MEDICOLEGAL ASPECTS OF
TRAUMA MANAGEMENT
Dr T. Kombora
CONTENTS
• Completion of J88
• Wound Descriptions
• Doctor and the Law
COMPLETION OF THE J88
Divided into 9 Sections
A. Demographic Information
B. General History
C. General Examination
D. 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 information
1 . 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 cycle
3 . Contraception use, when last used and type
4 . 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 – 5
2 . Pubic Hair use Tanner Stage 1 - 5
- Tanner Staging best way to determine discrepancies
between apparent and chronological ages
3. Examine external genitalia noting any injuries old or new
4. 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 it
6. Cervix and Perineum
TANNER STAGING- FEMALE
F. SAMPLES TAKEN FOR
INVESTIGATION
1.
2.
3.
4.
5.
Forensic Specimen taken
Urine Pregnancy Test
Seal number of Evidence Collection Kit
Note name, rank, Force Number of person given Kit for
preservation on chain of evidence
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