Recent mass casualty incidents in the United States, including the movie theater shooting in Aurora, Colo., the school shooting in Sandy Hook, Conn., and the Boston Marathon bombing have highlighted the important role emergency medicine plays in our nation’s health system. These incidents have also highlighted and brought attention to another important need in emergency medicine, clinical forensic emergency medicine.

In an article just days after the Boston Marathon bombing, Dr. Louis Alarcon, medical director of trauma surgery at the University of Pittsburgh, highlighted the importance of forensic evidence collection.

“We collaborate closely with forensic pathologists and law enforcement,” he said

“Our first priority is to save the patient’s life – life and limb over everything. Once we achieve those goals, we also have a strong duty to the evidence.”

Dr. Alarcon went on to say, “‘At Tufts Medical Center in Boston after Monday’s marathon bombing, doctors worked with law enforcement to collect and save fragments of shrapnel that became projectiles with the force of the bombing,’ Robert Osgood, M.D., told Boston’s WBUR-FM.”¹

Dr. Alarcon added, “Emergency physicians painstakingly search for bullets, metal, wood, plastic, or other substances that become projectiles in bombings or other events.” His hospital formalized that search with a standard process for evidence collection and preservation, a process so detailed that it stipulates when plastic versus metal instruments should be used for collection.¹

Clinical forensic emergency medicine (CFEM) is defined as the application of forensic medical knowledge and appropriate techniques to living patients in the emergency department.²

CFEM is the link for survivors of crime and violence to the criminal justice system. Victims who do not survive the violence have the voice of the coroner or medical examiner, but survivors have to rely on emergency physicians and trauma surgeons who have had little or no training in forensics.

Several studies have shown that emergency department personnel do not do an adequate job at handling the forensic needs of their patients. Smialek wrote that evidence from crimes was disappearing from emergency departments because of lack of staff knowledge and training.³ A study of 100 charts from a Level I trauma center found that documentation in 70% was poor, improper, or inadequate. In 38% of cases potential evidence was improperly secured, incorrectly documented, or inadvertently discarded.⁴ In 1983 a paper in the American Journal of Nursing emphasized the importance of evidence recognition and preservation in the emergency department.⁵

Drs. Wiler and Bailey highlighted the fact that emergency physicians are prepared to manage medical issues of acutely ill patients but do not receive formal training in clinical forensic medicine.⁶ Their paper highlights forensic emergency medicine efforts and calls for residency training in forensic emergency medicine. Far beyond what is currently provided. Dr. William Smock first proposed a potential forensic emergency curriculum in 1994, yet it has not been adopted by most programs.⁷

This article will highlight some important forensic principles to apply when caring for victims of violent crime and provide information about developing a Forensic Care Program in your department.

As with everything in emergency medicine, the ABCs and lifesaving procedures always take precedence. However, forensic needs should not take a backseat entirely. Some simple tips and techniques can make a difference in fulfilling the forensic needs of the patient and the criminal justice system.

Injury Documentation

One of the most important forensic techniques emergency medicine personnel have at their disposal is proper documentation. Proper documentation of injuries is crucial because many procedures performed during resuscitation, and even wound cleansing techniques, can alter the appearance of wounds, and the initial emergency department documentation may be the only accurate description of them. Wounds also change their appearance over time, which can lead to misinterpretation by the time they are evaluated.

Descriptions of wounds should include their shape, precise body location, and size (a measuring device should be used). Be as specific as possible. Specific characteristics should be noted, such as the presence of foreign materials, coloration, and patterned injuries. Patterned injuries (abrasions or contusions) retain some features of the impacting object, possibly allowing it to be identified.⁸

In addition to written documentation, body diagram maps, illustrations, and photodocumentation should accompany all written documentation of injuries. Proper forensic photographic protocols should be followed. A digital camera should suffice for most image capture. The department and/or hospital should have a policy regarding image security and storage.

The use of correct terminology is also important. Incised wound/cut is the correct term for violation of the epidermis by a sharp instrument. A laceration is caused by blunt force trauma and often includes crushed edges and tissue bridges. So, for example, a patient struck in the head with an intact beer bottle sustains a laceration, while a patient slashed with a broken bottle sustains an incised wound.

Wounds/bruises should not be dated.^9,10,11 The science of dating/timing an injury is very imprecise and several patient factors, tissue types, medications, and injuring items can influence a wound’s coloration. Wound colors should be described as they are seen, and no comment on age of the bruise or time of occurrence should be provided.⁹

Clothing Evidence

Clothing is another important piece of forensic evidence encountered in the emergency department. Clothing is almost always removed in the care of trauma patients.

When cutting clothes, avoid cutting through bullet holes or sharp force injuries. Clothing items should be individually placed in PAPER bags, labeled, sealed, and turned over to law enforcement. Plastic bags retain moisture and promote the growth of bacteria and potential degradation of DNA. If clothing items are wet, the clothes can be wrapped in craft paper and placed into the paper bag. The bag should be labeled as “WET” and law enforcement notified so that they can place the clothing in driers at the crime lab.

Firearms Injuries

Firearm violence is one of the important public health issues facing the U.S. today. It is estimated that for every firearm fatality there are 3-5 times as many survivors.¹² Firearm injury victims often present with forensic evidence. Clothing should be handled as previously mentioned.

Cases and cartridges can often be found intermixed with patient clothing and bandages, and on the stretcher. They should be handled as little as possible and with gloved hands. These items should be placed in a small box or coin envelope and sealed.

Bullets themselves contain important forensic evidence and ballistic markings. Bullets should not be handled with metal instruments. Plastic forceps or metal forceps with rubber tips or Surgical BootsTM should be used to remove bullets from the body. The bullets should not be dropped into metal bowls or emesis basins. This metal on metal contact can alter the ballistic marks on the bullets and make comparative analysis impossible. Bullets should be placed in a small envelope or small box and sealed.

In addition, firearm wounds should not be classified as exit or entrance wounds by the untrained practitioner. Entrance and exit wounds have unique characteristics that allow their identification; however, the majority of emergency physicians and trauma surgeons do not have adequate training to properly classify these wounds and often do it erroneously.¹³ Size is not an important determinant in classifying entrance and exit wounds. Wounds should be described by their size, shape, precise anatomic location, and surrounding characteristics, such as soot and tattooing.

Bullet caliber should not be estimated by merely looking at the size or shape of a wound, as many factors go into creating these wounds.¹⁴ Also, caliber should not be estimated by looking at a bullet on a radiograph. Radiographs may over or underestimate the size of a bullet and can lead to mistakes.¹⁵

Other Important Forensic Tips

Shrapnel and other objects associated with blasts should be handled in the same manner as bullets. Items should be carefully removed from the victim’s body and placed in a box or coin envelope. Sharp force weapons that are recovered should be wrapped in craft paper or cardboard to protect them from causing injury and sealed.

Chain of Custody

An important aspect of collecting forensic evidence is the chain of custody. The chain of custody is documentation of evidence handling. It recreates the trail of the evidence from victim to collector to police officer to crime lab. A specific Chain of Custody Form should be used. It should include the patient name and information, description of the evidence, time collected, location collected, and name and signature of the collector. It should also include what was done with the evidence, date and time it was turned over, and name and signature of the person it was turned over to.

A new trend is the development of Forensic Care Programs in emergency departments. These programs tend to be an expansion of Sexual Assault Nurse examiner programs. In a Forensic Care Program, sexual assault nurse examiners respond to all victims of violence who present to the emergency department, including adult and pediatric sexual assault, child abuse, elder abuse, intimate partner and other interpersonal violence, and gun violence.

The nurses provide forensic injury examination and documentation, forensic evidence recovery, and photodocumentation of injuries and wounds. These programs allow the primary team caring for the patient to focus on the patient’s medical needs, while the experts handle the forensic needs. These teams work hand in hand with medical providers, law enforcement, and the criminal justice system. Some examples of Forensic Care Programs include Carolinas Medical Center, Charlotte, N.C.; St. Luke’s Hospital, Kansas City, Mo.; and Christiana Care, Newark, Del.

As emergency physicians, we treat victims of violence and crime every day. Our care has a great impact on the patient and their outcome. Forensic knowledge should be part of the routine care we provide to the victims we treat. For more information, see ACEP’s Forensic Medicine Section.

References

1. Struck B. Boston bombing: finding evidence in the ER. MedPage Today, April 17, 2013.
2. Eckert WG, Bell JS, Stein RJ, Tabakman MB, et al. Clinical forensic medicine. Am J For Med Path. 1986;7(3):182-5.
3. Smialek J. Forensic medicine in the emergency department. Emerg Med Clin N Am. 1983;1(3):693-704.
4. Carmona R, Prince K. Trauma and forensic medicine. J Trauma. 1989;29(9):1222-1225.
5. Mittleman R, Goldberg H, Waksman D. Preserving evidence in the emergency department. American Journal of Nursing 1983; 83: 1652–1656.
6. Wiler JL, Bailey H, Madsen TE. The need for emergency medicine resident training in forensic medicine. Ann Emerg Med 2007 Dec; 50(6) :733-738.
7. Smock WS. Development of a clinical forensic medicine curriculum for emergency physicians in the USA. J Clin Forensic Med. 1994 Jun;1(1):27-30.
8. Dolinak D, Matshes EW, Lew EO. Blunt force injury. Forensic Pathology: Principles and Practice. Burlington, Mass: Elsevier; 2005:Chapter 5.
9. Langlois NE, Gresham GA. The ageing of bruises: a review and study of the colour changes with time. Forensic Sci Int. 1991 Sep;50(2):227-38.
10. Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Arch Dis Child 2005;90(2):182-186.
11. Stephenson T, Bialas Y. Estimation of the age of bruising. Arch Dis Child. 1996;74(1):53-55.
12. Firearm & Injury Center at Penn (FICAP). Firearm injury in the US. 2011 update. Available at: www.uphs.upenn.edu/ficap/resourcebook/pdf/monograph.pdf
13. Collins KA, Lantz PE. Interpretation of fatal, multiple, and exiting gunshot wounds by trauma specialists. J Forensic Sci 1994; 39:94-99.
14. Berryman HE, Smith OC, Symes SA. Diameter of cranial gunshot wounds as a function of bullet caliber. Journal of Forensic Sciences, 1995;40(5):751-4.
15. Bixler RP, Ahrens CR, Rossi RP, Thickman D. Bullet identification with radiography. Radiology. Feb 1991;178(2):563-7