resuscitative efforts are unsuccessful and the infant is pronounced dead an hour after arrival. On initial clinical assessment, the physician notes a bite-mark-type abrasion the upper right arm and numerous bruises of various ages on the infant’s torso, arms and legs. Imaging also revealed rib fractures of various ages. The parents arrive and are told the tragic news. They ask to hold the infant. The best practice would be to:

c. Swaddle the infant in a clean hospital sheet placed over the sheet used during resuscitation, with all resuscitative devices left in place, and allow parents access to the infant to grieve, but within direct sight of a police officer; secure all clothing according the established hospital protocol

Care must be taken to contain any on-body evidence and to prevent the alteration of existing evidence or the introduction of any additional potentially confounding evidence, whether unknowingly or deliberately, in a homicidal infant death. This may be difficult for grieving parents to grasp and will require the use of special protocols that attend to the emotional needs of the parents without compromising the death investigation.

 

6. A patient presents to the emergency department in extremis as a result of a perforating gunshot wound to the left lateral chest in the region of the 6th intercostal space, exiting the same level on the right lateral chest.

False. The chest wounds are ideal ports for placement of chest tubes.

While it may be tempting to use convenient “pre-made” ports for placement of tubes and catheters, it should be avoided if at all possible, with the understanding that all emergent, potentially life-saving measures have precedence. Manipulation of wounds such as gunshot wounds, stab wounds and other penetrating or perforating injury may alter or destroy identifying characteristics that could be vital to reconstruction of the death circumstances. Cleansing, suturing, and bandaging wounds in a patient with an interval of survival before death is obviously necessary and the forensic pathologist  is aware of the limitations of wound interpretation in that setting and will seek medical records for any description of injuries prior to therapeutic intervention. However, postmortem manipulation of wounds, such as suturing, must be avoided for the reasons given above. The placement of gauze banding over wounds is sufficient.

Foreign materials such as bullets recovered during surgery must also be properly handled as evidence according to established protocol.

 

References:

  1. Association of Surgical Technologists Standards for Handling and Care of Surgical Specimens, Section XI. Available at: http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Handling_Care_Surgical_Specimens.pdf.
  2. O’Malley P, Barata I, Snow S, et. al. Death of a child in the emergency department. Pediatrics. 2014;134:e313-e330.
  3. Armstrong E J. 2017. Chapter 4: Medical Examiner-Coroner Cases at Medical Facilities. In: Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

 

 

Will there be an Episode III? May be. Stay tuned.

Body of Evidence: Part I

Evidence. It’s more than blood, hairs and fibers found at the crime scene.

The body can harbor many forms of evidence whether on clothing still worn by the victim upon initial assessment by paramedics or on the skin surface and within the depths of wounds encountered the surgeon. Wound patterns also have evidentiary value. The death of victims of homicidal violence or suspected foul play will come under the jurisdiction of the Medical Examiner or Coroner. Meticulous documentation, collection, and scientific analysis of bodily evidence will follow.

Test your knowledge on this topic with the following PPQ (Practice Pearls Quizlet):

1. A patient is pronounced dead on arrival as a result of multiple gunshot wounds and is placed in the hospital’s secure morgue room. Family members arrive and are told of the tragic news. They request the deceased’s clothing and personal effects.

True or False. All clothing and personal effects may be released to the family.

2. A victim of a single stab wound of the chest expires despite surgical intervention. Blood-soaked clothing accompanies the victim. The clothing should be handled in which of the following manners:

a. The clothing should be washed and given back to the family

b. The clothing should be sealed in a paper bag labeled with the patient’s identifying information, signed and dated, and placed in a secured, monitored room within the hospital

c. The clothing should be sealed in a plastic bag labeled with the patient’s identifying information, signed and dated, and placed in a secured, monitored room within the hospital

3. A patient expires as a result of multiple gunshot wounds and is pronounced dead in the emergency room. A handgun is found in a pocket of the patient’s clothing. The best practice would be to:

a. Give the gun to the next-of-kin for safekeeping

b. Examine the weapon to make sure it is “safe”

c. Refrain from handling the gun and notify law enforcement immediately

4. A patient with a known history of viral hepatitis is the victim of homicidal violence and is pronounced dead 2 hours after arrival despite therapeutic intervention. The patient’s hands are bloody with adherent debris . The best practice would be to:

a. Secure plastic bags over the hands to provide a barrier against blood borne pathogens

b. Secure paper bags over the hands to contain any potential foreign material

c. Wash all blood and debris from the hands with antiseptic soap

5. An 8-month old infant is brought to the emergency room unresponsive by a frantic caretaker. Resuscitative efforts are unsuccessful and the infant is pronounced dead an hour after arrival. On initial clinical assessment, the physician notes a bite-mark-type abrasion the upper right arm and numerous bruises of various ages on the infant’s torso, arms and legs. Imaging also reveals rib fractures of various ages. The parents arrive and are told the tragic news. They ask to hold the infant. The best practice would be to:

a. Remove airway and intravenous tubes, clean the infant, and allow the parents to hold the infant

b. Inform the parents that while they cannot be permitted to hold the infant, pending notification of the Medical Examiner and police, the infant’s clothing will be released to them

c. Swaddle the infant in a clean hospital sheet placed over the sheet used during resuscitation, with all resuscitative devices left in place, and allow parents access to the infant to grieve, but within direct sight of a police officer; notify police and report the death to the Medical Examiner; secure all clothing according the established hospital protocol

6.. A patient presents to the emergency department in extremis as a result of a perforating gunshot wound to the left lateral chest in the region of the 6th intercostal space, exiting the same level on the right lateral chest.

True or False. The chest wounds are ideal ports for placement of chest tubes.

…To be continued and tune in to the next episode of Practice Pearls!

 

Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408