Injury, Int. J. Care Injured (2006) 37, 595—601

www.elsevier.com/locate/injury

REVIEW

Clinical forensic medicine in the present daytrauma-care system–—An overview

B.R. Sharma *

Department of Forensic Medicine and Toxicology, Government Medical College & Hospital,Chandigarh 160030, India

Accepted 28 July 2005

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596At the scene of trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596

ABCDE of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596Injury severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596Salvageability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597Time, distance, environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597

Application of triage principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597In the hospital/trauma centre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 598Chain of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599

KEYWORDSTrauma;Clinical forensicmedicine;Forensic protocols;Documentation;Chain of evidence

Summary Criminal violence and its associated trauma comprise a critical healthproblem throughout the world. Clinical forensic medicine represents a new disciplineof medical practice that is evolving in direct response to the sequelae of criminal andinterpersonal violence. The application of the principles and standards of the forensicspecialist has been increasingly recognized as playing a crucial role in trauma care;the results of the extremes of human behaviour–—abused children, individuals suffer-ing from blatant neglect and maltreatment, or self-inflicted injury, and victims ofroad-traffic accidents, firearm injuries and other assaults. These cases must bereported to a legal agency for investigation and follow-up.

As trends in crime and violence change, new antiviolence legislation is likely to beimplemented; consequently, new personnel resources are required to ensure thatthese legislative mandates effectively meet the needs of society.# 2005 Elsevier Ltd. All rights reserved.

* Tel.: +91 172 2622145.E-mail addresses: drbrsharma@yahoo.com, drbrsharma@gmail.com.

0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2005.07.038

596 B.R. Sharma

Need to incorporate a forensic medicine expert in trauma team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600

Introduction

Trauma physicians are frequently involved in theassessment and treatment of patients who may bevictims of violence or accidents. These physiciansusually have little or no training in the forensicaspects of trauma, and therefore, necessary evi-dence may often be overlooked, lost, inadvertentlydiscarded, or its subsequent admissibility denied,because of improper handling or documentation.16

Furthermore, trauma surgeons have a duty to pro-vide timely care for injured patients, while simul-taneously recognizing and preserving evidence.24

The roles of the trauma physician and themedicalexaminer/police surgeon/forensic medical scien-tists, have recently been recognized to have areasof mutual and complementary interest, such as theproper assessment and documentation of themechanism of injury, in determining injury extent,or reconstructing an accident scene, or cause ofdeath. In addition, appropriate securing, handlingand documentation of evidence will not only assistthe medical examiners or pathologists, but alsoassist the police and legal authorities in the forensicaspects of an investigation.8

In some countries, physicians are additionallytrained as ‘police surgeons’ in order to fill the voidbetween the office of the medical examiner/pathol-ogist, which is largely involved in homicides andunexplained deaths, and the police and the legalauthorities responsible for investigating both civiland criminal complaints in homicides, non-homi-cides and surviving injured patients.8 Throughproper and timely preservation of evidence, thepolice surgeon facilitates both medical and non-medical examiner’s investigations.

Since trauma physicians are frequently called totestify in the civil and/or criminal cases involvingtheir patients, they have a responsibility to appro-priately document care and secure evidence, sinceit is rarely possible without a proper written recordto rely on personal recollection, months or yearslater, of the actual events of a given patient’s care,or the location of evidence. Studies from level-1trauma centres have identified and reported areasof concern in documentation, handling and securingof evidence.4

Clinical forensic medicine has been challenged toshare responsibility with the legal system to aug-ment the resources available to patients withliability-related injuries, victims of crime and

perpetrators, or suspects, in police custody. The‘mutual responsibility’ concept represents a newperspective in the holistic approach to legal issuessurrounding patient care in clinical or community-based, institutions. There has been strong supportfor this concept from those who recognize theamount of knowledge required, extending beyondthe traditional treatment of crime victims, and theneed to fill loopholes through forensic health careexpertise. The role of forensic medicine has beendesigned expressly to provide solutions to some ofthe most urgent concerns in our society. Forensicmedicine focuses on those areas in which medicineand human behaviour have an interface with thelaw. Existing problems are great, multifaceted andcall for innovative solutions. The application offorensic science to contemporary medical practicebrings a wider role, one that contributes to publichealth and safety in the fields of investigation ofcrime and the legal process. The responsibility offorensic medicine is to provide continuity of carefrom the healthcare institution, or the crime sceneto the courts of law . . . ‘from trauma to trial’.22

At the scene of trauma

The triage principles listed below have their ownlegal implications, and accordingly, the utmost caremust be exercised to avoid any litigation at a laterstage. The emergency personnel must be preparedto justify the rationale for assigning priorities andidentify the standard indicators that he/she woulduse for pre-hospital notification and documentationduring transfer of the patient from incident scene tohospital or trauma centre report.

ABCDE of care

The degree of threat to life posed by each injury isdetermined by considering the order of priorities, asrevealed by the primary survey of the patient andapplying those same principles to groups of patients.Thus, a patient with an airway or breathing problemhas priority over a patient with circulatory or neu-rological disability.

Injury severity

The overall severity of injury in a particular patientmay not just be related to one individual injury. It is

Clinical forensic medicine in the present day trauma-care system–—An overview 597

also important to consider the effects of differentinjuries and how the patient responds to the com-bination of these injuries, in an overall sense. Anisolated fracture may by itself be a low priorityinjury, but combined with another source of majorhaemorrhage, the overall injury severity increases;the level of priority in the triage process may wellincrease accordingly.

Salvageability

The patient with the most severe injury or the great-est threat to life is not necessarily the patient whoreceives thehighest prioritywhendealingwithmulti-ple patients. The likelihood of survival of the patientmust be considered. In trauma triage, the patientwho is least likely to survive is often given the lowestpriority, especially when personnel and facilities arepresented with a serious challenge. In such circum-stances, resources may need to be expended on thepatients that are more likely to survive.

Resources

The patient whose needs exceed the availableresources is given a lower priority, until the neces-sary resources are secured. Personnel capabilities(skill level, number) and equipment are included inthe consideration.

Time, distance, environment

An injury that could bemanaged rapidly, although oflower severity and lower life threat, may be treatedas a higher priority, because of the short length oftime it takes to correct the identified problem.Patient transport distance to travel in order tosecure definitive care, and other environmentalfactors also need to be considered when prioritizingmanagement of multiple patients.

Application of triage principles

Triage is a process in which time is of the essence andis often based on incomplete information. Detailedinformation and patient status are unlikely to beavailable immediately. Indecision and procrastina-tion must be avoided. Triage decisions are made onthe best information available at the time. It is oftennecessary to make these decisions by standing backand surveying the entire situation in order to deter-mine which patients are most severely injured.The order of priorities withmultiple patients remainsthe same as in an individual patient.

Adhering to the ABCDE priority acronym of care,airway overrides breathing and circulation. Thepatient with an airway problem is managed beforea patient with a circulatory problem. There areoccasions in which it may be necessary to prioritizepatients basedon salvageability. Thepatientwith theleast chance for survival, despite being the mostseverely injured, should be managed after a patientwho can quickly be stabilized with a simple man-oeuvre. With large numbers of patients, it may behelpful to categorize patients into smaller groups,i.e., high priority, intermediate priority, and lowpriority, based on a global assessment or emergent,urgent, and ‘‘walking wounded.’’ The triage processalso involves the identification of the resourcesnecessary for stabilizing patients. Should theresources not be available, the patients in need ofthose resources may not be given as high a triagepriority. In addition, the triage process also includes adetermination of the most appropriate method oftransfer. Identification of the patient requiring earlytransport to a health care facility, or early transfer toa definitive care facility for early definitive manage-ment, must be undertaken. Part of this early processis the pre-hospital notification of the closest, mostappropriate facility.

There is a distinct difference between civilianand military triage. Civilian triage establishes asystem of care for all and limitation of resourcesis considered only after an initial life-saving effort ismade. Military triage is aimed at maintaining afighting force and resources are directed to thatend. The priorities are based on the ability to returnthe injured person to fighting capability. In militarytriage, the priorities may appear to be reversed,since the least injured may receive highest priorityin management.

It is important to remember that triage is afluid, continuing process. Constant reassessmentof patients in each category must occur. Patientswhose condition may have worsened are then re-allocated to a higher priority. Conversely, thosewhose condition has improved can then be given alower priority status.23

Can we expect a paramedic or emergency tech-nician to gather the evidence and document itproperly, while simultaneously providing pre-hospi-tal care so as to meet legal requirements withoutproper training in forensic nursing and defining thepriorities?

In the hospital/trauma centre

Theemergency staff become involvedwhenapatientis admitted for care following suspicious injuries that

598 B.R. Sharma

may be accidental, but may also be crime related orself-inflicted. In such cases, clinicians need to beaware of the manner in which the assessment ofinjury, forensic evidence and critical data are docu-mented with law enforcement and crime scene offi-cers. Hospital emergency departments regularlycome into contactwith essential evidence in criminalcases. Themost common types of evidence are cloth-ing, bullets, bloodstains, hairs, fibers and fragmentsof material, such as metal, glass, paint, and wood.The problem of gathering evidence in the emergencydepartment is compounded by failure to develop andimplement forensic guidelines for general duty doc-tors and the nurses. A classical problem is the lack ofan acceptable method for preserving evidence fromcrimes that are discovered long after the patient hasbeen admitted, or has died. This is further compli-cated when a trained forensic pathologist becomesinvolved after the destruction of the evidence, or thecondition of the body has been altered by surgicalintervention.

Themedico-legal interface is critical amongmulti-disciplinary teams investigating physical injuries,whether accidental, criminal, self-inflicted, or fromunknown causes. The interface can be compromized,with serious consequences, when no forensic proto-col exists. This occurs when police officers and hos-pital staff are unfamiliar with the procedures thateach should follow. The appointment of a designatedhospital liaison officer to network with police, thecoroner, and/or medical examiner, can provide asystematic approach to communication and coordi-nation. This liaison officer should be trained in for-ensic concepts, legal responsibilities, and victim’sissues.

On the other hand, trauma patients may pose acomplex clinical challenge, which predisposes tosome injuries being diagnosed late, or indeedmissed, and delaying treatment, whereas life-threatening injuries usually are not missed; clinicalexperience and a review of the literature indicatethat not all injuries are identified during the initialassessment and resuscitation phase.5 The AdvancedTrauma Life Support (ATLS) protocol has establishedan internationally accepted approach to primaryand secondary trauma survey, which, if adheredto, may minimize the chance of an injury’s remain-ing unrecognized. However, even this structuredapproach can not guarantee that all injuries willbe discovered and a concept of tertiary traumasurvey or standardized clinical reassessment, within24 h of admission has been proposed, further toreduce the incidence of unrecognized injuries.6

Reported rates of unrecognized injuries in traumapatients vary from 2% to 50%.1,7,11,14 An evaluationof early missed injuries has reported the incidence

as 65%. According to this study of 206 patients, therewere clinically important missed injuries in 30patients (15%) with complications in 11 patients,of whom two died. The study further reports 224contributing errors, of which 123 (35%) were in theclinical assessment, 83 (40%) in radiology, 4 (2%)were technical errors and only 14 (7%) were patientrelated.13 According to another study of 123 missedinjuries in 117 patients, the cause of missed injurywas incomplete initial assessment or investigation in51 (41%) cases, incomplete surgical exploration in 43(41%) cases, failure to surgically explore the patientin 17 (14%) cases and patient-related factors in 12(10%) cases.10 In a further series of 607 patients withabdominal trauma, only 12 (2%) were reported tohave missed injuries.25 Patients sustaining blunttrauma have been reported to have a higher rateof missed injuries3 than patients sustaining pene-trating injury,20 and the unrecognized injuries havebeen reported to range in severity from trivial tofatal.9

Hitherto, only a handful of autopsy assessmentsof unrecognized injuries have been reported.Albrektsen and Thomsen1 reported a 34% missedinjury rate, but included only clinically insignificantinjuries (abbreviated injury score <4). Hodgsonet al.12 reported an unrecognized injury rate of47%, whereas clinical studies have reported thatthe incidence of unrecognized injuries decreasedfrom 2.4% to 1.5% overall and from 5.7% to 3.4% intrauma intensive care unit patients, after the intro-duction of structured trauma survey.2 These varia-tions suggest that clinical reviews, without autopsyevaluation, do not estimate the true magnitude ofunrecognized injuries. Furthermore, it raises doubtsabout the accuracy of the certificated cause ofdeath reported by the treating physician21.

Under these circumstances, can we expect thetrauma physician, who has a priority and duty toprovide timely care for injured patients, to recog-nize, preserve and document the evidence, so as toassist the competent authorities responsible forinvestigating both civil and criminal complaintspertaining to the injured patients?

Documentation

The evaluation and documentation of injury severityare not only legal requirements, but also prerequi-sites for the development, assessment and improve-ment of trauma care systems, as well as for theadvancement of public policy for the control ofinjuries.18 Although adequate documentation hasalways been important, and various hospital com-mittees and the Joint Commission on Accreditation

Clinical forensic medicine in the present day trauma-care system–—An overview 599

of Hospitals (JCAH) havemonitored compliance, thisarea has recently come into even greater promi-nence in an increasingly litigious society. In addi-tion, with the advent of regionalized emergencycare and trauma centres, these specialty hospitalsare more involved in emergency patient care thatmay have an increased propensity for forensic impli-cations.

Many hospitals have found that a trauma registryis an efficient method for storing and analyzing dataon trauma patients. Basic data elements in theregistry should include demographics (patient’sage, sex, injury cause and injury type), informationon pre-hospital care, data on the process of acutecare (treatment, major surgical procedures, iden-tification of the attending service, response time),laboratory investigations (including blood alcohollevel), final anatomical diagnosis (from examina-tion, X-rays/CT, surgery, or autopsy) and outcomedata (discharge status, hospital and ICU length ofstay, complications and functional disability at dis-charge).19 Trauma registries must be founded oncomplete, accurate data that includes explicitand accurate descriptions of physiological derange-ment and injuries, as well as a record of accurateinjury coding, based on clinician-determined ICD-9-CM codes.15

However, no specific guidelines exist for the doc-umentation of evidence and this responsibilityseems to be left to the trauma surgeon. Some areasof potential forensic deficiency can be identified as:

� Il

legibility of hurriedly written notes in emer-gency.

� N

o record of restraint device and/or safety hel-mets use (if applicable) in cases of motor vehicleaccidents.

� A

bsence of comments about the methods of trans-port of the trauma victims; patients may arrive byprivate vehicles, ground ambulance or air trans-port.

� P

re-hospital trauma care teams frequentlyadminister treatment and various forms of stabi-lization, but often missing is a general statementas to the patient’s appearance and condition, andif during this treatment, there was improvementor deterioration.

� M

echanism of injury is not properly documentedon many occasions: this has become an extremelyimportant factor for a number of reasons, such asheightening the index of suspicion of occult inju-ries, designing regional patient triage protocols,so that the patients with potential serious injuriesare directed to trauma centres, and to assist ininvestigation of the accident/crime scene, by amedical examiner/autopsy surgeon.

Furthermore, objective descriptive terminologyis extremely important in forensic cases. Examplesof potential problems encountered in this areainclude references to gunshot wounds as ‘‘entranceor exit’’, patients being labeled as ‘‘drunk’’ becauseof an altered mental status, possibly due to headinjury yet smelling of alcohol, and patients sus-pected of complaining for secondary gain beingwritten up as ‘‘malingerers’’. On many occasions,physicians’ early subjective statements have beenproved to be incorrect during subsequent investiga-tion and/or court testimony, thereby diminishingphysician credibility.

Chain of evidence

One of the most important aspects of any case withforensic potential is the preservation of the chain ofevidence, or accounting for the whereabouts of allevidence at all times, until its use by the courts.Failure to maintain the chain of evidence may latercause its admissibility to be denied in court, eventhough the evidence is physically present. This pre-servation of the chain of evidence includes bothproper documentation, and the securing and hand-ling of evidence at all times. Any belongings, bodyparts or fluids, or foreign bodies, removed from thepatient, are to be regarded as potential evidence.Therefore, there should exist a protocol for docu-menting and securing all such substances. Clothescut off during resuscitation must not be discarded,and bullets, fragments and foreign bodies removedfrom the wounds should be carefully documented asto site of removal and cautiously preserved. Inaddition, when blood is drawn for alcohol levels,the site, method of site preparation and phleboto-mist should be recorded and the specimen secured.

Should this be expected from a treating physicianor attending nursing staff, without specific forensicknowledge or training?

Need to incorporate a forensicmedicine expert in trauma team

The loss of human life and function due to violenceaffects millions of people annually. Society demandsan investigation of trauma associated with criminalactivity. No longer is it acceptable for health careprofessionals to operate in isolation of forensicphilosophies and principles. It is assumed that theindividuals responsible for the performance of theexamination of the victims have the necessary basicforensic education, experience and skills. Healthcare professionals involved in the initial response

600 B.R. Sharma

to these victims, in the emergency department, arefaced with unique problems, as social changesrequire continual re-evaluation of standards andprofessional responsibility. Any patient admitted tothe hospital with liability-related injuries must beconsidered a clinical forensic patient. The case mustbe reported to the competent legal agency, to ensurethat proper investigation and follow-up action willtake place. Hospital staff in the emergency depart-ment often come into contact with police, victims,and perpetrators of criminal violence. Protection ofthe patient’s rights remains the common goal ofpoliceofficers and thehealthworkers at traumacare.The term ‘forensic physician’ is increasingly used fordoctors engaged in non-pathological aspects of for-ensicmedicine.17 The forensicmedicine expert’s roleas a clinical investigator provides a vital liaisonbetween the investigative process and courts of law.

Training in clinical forensic medicine can providea uniquely skilled and qualified forensic professionalwhose responsibilities would be:

(1) t

o develop the appropriate forensic protocols incompliance with accreditation standards;

(2) t

o conduct triage of patients at risk for forensicinjuries;

(3) t

o report to the proper legal agencies; (4) t o document collection, and preservation of

evidence;

(5) t o secure evidence and maintain the chain of

custody; and

(6) t o serve as liaison between the health care

institution, law enforcement agencies, andmake referrals when medical treatment and/or crisis intervention is required.

This essential component of a network ofmedical,legal, and social services could initiate significant,constructivechanges.Forensicstandardsalsoserveasa means to transmit developing knowledge in techni-calandsocial interventions,andtherebyhelpnotonlyto protect the patient’s rights, but also the bestinterestsof thehealthcare institutionand itsemploy-ees against liability claims. The implementation ofregular in-serviceprogramsontheForensicAspectsofHealth Care would be a primary responsibility of theforensic medicine specialist. He or she would advisethe medical and nursing staff and other first respon-ders on the legal requirements of trauma care.22

Conclusion

The courts, both in civil and criminal cases, notinfrequently draw attention to deficiencies in phy-sicians’ forensic knowledge and/or compliance, at

times resulting in the acquittal of criminals for lackof scientific evidence, or non-admissibility of evi-dence, on account of an incomplete chain of for-ensic medical evidence. In trauma cases, theproblem appears to begin at the incident scene,with documentation of the events of the accident,including the position and condition of the patient.In the emergency department, it becomes appar-ent that it is important to assess the patient interms of any need for special laboratory studies.Equally important is the status of the patient onarrival. Whilst trauma surgeons in the emergencydepartment are focusing their energies on stabili-zation and assessment, the forensic medicineexpert will ensure proper collection, preservationand documentation of evidence, later required in acourt of law. In the present medico-legal environ-ment, with the prominence of litigation, physicianscannot afford to expose themselves for want ofknowledge of proper forensic principles. There-fore, there is an urgent need, either to train thedoctors, the nursing staff and the paramedics todeal with the forensic implications of trauma man-agement at all levels, or to incorporate forensicexperts in trauma teams.

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